Vital Signs November 2012

November 2012 • Vol. 34 No. 11Official 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

November 2012 • Vool. 34 No. 11

Vital Signs

See Inside:

California Launches Health Reform Study

New Mammogram Law Explained

Infectious Disease Reporting Mandate

2 NOVEMBER 2012 / V ITAL S IGNS

S A N D I E G O

O R A N G E

L O S A N G E L E S

P A L O A L T O

S A C R A M E N T O

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CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

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VITAL S IGNS / NOVEMBER 2012 3

Official Publication of

Fresno-Madera Medical Society

Kings County Medical Society

Kern County Medical Society

Tulare County Medical Society

November 2012Vol. 34 – Number 11

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 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.

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

NEWS

HEALTH REFORM: California Launches Probe Into Health System Consolidation..........................7

INFECTIOUS DISEASE: Mandated Disease Reporting Requirements: A Road Map........................9

MAMMOGRAM UPDATE: What is This New Law About Breast Density?........................................9

CHRONIC OBSTRUCTIVE PULMONARY DISAEASE: November is National COPD Awarness Month!...10

AIR QUALITY: Driving Change: Reducing Vehicle Miles Traveled in California ..................................11

CMA Foundation Publshes 2013 Aware Provider Tool Kit ..............................................................10

32nd Annual Central Valley Cardiology Symposium..................................................................11

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

TULARE COUNTY MEDICAL SOCIETY.........................................................................................12

• November is National Healthy Skin Month

• TCMS Board of Directors Votes to Oppose Proposition 37

• Membership News

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

• President’s Message

• Membership News

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

• President’s Message

• Educational Series for FMMS members

• Walk With A Doctor Program

• Season of Light: FMMS Member Event Wednesday, December 5

Cover photography: “Autumn Duck,” Woodward Parkby Robert Bernstein, MD

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


MICHAEL J. KHOURIATTORNEY AT LAW

CRIMINAL DEFENSE.PROFESSIONAL BOARD DISCIPLINE DEFENSE.

MEDICARE AND MEDI-CAL AUDIT AND FRAUD DEFENSE.Former Deputy District Attorney

Over 30 Years ExperienceAdmitted in all California state and federal courts

Telephone: (949) 336-2433; Cell: (949) 680-63324040 BARRANCA PARKWAY, SUITE 280

IRVINE, CALIFORNIA 92604www.khourilaw.com

Law Offices ofMICHAEL J. KHOURI

CMA NEWS(Networks A, B and C). What types of products are these?Exhibit B in the Blue Shield contract identifies these networks asCommercial PPO/EPO (Blue Shield Networks A, B and C),respectively reimbursing at staggered percentages of the rates setforth in the Blue Shield Provider Allowances. Blue Shield hasadvised CMA that these three tiered networks are being offeredin anticipation of possible participation in the exchange.

CMA has been actively working with exchange stakeholdersto address significant concerns regarding the exchange graceperiod, monitoring of network adequacy and clinician-levelperformance measurement in qualified health plans offered in theexchange. More information regarding contracting withexchange plans can be found in the “Reform Essentials” sectionof the CMA’s website, www.cmanet.org/cma-reform-essentials.

Can I designate which products I am willing to participatein? Yes. Exhibit A of the new Blue Shield contract allowsphysicians to designate which products they are willing toparticipate in by product type. Additionally, a section of BlueShield’s frequently asked questions (FAQ) encourages physiciansto read Exhibit A carefully to ensure you clearly understand yourparticipation choices.

Is there a fee schedule change associated with this newcontract? While Blue Shield did update its fee schedule statewideon July 1, there is no fee schedule change associated with thisrecontracting initiative, with the exception of the DirectContract HMO Medicare product, which will be reimbursed at95 percent of the Medicare allowed amount.

What happens if I do not sign and return the agreement bythe date requested? Blue Shield has assured CMA that if aphysician chooses not to sign the new agreement, his or herparticipation status with Blue Shield will not be affected.However, you may receive a call from a Blue Shieldrepresentative if they do not receive the signed agreement by thespecified date inquiring about the status.

Physicians are encouraged to carefully review and understandthe vast range of legal and practical implications associated withthe execution of any new contract and new product types.

To assist physicians, CMA recently published an updatedanalysis of the new Blue Shield contract, which is available tomembe r s i n CMA’s o n l i n e r e s o u r c e l i b r a r y a twww.cmanet.org/resource-library.

FAQ: CAN I PROVIDE TREATMENT FOR MY FRIENDS,FAMILY MEMBERS AND COLLEAGUES?Physicians are often called upon to treat or write prescriptionsfor friends, family members, or colleagues. Although Californialaw does not specifically prohibit treating oneself or one’s familymembers, American Medical Association (AMA) policy and theCalifornia Medical Board strongly discourage the practice.California law does prohibit prescribing or administeringcontrolled substances to oneself.

AMA policy points out that treating a family member maycause the physician to lose objectivity and allow personal feelingsto unduly affect his or her professional medical judgment.Patients may feel uncomfortable disclosing sensitive informationor undergoing an intimate examination if they have a familial or


PALMETTO GBA LOSES MEDICARE MAC CONTRACTThe Centers for Medicare & Medicare Services (CMS)announced last month that Noridian Administrative Services(NAS) has been named the new Medicare AdministrativeContractor (MAC) for Medicare Parts A and B in California,Nevada and Hawaii, as well as the US territories of AmericanSamoa, Guam and the Northern Mariana Islands (Jurisdiction E,previously called Jurisdiction 1).

Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500physicians. MAC’s process Part A and Part B claims and performother critical Medicare operational functions, includingenrolling, educating and auditing Medicare providers.

It is not yet clear whether Palmetto GBA plans to appeal thedecision. If there is an appeal, the earliest the handover couldtake place would be mid-to-late 2014.

CMA will work with CMA and the new contractor to helpminimize any disruption to physicians and patients.

CMA PUBLISHES GUIDE FOR PHYSICIANSTERMINATED BY AETNA FOR OUT-OF-NETWORKREFERRALSThe California Medical Association (CMA) has received anumber of calls from physicians who have recently beenterminated from Aetna’s provider network for referring PreferredProvider Organization (PPO) patients to out-of-networkfacilities.

CMA has prepared a guide to answer questions, provideoptions and resources available to physicians who have receiveda termination notice. The toolkit is available free to members inCMA’s online resource library.

Affected physicians are also encouraged to call CMA’smember help center for assistance.

Contact: CMA member help center 800-786-4262 [email protected].

DID YOU KNOW THAT THE NEW CONTRACTSBEING OFFERED BY BLUE SHIELD MAYLOCK YOU INTO CALIFORNIA HEALTH BENEFITEXCHANGE NETWORKS?The California Medical Association (CMA) has received anumber of calls from physicians and their staff regarding the newBlue Shield contracts. As previously reported, Blue Shield isrecontracting with physicians across the state. The newagreements were rolled out in phases across a majority ofCalifornia’s counties, with doctors in Orange County receivingnotice as recently as August 23.

Below are answers to the most common questions:Why is Blue Shield asking me to sign a new agreement?

According to Blue Shield, the reason for the recontractinginitiative is twofold: 1) Blue Shield has not done a large scalerecontracting with physicians in over a decade, so the newcontracts will ensure consistency and compliance with new lawsand regulations; and 2) Blue Shield is offering various tierednetworks based on price point in anticipation of possibleparticipation in California’s Health Benefit Exchange and othernew delivery models.

The new contract includes three new product types Please see CMA News on page 6


personal relationship with the physician.Physicians may also feel obligated toprovide treatment even if they are notcomfortable doing so.

Physicians should also be aware thatsome payors limit their obligation toreimburse physicians who treat themselvesor their relatives. Medicare, for example,expressly excludes coverage for treatmentof a physician’s immediate relatives.

For more information on treatingoneself, friends or family, see CMA On-Call document #0160, “Treatment ofRelatives (or Oneself).” For informationon treating colleagues, see CMA On-Calldocument #0818 “Establishment of thePhysician-Patient Relationship.”

These documents, as well as the rest ofthe California Medical Association’shealth law library, are available free tomembers in CMA’s online resource librarya t www.cmanet .o rg / cma-on-ca l l .Nonmembers can purchase documents for$2 per page.

Contact: Melanie Neumeyer, 916-551-2872 or [email protected].

PROBLEMS GETTING PAID?The California Medical Association’sCenter for Economic Services providesdirect reimbursement assistance to CMAphysician members and their office staff.Reimbursement Help Line 888-401-5911

• One-on-one educational andreimbursement assistance tophysician members and their staff

Practice Empowerment• Tools and resources to empower

physician practices• Seminars and toolkits for physiciansand their staff

Experienced Staff• Staffed by practice management

experts with a combined experienceof over 125 years in medical practiceoperations

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

CMA NEWSContinued from page 5


H E A LT H R E F ORM

California Attorney General Kamala Harris (D) has launched abroad investigation into whether increasing consolidationamong hospitals and physician groups is leading to higher healthcare costs, the Wall Street Journal reports.

According to an estimate from the Advisory Board Company,nearly 25 percent of all specialty physicians who see patients athospitals are employed by the hospitals, up from five percent in2000. The Advisory Board Company produces CaliforniaHealthline for the California HealthCare Foundation.

Meanwhile, 40 percent of primary care physicians who seepatients at hospitals are employed by the hospitals, a rate that hasdoubled since 2000.

American Hospital Association General Counsel MelindaHatton said that hospitals are merging and employing morephysicians in an effort to increase efficiency and improve carequality, as federal regulators are pushing for more integrated care.

A 2010 study published in the journal Health Affairs foundthat health care consolidation in California led to “a definiteshift in negotiating strength toward providers, resulting in higherpayment rates in premiums.”

However, an AHA-funded evaluation of the study concludedthat the research was flawed because it relied on “anecdotalobservations” and did not adequately look into factors such asconsumer preference that might have contributed to variationsin hospital reimbursement.

Generally, acquisitions of not-for-profit hospitals in Californiamust be approved by the state attorney general’s office, and if thedeal is large enough, it must receive a federal antitrustexamination. However, hospital systems’ acquisitions ofphysician groups, particularly smaller practices, might not requirepre-review.

Although California law typically prohibits hospitals fromdirectly employing practicing physicians, doctors can beemployed by the systems’ affiliated foundations.

Richard Feinstein, director of the Federal Trade Commission’sbureau of competition, said the agency is closely monitoringhospitals’ purchases of physician groups and mergers combiningphysician practices. FTC recently has filed several lawsuits toblock hospital acquisitions.

California’s investigation, which has been under way forseveral months, is focusing on whether consolidation deals havegiven health systems enough market power to increase prices ina way that violates antitrust laws, according to individualsfamiliar with the matter.

As part of the investigation, Harris has issued subpoenas toseveral large hospital systems in California, including:

• Cottage Health System in Santa Barbara; • Dignity Health, based in San Francisco; • Scripps Health in San Diego; • Sharp HealthCare in San Diego; and • Sutter Health in Northern California.• Large health insurers in the state also have received

subpoenas, according to the sources (Mathews, Wall StreetJournal, 9/13).

Read more: http://www.californiahealthline.org/articles/2012/9/14/cal i fornia- launches-probe- into-heal th-system-consolidation.aspx#ixzz296eRRZKV

MEDICARE SPENDING CUTS TO LEADTO LOSS OF 766K HEALTH JOBS, REPORT SAYS

As many as 766,000 health care jobs will be lost by 2021 iflawmakers do not avert a two percent cut in Medicare spendingoutlined in the 2011 debt reduction agreement, according to areport by a coalition of three large medical groups, MedPageToday reports.

The report – by the American Medical Association, theAmerican Hospital Association and the American NursesAssociation – predicts that the automatic cuts, known assequestration, would cost 496,000 jobs in the first year. Job lossesin physician, dentist and other practitioner offices alone wouldexceed 40,000 in 2012, growing to nearly 62,000 by 2021,according to the report. Sequestration also would negativelyaffect other industries whose clients are in the health care sector,the report stated (Pittman, MedPage Today, 9/12).

Meanwhile, nursing homes also would be negatively affectedby the sequester, according to a press release from the Alliance forQuality Nursing Home Care. Skilled nursing facilities in Floridawould see their Medicare funding cut by $66 million, whilefacilities in Ohio and Pennsylvania would see their fundingdecline by $37.3 million and $36.9 million, respectively(Kulkarni, “Capsules,” Kaiser Health News, 9/12).

In a letter, the coalition urged Congress to take action againstthe provider cuts under the sequestration, as well as theexpiration of the sustainable growth rate formula, at which pointphysicians face a scheduled 27 percent cut to Medicarereimbursements. Both will take effect in 2013 and “devastate”health care providers and patients’ access to care, the groupswrote.

At a news conference, AMA President Jeremy Lazarus said thecuts would coincide with an anticipated influx of baby boomersin Medicare. Physician reimbursement for treating beneficiarieshas remained flat for more than a decade, while the cost of caringfor them has increased by 27 percent, he added. “Common sensetells you that this is not a good time to take a hatchet to healthcare,” he said.

AHA President Rich Umbdenstock offered severalalternatives to the Medicare payment cuts, including liabilityinsurance reform, increasing the Medicare eligibility age andreducing payments to pharmaceutical and medical devicecompanies. Although AMA has not proposed an alternative tothe cuts, the group supports alternative-payment models, Lazarussaid (MedPage Today, 9/12).

Read more: http://www.californiahealthline.org/articles/2012/9/14/medicare-spending-cuts-to-lead-to-loss-of-766k-health-jobs-report-says.aspx#ixzz296eqN4DY

California Launches Probe Into Health System Consolidation


At Kaiser Permanente Southern California, we believe our achievements are best measured by the health and wellness of the community we serve. That’s why we provide a fully integrated system of care guided by values such as integrity, quality, service and, of course, results. The advantages of working with us reach far beyond our comprehensive network of support and state-of-the-art electronic medical records system. We also offer a multi-disciplinary team approach and manage your administrative concerns.

If you would like to work with an organization that gives you the tools, resources and freedom you need to get the best outcomes possible for your patients, come to Kaiser Permanente. Per Diem opportunities offer flexible schedules as well as the chance to earn supplemental income. As for full-time opportunities, physicians have access to a compensation and benefits package that’s designed to impress you.

For consideration, please forward your CV to [email protected] or [email protected]. You may also call Natalie or Virginia at 877-608-0044. We are an AAP/EEO employer.

Full-time & Per Diem

Physician Opportunities in

Kern County-Bakersfield.

Southern California Permanente Medical Group

YOUR CAREER.YOUR LIFE.Pursue them with equal passion.

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What is This New LawAbout Breast Density?

Bonna Rogers-Neufeld, MD, FACRBreast Imager, WISH,Fresno Breast Center

The California Gov -er nor has signed SB1538 (Simitian) re -garding providingnotice to women whoundergo screeningmam mography andare determined to have dense breast tissue.This is nicknamed “Henda’s law.”

Women who are determined to haveheterogeneously dense or extremely densebreast tissue on a mammographicexamination will receive the followingnotice in the required letter sent by themammography facility;

Your mammogram shows that your breasttissue is dense. Dense breast tissue is commonand is not abnormal. However, dense breasttissue can make it harder to evaluate the resultsof your mammogram and may also beassociated with an increased risk of breastcancer.

This information about the results of yourmammogram is given to you to raise yourawareness and to inform your conversationswith your doctor. Together, you can decidewhich screening options are right for you. Areport of your results was sent to yourphysician.

Background: About two years ago, thestate of Connecticut passed a similar lawwith additional provisions that insurancecompanies pay for additional studies inpatients who have been determined tohave increased breast density. Texas,Virginia, and New York have followed withsimilar laws, but none require insurancecoverage. The theory behind this is thatincreased breast density on mammographyis associated with an increased risk forbreast cancer. Although you will hear thisrepeated over and over, especially in the laymedia, this is not a proven fact. There areconflicting reports on this issue. As recentlyas September 7, 2012, the National CancerInstitute reported a study of 9,000 breastcancer deaths. They determined there wasno correlation with breast density. What

MAMMOGRAM U PDAT E

Mandated Disease Reporting Requirements:A Road Map

Linda Louise Hill, MD, MPH

The DHS and DMV would rather have duplicate reporting than none at all.Therefore, while a loss of consciousness due to diabetes-associated hypoglycemia isreportable, the loss of consciousness from an injury-induced mild concussion is not.

Practicing physicians are mandated to report a number of conditions to their localDepartment of Health Services (DHS); the list of reportable conditions in California hasbeen recently updated and can be found at www.cdph.ca.gov/HealthInfo/Pages/ReportableDiseases.aspx. Compliance is less than ideal, despite potential sanctions againstphysicians for not reporting. Of importance to note is that some of the conditions must bereported within the hour of diagnosis, others within a day, and the rest within a week.Guidance is provided by the icons (phone, fax, etc.) that precede the diagnosis on the list.

The California Department of Public Health provides forms by County for reportingcommunicable and noncom municable diseases, and a separate form for tuberculosis use:http://www.cdph.ca.gov/HealthInfo/Documents/LHD_CD_Contact_Info.pdf. Do notassume that your laboratory will report for you; it remains the responsibility of thephysician to report these diseases to the county. The DHS would rather have duplicatesthan lapses in reporting.

The noninfectious diseases that must be reported to DHS include lapses ofconsciousness, cancers, and pesticide-related illnesses. Lead poisoning is reported bylaboratories, but DHS would welcome physician reporting as well. Compliance withreporting of non-communicable disease has been even more problematic. This is at leastpartially due to the impaired understanding of the mandate and (unfounded) concernsabout the protections afforded to reporting physicians.

The California Department of Motor Vehicles’ (DMV) reporting requirement, “everypatient 14 years of age or older, when a physician and surgeon has diagnosed a disordercharacterized by lapses of consciousness in a patient,” (dmv.ca.gov/pubs/vctop/appndxa/hlthsaf/hs103900.htm) Title 17, section 2806, describes lapses of consciousness(LOC) as those conditions that involve:

Marked reduction of alertness or responsiveness to external stimuli• Inability to perform one or more activities of daily living, or• Impaired sensory motor functions used to operate a motor vehicle.• Examples of these conditions include:• Loss of consciousness (e.g., syncope, hypoglycemia)• Seizures• Dementia, including Alzheimer’s disease and other dementias (e.g., post-CVA, brainneoplasm)

• Conditions such as sleep apnea and narcolepsy where they interfere with drivingPhysicians are protected from liability with good-faith reporting for these and other

conditions they feel interfere with safe driving. In fact, physicians have had judgmentsagainst them for failure to report when drivers with these conditions had subsequent motorvehicle crashes. Physicians do not need to report former drivers who are unlikely to driveagain (admitted to long-term care facility, severely impaired, coma, etc.), or when there isdocumentation in the chart that the patient has been reported previously and you believethey no longer operate a motor vehicle.

As stated above, non-communicable disease including, lapses of consciousness, can alsobe reported on the CMR form. The reported cases of lapses of consciousness are forwardedby the DHS to the DMV; however, simultaneous direct reporting to the DMV will result intimelier follow-up by the DMV. To report directly to the DMV, it is best to use the DMV’sRequest for Driver Reexamination (DS699), which can be found at: dmv.ca.gov/forms/ds/ds699.pdf, but faxing the CMR form, or even using office letterhead, is acceptable.

Lapses in consciousness should be reported only when associated with an event in apatient who has an underlying condition likely to impair driving. Therefore, while a loss of

I N F E C T I O US D I S E A S E

Please see Mammogram on page 18Please see Infectious Diseases on page 14


CHRON I C O BS T RUC T I V E P U LMONARY D I S E A S E

Known by many names, COPD (chronic obstructive pulmonary disease) is a seriouslung disease which is now the 3rd leading cause of death in the United States. It is oneof the nation’s largest health care concerns and is severely under-diagnosed andundertreated, according to the COPD Foundation. More than 12 million people arecurrently diagnosed with COPD and it is estimated that another 12 million may haveCOPD but not realize it; and according to the Centers for Disease Control (CDC), in2005, COPD caused an estimated 126,005 U.S. deaths in people older than 25 years

Prevention of COPD begins with reducing or eliminating smoking initiation amongteens and young adults and encouraging cessation among current smokers.Approximately 75 percent of COPD cases are attributed to cigarette smoking. You cantake an active role in talking to your patients about smoking cessation and provide themwith resources to help them. A referral to the California Smokers Helpline website at:http://www.nobutts.org/Information/p.shtml or call: 1-800-NO-BUTTS, where they willbe provided with a live person to counsel them on cessation options.

Although tobacco use is a key factor in the development and progression of COPD,asthma, exposure to air pollutants in the home and workplace, as well as genetic factorsand respiratory infections also play a role. Some of those occupational exposures are tochemical fumes, gases, vapors and dust.. If your patient works with this type of lungirritant, suggest they talk to their supervisor about the best ways to protect themselves,such as wearing a mask.

A simple Spirometry test can be used to measure pulmonary function and detectCOPD in current and former smokers aged 45 years and older, and anyone withbreathing problems due to environmental exposure to smoke or occupational pollutants.

By taking steps now and talking with your patient about smoking cessation, treatmentoptions, and symptoms such as coughing or wheezing, many of these conditions can betreated with medications. IF your patients have respiratory infections, they should betreated with antibiotics, if appropriate. Antibiotics are not recommended except for usein the treatment of bacterial infections.

Resources:For more information, go to the CMA Foundation website at: http://www.aware.md/PatientsAndConsumers/

EdMaterials.aspxThe COPD Foundation has a handy pocket guide for diagnosing and managing COPD available at:

http://www.copdfoundation.org/Resources/EducationalMaterials/ COPDPocketConsultantGuide.aspxThe CDC website has a list of estimated prevalence by industry at: http://www2a.cdc.gov/

drds/WorldReportData/FigureTableDetails.asp?FigureTableID=950&GroupRefNumber=T10-03

CMA FOUNDATION PUBLISHES2013 AWARE PROVIDER TOOL KIT The California Medical Associ ation(CMA) Foundation’s Al liance Work ingfor Antibiotic Resistance Education(AWARE) project has published its sixthannual antibiotic awareness toolkit forphysicians and other clinicians. The toolkitcontains an array of clinical resources andpatient education materials to help reduce inappropriate antibiotic use. The2013 toolkits were mailed last month to 28,000 providers. Physicians areencouraged to utilize the toolkit to educate patients about antibiotic resistance.

The toolkit can also be downloaded at www.aware.md. Physicians are also encouraged to take a brief survey to let us know what we can

do to improve future versions of the toolkit. To take the survey, please visit: http://www.zoomerang.com/Survey/WEB22

GHRJXVCQ4.

November is National COPD Awareness Month!

SAVE THE DATE:April 12-14, 2013

2013 YosemitePostgraduateInstitute

Yosemite National ParkInformation: [email protected]

or 559-224-4224x 118


Senate Bill (SB) 375, adopted in 2008, calls on regionaltransportation planning agencies and local governments todevelop strategies for reducing greenhouse gas emissions frompassenger vehicles by reducing per capita vehicle miles traveled(VMT). Three specific strategies, traditionally used to reducetraffic congestion and improve air quality, are to be employed tohelp reduce emissions:

• Higher-density development, particularly in areas well-served by transit;

• Investments in alternatives to solo driving, such as transit,biking, walking, and carpooling; and

• Pricing policies that raise the cost of driving and parking.Although SB 375 is expected to reduce emissions only

modestly relative to vehicle efficiency standards and low-carbonfuels, it is also expected to improve public health and reduceenergy and water use by encouraging denser development andmore “livable” communities. The integration of these threeapproaches is consistent with an emerging research consensusthat policies integrating all three strategies have a much greaterchance of reducing VMT than any one approach on its own. Thisreport reviews the opportunities and challenges of each of thesestrategies and assesses California’s recent experience and futureprospects for successfully integrating them.

On balance, California has started with the right approach byattempting to integrate its emission-reduction policies. However,recent experiences within the state and elsewhere have revealednumerous challenges – some quite formidable. On the plus side,more local governments are undertaking climate changeactivities, and many local planners see significant potential forreducing VMT, especially in localities that have experience inimplementing these strategies and in more populous areas of thestate. Also, planners are beginning to recognize the importance ofusing multiple approaches. And transit ridership in California isincreasing, with recent transit investments appropriately directedtoward higher-density areas.

But red flags abound, potentially limiting California’s ability toreduce VMT. Employment density (the number of jobs per squaremile) is low and declining, and employment density matters more

than residential den -sity for encouragingtransit use as an alter -native to driving.Further more, majortransit investmentssince the early 1990shave not produced anoverall reduction inVMT, and densitiesaround new stationshave not increased.The vast majority ofcommuters still drive

to work, even if they live or work near a transit station. Andplanners are skeptical about pricing policies – a key componentof integrated strategies – especially in localities with higher-income households, which tend to be less sensitive to changes inthe cost of driving and parking. Finally, funding transitinvestments and operations remains a perennial challenge.

If California is to make the most of SB 375, several prioritiesrequire attention. Regions and localities should encouragegreater commercial (that is, nonresidential) development aroundtransit stations. Pricing policies need to accompany land use andtransportation strategies, despite public resistance. State orfederal leaders need to raise general road use fees (either thetraditional gas tax or a new VMT-based fee), both to provideincentives to reduce driving and to help fill the widening gap intransportation funding. And, finally, regional strategies mustrecognize the wide variation in attitudes and conditions amonglocalities and address the lack of coordination (even amongtransit systems within the same region) that exists today.

This report is based on reviews of the research literature, our survey of localgovernments and planning agencies, and our analysis of population, employment, andtransportation data. The report draws heavily on two companion papers: “Views fromthe Street” (Bedsworth, Hanak, and Stryjewski 2011) and “Making the Most ofTransit” (Kolko 2011). To find these and other related resources, please visit the report’spublication page: http://www.ppic.org/main/publication.asp?i=948

Driving Change: Reducing Vehicle Miles Traveled in CaliforniaLouise Bedsworth, Ellen Hanak, Jed Kolko

with research support from Marisol Cuellar Mejia, Davin Reed, Eliot Rose, Eric Schiff,Elizabeth Stryjewski, and Maggie Witt

Supported with funding from The William and Flora Hewlett Foundation and the David A. Coulter Family Foundation

A I R Q U A L I T Y

James A. Sugar/National Geographc/Getty Images

SPEAKERS AND TOPICS:Gabriel S. Aldea, MD, FAHA, Section Chief, Univ. of WashingtonEzra A. Amsterdam, MD, FACC, Professor, Univ. of Calif., Davis

Roger A. Winkle, MD, FACC, Silicon Valley Cardiology Medical Group• Endovascular Treatment of Thoracic and Abdominal Aortic Aneurysms• Ischemic Heart Disease in Women: Diagnostic Approaches and Management• (TAVR) Percutaneous Aortic Valve Replacement in High Risk Patients with Aortic Stenosis • Current, Evolving and Futuristic Therapies for Management of Atrial Fibrillation• Management of Ventricular Arrhythmias, including breakthrough Vent Arrhythmias in patients with ICD• Appropriate Triage of Chest Pain in the ED: who to refer for workup, testing and who can be sent home

INFORMATION: 559-224-4224 x 118 or [email protected]

32nd AnnualCentral ValleyCardiologySymposium

November 10, 2012Madera Municipal

Golf Center8:00am-3:30 pm


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

Thelma YearyExecutive Assistant

Dana RamosAdministrative Assistant

November is National Healthy Skin MonthDr. Betsy McCarley Billy, Dermatologist

McCarley Dermaspa of Visalia

FOOD FOR THOUGHT (AND SKIN)The incidence of melanoma and non-melanoma is increasing in the UnitedStates, especially among young adults. There are an estimated 2.8 million newcases of basal cell cancer, 700,000 of squamous cell cancer and 120,000 ofmelanoma each year in the general population. More importantly, recent studiesshow that melanoma among people aged 18-39 has climbed by 800 percent inwomen and 400 percent in men over the past 40 years. Indoor tanning, popularamong women, is thought to perhaps be to blame. Known risk factors for skincancers include UV radiation from the sun and tanning beds, skin type, hair andeye color, number of moles, use of sunscreen and family history. UV light is the main risk factor anda potent carcinogen for the development of skin cancer. UV light produces toxic substances in theskin known as free radicals. It has been suggested that up to 50 percent of UV skin damage is causedby free-radical formation that damages cellular DNA. Our bodies use antioxidants to neutralize theeffects of free radical damage. Humans produce endogenous free radicals, but also ingest them in fruitsand vegetables.

While the risk factors listed above are well recognized, the lack of a nutritious diet containingantioxidants may also be a risk. With the exception of Vitamin D, studies have not supported the useof isolated vitamins or minerals in pill form. However, studies centered on whole foods have beenpromising. An Australian study showed that in patients with a history skin cancer that the ingestionof green leafy vegetables decreased the incidence of squamous cell cancers while a high intake ofunmodified dairy increased it.1 Furthermore, pre-skin cancers known as actinic keratosis are known tobe reduced when patients adhere to a low fat diet.2 Diets rich in long chained fatty acids and saturatedfats are known to produce inflammation via production of free radicals. Inflammation is thought tobe the basis for all sorts of diseases including diabetes, coronary artery disease and cancer (NIHwebsite).

If UV light is the bad initiator of DNA change and free radicals found in fruits and vegetables arethe good antidotes, the American teenager is getting the bad and no good. At the same time we arewitnessing a dramatic rise in melanoma among the young, we have seen a similar shift in theAmerican diet. One hundred years ago, the American family ate freshly cooked foods from the localgarden. Today nutritious high-fiber foods represent only 24 percent of our daily calories, while fat andsugar intake have increased by 250 percemt!

Dermatologists recommend staying out of the sun between 10:00am and 2:00pm, wearing sunprotective clothing, adequate sunscreen, and UV protective sunglasses. Avoidance of tanning bedsand routine skin exams are encouraged. Consider adding to that list the ingestion of 7-10 servings offruits and vegetables daily as recommended by the FDA. Your daily dose of antioxidants in wholefoods may be the best defense you have.1. Hughes MC, van der Pols JC, et al. Food intake and risk of squamous cell carcinoma of the skin in a community: TheNambour skin cancer cohort study. Inter Jour of Cancer. 2006;119;1953-1960.2. Black HS, Herd JA, et all. Effect of a low-fat diet on the incidence of actinic keratosis. N Engl J Med. 1994; 330:1272-1275.

TCMS BOARD OF DIRECTORS VOTES TO OPPOSE PROPOSITION 37At the September meeting of the Board of Directors the Board voted to oppose Proposition 37,the Mandatory Labeling of Genetically Engineered Food Initiative. There was significantdiscussion by the Board members over the issue along with the medical students who attend andparticipate.

M E D I C A L C E N T E R SCommunity

Winter CME Symposium 2013“The Pursuit of Excellence”

Paul B. Ginsburg PhDPresident, Center for Studying Health System Change; nationally known economist and health policy expert; prior to founding Health System Change (HSC), Ginsburg was the founding Executive Director of Physician Payment Review Commission and was Deputy Assistant Director of the Congressional Budget Office; consultant to the Bipartisan Policy CenterTOPIC: “Healthcare 2013: Report from National Center

for Studying Health System Change"

Donald Goldmann MDSenior Vice President,Institute for Healthcare Improvement (IHI), responsible for training IHI’s innovation, research and evaluation programs; Clinical Staff, Infectious Disease at Boston Children’s Hospital; Clinical Professor Pediatrics of Harvard Medical School; Professor of Immunology and Infectious Diseases at Harvard School of Public Health

TOPIC: “The Science of Quality Improvement: Developing Evidence for What Really Works”

W. Gregory Feero MD, PhDFormer Senior Advisor to the Director, National Human Genome Research Institute, National Institutes of Health; Contributing Editor, Journal of the American Medical Association; Faculty at Dartmouth-Maine

TOPIC: “Moving Genomic Medicine into the Doctor’s Office”

Richard “Chip" Davis PhDPresident, Sibley Memorial HospitalJohns Hopkins Medicine; established Johns Hopkins Medicine Center for Innovation; professor Johns Hopkins University’s Carey School of Business

TOPIC: “Johns Hopkins: Changing the Way we Care(the Johns Hopkins Journey of Achieving Unprecedented Levels of Quality & Safety)”

Joanne M. Conroy MDChief Health Care Officer, Association of American Medical Colleges; was Chief Medical Officer of Atlantic Health Systems

TOPIC: “Academic Hospitals and Physician Training in the World of Health Care Reform: An Update"

Eric Coleman MD, MPHProfessor of Medicine, Head of Division of Health Care, Policy & Research; Director Care Transitions Program, University of Colorado; Teaching Faculty, Institute of Health Improvement (IHI); recently awarded 2012 MacArthur Foundation Fellow “Genius Grant”

TOPIC: “Innovative Models: What Will It Take to EnsureHigh Quality for Patients' Transitions of Care"

February 6-10, 2013 [Wednesday-Sunday]2013 Winter Symposium Speakers Scheduled to Appear

Thomas J. Graham MDChief Innovation Officer, Justice Family Chairin Medical Innovations; Vice Chair, Department of Orthopaedic Surgery, Cleveland Clinic; Associate Professor, Orthopaedic and Plastic Surgery, Johns Hopkins; Director, Curtis National Hand Center, Baltimore, Maryland

TOPIC: “Great Expectations – Medical Innovationat Cleveland Clinic"

Paul Grundy MD, MPH, FACOEM, FACPMGlobal Director, IBM Healthcare Transformation;his work has been reported widely in the New York Times, BusinessWeek, The Economist, New England Journal of Medicine and newspapers andtelevision around the country

TOPIC: “Transforming Health Care Delivery:Creating the Patient-CenteredMedical Model”

Brent C. James MD, MStatChief Quality Officer and Executive Director,Institute for Health Care Delivery ResearchIntermountain Healthcare; holds faculty appointments at University of Utah School of Medicine, Family Medicine and Biomedical Informatics; Harvard School of Public Health, Health Policy and Management; and University of Sydney, Australia, School of Public Health TOPIC: “The Health Reform Debate Has

Overlooked the Physician-Patient Dynamic”

Steven T. Valentine MPAPresident, The Camden Group (a national healthcare management consulting company)and a nationally recognized author andspeaker on healthcare issues

TOPIC: “10 Healthcare Trends for 2013"

Glenn D. Steele Jr. MD, PhDPresident & CEO, Geisinger Health System; Past Chairman of the American Board of Surgery; serves on the medical board of numerous prominent medical journals; a prolific writer, he is the author or co-author of more than 460 scientific and professional articles

TOPIC: “Excellence in an Integrated Health System: Things Geisinger Has Learned Along The Way"

at theLAS VEGAS

HISTORICALSPOTLIGHT

Captain Chesley B. (Sully)Sullenberger, III

“Miracle on the Hudson”

SPACE IS LIMITED. NO TUITION FEE.

PLAN NOW

TO ATTEND!

For information/details, please contact: Group-discount hotel rooms are available.We encourage you to learn more and register online at: www.wintersymposium.com


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

CMA President-Elect Speaks to MembershipPaul Phinney, MD was the special guest at the Tulare County Medical SocietyGeneral Membership Meeting on September 13, 2012 at the Visalia Country Club.Dr. Phinney spoke about the upcoming year and the priority issues that theCalifornia Medical Association would focus on in the upcoming year on both theState and National level.

In California the Health Care Exchange created by the Affordable Care Actwill significantly transform the manner in which health insurance is purchased byseveral million Californians. CMA continues to advocate for quality health careplans that provide patient access to their medical providers. Dr. Phinney spokeabout the scope of practice and MICRA legislation that could be put before the legislature.

Dr. Phinney reported that both CMA and AMA have led the discussion regarding the ongoingMedicare fee schedule reductions that have been kicked down the road for more than ten years byCongress. Currently the SGR formula calls for a 30 percent reduction in physician fees. However, withthe ongoing Federal Budget issues before Congress, organized medicine needs to be at the forefront ofthe discussion and be proactive in Washington.

It was an informative evening that was enjoyed by over eighty physicians and their guests.

Paul Phinney, MD

consciousness due to diabetes-associated hypo -glycemia is reportable, the loss of consciousnessfrom an injury-induced mild concussion is not.Narcolepsy associated with somnolence duringdriving is reportable, but recumbent-onlyassociated sleep apnea is not. Even milddementia is reportable, but confusion post-operative is not.

The development of a reporting system andwritten protocols will improve compliance inyour institution. The physician making thediagnosis is responsible for the reporting,whether in the emergency department oroffice. However, do not assume that anotherphysician has reported, unless there is writtendocumentation in the chart. Again, the DHSand DMV would rather have duplicatereporting than none at all. For example, if yourepileptic patient had a seizure, was brought tothe emergency department, and follows upwith you the next week, you should report theincident if you don’t see documentation ofreporting in the emergency departmentrecords. Similarly, if a patient with dementiatransfers to your care, you must report them tothe DHS unless the prior records reflectnotification in your state.

As mandated reporters, we are required toreport lapses of consciousness, but we canreassure our patients that this does not equalthe loss of one’s driving privilege, as only the

Infectious Diseases

Continued from page 9

DMV is authorized to make this determination.The DMV wants to hear about all reportableLOC, but makes a decision on each driver afterconducting a thorough investigation that willinclude additional medical information, usuallyobtained through DMV form DS 326 (dmv.ca.gov/forms/ ds/ds326.pdf), and may include inter -views, vision and written exams, and on-the-road testing. In patients with mild dementia, forexample, the DMV may determine that they aresafe to continue driving for an abbreviatedperiod of time, with close monitoring.

Identification of age-related driving dis ordersincludes the screening and diagnosis of lapses ofconsciousness, frailty, vision deficits, and othermedical conditions (e.g., use of medications thatimpair cognition) that in fluence driving abilities.AMA has provided guidelines for screen ing atwww.ama-assn.org/ama/pub/physician-resources/public-health/ promoting-healthy-li festyles/geriatric-health/older-driver-safety/assessing-counseling-older-drivers.page.Of the disorders identified through thisscreening, only lapses of consciousness requirereporting. Keeping our patients and the publicsafe requires attention to driving safety,including compliance with non-communicable-disease mandated report ing laws. Moreinformation on the physician’s role in olderdriver safety can be found on the TREDSwebsite, treds.ucsd.edu.

Dr. Hill is a Professor in the Department of Family and

Preventive Medicine at UCSD, Director of the UCSD/SDSU

General Preventive Medicine Residency, and the Director of

TREDS (Training, Research, and Education for Driving Safety).


The following physicians’ names, etc. are beingpublished in compliance with the KCMSConstitution & Bylaws. Board Certification willbe listed only if the physician has been certifiedby a Specialty Board recognized by theAmerican Board of Medical Specialists, asapproved by the American Medical Association.

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

STAY CALM AND CARRY ON…By the time this column is published, the November elections will be history and everything thatfollows will be in the future. By now, we will have a better idea of what to expect in the near termfuture. We may have higher taxes at both a state and federal level. We may have more regulation andscrutiny of our practices and of our lives. We may have severely restricted choices both in medicineand in finances.

Whatever the outcome of the election, it is clear that, just as our European allies said in pastgenerations, we must “stay calm and carry on.”

No matter the policy changes that are coming, we can help one another to carry on. There aremany ways to do this. Of course, the first is to join the local medical society. Take advantage of theopportunity they provide for society and education and potentially significant cost and practicesavings. In addition, we can support one another professionally, we can mentor the upcominggeneration of health care professionals, doctors and nurses and those who work with us in medicine.

January is the official month of the mentor. We can mentor each other by providing advice andhelp with new procedures, coding and the like. We can all learn from one another’s experience withthe electronic health records.

We can mentor the next generation – this is how medicine will “carry on.” There is a tradition ofteaching and mentoring going back thousands of years to Hippocrates. We owe it to ourselves and ourloved ones to insure that the doctors taking care of us, in our old age, are well trained, well mentoredand well learned.

There are formal mentoring programs and informal ones. Some of the formal ones are organizedthrough local schools and churches and typically supported by medical practices or organizations. Theones that I am most familiar with are the Medical Academy at Stockdale High School andHippocrates Circle in Kaiser-Permanente. I know from discussions in the community that there aremany, many others. Residents and medical students spend time at our local county hospital. Nursingstudents rotate through our hospitals and practices all the time. Give a hand… get involved!

By becoming and staying connected, as a profession, we will manage to stay calm and to carry on.

President’s Message

JOEL R. COHEN, MD

OCTOBER 2012Active.............................................................246Resident Active Members .................................2Active/65+/1-20hr .............................................5Active/Hship/1/2 Hship.....................................0Government Employed......................................7Multiple memberships........................................1Retired..............................................................58Total...............................................................319New members, pending dues .............................3New members, pending application ..................1Total Members ..............................................323

Membership Recap

Luis F. Lopez, MD (Obstetrics/Gynecology)San Dimas Medical Group300 Old River Road Ste 200, 93311-9506661-663-4800 / FAX: 661-663-4871Medical Degree: U of Columbia 1992Residency: U of Puerto Rico 1996-2000Board Certified: Obstetrics/Gynecology 2007

New MemberMEMBERSHIP NEWS


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 PalumboExecutive Director

President’s Message

SERGIO D. ILIC, MD

IS PRIVATE PRACTICE DISAPPEARING?

I believe that one of the unintended or perhaps “intended” consequence of the Health Care Reform(HCR) is that solo or small group (3 to 5) medical practices are going to disappear. The trend isalready going down, according to the accounting firm Accenture. In 2000, 57 percemt of graduatingphysicians were going to open small private offices. By 2013 only 33% are projected to own their ownpractices.

The reasons for this are multiple. More doctors want to work from 9 to 5 and be employees,especially female doctors who want more of a family life, and there is more financial security withbeing employed. But one loses independence, and the relationship with patients becomes differentbecause they don’t see the same doctor each time.

Doctors who own their practices are also small business owners, and these practices employhundreds of thousands of people. A study conducted by a county medical society in the State of NewYork, showed that private physician practices were the fifth largest employer in the county, second inbusiness establishments, third in personal income taxes paid and seventh in corporate sales taxes.Private practice is a significant economic engine employing vast numbers of people and supportinggovernment services by paying significant amount of taxes.

Private practice is also disappearing because of the increasing administrative and regulatoryburdens, decreasing reimbursements, the need for huge monetary outlays for technologyimprovements and other increasing costs along with the uncertainty about future potential earnings.(Excerpts taken from AAOS NOW, Sept. 2012)

I feel that private practice is extremely important and is the basis in which this country deliversgreat medical care. Changes need to be made to the HCR so private practice doesn’t disappearcompletely. It needs to be protected.

As I mentioned in my October President’s message, Health Saving Accounts need to be reinstatedand promoted. These accounts put the patient in charge of their medical care and makes them moreresponsible for the money being spent and how. It is their own money. They pay the doctor, thehospital and all medical bills. Then they may not insist on unnecessary tests, MRI’s, etc because theyare expensive.

We need to have a system in which all the players are responsible for the money spent. I feel thiswould bring medical care costs down – not socialized medical care.

Fresno-Madera

SAVE THE DATEGeneral Membership Meeting

2012 INSTALLATION & AWARDS BANQUETWednesday, November 7, 2012 • 6pm

Roger Rocka’s Dinner Theater

Featuring:• Installation: 2013 FMMS President Ranjit Rajpal, MD• Honoring: 2012 Physician Lifetime Community Service Awardrecipients John Bonner, MD and Joan Voris, MD

• Benefitting: FMMS Foundation

$60 open seating – includes dinner and showSponsorship opportunities: Contact [email protected]


Educational Seriesfor FMMS MembersNOVEMBER 28 & 296-7:30PM:“UNDERSTANDING SOCIALSECURITY BENEFITS” This presentation will include:

• The history and benefits pro -vided by Social Security

• Explanations of full retirementage, primary insurance amountand eligibility

• Strategies for optimizing SocialSecurity benefits

• Issues related to the taxation ofbenefits

Seminars are held at the MedicalSociety offices, 1040 E. Herndon Ave.#101 (NE corner of First/Herndon).Space is limited; RSVP to the MedicalSociety, 559-224-4224, ext. 118 or to:[email protected]. A light meal will beavailable.

Eric Van Valkenburg and Amy Nuttall-Zwaan

are Registered Representa tives with and securities

offered through LPL Financial. Member

FINRA/SIPC.

Fresno-Madera

‘Walk With ADoc’ Take AStep TowardsA Healthier You!The Fresno-Madera MedicalSociety has started a local “Walkwith a Doc” Program, encour -aging people to get out and walkwith a physician. Walks are heldon Saturday mornings for aboutan hour each, starting with aphysician giving a quick 5-10minute talk about healthy living. These FREE and FUN walks are for anyone interestedin taking steps to better their health.

WALKERS: Everyone is invited to join us on our Saturday walks for some fresh air,fun and fitness. All you need to do is lace up a pair of comfortable shoes. For moreinformation, times and locations, visit www.fmms.org or e-mail us [email protected].

VOLUNTEERS: Physician walk leaders and program volunteers are needed.Physician walk leaders and program volunteers must be energetic, enjoy meeting andmotivating people and most importantly, enjoy walking and the benefits associated withit. Physician walk leaders and program volunteer roles include: 1) working with theprogram team to plan the dates and locations of the regular short, safe and friendlywalks; 2) helping promote the Walk with a Doc Program to local people andcommunities and; 3) supporting your fellow volunteers and any new Walk Leaders. Tovolunteer, please contact Sandi Palumbo at spalumbo@ fmms.org, email [email protected] or call the FMMS office 559-224-4224.

FMMS kicked-off the event on Saturday, October 27 at Fresno City College RatcliffeStadium.FUTURE DATES AND LOCATION:NOVEMBER 17 AND DECEMBER 15, WOODWARD PARK.

Holiday Traditions: Their Connections to the SkyDowning Planetarium • Wednesday, December 5, 2012

This family-oriented program focuses on winter holiday traditions from manycultures and how they have been used for millennia to light up this darkest andcoldest of seasons. It showcases customs, highlights some of the winterconstellations, demonstrates the cause of the four seasons and the meaning ofthe winter solstice. This exclusive FMMS showing is at the Downing Planetarium,a 74-seat Star Theater under a 30-foot hemispherical dome located on the CSUFresno campus. Celebrate the holidays by spending a relaxing and educational-filled evening learning the history and development of many of the world’sDecember holiday customs. This show is designed for audiences grade K to adult.

Doors Open: 6:30 pm • Show time: 7:00 pm • Star Gazing: 8:15 pm (weather permitting)Cost: No Charge FMMS member • $6 non-FMMS member

Tickets & parking passes held at door • Confirmation & directions will be emailedNo food or drinks allowed in theater • Information: 224-4224 x 118/[email protected]

***Limited Seating = must RSVP to attend


Classifieds

MEDICAL OFFICES

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

FOR LEASE2701 16th St. – 2,400

2005 17th St. – 2,955 sf.Crown Pointe Phase II – 2,000-9,277 rsf.

3115 Latte Lane – 5,637 rsf.3115 Latte Lane – 2,660-2,925 sf.

Meridian Professional Center – 1,740-9,260 rsf.2204 “Q” Street – 3,200 rsf.

4040 San Dimas St. – 2,035 rsf.9300 Stockdale Hwy. – 3,743 - 5,378 rsf.9330 Stockdale Hwy. – 1,500-7,700 rsf.

1919 Truxtun Ave. – 2,080 sf.

SUB-LEASE4100 Truxtun Ave. – Can Be Split

Medical Records & OfficesSprinklered – 4,764 usf.

Adm. & Billing – 6,613 rsf.FOR SALE

1911 17th Street – 2,376 sf.Crown Pointe Phase II – 2,000-9,277 rsf.

Meridian Professional Center – 1,740-9,260 rsf.9900 Stockdale Hwy. – 4,000 rsf.

Naeem Akhtar, MD, Ambreen Khurshid,MD and Mikhail Alper, PA-C at CaliforniaGastroenterology Associates arepleased to welcome Carlos C. Hernandez,MD to their practice. For appts. Call 559-299-9395University Psychiatry Clinic: A slidingfee scale clinic operated by the UCSFFresno Dept. of Psychiatry at CRMC M-F8am-5 pm. Call 559-320-0580.

Medical office space. 850-3500 sf at ValleyMedical Plaza at Herndon, near SAMC.Rates starting at $1 sf, no triple net. Tenantimprovements available. Call Brian at 559-281-1500FresnoTimeshare. Newly renovated fur-nished office in medical complex. Includesinternet. No minimum. Reasonable [email protected]

2,466 sf medical/dental office at 924Emily Way, Madera. $400,000 or for leaseat 50¢ sf. Contact Brett Visintainer at 559-447-6265 or [email protected]

ANNOUNCEMENT

FOR RENT / LEASE

FOR SALE

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/3lines* $30. *Three lines are approximately 40to 45 characters per line. Additional words are$1 per word. Contact the Society’s PublicAffairs Department, 559-224-4224, Ext. 118.

3,400 sq.ft. spaceSuitable for a Physical Therapy or

Individual practice; may be divided & remodeled to suit

Excellent parking andclose to St. Agnes Medical Center

Carl Abercrombie559-227-4658

c: 559-970-9035Jim Abercrombie

530-626-0321

Professional/Medical Office for LeaseCambridge Court

6335 N. Fresno Street, Fresno

NEWLYREMODELED1,200sq.ft. officewith fiveexam rooms

FRESNO/MADERA

TULARE

KERN

Cardiology practice in Bakersfield closingSept. 15. All office furnishing, supplies andequipment for sale. Call for specifics andarrangement: 661-323-5976.

FOR SALE

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

FT opening for MD in busy practice inVisalia. Offering full benefit package andmore. Contact Rhonda: 559-627-2333 [email protected].

PHYSICIAN/PROVIDED WANTED

FOR RENT / LEASE

is accepted as fact is that it is more difficultto detect cancers in a dense breast.

Starting April 1, 2013, all mammo -graphic facilities must include the exactwording in the patient notification lettersin patients with dense breasts. These lettershave been required of breast facilities since1994 under federal law, the MQSA(Mammography Quality Standards Act).

This law puts the burden for thediscussion on the primary care provider.And with any discussion with the patient,it should be documented, although there isno requirement for this in the law.However, without your documentation,you will have no proof you had thediscussion. What isn’t said in the Californialaw, but is implied, and thoroughlydiscussed in the media, is that thosepatients with dense breast may benefit fromsupplemental studies or screening. Thedesignation for the breast tissue density iscontained in the mammography report.The website that the public is directed to isAreYouDense.org. This might be a goodplace to review. Information is alsoavailable at MammographySavesLives.organd a San Francisco Chronicle articlehttp://www.sfgate.com/ health/article/Law-may-encourage- mammogram-alternatives-3901022.php

Supplemental imaging tests mightinclude:

• Bilateral screening ultrasound• MRI of the breasts• 3-D Mammography (also known as

tomosynthesis)Although the intent of the law was not

to set forth a new standard of care, the legalopinion of the Society of Breast Imagingwas follows: “While the motivation behindHenda’s Law was a noble one, legislatorsdid not sufficiently appreciate the practicaland legal challenges of its implementation.At this early stage, we can only speculate asto the extent of malpractice liability it hascreated. But we can be fairly certain that ithas given the plaintiff’s attorneys anotherarrow in their quiver.”

For additional information regardingthis issue, please e-mail the author [email protected].

Mammogram

Continued from page 14

time for the Societies’ sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-

pocket expense of regular dental care.

This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Following are many valuable benefits

that can save you money:

per person for dental care, using network providers ($1,500 if you use non-network providers).

members may join as an individual or as a group with your employees.

per person ($100 per calendar year maximum for families).

on oral exams, x-rays and routine cleanings.

To be eligible for coverage, applications must be received during the special open enrollment period ending on

January 1, 2013.

Call a Client Service Representative at for more information. Or visit to download a brochure and application.

Sponsored by:

Underwritten by: (IL) - First Commonwealth Insurance Company, (MO) - First Commonwealth of Missouri, (IN) - First Commonwealth Limited Health Services Corporation, (MI) - First Commonwealth Inc., (CA) - Managed Dental Care,

(TX) - Managed DentalGuard, Inc. (DHMO), (NJ) - Managed Dental Guard, Inc., (FL, NY) - The Guardian Life Insurance Company of America. All First Commonwealth, Managed DentalGuard, Inc. and Managed Dental Care entities

referenced are wholly-owned subsidiaries of The Guardian Life Insurance Company of America. Products are not available in all states. Limitations and exclusions apply. Plan documents are the �nal arbiter of coverage.

56397 ©Seabury & Smith, Inc. 2012

AR Ins. Lic. #245544 • CA Ins. Lic. #0633005d/b/a in CA Seabury & Smith Insurance Program Management

777 South Figueroa Street, Los Angeles, C

Underwritten by:

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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