Vital Signs May 2012

May 2012 • Vol. 34 No. 5Official 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 Society

May is Clean Air Month

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o

Vital Signs

2 MAY 2012 / V ITAL S IGNS

VITAL S IGNS / MAY 2012 3

Official Publication of

Fresno-Madera Medical Society

Kings County Medical Society

Kern County Medical Society

Tulare County Medical Society

May 2012Vol. 34 – Number 5

Editor, Prahalad Jajodia, 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 RepresentativeGail Locke

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.

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

NEWS

HEALTHCARE REFORM: US Supreme Court: How is Health Insurance Different Than Broccoli?.....7

An Evening With Ray Kurzweil ..................................................................................................8

AIR QUALITY: Practical Information and Helpful Tips from Your Allergist ....................................10

AIR QUALITY: May is Asthma Awareness Month ......................................................................11

AIR QUALITY: A Year With My Chevy Volt .................................................................................12

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

CME ACTIVITIES .......................................................................................................................18

TULARE COUNTY MEDICAL SOCIETY.........................................................................................13

• President’s Message

• Predictive Modeling Analysis of Medicare Claims

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


• Membership News

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


• Medical Society Presents Awards at Regional Science Fair

• Educational Series for FMMS Members

• Economic Forums for FMMS Members

Cover photography: “Yokohl Valley near Exeter”by Justin Stoner

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



CMA NEWSCMS E-PRESCRIBING BACKLOG REDUCES FEESTO PHYSICIANS DESPITE HARDSHIP EXEMPTIONSCalifornia physicians are reporting that the Medicare paymentsthey are receiving in 2012 have been reduced for a failure toprescribe enough electronically in 2011 – despite the fact thatthese physicians have filed hardship applications to the Centersfor Medicare & Medicaid Services (CMS). CMS responded toCalifornia Medical Association (CMA) inquiries that it was notable to process all hardship applications prior to January 1,although the agency says it has since approved or denied all ofthose exemption requests. This means that CMS has levied a 1percent penalty for what it considers “noncompliant physicians.”

CMA is working with CMS to build clarity over whetherpenalties will apply to physician reimbursement rates goingforward, and to ease confusion over the process in the future.CMA has urged CMS to re-evaluate the penalty timelinesassociated with the e-prescribing incentive program, as well asother health information technology incentive programs thatare kicking in at the same time.

For now, there is no official appeals process for the e-prescribing penalty program. However, CMS has expressed awillingness to work with individual physicians on concerns withthe payment adjustments.

CMS encourages physicians who think they are receiving thee-prescribing penalty in error to contact its help desk. TheQualityNet Help Desk can be reached by phone Mondaythrough Friday, 7am to 7pm (CST) at 866-288-8912 or by emailat [email protected]

Avoid the 2013 penaltyOn March 1, the agency reopened its hardship requests from

physicians looking to avoid the 2013 e-prescribing penalty,which will grow to 1.5 percent. Physicians seeking waivers willhave until June 30 to file exemption requests. A request for afeedback report, and an application for a hardship exemption,can be filed online by clicking on the Communications SupportPage.

CMA has published a guide to the e-prescribing process withpertinent deadlines and qualifications.

Contact: Michelle Kelly, 213-226-0338 or [email protected]

CMA RECOMMITS TO PATIENT SAFETY DESPITECOURT RULING FAVORING NURSE ANESTHETISTSA state court of appeal has ruled that nothing in California lawrequires nurse anesthetists to be supervised by physicians whenadministering anesthesia to patients. The ruling came withoutregard for the numerous concerns and objections raised by theCalifornia Medical Association (CMA) and the CaliforniaSociety of Anesthesiologists (CSA).

The court’s ruling lets stand a 2009 decision by formerGovernor Arnold Schwarzenegger to exempt California fromfederal rules requiring physician supervision of nurse anesthetistsin Medicare participating hospitals. According to the court, anyconcerns “that a physician’s practical, ethical and legalresponsibilities for his or her patient’s care will be jeopardized bythe use of unsupervised certified registered nurse anesthetists toadminister anesthesia” should be resolved “with the Legislature,not this court.”

CMA and CSA challenged Schwarzenegger’s decision incourt because they believe it is inconsistent with California law,which requires that a physician always retain responsibility andcontrol over the medical care of his or her patient. Physiciansupervision over nurse anesthetists is necessary within thisframework, according to CMA, to ensure that the medicalprofessional with the best training and the most clinicalexperience remain involved through all aspects of anesthesiacare. Although nurse anesthetists can and do administeranesthesia, physicians are the most qualified to monitor theeffects of the anesthesia, and to react immediately whenmedically necessary.

Despite the recent court ruling and Schwarzenegger’s opt-outdecision, hospitals in California still have the authority torequire physician supervision of nurse anesthetists at theirfacilities. Furthermore, medical staffs at hospitals may also beable to implement a supervision requirement within the scope oftheir self-governance rights over the professional work in ahospital.

While disappointed with the decision, CMA remainsundeterred and committed to protecting the quality and safety ofall medical care provided to Californians. CMA is analyzing theopinion and exploring all legal, regulatory and legislativeoptions.

Contact Samantha Pellon, 916-551-2872 or [email protected]

A GUIDE TO RECORD RETENTIONUNDER CALIFORNIA LAWStatutory authorities that specifically regulate the retention ofmedical records in a physician’s office are found broadly inCalifornia law. These include the Medi-Cal Act, the lawgoverning the Emergency Medical Services Fund, the CaliforniaUniform Controlled Substances Act, the Knox-Keene Act,OSHA rules and the laws governing workers’ compensation.

The California Medical Association’s (CMA) ON-CALLdocument #1160, “Retention of Medical Records,” discusses themajor issues raised by the retention, abandonment, theft anddestruction of medical or health insurance information andphysician practice business records, including: statutory recordretention requirements, the rules applicable to recordsabandoned in bankruptcy or otherwise, recommended retentionperiods, options for record management on the sale or closing ofa medical practice, record destruction requirements, andobligations for safeguarding patients personal information and forresponding when records containing identifying information arestolen or otherwise breached.

This document, as well as the rest of CMA’s health law library,is available free to members in CMA’s online resource library.Nonmembers can purchase CMA ON-CALL documents for $2per page.

Contact Samantha Pellon, 916-551-2872 or [email protected]

MORE PHYSICIANS WORK PART-TIMEAND FLEXIBLE SCHEDULESTwo of the fastest-growing physician demographics – men nearthe end of their careers and women at the beginning or middle –are the most likely to demand part-time or flexible work

Please see CMA News on next page


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schedules, according to experts inphysician recruitment.

This is according to a survey releasedMarch 12, 2012, by the American MedicalAssociation and Cejka Search, a physiciansearch firm based in St. Louis. The studyfound that male physicians headed towardretirement and young female physicians ofchild-bearing age are driving a change inmedical practices across the nation.

In 2011, 22 percent of male physiciansand 44 percent of female physiciansworked less than full time, up from 7percent of men and 29 percent of womenin a 2005 survey conducted by Cejka. The2011 survey covered 14,366 physicians in80 practices, which had from three tomore than 500 doctors each.

Larger practices offer more part-time workAccording to the survey, the shift is

coming from within larger practices of 500or more physicians as opposed to smallerpractices. Twenty percent of male and 23percent of female physicians in practicesof 500 or more doctors worked part-time.Meanwhile, only 6 percent of male, and 4percent of female physicians in practicesof three to 50 physicians worked part-time. Total part-time work for in-hospital-based practices was 5 percent of male and7 percent of female physicians.

Physician search firms said theincreasing demand for part-time work –and large practices’ positive reaction tophysicians’ part-time requests – ispressuring smaller groups to offer similaroptions. According to the survey, 75percent of groups in 2011 offered a four-day workweek, and 30 percent allowedjob-sharing.

Some specialties, however, may find itmore difficult than others to set up a part-time or flexible arrangement, physicianrecruitment experts and consultants said.Part-time practice is not uncommon inpediatrics and other nonsurgicalspecialties, but can be harder to set up forsurgeons. Specialties that are more shift-oriented, such as hospitalists and urgentcare and emergency departmentphysicians, may find part-time easier toarrange.

Continued from CMA News page 5

CMA NEWS


In March, attorneys representing the twosides in the debate around the federalAffordable Care Act (ACA) squared off ina round of oral arguments before theUnited States Supreme Court.

While the arguments spanned a total ofthree days, much of the action was focusedon the second day’s key question: Can thefederal government require its citizens topurchase health insurance?

In an effort to undermine theAdministration’s call for an individualmandate, Chief Justice Roberts, as well asJustices Scalia and Alito, levied a series ofhypothetical “slippery slope” arguments atthe Administration. Through thesearguments, opponents of the mandateattempted to highlight the key question of which market shouldbe regulated by the mandate: the insurance market, all healthservices, or the portion of health services that uninsured peopleare likely to use.

Justice Scalia challenged the Administration with broccoli.“Everybody has to buy food sooner or later, so you define themarket as food, therefore, everybody is in the market; therefore,you can make people buy broccoli.”

Chief Justice Roberts preferred comparing health insurance tocell phones on the basis that anyone might need to contactemergency services at some point, while Justice Alito likened itto burial insurance, saying, “I don’t see the difference... You canget burial insurance. You can get health insurance. Most peopleare going to need health care. Almost everybody. Everybody isgoing to be buried or cremated at some point. What’s thedifference?”

Speaking from a policy perspective – the legal perspective willbe discussed in the next issue of Reform Essentials – thedifference between health insurance and broccoli, cell phones orburial insurance can be boiled down to a basic question of cost.

In one of the most reputed studies of its kind, Milliman, Inc.showed that uncompensated care cost the commercially insuredan average of $1,017 per insured family and $368 per insuredindividual in 2008. By 2014, the first year of the mandate, thiscost shift is likely to be even higher.

Considering that health care spending made up nearly 18percent of the gross domestic product (GDP) in 2011, thesenumbers take on even greater significance in the context ofSupreme Court commerce clause precedent.

In 2005, the Court found that in order to act under the

U.S. Supreme Court:How is Health Insurance Different Than Broccoli?

CMA, Reform Essentials

commerce clause, Congress must only havea rational basis for concluding that a targetactivity, taken in aggregated, wouldsubstantially affect interstate commerce.(Gonzales v. Raich)

If the “target activity” is defined asreceiving uncompensated health care, theeffect on interstate commerce is clearlysubstantial, as data suggests it accountedfor more than 10 percent of California’spremium costs in 2008.

Regardless, the consensus amongobservers is that the Supreme Courtappears likely to strike down the individualmandate, raising the issue of what in theACA might fall with it.

WHERE DOES CALIFORNIA GOIF THE MANDATE IS STRUCK DOWN?

Diana Dooley (Secretary of the California Health and HumanServices Agency), Peter Lee (Executive Director of theCalifornia Health Benefit Exchange), Dave Jones (InsuranceCommissioner), and William Monning (Chair of the AssemblyHealth Committtee), among others, have all implied Californiawill continue forging ahead on health reform even if the entireACA is struck down.

Secretary Dooley has specifically suggested that the state mayfollow Massachusetts’ lead and institute an individual mandate atthe state level if the ACA’s requirements that insurers accept allapplicants without screenings and exclusions on account of pre-existing conditions are permitted to stand.

Dooley’s statement makes sense in light of a recent economicstudy from the Massachusetts Institute of Technology (MIT) thatsuggests, without the individual mandate, Exchanges eventuallyturn into nothing more than high risk pools. This is due to theability of those with medical conditions to somewhat accuratelyproject their health care costs for the next year.

Even if the state is able to institute a mandate and dodge thehigh risk pool bullet, a lack of public funding could still doomCalifornia’s Exchange effort.

A recent RAND Institute study estimated that without theindividual mandate the amount of government spending pernewly insured individual would more than double, from $3,659 to$7,468. Considering California’s growing budget struggles andthe fact that even the lowest 2014 California Exchangeenrollment estimates have exceeded 800,000, it is hard toimagine how the state could take on such potential costs withoutsubstantial federal assistance.

HE A LT HC AR E R E F ORM


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“Ray Kurzweil is the best person I know at predicting the future of artificial intelligence.”

– Bill Gates

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A I R Q U A L I T Y

Spring allergies – if the coming of spring fills you with dread,you’re probably among the 50 to 60 millionAmericans who suffer from seasonal allergicrhinitis more commonly known as hay fever.Allergens themselves don’t make us sick, it’sour body’s over reaction to the substancesthat produce the allergic reaction. The mostcommon symptoms include sneezing, runnyor congested nose, red, itchy, watery eyes,itchy skin, hives and in some peoplecoughing, wheezing, tightness in the chestand asthma.

Common allergens include pollen, mold, animal dander anddust mites. Some people also have allergies to food, medicationsinsect stings and skin products. These substances called antigenswhich are usually harmless react with allergy antibodies in theallergic person to cause cells in the body to release histamine andother chemical substances. Histamine and other mediators startan inflammatory response which leads to allergy associateddiscomforts.

CAN ALLERGIC REACTIONS BE AVOIDED? Probably not altogether if you inherit an allergic tendency. However, understanding more about what causes allergic

reactions and taking some precautions can make the hayfeverseason more bearable. Some general things you can do tominimize allergic problems is to take care of yourself. Get plentyof rest, eat a well-balanced diet with plenty of fruits andvegetables. Exercise can be very helpful by improving yourcirculation and opening up your nose and sinuses. Smoking anddrinking will aggravate allergy symptoms.

There are three specific things you can do to minimize yourallergic symptoms:

1. Avoidance 2. Medications 3. Allergy shotsAvoidance – the most important thing to do is to stay away

from the allergens that gives you problems.Study the pollen patterns in your area and watch for pollen

indexes in your local newspaper. Avoid pollen by keeping indoorsin an air-conditioned building when the pollen count is high.Keep the car windows closed. Try to limit your outdoor activitywhen the wind is blowing. The wind really stirs the pollen and

carries it for tens if not hundreds of miles. If you’re allergic toanimals keep the pets out of the house and those that cannot beleft outside at least keep them out of the bedroom. Some studiesindicate that bathing your pet once a week can reduce theallergen load.

Vacuum frequently and keep the house neat and simple. Limitthe number of indoor plants that can produce mold spores fromthe moisture in the soil. Keep the bathroom free of excessivemoisture to keep the mold to a minimum. The mold count canbe very high in the soil outside especially if they’re old grassclippings or old leaves in the soil.

Medications – most people can get allergy relief from over-the-counter antihistamines, decongestants, or a combination ofboth.

Although you can buy them without a prescription, youshould note precautions with their use. For example alcohol andantihistamines don’t mix well, so avoid alcohol while treatingallergy symptoms. These drugs can make you sleepy or dizzy andimpair your judgment so be very careful when driving oroperating heavy machinery. Be sure to talk with your doctor if

you are already taking othermedications for possibleadverse interactions.

I will generally recommenda combination antihistamine/decongestant in the daytime ora straight antihistamine in theevening. There are also someanti-inflammatory nasal corti -costeroid sprays and anti-

histamine nasal sprays that are very effective and these areusually obtained with a prescription from your primary caredoctor or your allergist.

Our understanding of the immune system and allergyantibodies has come a long way in recent years so there is a greatchance that an effective treatment plan can be worked out foryou after appropriate allergic evaluation of exposures and skintesting.

Allergy Shots – or desensitization injections are given on aweekly basis and administered subcutaneously. One developsprotective antibodies to the antigens that they are allergic to.These type of injections are FDA approved for the following:

1. Allergic rhinitis 2. Asthma3. Allergic conjunctivitis 4. Atopic dermatitis or eczemaThese injections do not contain steroids. The mechanism of

action is thought to be by an increase in immunoregulatory cellsknown as T regulatory cells that modulate and decrease theoverall inflammatory mechanisms that result in allergic rhinitis,asthma, allergic conjunctivitis and atopic dermatitis.

Practical Information and Helpful Tips fromYour Allergist Regarding Allergies and Asthma Care

Praveen Buddiga, MD, FAAAAI,Member FMMS Air Quality Committe

First Exposureto pollen

IL-4 drives B cells toproduce IgE in response

to pollen antigens

Pollen-specific IgEbinds to mast cell

Second exposureto pollen

Acute release of mastcell contents causes

allergic rhinitis (hay fever)

Praveen Buddiga,MD, FAAAAI


A I R Q U A L I T Y

• Direct medical expenditures associated with asthma, includinghospital care, physicians’ services and medications, areestimated at $14.7 billion annually.

• Indirect medical expenditures, including lost work days foradults suffering from asthma or caring for children with asthmaand lost future earnings from premature deaths associated withasthma, total $5 billion annually.

• Triggers that can initiate an asthma attack include allergenssuch as pollen, dust, animal dander, drugs and food additives,as well as viral respiratory infections and physical exertion.Obesity, use of acetaminophen and exposure to formaldehyde

What is asthma and what triggers it?Asthma is an abnormality of the bronchial tubes – airways

that are reversible.The common feature of asthma is the hyperresponsiveness or

“twitchiness “of the bronchial tubes to multiple stimuli.The most common triggers or stimuli of asthma are viral

upper respiratory infections and allergy. Other triggers includeexercise, temperature or barometric pressure change, sinusinfections and medication such as aspirin. The common allergictriggers are tree pollen, grass pollen, weed pollen, dust mite,mold spores, cockroach and animal dander.

Important Asthma facts:• Asthma is a chronic inflammation of the lung airways thatcauses coughing, chest tightness, wheezing or shortness ofbreath.

• An estimated 22 million Americans have asthma; 6.5 millionare under 18.

• Asthma mortality is 4,000 deaths per year.• Asthma results in 497,000 hospitalizations and 1.8 millionemergency room visits.

• Asthma is the most common chronic illness in childhood,accounting for 12.8 million missed school days each year. Italso accounts for 10.1 million lost work days for adults.

• The estimated economic cost of asthma is $19.7 billion annually.• Asthma is often hereditary.

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Asthma&

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Asthma and allergiesstrike 1 out of 4 Americans

Parkinson’s Alzheimer’s Stroke

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May is Asthma Awarenss Month

Please see Asthma on page 11


A I R Q U A L I T Y

In March of last year Itraded my BMW for aChevy Volt. That was thebest decision I’ve made inyears! I’m very worriedabout air pollution not onlyin our Valley but worldwide,and I felt this would be mycontribution to clean air. Ibelieve that motor vehiclespollute a great deal, andeventually we will have todo something about it. I feltI could start now.

Let me remind you thatthe car is an ultra clean car. This is because when the battery goesdead there is a small generator that kicks in and charges the motor,allowing the car to continue to run on electricity. The generatorproduces a small amount of pollution. The nine-gallon gas tankuses premium gasoline, and I have filled it up only five times for anaverage of 155 miles per gallon!!! The highest mileage I have goneis 172 miles per gallon. If one uses the car on a long trip, theaverage goes down. One full battery charge plus a full tank ofgasoline takes you about 350 miles! I have spent about $100 ingasoline this year.

I have driven to Indian Wells, (the resort has chargers one canuse), San Francisco twice and Bakersfield once. The transition tothe generator is seamless. When I’m home in the evenings, I chargethe car from a direct 110-volt outlet. It takes 8 hours to fully chargethe car. If you plug the car into a 240-outlet, it charges the car infour hours. (I put in a 240 outlet, but haven’t used it). The batterylasts all day during a typical full day of driving – from my house inClovis to CRMC downtown, back to Fresno Surgical Hospital, to

A Year With My Chevy VoltSergio Ilic, MDFMMS President

my office, to SummitSurgical, run ning a coupleof errands and back to myhome.

During the summermonths, the battery laststhe equivalent of 42 miles,but during the wintertimewhen it’s really cold, thecharge goes for about 28miles. Unfortunately themiles are not physicalmiles, but what would bethe equivalent to them.This is because extra

electricity is consumed if using the radio, the air conditioner,driving erratically, accelerating really hard etc.

Owning this car has also had beneficial and unintendedconsequences. Since the car has a mechanism to measure theamount of electricity being spent, I’ve modified the way I drive. Inow tend to have a more consistent speed driving between stoplights and I don’t accelerate or break really hard, becoming a lessaggressive driver. I also don’t charge the battery during peak usetime, saving money. It costs about $1 to $1.50 to charge thebattery.

What is the one thing I like best about the car? The quietness.It’s so quiet that sometimes I forget to turn the motor off, whichhas happened a couple of times.

In summary, I really like the car, have not had any problemswith it, it’s economic, comfortable, pleasant to drive, can goanywhere using the generator, and it has made me a more carefuldriver. Plus this year I am saving $10,000 in tax credits. Irecommend it wholeheartedly to everyone.

and other volatile organic substances are identified as new riskfactors for asthma.

• Weather conditions such as extremely dry, wet or windyweather can worsen an asthma condition.

• Effective asthma treatment includes monitoring the diseasewith a peak flow meter, identifying and avoiding allergentriggers, using drug therapies including bronchodilators andanti-inflammatory agents, and developing an emergency planfor severe attacks.

• There are two types of asthma medications: long-term controland quick-relief medications. Long-term control medicationsare preventive, taken daily to achieve and maintain control ofasthma symptoms. Quick-relief medications are used to treat

asthma attacks. They relieve symptoms rapidly and are takenon an as-needed basis.

• One of the most effective medications for controlling asthma isinhaled corticosteroids, which are anti-inflammatory medications.Taken early and as directed, these well-tolerated and safemedications can improve asthma control, normalize lungfunction, and possibly prevent irreversible injury to lung airways.

• Combination therapy (inhaled corticosteroid plus a long-acting beta2-agonist) is the preferred treatment for asthmawhen inhaled corticosteroids alone do not control the disease.

• Immunotherapy or allergy vaccinations should be considered ifasthma is triggered by exposure to unavoidable allergens, ifsymptoms occur year-round or during a majority of the year, orif it is difficult to control symptoms with medication.Sources: ACAAI website – American College of Allergy Asthma and Immunology

www.acaai.org; AAAAI website – American Academy of Allergy Asthma andImmunology www.aaaai.org; AAFA website – Allergy and Asthma Foundation ofAmerica www.aafa.org

Asthma

Continued from page 10

Marsh is sponsored by: Underwritten by:

Fresno-Madera Medical SocietyKern County Medical Society

Tulare County Medical Society


Tulare

3333 S. FairwayVisalia, CA 93277

559-627-2262Fax 559-734-0431

website: www.tcmsonline.org

TCMS OfficersGaurang Pandya, MD

President

Steve Cantrell, MDPresident-elect

Thomas Gray, MDSecretary/Treasurer

Steve Carstens, DOImmediate Past President

Board of DirectorsVirinder Bhardwaj, MDCarlos Dominguez, MD

Parul Gupta, MDMonica Manga, MD

Christopher Rodarte, MDH. Charles Wolf, 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

Sixth District CMA AlternateThomas Daglish, MD

Staff:Steve M. BeargeonExecutive Director

Francine HipskindProvider Relations

Gail LockePhysician Advocate

Thelma YearyExecutive Assistant

WE ARE HERE TO HELP AND WE ARE NOT FROM THE GOVERNMENT…

I am expected to communicate with our members as president of TCMS. Considering the task, itquickly dawned upon me that without members there is no president. All value of the Society is inour members and we on the TCMS Board have an assignment to make a difference to all themembers. We all work for you. We are at your service.

The next question I have is this, how good a job are we doing? Are we meeting your needs? Arewe available to you when you need help? Are you proud and able to ask your friend or associate tojoin the Tulare County Medical Society?

I need guidance from all of you. I wantto know your thoughts about the value ofyour membership in TCMS and CMA. Isthere anything that we can change,improve or make available to you? Pleaselet us know. Call us at 559-734-0393 andask for Gail. FAX your hand writtenquestions to: 559-334-0090 or [email protected]. Or visit us in person at3335 South Fairway, Visalia, CA 93277. Iam available to you by cell phone 559-361-2095 and by email: [email protected].

We have a dedicated physician advo -cate, Gail Locke. Gail is very personable,knowledgeable and experi enced. She isable to activate help for the members andtheir staff. When needed members canhave access to CMA staff that can help inissues like nonpayment for services, unfairutilization review practices by healthplans, Medicare etc. In fact last year CMAstaff was able to help members recoverseveral million dollars in reimbursementdue to them from health plans. Thatincludes me also.

Although it is not well publicizedCMA’s legal department is continuouslywatching out for legislation and courtcases weakening MICRA. It is true thatwithout MICRA protection, many of uswill have to close our practices. Such is thecase of Rahm vs. Kaiser Health plan. Although this is an ongoing case at this time and final case lawhas not been decided, it is very interesting to note that the trial lawyers want to have a trial by jury,in this case against Kaiser for determining punitive damages, for providing coercive inducements tophysicians of Permanente group to deny an MRI examination for a 17-year-old patient. So does thatmean that next time a health plan denies services for our patients, we will be dragged into a legaldispute? Probably not, but it could increase frequency of claims made against physicians, just in case,the trial attorney is hoping to drag health plans with deep pockets into the complaint. I am gladCMA staff is vigilant about protecting our flanks when we are busy taking care of our patients.

President’s Message

GAURANG PANDYA, MD

I would appreciate it if you let me know youropinion and priority. Please remove this page,complete the survery below and fax it to theMedical Society at 559-334-0090. Thank you foryour time.

Name

Contact Phone

Address

Email

Value Priority1=highest 1=highest

Goal 1,2,3,4,5 1,2,3,4,5ImprovePractice economicsImproveSocial opportunitiesDisaster preparednessHandle MedicareissuesIncrease our presencein community serviceBe able to teachnew residentsLeadershipopportunities at CMALegislative andpolitical actionDiscountpurchasing groupCost effective CMEOther

Please see Pandya on page 17


PO Box 1029Hanford, CA 93230

559-582-0310Fax 559-582-3581

KCMS Officers

Theresa P. Poindexter, MDPresident

Jeffrey W. Csiszar, MDPresident-elect

Mario Deguchi, MDSecretary Treasurer

Mario Deguchi, MDPast President

Board of DirectorsBradley Beard, MDJames E. Dean, MDLaura Howard, MDYing-Chien Lee, MD

Bo Lundy, MDMichael MacLein, MD

Kenny Mai, MD

CMA Delegates:Jeffrey W. Csiszar, MD

Thomas S. Enloe, Jr., MDTheresa P. Poindexter, MD

CMA Alternate Delegates:Laura L. Howard, MD

Staff:Marilyn Rush

Executive Secretary

Tulare Kings

Predictive Modeling Analysis of Medicare ClaimsProvided by Judy Cotta, Compliance and Privacy Officer

Kaweah Delta Health Care District

The Centers for Medicare & Medicaid Services (CMS), has implemented a predictive analyticssystem to analyze Medicare claims to detect potential fraudulent activity. The predictive analyticssystem uses algorithms and models to examine Medicare claims in real time to flag suspicious billing.This new process is similar to the pre-payment analysis already done by the financial and credit cardindustries. Medicare will incorporate this system into its claims payment process.

As of June 30, 2011, CMS is streaming all Medicare FFS claims through its predictive modelingtechnology. As each claim moves through the predictive modeling system, the system builds profilesof providers, networks, billing patterns, and beneficiary utilization. These profiles enable CMS tocreate risk scores to estimate the likelihood of fraud and flag potentially fraudulent claims and billingpatterns. Risk scores enable CMS to quickly identify unusual billing activity and flag claims for morethorough review prior to releasing payment. The system automatically prioritizes claims, providers,beneficiaries, and networks that are generating the most alerts and highest risk scores. CMS isleveraging the benefits of its new high-tech system to complement, not replace, the expertise of itsexperienced analysts:

Analysts review prioritized cases by closely reviewing claims histories, interviews, and performingsite visits as necessary.

If an analyst finds only innocuous billing, the outcome is recorded directly into the predictivemodeling system and the payment is released as usual. This feedback loop refines the predictivemodels and algorithms to better target truly fraudulent behavior.

Analysts who find evidence or indicators of fraud will work with the CMS Center for ProgramIntegrity, MACs, and Zone Program Integrity Contractors to enact targeted payment denials, and incases of egregious fraud, revoke Medicare billing privileges. Program integrity entities may also,as appropriate, coordinate with law enforcement officials to investigate cases for criminal or civilpenalties.

Risk scores alone do not initiate administrative action and serve only to alert CMS to thenecessity of more careful review of claims activity. While providers will be unable to appeal riskscores, CMS’s new technology will in no way alter a provider or supplier’s existing rights to appealadministrative actions or overpayment recovery efforts.

Currently, CMS is not denying claims solely based on the alerts generated by predictive models.CMS is focused on developing and refining models that identify unusual behavior without disruptingits claims processing for Medicare providers.

Working closely with clinical experts across the country and of every provider specialty, CMS isdeveloping and refining algorithms that reflect the complexities of medical treatment and billing.The new technology will ultimately benefit the program’s many honest providers and suppliers byenabling the agency to prioritize the highest-risk cases for investigation and review. Prioritizing thealerts will minimize disruption to providers who may occasionally exhibit unusual but honest billing.

Action NeededHospitals and physician providers must make a point of planning for these analytics through clean

charge capture processes and clean claim submission. While not directly a result of Medicare’sRecover Audit Contractor (RAC) and other audits taking place it provided Medicare with yetanother tool to detect improper claims submission. The best defense is to ensure your processes aredocumented and working to ensure clean and accurate claims submission. This is just another steptowards ensuring that Medicare only pays for medically necessary services.

Reference: http://cms.gov/MLNMattersArticles/Downloads/SE1133.pdf


Kern

2229 Q StreetBakersfield, CA 93301-2900

661-325-9025Fax 661-328-9372

website: www.kms.org

KCMS Officers

Joel R. Cohen, MDPresident

Wilbur Suesberry, MD President-elect

Noel Del Mundo, MDSecretary

Ronald L. Morton, MDTreasurer

Portia S. Choi, MD Immediate Past President

Board of DirectorsAlpha Anders, MDBrad Anderson, MD

Eric Boren, MDLawrence Cosner, MD

John Digges, MDJ. Michael Hewitt, MD

Calvin Kubo, MDMelissa Larsen, MDMark Nystrom, MDEdward Taylor, MD

CMA Delegates:Jennifer Abraham, MD

Eric Boren, MDJohn Digges, MD

Ronald Morton, MD

CMA Alternate Delegates:Lawrence Cosner, Jr., MD

Patrick Leung, MDMichelle Quiogue, MD

Staff:Sandi Palumbo, Executive Director

Kathy L. HughesMembership Secretary

ASTAKHOVA, Inga – 3700 Mall View Road,93306 FAX: 334-2994

BELLA, George – Delete information (pg. 71) BLACK, Jennifer – 3733 San Dimas Street,

93301 FAX: 635-3430CAMPOS, Marvin – 3501 Stockdale Hwy.,

93309 FAX: 398-5057DIGGES, John – DBP*HARMON, David – 3501 Stockdale Hwy., 93309

FAX: 398-5057JAMALUDDIN, U. – Phone: 321-4310 LOOS, Donald – Move to Retired Section –

3821 Braeburn Dr., 93306-3607MERCY HOSPITAL – Change name to Dignity

Health (Hospital Index Tab – Back) MORTON, Ronald – Email:

[email protected], Nandakumar –

[email protected], Madhavi – 3501 Stockdale Hwy.,

93309 FAX: 398-5057SMITH, Shannon – 3733 San Dimas Street,

93301 FAX: 635-3430STAIGER, Pamela – 8800 Ming Avenue, 93311

FAX: 664-3729KAISER PERMANENTE – Change the following

addresses to 2531 Chester Avenue, 93301:AUNG, Kyi – FAX: 337-7271BERTIZ, Augusto – FAX: 337-7271CHRISTOPHER, Robert – FAX: 337-7096DINH, Long – FAX: 337-7271HOFFMAN, Douglas – OTO*/HNS

FAX: 337-7258HTOO, Aung – FAX: 337-7271LEVINS, Anthony – FAX: 337-7096MIRANDA, Elva – FAX: 337-7271MIRANDA, Rodrigo – FAX: 337-7253MISHKIND, Mark – FAX: 337-7253

NALESNIK, Jeffrey – FAX: 337-7258NYSTROM, Mark – FAX: 337-7096PATEL, Umesh – FAX: 337-7271PENROSE, James – FAX: 337-7271SALES, Jonathan – FAX: 337-7253SELIGMAN, Jay – FAX: 337-7253STONE, David – HNS/FPS* - FAX: 337-7258TRAN, John – FAX: 337-7271TRAN, Tan – FAX: 337-7271VALOS, Nicholas – FAX: 337-7096YEIN, Thu – FAX: 337-7271

Organizations of InterestTab Changes, CorrectionsAMERICAN DIABETES ASSOCIATION –

Remove P.O. Box Phone: 800/342-2383 BAKERSFIELD PREGNANCY CENTER –

326-1915EMERGENCY MEDICAL SERVICES OF KERN –

1800 Mt. Vernon Ave., 93306 PH:321-3000FAX: 868-0225

KERN AUTISM NETWORK – FAX: 588-4235KERN COUNTY CORONER’S OFFICE –

FAX: 868-0149KERN COUNTY DENTAL SOCIETY –

FAX: 327-1229KERN COUNTY HEALTH DEPARTMENT –

Phone: 321-3000KERN COUNTY MENTAL HEALTH

DEPARTMENT – Phone: 800/991-5272KERN COUNTY VETERANS SERVICE

DEPARTMENT – FAX: 868-7301ODYSSEY HOSPICE – 5001 E. Commerce Dr.

#140, 93309 Phone: 324-1232FAX: 3240931

ONE LEGACY – Remove address; Phone: 800-786-4077

SOCIAL SECURITY ADMINISTRATION –Remove Haley St.; Phone: 866-476-1489


JOEL R. COHEN, MD

WE ARE THE 1%… AND WE ARE THE 99%We are the 1%. We all share the same characteristics that made us doctors - hard work,dedication, unbending focus on a goal, the pursuit of perfection in our lives and in our practices,and a strong independent streak.

We work hard, very hard and often to the point of fault. We sacrifice to serve others for a highergood. We are very diverse. But as far as I know, there is not one among us who is a Wall Street“Fat Cat.” Like me, many of us grew up on the bad side of the train tracks – absent a silver spoon.And like me, many of us worked hard to get through school and then have to pay for it for years.We are the 1% who then have suffered when these characteristics are taxed at an even higher rate.Yes, we suffer because we are the dedicated 1%.

Yet, we are also the 99% who rely on the largesse of the government to supply our daily breadand who look to bureaucratic red tape as a way of life. We need the bureaucrats to tell us how torun our offices and practices, how to treat our patients and how to hire our staff. We have come torely more and more on these bureaucrats.

Whenever they visit, we end up with a raft of new regulations to determine how we dress, howwe speak to patients, and even how much we sleep. We are the dependent 99%. All we need to do

Please see Cohen on page 17

2012 Membership Directory Changes and Corrections


Fresno-Madera

Medical Society Presents Awards at Regional Science FairThe 59th Annual Central California Regional Science, Mathematics & Engineering Fair was heldin March at the Fresno County Fairgrounds. In addition to the regular panel of judges for the entireevent, independent judges who represent government, professional and service organizations alsojudge and present awards within their specific areas. The FMMS sponsors awards related tomedicine. The event provides an educational experience and stimulates young people’s interest inscience, mathematics, computer, technology and engineering. It also provides for public recognitionfor their work.

This year, Drs. Bonna Rogers-Neufeld and Joan Rubinstein served as the judges for the MedicalSociety. This year’s winners and their projects are:Junior Division• 1st place: Vinisha Prajapati, Alta Sierra Middle School, Clovis; “Bacteria vs. Turmeric”• 2nd place: Elizabeth Schulz, Granite Ridge; “Does the type of casting material and amount ofcotton padding affect the peak temperature of a cast”

Senior Division• 1st place: Michael Brooks, Clovis East High School; “Blood Proteins TRMPI and Clusterin atminimally invasive biomarkers of AR in renal and cardiac

• 2nd place: Lindsey Greenwood, Sanger High School; “How child proof are child proof medicinebottles?”

Air Quality Award• Yousef Joseph and Nick Mah, Clovis West High School; “The efficiency of the amount of lightabsorbed by chlorophyll under various color of light”


SERGIO D. ILIC, MD

FMMS HAS BEEN BUSY

Well, March came and went by very fast. The Medical Society’s annual Yosemite PostgraduateInstitute CME conference was held March 23-25, and it was excellent. Thank you Drs. Aminian,Linder and Monteleone for the very good quality of speakers and interesting topics you brought tothe conference. It was a pity that fewer doctors attended this year. As it has been said before, this isa jewel of a conference that is held in a beautiful environment, Yosemite National Park. We arehoping more doctors, especially our local doctors, will attend next year. A big thank you goes toCarol and staff for organizing it so well.

Also in March we had the first in a series of Financial Education classes for our members. To allowfor more scheduling flexibility, the classes are repeated the last Wednesday and Thursday eveningsof the month. We had 17 people, most of them residents, which accomplishes one of our goals toteach the young doctors how to get savvy in this seemingly easy but really difficult area. Investingwisely is difficult, and many mistakes are made when we don’t have the knowledge on how to goabout it. These mistakes are costly, and in this era of diminishing reimbursements, it is of paramountimportance to invest wisely. See page 17 for this month’s topic.

Great publicity has been given to the hearings of the Affordable Care Act by the Supreme Court.Depending on what you read, the justices are going to invalidate all or part of the law or uphold it.We don’t know how the Court is going to decide, but a great deal is at stake. If the court decides thelaw is constitutional, it will have great future repercussions. It will apparently expand the power ofthe executive branch over the States. On the other hand if it’s rejected, there will be 47 millionAmericans left without health insurance. I certainly do not envy the task of the Supreme Court.

Finally, our biggest event ever is Friday, May 11. As most of you have already heard, RaymondKurzweil is going to present a talk on a very interesting and controversial topic: “2045: The Year ManBecomes Immortal.” His theory is that scientific knowledge is growing at such an exponential ratethat by 2045 we’ll have the technology to achieve this fete. Purchase your tickets or better yet a tableof 10, and bring your family and friends to hear how Mr. Kurzweil believes how this can happen.

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 Officers

Sergio Ilic, MDPresident

Ranjit Rajpal, MDPresident Elect

Prahalad Jajodia, MDVice President

Stewart Mason, MDSecretary/Treasurer

Oscar Sablan, MDPast President

Board of GovernorsA.M. Aminian, MDHemant Dhingra, MD

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

Constantine Michas, MDKhalid Rauf, MD

Rohit Sundrani, MDMohammad Sheikh, MD

CMA DelegatesFMMS President

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

Andre Minuth, MDRoydon Steinke, MDToussaint Streat, MD

CMA Alternate DelegatesFMMS President-electDon H. Gaede, MDPrahalad Jajodia, MDPeter T. Nassar, MDTrilok Puniani, MD

Dalpinder Sandu, MDSalma Simjee, MDSteven Stoltz, MDRajeev Verma, MD

CMA YPS DelegatePaul J. Grewall, MD

CMA YPS AlternateYuk-Yuen Leung, MD

CMA Trustee District VIVirgil Airola, MD

Staff:Sandi Palumbo

Executive Director


Fresno-Madera

Financial Series for FMMS MembersAs a member benefit, a series of Financial Education seminars will be offered toFMMS members and their guests during the months of May and June – repeatingin August, September, October and November. In order to allow membersattendance flexibility, the seminars will be offered twice each month – the lastWednesday and Thursday evenings at 6pm.

MAY 30 & 31, 2012 “FINANCIAL PLANNING BASICS” Presented by Eric Van Valkenburg, CLU, CHFC®.and Amy Nuttall-Zwaan,

CRPC, CSNA, Financial Consultants with Central Valley Physician Benefits. Presentation will include:• Setting financial goals, such as retirement, college and/or Estate Conservation• Building a plan around those goals• Investment Planning• Risk Management• Insurance Protection• Credit FundamentalsSeminars will be held at the Medical Society offices, 1040 E. Herndon Ave.

#101. (NE corner of First/Herndon) Space is limited, so please reserve your spot assoon as possible by contacting the Medical Society at 559-224-4224, ext. 118 or [email protected]. A light meal will be available.

Future topics: Understanding Social Security and Medicare

Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives withand securities offered through LPL Financial. Member FINRA/SIPC.

Economic Forums for FMMS MembersThe month of May will mark the start of a series of quarterly “Economic Forum”events being offered as a benefit to FMMS members and their guests. The Forumsare intended to be informative, as well as social, and each will incorporate apertinent and timely topic of interest in today’s economy. The events will behosted by Eric Van Valkenburg, CLU, ChFC® and Amy Nuttall-Zwaan, CRPC,CSNA, Financial Consultants with Central Valley Physician Benefits. EachForum will host an industry expert as the featured Guest Speaker.

The topic of May’s Economic Forum is “The State of the Health Care RealEstate Market”.

• Opportunities & Risks in today’s market;• Current Health Care industry trends;• Factors Driving Supply & Demand today;Featuring Guest Speaker, Danny Prosky*, President & COO of Griffin-

American Healthcare REIT II

Wednesday, May 16, 2012 at 6 pmThe Daily Grill (private room), Palm and Nees Avenues, Fresno

Complimentary hors d’oeuvres and drinks will be served. Space is limited soplease reserve your spot as soon as possible by contacting Central Valley PhysicianBenefits: 559-492-9592 or [email protected].

* Danny Prosky has spent the entirety of his 20-year career in the specialized field ofhealthcare real estate investment, where he has been responsible for more than 14 millionsquare feet of acquisition transactions.

Eric Van Valkenburg and Amy Nuttall-Zwaan are Registered Representatives withand securities offered through LPL Financial. Member FINRA/SIPC

At best these are changing times and by2014 we all will see changes in theprocesses by which we manage ourpatients. CMA has redesigned the websitewww.cmanet.org and I recommend that ifyou have not signed up for the web sitethen please do as soon as possible. Getyour login ID and password. If you needhelp, please let us know. We can help youget connected. It is important to beconnected. This way we can get pertinentuseful knowledge in timely manner inrapidly changing battlefield.

There are also many other benefits.Please call Gail at 559-734-0393 to findout about many local benefits for TCMSmembers.

I thank you for your membership andgiving me an opportunity to be of serviceto the Tulare County Medical Society.

Please ask your physician friends andassociates to join our local medical societyand California Medical Association.

is to look at the recent SGR “Doc” fix tounderstand that we are dependent on ourbureaucrats to stay afloat. We are clearlythe 99%. We cannot survive on our own.

The upcoming elections in June andNovember are indeed critical ones. Theywill decide if we will nurture our 1% orchoose to remain firmly entrenchedamong the 99%. Will we choose to castour lot with the bureaucrats and tax our1%, the hard working part of ourselves, inthe hope (as long as we can trustpoliticians to remain true to their word)that they will preserve our dependent99%? If we do so, can we indeed trust ourelected politicians? (think SGR “Doc” fix)

This is my final column before the nextelection. Please consider the ballotchoices and decide whether we shouldencourage and nurture the 1% or the 99%inside of us that we all share.

An old political saying is to “vote earlyand vote often.” I would recommend thatwe all vote – and vote wisely.

CohenContinued from page 15

PandyaContinued from page 13


Classifieds

MEDICAL OFFICES

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

FOR LEASE2701 16th St. – 2,400

2007 17th Street – 5,090 rsf.2031 17th Street – 1,776 sf.

4817 Centennial Plaza Way – 2,370 rsf.Crown Pointe Phase II – 2,000-9,277 rsf.

2525 Eye Street – 3,000 – 6,173 – 12,315 sf.3115 Latte Lane – 5,637 rsf.

3115 Latte Lane – 2,660-2,925 sf.Meridian Professional Center – 1,740-9,260 rsf.

3815 Mt. Vernon – 1,000 sf [MD or DDS]2204 “Q” Street – 2,894 rsf.

3941 San Dimas Street – 3,959 rsf.4040 San Dimas St. – 2,035 rsf.

9300 Stockdale Hwy. – 3,743 - 5,378 rsf.9330 Stockdale Hwy. – 1,500-7,700 rsf.

SUB-LEASE4100 Truxtun Ave. – Can Be Split

Medical Records & OfficesSprinklered – 4,764 usf. • Adm. & Billing – 6,613 rsf.

DENTAL OFFICE FOR SALE2023 Brundage Lane – 3,500 sf.

FOR SALE2007 17th Street – 5,090 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.

California Gastroenterology Associatesis announcing a change of their telephonenumber in their Fresno office. New number:559-299-9395, fax: 559-299-0400Christine Lopopolo, MD announces herboutique obstetrics and gynecology prac-tice in Fresno. Accepting new patients. Call559-261-9320.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 space 1,000sf up to 2,500sfat First & Herndon and First & Bullard,starting at $1psf++ by owner. Call 559-449-7668 or 559-284-2625.

PA or NP wanted in busy primary care work-ers comp facility. Good social skills a must.Unlimited growth, no weekends, no call.Part or full time. Contact: [email protected].

ANNOUNCEMENT

FOR RENT / LEASE

PHYSICIAN/PROVIDED WANTED

CME Activities

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.

18th Annual Hispanic Medical Conference – May 5, 2012Location: Fresno Art Museum; 7:30 am- 1:30 pm; Credit: 4 hours; Fee: $75; Contact:Yolanda at 559-266-8300 or [email protected]

7th Annual Cardiology in the Valley Symposium – May 19, 2012Location: UCSF Fresno Center; 8am–1:45 pm; Credit: 5 hours; Fee: N/C; Contact:Renee at 559-459-3872 or [email protected]

Natural Disasters & Terrorist Events – The Role of the Neurologist – May 24, 2012Location: CRMC, Sequoia East; 12-1pm; Credit: 1 hour; Fee: N/C; Contact: Virginiaat 559-459-6299 or [email protected]

Pulmonary Arterial Hypertension – State of the Art – June 20, 2012Location: Medical Society offices; 6-7pm; Credit: 1 hour; Fee: No charge; FMMSmember; Contact: 559-224-4224 x118 or [email protected]

FRESNO/MADERA

TULARE

KERN

ATL HDI 5000 Colorflow Doppler DigitalUltrasound Echo Machine with 3 Probes – L7-4, P4-2 and C5-2 – $7,500. Call 661-703-0000 or email [email protected]

FOR RENT / LEASE

IM/FP needed to join Tulare outpatient clin-ic practice. Friendly, collegial work environ-ment. Part/full time. Competitive salary/benefits – paid vacation, holidays, retire-ment, loan repayment. Send resume toCatherine.mcharry@ va.gov. or call Cathy at559-225-6100 ext. 6339.

PHYSICIAN/PROVIDED WANTED


Take a look, you might see us more clearly too.

Fresno Heart & Surgical Hospital might seem small, but big things are

happening here. Our hospital near Woodward Park consistently earns

national acclaim for clinical excellence and patient satisfaction. Our

256-slice intelligent CT scanner is one-of-a-kind in the Valley. It is lightning

fast and gives physicians clear, 3-D images with less radiation exposure

for patients and available only at Fresno Heart & Surgical Hospital.

fresnoheartandsurgical.org

We’re seeing our patientsin a whole new way

Fresno Heart & Surgical Hospital

Fresno Heart & Surgical Hospital belongs to the nonprofit Community Medical Centers network. Known for leading edge technologies, state-of-the-art facilities and top physicians, Community Medical Centers is the region’s largest health care provider.

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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

CALL 1-800-652-1051 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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Documents

Vital Signs May 2012