March 2014 by Fresno Madera Medical Society

Official Magazine of FRESNO COUNTY Fresno-Madera Medical Society KERN COUNTY Kern County Medical Society KINGS COUNTY Kings County Medical Society MADERA COUNTY Fresno-Madera Medical Society TULARE COUNTY Tulare County Medical Society

Vital Signs

March 2013 â&#x20AC;˘ Vol. V l. 35 No. 3 Vo

See Inside: SGR Repeal and Medicare Modernization Act Surviving the Second Month of Covered California Blue Shield Exchange / Off-Exchange Plans Confusion

We Celebrate Excellence – James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

800-252-7706 www.CAPphysicians.com

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MARCH 2014 / VITAL SIGNS

Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society March 2014 Vol. 36 – Number 3

Contents EDITORIAL.................................................................................................................................5 CMA NEWS................................................................................................................................7 NEWS

CMA EDUCATION SERIES.........................................................................................................8

MEDICARE: SBR Repeal of Medicare Modernization Act.............................................................9

AFFORDABLE HEALTHCARE ACT: Surviving the Second Month of Covered California...................11

2014 Yosemite Postgraduate Institute: March 28-30...............................................................19

CLASSIFIEDS..........................................................................................................................18 Managing Editor Carol Rau Yrulegui Fresno-Madera Medical Society Editorial Committee Virgil M. Airola, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD

TULARE County Medical SocieTY.......................................................................................12

• Individual Health Insurance Plans 2014 and Beyond

• MGMA: Physician Practices

• Walk With A Doc

Kern County Medical Society...........................................................................................14

• President’s Message

• National Kidney Month

Kings Representative TBD

• New Member

• Membership Recap

Kern Representative John L. Digges, MD

Fresno-Madera Medical Society......................................................................................16

Tulare Representative Thelma Yeary

Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medi cal Society, PO Box 28337, Fresno, CA 93729-8337. Advertising Contact: Display: Annette Paxton, 559-454-9331 apaxton@cvip.net Classified: Carol Rau Yrulegui 559-224-4224, ext. 118 csrau@fmms.org

• President’s Message

• FMMS Member Bonna Rogers-Neufeld Appointed to State Post

• In Memoriam: Bernard Freeburg, MD

• Be Sure to Purchase your 2014 FMMS Pictorial Directory

• Dramatic Increase in Fresno County Pertussis Cases

• Walk With A Doc

Cover Photograph: “ Water Lily” By Robert Bernstein, MD Golden Gate Park Arboretum, San Francisco Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118. MARCH 2014 / VITAL SIGNS

How Successful Is Your Practice? Let physician members know your practice is available for referrals Use Vital Signs to advertise your practice at special rates offered to member physicians. contact: Annette Paxton Vital Signs Advertising Representative (559) 454-9331

MARCH 2014 / VITALâ&#x20AC;&#x2C6;SIGNS

EDITORIAL

Private Practice Sergio Ilic, MD President 2012 Fresno-Madera Medical Society

Until now, the way we deliver care in the USA has been predominantly through private practice. The cost of providing care for the American people is nearing $3 trillion per year and rising. The cost is becoming unsustainable, and therefore the efforts to limit it is increasing. In addition, there are a great number of uninsured people that are left out of mainstream medical care. These issues have prompted the Obama administration to reform the way to deliver care, and we now have – among other things – the “Obamacare” reform. Whether we like it or not, it is starting to take effect. Because we, the physicians, are usually the ones blamed for the rising health The idea is care costs, Congress formed a committee, the National Commission on Payment Reform. The Commission is led by Senator Bill Frist and includes doctors and to do away health care policy, delivery and payment experts to study recommendations to with fee transition away from the fee for service model. for service According to the report, our (physician) fees and salaries account for 20 per within five cent of health care expenses, but the decisions we make influence an additional 60 percent of the spending. Basically, the more you do, the more you get paid. Their to seven recommendation for a fixed payment mechanism, such as capitation and bundling years. of fees, has the potential to decrease expenses and promote high value health care. The idea is to do away with fee for service within five to seven years. Everyone knows that private practice is becoming more and more difficult to sustain due to declines in reimbursements and increase cost in overhead including increased regulations and audits, etc. Although we doctors take most of the blame, no one takes into account the risings costs of medications and the rising costs and benefits paid to hospitals and to insurance administrators and executives (millions of dollars paid to their CEO’s amongst them). The other part of the equation is the patient. Unhealthy life styles such as smoking, overweight, lack of exercise, alcoholism, prescription drug use and overuse, etc. increases health care costs tremendously. Are we to blame for taking care of these patients? With people living longer, are we to blame for taking care of the elderly? We shouldn’t be blamed, but it certainly feels like it. These other issues associated with the rising costs of healthcare delivery are not being addressed adequately. There should be a national campaign explaining these issues and encouraging people to change their habits. Otherwise the costs of health care will not come down significantly, no matter how much physician fees are reduced. Fee for service is a good way to deliver medical care if everyone does their part. (Based in part on an article by Dr. Douglas W Jackson, M.D., Orthopedics Today, May 2013)

MARCH 2014 / VITAL SIGNS

A ﬁnancial safety net for you—

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

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

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

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

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 90 days’ advance written notice. The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

CMA NEWS Blue Shield exchange/off-exchange plans leading to confusion among physicians

The California Medical Association (CMA) has seen a large increase in calls from physicians confused about the plans/products offered by Blue Shield both on and off the exchange. As you may know, federal law requires that every plan offered in the exchange also be offered off the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-network for products that use the insurer’s narrower exchange network. It has also created an additional level of confusion for physician practices when checking patients’ coverage status. In the case of Blue Shield, the insurer offers 12 separate products linked to its exchange network, which it calls the “Exclusive PPO Network” or “Exclusive EPO Network.” These products, whether purchased on or off the exchange utilize the Blue Shield “Exclusive” (aka exchange) networks. While plans purchased through Covered California will have the CoveredCA logo on them, the “off exchange” versions of these plans will not. However, regardless of whether they were purchased on or off the exchange, these plans will all utilize the insurer’s “Exclusive” exchange networks. When identifying Blue Shield Exclusive Network patients you will need to review both plan and product. Mirror products offered both on and off the exchange may be subject to the lower rate structure. Help with provider directory

Following numerous complaints from both enrollees and providers, Covered California has removed its provider directory from the exchange website until further notice. During the directory’s initial debut, the California Medical Association was instrumental in notifying Covered California of multiple errors present within the database. Even in its more recent directories, however, CMA identified more than 300 providers located in states other than California, and as far away as Winnipeg, Canada. With the directory now offline indefinitely, Covered California is asking potential enrollees to locate providers using links to each health insurance plan’s respective provider directories, which are available on the exchange’s website. Meanwhile, California physicians are able to identify which exchange plans are listing them as a participating provider using CMA’s membersonly physician participation lookup took. The tool, which is available at www.cmanet.org/exchange-lookup, allows physicians to quickly identify which exchange plans list them as participating physicians. Practices, however, should also take the extra step of verifying participation status with the health plans themselves, as they will have the most updated information. For further information on verifying participation status with the health plans, please refer to CMA’s “Surviving the Second Month of Covered California,” which is available at CMA’s exchange resource center, www.cmanet.org/exchange. Contact: CMA’s reimbursement helpline, 888-401-5911 or economicservices@cmanet.org. Become an official opponent of anti-MICRA ballot initiative

If you haven’t already, please take a moment to sign up to be an official opponent of a possible November 2014 ballot measure being pushed by trial lawyers that would significantly weaken California’s Medical Injury Compensation Reform Act (MICRA) and increase lawsuits against doctors, community clinics, health centers, hospitals and other health care providers.

It only takes a moment to join and add your and/or your organization’s name to the official list of opponents to this greed-fueled initiative. Once you do, you also will receive regular email updates from the campaign to protect MICRA. Ballot measure update To date, trial lawyers and their allies have raised more than $1 million to pay for signatures to qualify the measure for the ballot. The main component of the proposed ballot measure would quadruple MICRA’s $250,000 cap on non-economic damages – raising the cap to $1.1 million plus an automatic annual increase. If successful, these efforts would be devastating to California’s health care system. Raising the cap would increase lawsuits against health care providers leading to a significant increase in medical liability insurance costs. Ultimately, this measure will increase health care costs for all consumers and reduce patient access to affordable, quality health care – especially in rural and underserved communities. We need your involvement! Please join us in opposing the trial lawyers’ ballot measure. To learn more and what you can do to help, visit www.cmanet.org/micra.

MICRA patient brochure available in Spanish

The California Medical Association (CMA)-led coalition working to protect California’s landmark Medical Injury Compensation Reform Act (MICRA) has published a patient education brochure to help inform California voters about the ballot initiative being pushed by trial attorneys. The pamphlet, available in English and Spanish, can be distributed to patients during office visits and will be accompanied by talking points for physicians so you can have meaningful conversations with patients on the real impacts the proposed ballot measure would have, if passed. If you would like to receive brochures for your office, please contact Yna Shimabukuro at yshimabukuro@cmanet.org or 916-551-2567 Problems getting paid?

The California Medical Association’s Center for Economic Services provides

direct reimbursement assistance to CMA physician members and their office staff. Reimbursement Help Line 888-401-5911 or economicservices@cmanet. org. When to call CMA? CMA members can call on CMA’s practice management experts for free one-on-one help with contracting, billing, and payment problems. If you answer “yes” to any of the following questions, it might be time to call for help. • Are your claims not being paid in a timely manner? • Are you not being paid according to your contract? • Are your claims being denied after obtaining prior authorization or verifying eligibility? • Are you receiving unreasonable requests for medical records or untimely requests for refunds? • Are you having difficulty obtaining fee schedules and/or payment rules? • Are your claims denied for timely filing? • Have you been presented with a managed care contract and you’re not sure if the terms are consistent with California law? • Have you done everything you can to resolve an issue with a payor, including appealing, and have been unsuccessful in getting the payor to resolve the issue?

MARCH 2014 / VITAL SIGNS

CMA NEWS

2014

EDUCATION SERIES CMA Center for Economic Services Webinars At-A-Glance

Most webinars are FREE for CMA members and their staff, $99 for non-members.

A Webinar Invitation for All Physicians and Their Staff

The California Medical Association (CMA) offers programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon. Most webinars are held over the lunch hour, from 12:15 to 1:15 p.m.

MAYBE IT’S TIME TO PURSUE A NEW CAREER FACULTY PHYSICIAN(S) – FAMILY MEDICINE KERN AND FRESNO COUNTIES Board Certified Family Practice Physicians to serve as faculty for the Sierra Vista Family Practice and Rio Bravo residency programs. Full and part-time positions available providing teaching and instruction to residents. Make a difference in the lives of new physicians and join the faculty! Competitive salary and benefits. Positions available in Kern and Fresno counties. PHYSICIAN(S)– FAMILY MEDICINE – FRESNO COUNTY Provide comprehensive medical services to an established patient population, in one or more of several satellite clinics in the Fresno area. The position requires an MD, or DO degree or equivalent and completion of residency training in Family Medicine. Board Certification or Board Eligibility in Family Medicine as evidence of completion of the training requirement is acceptable. Valid California medical license also required. DEPUTY CHIEF MEDICAL OFFICER – FRESNO COUNTY The Deputy Chief Medical Officer (DCMO) is responsible for the overall patient functioning of the medical program of the clinic and satellites, including the day-to-day management, planning and supervision of medical staff activities. The DCMO also assures an efficient system in which quality care is guaranteed to all patients. The DCMO should be a health care provider (MD/DO) licensed to practice in the State of California. The DCMO should have a strong community health/public health orientation, be experienced in patient care management, and have at least two years of experience in an administrative capacity. Interested applicants may contact Clinica Sierra Vista at (661) 979-0812. 8

MARCH 2014 / VITAL SIGNS

MARCH 5: HIPAA Security Risk Analysis-How to Make Sense of this Requirement – David Ginsberg • 12:15-1:15p.m. Conducting a HIPAA Security Risk Analysis is a requirement of the HIPAA Security Rule. It is also a CORE Meaningful Use (Stage 1 and 2) measure to earn EHR incentives and avoid Medicare penalties! This webinar reviews what is required to properly fulfill this compliance obligation and at the same time secure your patient’s health information. Failure to conduct a Risk Analysis or conducting an insufficient one are among the most common deficiencies found during compliance investigations! MARCH 26: Physician Practice Options – Self Employment or Group Affiliation – Debra Phairas • 12:151:15p.m APRIL 30: Stage 2 Meaningful Usethe 2014 Edition-what you need to know! – David Ginsberg • 12:151:15p.m. MAY 14: Merging Practices – Strategies to Remain Independent – Debra Phairas • 12:15-1:15p.m These webinars are hosted by the California Medical Association. You must register at least one hour prior to the event. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Help Line at 800786-4262.

MEDICARE Brief Summary: Bipartisan House-Senate Legislation

SGR Repeal and Medicare Modernization Act Prepared by Elizabeth McNeil, Vice President CMA Federal Government Relations

H.R. 4015/S. 2000 1. Repeals the Medicare SGR formula. 2. Automatic payment updates: 0.5%/yr for 5 years: 2014-2018; New Payment Model Incentive Payments Begin 2018; Automatic Updates 2023 and beyond; 1% Fee For Service and 2% alternative models. 3. In 2018, Establishes Two Payment Tracks: a. Fee For Service Track with Performance Based Payments Performance is based on existing reporting programs: Physician Quality Reporting System (PQRS), EHR meaningful use, value modifier-resource use, and a new clinical improvement activity program – all combined into one program. Eliminates (8-9%) current law penalties and creates bonuses which are no longer available under current law. Penalties and Bonuses up to 9% annually. Penalties maxed at 4-5% first two years. This track is called the Merit-Based Incentive Payment System (MIPS). Physicians will receive a composite score based on performance in these four categories. Physicians above the mean will be paid bonuses, physicians below the mean will receive penalties. Physicians will receive credit for improvement and there are additional payments for exceptional performance. Based on current California physician quality scores and resource use, California ph ysicians should do well. • Requires CMS to reduce burdens on physicians and take all practice sizes and specialties into account so the performance standards are appropriate for each specialty; • A llows physicians to report on the individual, group or virtual group level. • Requires CMS to adopt quality measures and clinical activities approved by physicians. • A lso mandates CMS to make improvements to the Value Modifier methodology to ensure appropriate physician attribution. All expenditures will be cost and risk-adjusted. b. Alternative Payment Model Track with 5% Bonuses The Alternative Payment Models are to be developed by physicians with CMS. Physicians must accept some financial risk (except patient-centered medical home models), participate in quality improvement, and receive a significant percent of revenue from Medicare or a combination of Medicare and other payers. CMS is required to test models relevant to specialties and small practices. It establishes a Technical Advisory Committee to consider physician-developed models.

4. Updates the California Medicare payment localities and holds the rural counties harmless from cuts permanently. (The “CALIFORNIA GPCI FIX”) 5. Establishes New Codes to Pay for Complex Chronic Care Management Services 6. Provides Assistance to Small Practices: • $200 million in Funding Assistance for ALL Small Practices; Priority given to Rural/HPSA Physician Practices and practices with low performance scores. • Provides a 4 year transition period to help small practices. • In developing programs, requires CMS to take capabilities of small practices into consideration. 7. Requires Timely, Confidential Feedback to Physicians on Performance Measures. 8. O versees the Valuation of Services in the Physician Fee Schedule (AMA RUC). Continues to allow excess funding from misvalued codes to be reinvested in other physician services. 9. Establishes Appropriate Use Criteria for Imaging Services with Exceptions and Requires CMS to adopt criteria developed by physician organizations. 10. E xpands the Use of Non-Public Medicare Cost Data for Performance Improvement • Will provide physicians and medical societies with Medicare total cost of care data to help physicians accurately assess costs and effectively participate in new models. 11. Requires Additional Physician Data to be Posted on Medicare’s Website. 12. Ensures that the payment policies and treatment guidelines do not establish a standard of care for medical liability proceedings. 13. Eliminates the red-tape of repeated opt-out affidavit submissions to help physicians who desire to privately contract with their Medicare patients. 14. Requires Electronic Health Records (EHR) to be interoperable by 2017 and prohibits providers from deliberately blocking information sharing with other EHR vendor products. 15. Requires MedPAC to report to Congress on the impact of the legislation on patient access to care and whether further payment updates are necessary; and whether physician actions are reducing Medicare Part A spending. Also requires monitoring to ensure that the performance programs are not disincenting physicians from caring for the sickest patients. CMA Contact: Elizabeth McNeil, VP Federal Government Relations, emcneil@cmanet.org.

MARCH 2014 / VITAL SIGNS

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John Kulin, M.D. On the network since 2009

YOUR 2014 SUCCESS: GUARANTEED

In a year of massive change, athenahealth wants to help your practice stay independent Two fast-approaching initiatives—the ICD-10 transition and Stage 2 of the Meaningful Use program—are hitting the calendar at the same time. And both can cause administrative chaos and financial strain for practices. At athenahealth, we don’t believe government mandates—or any change—should take focus away from patients. So, as part of our continued dedication to caregivers, we guarantee your success as you face these programs. It’s an assurance no traditional vendor could even attempt. But with our proven combination of cloud-based software, network intelligence and back-office services, we are uniquely poised to come through for our clients.

ICD-10 Guarantee athenahealth guarantees we will be ready for ICD-10 by the October 1, 2014 deadline or you don’t pay for our services until we are. Additionally, any new clients who experience significant interruption in cash flow may be eligible to receive a cash loan from us.†

Meaningful Use If you participate in the Meaningful Use program—Stage 1 or Stage 2—athenahealth guarantees your Medicare incentive check. And our track record speaks for itself, with 96% of our participating providers attesting in 2012.††

TO LEARN MORE VISIT: athenahealth.com/fresnoprint † This Guarantee covers ICD-10-CM codes and does not cover the ICD-10-PCS code set. Eligibility for the cash advance is limited to independent practices that (i) are live on athenahealth’s athenaOne services, or on our athenaCollector, athenaCommunicator and athenaClinicals services, by June 30, 2014; (ii) have an overall average days in accounts receivable (DAR) of more than 60 days in regard to transactions occurring on or after October 1, 2014; (iii) have Client-responsible DAR of seven days or less for such month; and (iv) are not in breach of the athenahealth Master Services Agreement; provided, however, that the total aggregate amount of cash advances made by athenahealth to its clients will not exceed $50 million dollars in the aggregate and cash advances made to each practice will be capped based on the number of MDs and mid-level providers in such practice. Additional terms and conditions apply; please see your sales representative for more information. †† If you don’t receive the Federal Stimulus reimbursement dollars for the first year you qualify, we will credit you 100% of your EHR service fees for up to six months until you do. This offer applies to HITECH Act reimbursement payments only. Additional terms, conditions, and limitations apply.

MARCH 2014 / VITAL SIGNS

AFFORDABLE HEALTHCARE ACT

Surviving the Second Month of Covered California As of January 15, Covered California reports that more than 625,000 individuals have enrolled in exchange plans. With that figure expected to grow by the end of the 2014 open enrollment period, it is critical that physicians and their staff know what to expect. To help answer some of the more common questions, the California Medical Association (CMA) offers this second tip sheet to help physicians survive the second month of Covered California: 1. Check your participation status on Covered California’s central provider directory. The Covered California provider directory may not be as up-to-date as the individual plan websites, but it’s important for practices to see what patients are seeing. To verify your information in the Covered California directory, follow the directions found in CMA’s physician guide, “Surviving the First Month of Covered California” use the quick and easy CMA look-up tool. 2. Verify your participation status on the individual plan websites. Because the plan websites are updated much more frequently than the Covered California website, physicians should verify their participation status on the individual plan websites. This can be done using the plans’ provider directory search features, found on the plans’ main websites. When searching the provider directories it’s important to select the correct exchange product type. Many plans are utilizing narrowed networks for the exchange so the provider directory for their standard PPO plan will likely differ from the exchange provider directory. Sharp Health Plan, Western Health Advantage, Contra Costa Health

Plan, Valley Health Plan, and L.A. Care Health Plan are only offering HMO products and all are likely delegating to IPAs/medical groups. Practices Questions: CMA reimbursement help line, 888-401-5911 2/3/14 will need to contact the plans directly to determine to which IPAs/medical groups the plans may have delegated their exchange business, allowing the practice to then determine whether it may be contracted for exchange business via that IPA/medical group. Chinese Community Health Plan is delegating its exchange business to Chinese Community Healthcare Association, and its number is 415-216-0088, ext. 2806. 3. Call plans directly with questions or concerns about physician participation status. 4. Ensure that your front office staff has a clear understanding of the physician’s participation status as displayed on the Covered California website, but, more importantly, know what the plans show. Ideally, front office staff is having the conversation about physician participation status with patients before scheduling to avoid out-ofnetwork costs for and frustration from patients when they are faced with a larger than expected bill. 5. Know the participation status of physicians, facilities and other providers to which you refer. Covered California plans require Please see Covered California on page 18

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Tulare Individual Health Insurance Plans 2014 and Beyond: Are You In or Out? 3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org Officers Thomas Gray, MD President Monica Manga, MD President-Elect Virinder Bhardwaj, MD Secretary/Treasurer Steve Cantrell, MD Past President Board of Directors Anil K. Patel, MD Carlos Dominguez, MD Pradeep Kamboj, MD Christopher Rodarte, MD Antonio Sanchez, MD Raman Verma, MD CMA Delegates Thomas Daglish, MD Roger Haley, MD John Hipskind, MD CMA Alternate Delegates Robert Allen, MD James Foxe, MD Mark Tetz, MD Sixth District CMA Trustee Ralph Kingsford, MD Staff Francine Hipskind Executive Director Thelma Yeary Executive Assistant Dana Ramos Administrative Assistant

Judy Fussel, RHU and JoeAnna Todd, RHU, ChHC, Buckman-Mitchell Financial & Insurance Services, Inc.

On January 1, 2014, the health insurance environment was transformed under new regulations through the Affordable Care Act which passed March 23, 2010. For 2014, the biggest turmoil impacts individual health insurance plans. Since January, individuals purchasing coverage either through the Exchange (Covered California) or outside the exchange are confused as to how they can access care. When health insurance companies chose to continue to offer coverage in the individual market, the first course of action was to establish a network of providers. Companies created a separate network that applies to only the individual health insurance plans. No longer is it safe to just ask, “Do you participate in XYZ’s PPO/HMO plan?” You must be specific to the “individual PPO/HMO plan”. As we understand it, the contracts provided offer a substantial reduction in the reimbursement for services. For this reason, providers have opted not to accept them. What is confusing is that there is NOT a separate provider contract for plans purchased through Covered California versus plans purchased outside Covered California. Contracts for patients with individual coverage will be reimbursed at the same level regardless of where they were purchased. As agents, we are very concerned about access to care for our clients with an individual plan. While we have attempted to provide them with accurate information, there is uncertainty as to whether a provider is contracted or not with the new plans. We emphasize that the contracts through Covered California and outside of Covered California are one and the same for these new individual health plans. If you elect to participate as an in-network provider outside of the exchange, you will be reimbursed at the same level as you would if you accepted a patient who purchased their plan through Covered California. It is also important to note, that all billing and customer service issues will be handled by the insurance company, NOT Covered California. Providers will not be dealing with Covered California, just the insurance company. To alleviate the confusion, we reached out to the insurance companies and asked them to clarify the misnomers many of our clients, including our physician clients. Here is what we know: The following insurance companies are offering health insurance options to individuals in our area: • Fresno, Kings, and Madera County: Anthem Blue Cross PPO & HMO, Blue Shield PPO, Kaiser • Tulare County: Anthem Blue Cross PPO, Blue Shield PPO, Health Net PPO, Kaiser Provider Networks: Not Just PPO or HMO any longer Anthem Blue Cross – Anthem Blue Cross’ individual network for non-grandfathered plans purchased in or out of Covered California is the Pathway PPO or Pathway HMO network. An individual who purchased a plan outside of Covered California will have the word Pathway on their new ID card. Those who purchased an Anthem plan through Covered California will have Pathway X on their card, and their card will show the Covered California logo. Anthem has confirmed that regardless of which Pathway network one may have on their card, the network of physicians and hospitals are the same. Blue Shield – Blue Shield non-grandfathered individual health plans use the Exclusive PPO network. This network is also the same whether someone purchased their plan direct with Blue Shield or purchased through Covered California. The only separate identifying factor will be the Covered California logo on the ID card. Note: if a patient has a grandfathered health plan (and very few remain), they still have access to the full Anthem or Blue Shield PPO network. Health Net: In regions where Health Net is available, their network tends to be the least restrictive. Health Net indicates that they use their regular individual PPO network for Individuals and Small Groups. And, just like Anthem and Blue Shield, the network of physicians is the same regardless if a patient purchased their insurance through Covered California or not. Until the dust settles, we have advised our clients to check with their physicians to find out if they are contracted with the each individual health plan, and to make sure they indicate the specific network in which they are inquiring. It’s suggested that providers who might be unsure about their contract status contact the appropriate provider relations team with each insurance company mentioned above to confirm. If you have questions regarding this article, please email them to: info@tkfmc.org. All material presented herein represents the views and information of the respective authors and is considered to be current and reliable. It does not necessarily carry the endorsement of the Tulare County Medical Society and/or its officers.

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Tulare MGMA: Physician Practices Unprepared for Switch to ICD-10 Codes Physicians practices have made little progress on several ICD-10 implementation steps, including system testing and technology upgrades, according to a survey from the Medical Group Management Association, Healthcare IT News reports (Miliard, Healthcare IT News, 2/5). Background on ICD-10: U.S. health care organizations are working to transition from ICD-9 to ICD-10 code sets to accommodate codes for new diseases and procedures. The switch from ICD-9 to ICD-10 code sets means that health care providers and insurers will have to change out about 14,000 codes for about 69,000 codes. In August 2012, HHS released a final rule that officially delayed the ICD-10 compliance date from Oct. 1, 2013, to Oct. 1, 2014, partially to look at the incremental changes needed in reforming health care (iHealthBeat, 1/9). Survey Details : The survey – which was conducted in January – included responses from more than 570 physician practices (Pittman, “The Gupta Guide,” MedPage Today, 2/5). The surveyed practices represent more than 21,416 physicians (Murphy, EHR Intelligence, 2/5). Survey Findings : The survey found that: • 40.9% of physician practices said they are “somewhat ready” for ICD implementation; • 38.4% said they have not begun implementation; •11.3% said “approximately half ” of their preparations are completed; and • 9.4% said they have made “significant progress” in preparing for the transition to ICD-10 (“The Gupta Guide,” MedPage Today, 2/5). In addition, the survey found that before ICD-10 codes can be used: • 81.8% said they would need new or upgraded electronic health record systems; and • More than 80% of respondents said they would need new or upgraded practice management software. The survey estimates the cost for a 10-physician practice to upgrade or replace both systems would be $243,850. Meanwhile, the survey also found that internal and external testing was behind schedule. For example: • 60% of survey respondents said they were unaware when testing with major health plans would begin, with 5.4% having begun testing; • Nearly 50% said they were waiting to hear from their clearinghouse about a testing date, with 8.1% having begun testing; • Just over 10% said they had initiated or completed internal testing with their practice management vendor; and • 8.2% said they had begun or completed testing with their EHR vendor (Healthcare IT News, 2/5). Survey respondents also expressed some concerns about six core implementation issues: • 97% of respondents said they were concerned about changes to clinical documentation; • 94% said they were concerned about coding staff productivity losses; • 96% said they were concerned about clinician productivity losses; • 92% said they were concerned about the overall cost of converting to ICD-10; • 76% said they were concerned about the cost of upgrading or replacing software; and • 58% said they were concerned about support from executive management. MGMA Recommendations: • MGMA recommended that CMS address the lack of ICD-10 preparedness by: • Assessing vendor readiness; • Conducting complete end-to-end testing with physician practices; • Consistently publishing and updating the readiness level of all Medicare contractors and Medicaid agencies; • Expanding provider education efforts; and • Making all Medicare and Medicaid payment edits available to physician practices (Goedert,Health Data Management, 2/5). http://www.ihealthbeat.org/articles/2014/2/6/mgma-physician-practices-unprepared-forswitch-to-icd10-codes Tulare County Medical Society has class sessions for both staff and physicians planned to assist as you prepare for the ICD-10 changes. Please call our office at 559-627-2262 for more information. Also, upon payment of your 2014 dues, you will receive the ICD-10-CM 2014 Express Reference Mapping Cards (not all specialties available) free of charge.

Dr. Ravi Kumar hosts a Tulare

Join us at the next Walk With A Doc to take a step toward a healthier you! All you need to do is lace-up a pair of comfortable shoes and join us for some fresh air, fun and fitness. Dates: Saturday, March 22, 2014 and April 12, 2014 Beginning at 8:00AM Location: Del Lago Park, Tulare, CA Who can attend: ANYONE For more information, please contact Roberta Hurtado at (559) 685-4607

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Kern ALPHA ANDERS, MD

2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website: www.kms.org Officers Alpha J. Anders, MD President Michelle S. Quiogue, MD President-Elect Eric J. Boren, MD Secretary Bradford A. Anderson, MD Treasurer Wilbur Suesberry, MD Past President Board of Directors Lawrence N. Cosner, Jr., MD Vipul R. Dev, MD John L. Digges, MD Susan S. Hyun, MD Kristopher L. Lyon, MD Ronald Morton, MD Mark L. Nystrom, MD Edward W. Taylor, III, MD CMA Delegates Jennifer Abraham, MD John Digges, MD Lawrence N. Cosner, Jr., MD CMA Alternate Delegate Joseph H. Chang, MD CMA YPS Representive Joseph H. Chang, MD Staff Sandi Palumbo Executive Director Kathy L. Hughes Administrative Assistant

President’s Message HOOKAH LOUNGES HAVE BECOME SOCIAL GATHERING PLACES

As the dialogue about the legalization of marijuana continues, particularly the discussions of the potential medicinal benefit of marijuana, I fear the dedicated years of work and research into the ills of tobacco may be forgotten . It seems Tobacco is cool again and what’s more, it is being labeled as “healthy.” People are lighting up across the globe, falsely assuming they are shielded from the dangerous effects of cigarettes by using hookah. Hookahs are a pipe with one or more long flexible hoses attached to a bowl containing water. Shisha, flavored tobacco designed for hookahs, sits on top of the pipe and is warmed by a coal. The hookah tradition, dating back at least 500 years, originated in ancient Persia. Recently it has gained popularity in the United States, especially amongst college students. Hookah has gained a false reputation as safer than cigarettes, but new research shows that the typical hookah session produces the same disastrous effects on the body as smoking ten to forty cigarettes. Hookah smoking is a social activity; groups share one pipe smoking from the same mouthpiece. Hookah lounges, offering a variety of flavored shisha, are opening all across the country. Groups will spend anywhere from half an hour to all evening at a hookah bar. Establishments like cigar bars and tobacconists where smoking is the focal activity can get special permits to allow indoor smoking. The constant exposure to second hand smoke and the carbon monoxide emitted from the burning coal add to the dangers of hookah. The first hand smoke- generally inhaled deeper into the lungs than a cigarette- contains high levels of toxic compounds, including carbon monoxide, heavy metals, and cancer-causing chemicals. A study funded by the National Institutes of Health reports a single hookah session delivers 1.7 times the nicotine, 6.5 times the carbon monoxide, and 46.4 times the tar of a single cigarette. Despite the hard data of the disastrous health effects of hookah, there is still a pervasive belief in its safety. This is mainly due to the misconception that the water filters out the toxic substances before being inhaled into the body. The American Chemical Society recently tested this theory by comparing the chemical profile of twelve different varieties of shisha before being smoked and the chemical profile of the water after smoking hookah. The study found minimal traces of toxins in the water, discrediting the widely held belief that water purifies the tobacco. Hookahs and the tobacco used in them have been labeled as the “first new tobacco trend of the 21st century.” To halt the growth, we need to inform the public about the dangers of hookah and the illegitimacy of the water purification claim. Information dissemination, especially at college campuses, and tighter controls on the age limits of who can smoke in hookah lounges will help reverse this unhealthy resurgence in tobacco as we ponder more to smoke and the Health benefits and or Harms . Alpha Anders, MD may be reached at: dranders@bakolungdoc.com

New Member The following physicians’ names, etc. are being published in compliance with the KCMS Constitution & Bylaws. Board Certification will be listed only if the physician has been certified by a Specialty Board recognized by the American Board of Medical Specialists, as approved by the American Medical Association.

Cyrus R. Moon, MD (General Surgery) 432 Lexington St., Delano, 93215-3697 661/375-5871 FAX: 375-5877 cyrus.moon@gmail.com Medical School: UT Southwestern at Dallas 2007 Internship/Residency: UCSF Fresno 2007-2013 Board Certified: General Surgery 2013 14

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Membership Recap JANUARY 2014 Active.......................................................................................................255 Resident Active Members................................................................ 2 Active/65+/1-20hr............................................................................... 4 Active/Hship/1/2Hship.................................................................. 0 Government Employed..................................................................... 4 Multiple Memberships...................................................................... 1 Retired.......................................................................................................62 Total.......................................................................................................327 New Members (Pending Dues).................................................... 1 New Members (App Pending)..................................................... 0 Total Members............................................................................ 328

Kern Kings March is National Kidney Month The National Kidney Foundation Offers 5 Tips for Reducing Risk of Kidney Disease

March is National Kidney Month and March 13 is World Kidney Day. The kidneys work ‘round the clock to filter 200 liters of blood each day, removing two liters of toxins, wastes and water in the process. Simultaneously, the kidneys regulate fluid levels, release hormones to regulate blood pressure and produce red blood cells, and help maintain healthy bones. When the kidneys are damaged, they may not be able to keep you healthy and as kidney disease National Kidney FoundationTM progresses, wastes can build to high levels in your blood and make you feel sick. Prevention and early detection of kidney disease is critical. Help the National Kidney Foundation raise awareness about this vital pair of organs and the risk factors for kidney disease with these 5 tips to prevent kidney disease and manage risk factors. Consider your lifestyle habits. Following a healthy diet and exercising regularly is an important element of kidney disease prevention. Maintaining healthy blood pressure and blood sugar levels is a critical way to prevent kidney disease and slow its progression. To lower blood pressure and protect your kidneys, reduce your salt intake and watch for high sodium levels in processed foods. Get tested. If you’re the one in three Americans who is at increased risk for kidney disease due to high blood pressure, diabetes or a family history of kidney failure, it’s important to get your kidneys checked during your annual physical. There are two simple tests to check for kidney disease: A urine test for albumin, a type of protein. When there is too much protein in the urine, it means that the kidneys’ filters have been damaged and are starting to leak protein. Albuminuria – or too much protein in the urine – is one of the earliest signs of kidney damage. A blood test for creatinine. Creatinine is a natural muscle by product and this measurement is used to calculate your estimated glomerular filtration rate (eGFR). The eGFR tests how well the kidneys are filtering wastes from the blood.

PO Box 1029 Hanford, CA 93230 559-582-0310 Fax 559-582-3581 Officers Jeffrey W. Csiszar, MD President Vacant President-Elect Mario Deguchi, MD Secretary Treasurer Theresa P. Poindexter, MD Past President Board of Directors Bradley Beard, MD James E. Dean, MD Thomas S. Enloe, Jr., MD Ying-Chien Lee, MD Uriel Limjoco, MD Michael MacLein, MD Kenny Mai, MD CMA Delegate Ying-Chien Lee, MD Staff Marilyn Rush Executive Secretary

Weigh in. Maintaining a healthy weight has important implications for your kidneys. When you are obese, the kidneys have to work harder to filter out toxins and to meet the metabolic demands of the increased body mass index (BMI), increasing your risk of developing kidney disease. Obesity also increases your chance of developing diabetes and high blood pressure, two major risk factors for kidney disease. Weight loss can help reduce your risk of developing kidney disease. Be alert when taking meds. Many prescription and over-the-counter medications, including pain medications, are filtered by the kidneys. This means that your kidneys break down and remove these medications from the body. Always read labels and weigh the risks and benefits of taking a particular medication. Avoid excessive use of medications that can harm the kidneys, such as ibuprofen and naproxen. Commit to quit. Smoking can worsen kidney disease and diseases that damage the kidneys, such as diabetes and high blood pressure. Quitting can be difficult, but it is one of the most important lifestyle changes that you can make to protect your kidneys and impact your overall health. For more information about early detection and treatment of kidney disease, visit the National Kidney Foundation at www.kidney.org.

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Fresno-Madera PRAHALAD JAJODIA, MD

Post Office Box 28337 Fresno, CA 93729-8337 1040 E. Herndon Ave #101 Fresno, CA 93720 559-224-4224 Fax 559-224-0276 website: www.fmms.org Officers Prahalad Jajodia, MD President A.M. Aminian, MD President-Elect Hemant Dhingra, MD Vice President Ahmad Emami, MD Secretary/Treasurer Ranjit Rajpal, MD Past President Board of Governors Alan Birnbaum, MD S.P. Dhillon, MD Ujagger-Singh Dhillon, MD William Ebbeling, MD Anna Marie Gonzalez, MD David Hadden, MD Joseph B. Hawkins, MD Sergio Ilic, MD Alan Kelton, MC Constantine Michas, MD Trilok Puniani, MD Khalid Rauf, MD CMA Delegates FMMS President Don Gaede, MD Michael Gen, MD Brent Kane, MD Brent Lanier, MD Kevin Luu, MD Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD CMA Alternate Delegates FMMS President-Elect Perminder Bhatia, MD Praveen Buddiga, MD Surinder P. Dhillon, MD Trilok Puniani, MD Oscar Sablan, MD CMA Trustee District VI Virgil Airola, MD Staff Sandi Palumbo Executive Director

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President’s Message Protect Access to Quality Health Care and Patient Privacy – Oppose the Costly MICRA Measure

As a physician, I want nothing more than to protect my patients and provide quality medical care to those who need it most. Each of you in your own practices and throughout your careers has endeavored to do the same, undoubtedly. Unfortunately, our profession and the safety of our patients are being threatened in a very serious way. The California Medical Association (CMA) has joined a campaign coalition to protect the Medical Injury Compensation Reform Act (MICRA) by opposing a dangerous ballot measure that will appear on the November 2014 ballot. The group, “Patients, Providers and Healthcare Insurers to Protect Access and Contain Health Costs” is a broad coalition of doctors, community health clinics, hospitals, local governments, public safety, business and labor to oppose this costly, dangerous ballot proposition that would make it easier and more profitable for lawyers to sue doctors and hospitals If approved by voters, this measure could add “hundreds of millions of dollars” in new costs to state and local governments, according to an impartial analysis conducted by the state’s Legislative Analyst. These new costs would place additional burden on every Californian. This measure would also have devastating effects on access to care for patients everywhere, but especially in rural and already underserved areas like many communities in the San Joaquin Valley. Community health care clinics like Planned Parenthood and the Central Valley Health Network say this measure will cause specialists like OB/GYNs to reduce or eliminate patient services. This measure could also cause doctors to leave the state, meaning thousands of Californians could lose access to their current physician. I cannot think of a worse time to reduce access and increase health care costs – and so I ask you to join me in the campaign to defeat this costly measure. The initiative, being called the “Tory and Alana Pack Safety Act” by proponents, is bad for patients, taxpayers and health care as a whole. There has never been a greater need for physicians to band together and fight for our patients. What’s more is this measure was written by trial attorneys to make it easier and more profitable for lawyers to sue doctors and hospitals — even if that means higher health costs for the rest of us. Our health laws should protect access to care and control costs for everyone, not increase lawsuits and payouts for lawyers. Over the next 10 months, you’ll hear a lot of rhetoric from the proponents of the measure but really, this is another example of a special interest trying to fool the voters into thinking this is about something that it’s not. The authors of this proposal purposely threw in non-MICRA provisions, like drug testing doctors, to disguise the real intent, which is to increase the limits on medical malpractice awards so that trial lawyers make even more money. The main proponent of the measure was recently quoted in the Los Angeles Times, saying, “The drug rules are in the initiative because they poll well, and the backers figure that’s the way to get the public to support the measure. ‘It’s the ultimate sweetener.’” Furthermore, the proposal requires a government database with personal information on patients’ prescription drug history. Hackers have already managed to access personal information from millions of Target customers and even the Pentagon, and another big database will only make our information more vulnerable. Over 1,000 groups have joined together in support of MICRA and in opposition to this dangerous, costly measure. I invite you to be part of the effort, and encourage that you join me and CMA in this incredible opportunity to protect our patients and rally together with the medical profession. For information about how to get involved, visit www.cmanet.org/micra. Thank you for your support!

Fresno-Madera FMMS MEMBER APPOINTED TO STATE POST Bernard Freeburg, MD 47-year member Bernard “Bernie” Freeburg, MD, a retired obstetrician, died February 12, 2014 at the age of 80. Dr. Freeburg was born in San Francisco in 1933. He received his medical degree from the University of Southern California in 1962 and completed his internship and residency training at the Fresno County General Hospital in 1966. He had just recently retired full time. Dr. Freeburg is survived by his wife, three children and five grandchildren.

The State of Cali-

fornia has appointed radiologist, Bonna Rogers-Neufeld, MD FACR to the Radiologic Technology Certification Committee (RTCC) for a four year appointment. The RTCC perDr. Rogers-Neufeld forms valuable ser- takes the State of vice to the Califor- California oath. nia Department of Public Health with advice and recommendations regarding rules and regulations to ensure proper administration of an effective certification program for the use of radiation in the healing arts.

Dramatic Increase in Fresno County Pertussis Cases A dramatic increase in the number of pertussis (whooping cough) cases in Fresno County has been

identified by the Fresno County Department of Public Health which investigates all reported cases of the disease. In January and February of this year, 42 cases have been reported compared to just 2 cases during January and February of 2013. Early signs of pertussis include cold-like symptoms: runny nose, sneezing, mild fever and cough. The severity of the cough gradually increases and can continue for several weeks or months. The “whoop” sound often associated with the pertussis cough varies. There may also be vomiting following a coughing attack and periods without breathing. Very young infants may have episodes of not breathing rather than a cough.

REMIND YOUR PATIENTS To reduce the risk of infection and prevent the spread of pertussis: • Pregnant women should be vaccinated during the third trimester of EVERY pregnancy even if they have received the vaccine before. Vaccination in week 27 to 36 will provide the optimal protection for both mothers and newborns. • A ny person who lives or works with infants younger than 12 months of age should be vaccinated for pertussis (DTaP for children and Tdap for adolescents and adults). Infants, children, adolescents, and adults should be up-to-date on immunizations for protection against pertussis as well as other vaccine-preventable diseases. • The effectiveness of the pertussis vaccination decreases over time. Booster doses of vaccine are recommended. • Cover coughs and sneezes and wash hands thoroughly and often. • Persons with coughs lasting more than two weeks should consult a doctor. Residents should contact their health care provider to receive pertussis vaccination. For residents without a health care provider, pertussis vaccination is available at many pharmacies. Eligible children and uninsured adults may be able to receive pertussis vaccination from the Fresno County Department of Public Health. Contact the Department’s Immunization Program at 559-600-3550 for clinic location, hours, and fees. For additional information, visit the Fresno County Department of Public Health website at www. fcdph.org/pertussis or call Communicable Disease Investigations at 559-600-3332.

Fresno-Madera Medical Society presents

Just Walk! Walk with a Doc ‘Walk with a Doc’ strives to encourage healthy physical activity in people of all ages and reverse the consequences of a sedentary lifestyle. WHO CAN ATTEND: Participation is open to anyone interested in taking steps to improve their health. GRAB A FRIEND AND HEAD TO THE PARKS ON SATURDAY MORNINGS

FRESNO

Woodward Regional Park Sunset View Shelter Registration 8:45am Walk Event 9:00am-10:00am March 22, 2014 April 26, 2014

MADERA

Town & Country Park Pavilion Area Registration 8:15am Walk Event 8:30am-9:30am March 1, 2014 April 5, 2014 FURTHER INFORMATION Fresno-Madera Medical Society (559) 224-4224, ext. 110 or at www.fmms.org/receptionist@fmms.org

Find us on Facebook: Fresno-Madera Medical Society

http://www.facebook.com/pages/Fresno-MaderaMedical-Society/107731015917068

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Covered California Continued from page 11 that physicians provide advance notice to patients if they are being referred to an out-ofnetwork provider or an out-of-network provider is included in the treatment plan. If, however, the provider shows as participating in the plan’s directory, the practice cannot be held liable if the information is ultimately incorrect. Please refer to “CMA’s Got You Covered: A physician’s guide to Covered California” for more information. See #2 above on how to check the plan provider directories. Note: There is a lot of confusion for patients and physicians on participation status. Just because the directory states the physician is participating in the exchange plan, this does not mean the practice is aware. Call the practice to confirm. 6. Be aware of the off-exchange products that utilize exchange plan networks. Every plan offered in the exchange must also be offered outside of the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-network for products that use an exchange network, as these ID cards will not have the Covered California

logo on them. For example, Blue Shield products bought off of the exchange but utilizing the exchange network will list one of the following product names: Basic PPO/EPO, Enhanced PPO/EPO, Get Covered PPO/EPO, Preferred PPO/EPO, or Ultimate PPO/EPO. Anthem Blue Cross products bought off of the exchange but utilizing the exchange network will list “Pathway” on the card. If you see these product names on the ID card, it indicates the patient only has access to the exchange network. 7. What are the reimbursement rates are for the exchange products? There is no standard fee schedule. The reimbursement rates and terms vary by plan. Physicians with questions are encouraged to contact the plans directly to obtain specifics. CMA has provided contact information for each plan on our website (scroll to the bottom). 8. Still have questions? Visit CMA’s exchange resource center at www.cmanet.org/ exchange. There you will find all of CMA’s exchange related resources, including CMA’s comprehensive exchange toolkit, “CMA’s Got You Covered: A Physician’s Guide to Covered California, the state’s health benefit exchange.” CMA members and their staff also have FREE access to our reimbursement helpline at 888-4015911 or economicservices@cmanet.org.

Anthem Blue Cross* Under “Plan Type/Network” select one of the following: www.anthem.com/ca Pathway X – HMO/Individual via Exchange (click “Find a Doctor”) Pathway X – PPO/Individual via Exchange Pathway X Tiered (EPO)/Individual via Exchange Blue Shield of California* Under “select a plan” select one of the following: www.blueshieldca.com 2014 Individual and Family EPO Plans (including Covered California) (click “Find a Provider”) 2014 Individual and Family PPO Plans (including Covered California) Health Net Under “Plan” scroll down and under “Covered California” www.healthnet.com/portal/home select one of the following: (click “Provider Search”) HMO – CommunityCare Network PPO – Individual & Family PPO – Small Business (this is the SHOP) Molina Health Plan Under “Coverage” select Molina Marketplace www.molinahealthcare.com (click “Find a Doctor or Pharmacy”) * The Anthem Blue Cross and the Blue Shield websites will require you to also select a specific plan tier (e.g., gold, silver, etc.) to complete the provider search function. Select any tier.

Be sure to purchase our FMMS Pictorial Directory $20 FMMS Members • $30 Non-FMMS member Directories can be purchased and picked up at the FMMS office at: 1040 E. Herndon Ave. Suite 101, Monday-Thursday 8am-4:30pm • Friday by appointment only. Call 559-224-4224x118 or csrau@fmms.org

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CLASSIFIEDS Members: 3 months/3 lines* free; thereafter $20 for 30 words. NON-Members: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.

KERN FOR LEASE Small professional office, approx. 600 sf at 2520 H St. Bakersfield, next to San Joaquin Hospital. Call 661-900-5646 or 661-324-1090. FRESNO ANNOUNCEMENTS University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 559-3200580. PHYSICIAN WANTED Full or part time physician for Family Medicine office in Fresno. Good salary. Optional ownership in the future. Call Krystyna at 559-970-9191. Full or Part time physician wanted for local occupational medicine clinic to perform physicals on new hires. Call Su Rosenthal at 559-287-0172 or Su@PalmMedical.com Full or part time public health physician with Fresno County Depart. of Public Health. Contact David Pomaville at 559-445-3200. Part time physician for weight loss clinics in Bakersfield. Possible buy-in. Established practice with potential. Fax CV to 805-644-7943 or email: swhitcomb@pro-weight-control.com

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

MEDICAL OFFICES FOR LEASE 2323 16th St. – 1,194 rsf. 2323 16th St. – 1,712 rsf. 2323 16th St. – 2,568 rsf. 8327 Brimhall – 1,629 rsf. 8327 Brimhall – 2,288 rsf. Crown Pointe Phase II – 2,000-9,277 rsf. 3115 Latte Lane – 5,637 rsf. 3115 Latte Lane – 2,660-2,925 rsf. 9300 Stockdale Hwy. – 3,743 sf. 9330 Stockdale Hwy. – 5,754 rsf. 9508 Stockdale Hwy. – 454 sf (lab/draw station) 9900 Stockdale Hwy. – 2,085 sf. SUB-LEASE 4100 Truxtun Ave. – Can Be Split Medical Records & Offices Sprinklered – 4,764 rsf. Adm. & Billing – 6,613 rsf. FOR SALE 2019 21st Street – 2,856 sf. 3015 Calloway – 1,465-10,318 sf. Crown Pointe Phase II – 2,000-9,277 rsf.

2014 Yosemite Postgraduate Institute March 28-30, 2014 Yosemite National Park

Topics include: •Opioid Use and Misuse •Health and Wellness •Cardiology •Sports Brain Injuries • Rheumatology Tests & Diseases • HRT in Males and Females Osteoporosis

For Information and brochure: csrau@fmms.org or 559-224-4224x 118 or visit: www.fmms.org

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VITALâ&#x20AC;&#x2C6;SIGNS Post Office Box 28337 Fresno, California 93729-8337

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

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

NORCAL Mutual is owned and directed by its physician-policyholders, therefore we promise to treat your individual needs as our own. You can expect caring and personal service, as you are our first priority. Visit norcalmutual.com, call 877-453-4486, or contact your broker.

A N o r c A l G r o u p c o m pA N y