May 2015 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

See Inside: CMA Takes On Public Health, Medi-Cal With 2015 Sponsored Legislation Efforts to Curb Rx Misuse Could Be Fueling Heroin Use Antitrust Risk in Healthcare Provider Consolidation ICD-10-CM Code Set Boot Camp

May 2015 â&#x20AC;˘ Vol. 37 No. 5

Vital Signs

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Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society

Contents EDITORIAL.................................................................................................................................5 NEWS

CMA NEWS.............................................................................................................................6

HEALTHCARE REFORM............................................................................................................8

May 2015 Vol. 37 – Number 5

PRACTICE MANAGEMENT: Gorillas Under the Fist......................................................................9

Editor Alan Birnbaum, MD

Fresno-Madera Medical Society......................................................................................10

CLASSIFIEDS..........................................................................................................................15

• Physicians Needed

• In Memoriam: Edward J. Neufeld, MD

Fresno-Madera Medical Society Editorial Board Virgil M. Airola, MD Hemant Dhingra, MD David N. Hadden, MD Roydon Steinke, MD

• 2015 FMMS Directory Updates

• ICD-10-CM Boot Camp

• President’s Message

Kings Representative TBD

• Membership Recap

Managing Editor Carol Rau Yrulegui

Kern Representative John L. Digges, MD Tulare Representative Francine Hipskind Vital Signs Subscriptions Subscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medical Society, PO Box 28337, Fresno, CA 93729-8337.

Kern County Medical Society...........................................................................................12

TULARE County Medical SocieTY.......................................................................................13

• General Meeting

• Upcoming Events

• 2015 TCMS MICRA Savings Chart

• Walk With A Doc

Advertising Contact: Display: Annette Paxton, 559-454-9331 apaxton@cvip.net Classified: Carol Rau Yrulegui 559-224-4224, ext. 118 csrau@fmms.org 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 559-2244224, ext. 118.

Cover Photograph: “ Springtime” by Ning Lin, OD, MD

Calling all photographers: Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee MAY 2015 / VITAL SIGNS

Time to go shopping... ...for a better deal on workers’ compensation.

There has never been a better time to shop the sponsored workers’ compensation plans offered through the Fresno-Madera, Kern and Tulare County Medical Societies/CMA. That’s because workers’ compensation insurance rates in California continue to move upward. The Insurance Commissioner recommended an increase of 6.7% in pure premium rates for 2015 compared to the average premiums charged as of July 20141. Your plan may experience a higher or lower rate increase than recommended by the Department of Insurance. Don’t just sit back and accept higher rates! Call Mercer to see if you can get a better deal through FMMS, KCMS and TCMS. Working with Mercer as the program administrator, the Societies sponsor best-in-class insurance plans at competitive premiums. By becoming involved with the sponsored plans you will receive valuable protection for your practice and employees while supporting the good work of your Society! Take control of your workers’ compensation costs. Call 800-842-3761 now for your free, no-obligation quote. Or visit www.CountyCMAMemberInsurance.com for more information and to download an application or premium indication form.

Sponsored by: Fresno-Madera Medical Society Kern County Medical Society Tulare County Medical Society

Scan for more info! Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 Copyright 2015 Mercer LLC. All rights reserved. • 777 South Figueroa Street, Los Angeles, CA 90017 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com 800-842-3761 • 69907/71369 (4/15)

Source: Workers Compensation Insurance Rating Bureau of California, http://www.wcirb.com/sites/default/files/documents/insurance-commissioners-decision-01012015_1.pdf 1

4 MAY 2015 / VITAL SIGNS

EDITORIAL Workman’s Wages: Value Versus Volume How Emerging Payment Plans Threaten Practice Viability Alan M. Birnbaum, MD Editor, Vital Signs

When Medicare trumpets that it will prospectively pay medical providers on the basis of VALUE rather than

VOLUME, doctors should be wary of political pickpockets in the room. Is “volume” such an evil word? Perhaps “productivity” sounds more politically correct! In truth VOLUME itself in healthcare has become harder to measure and confirm. WHAT really happened at the hospital or office visit? Mandated use of electronic health records persuades providers to cut and paste recycled content into a new note, corrupting charts with corpulent content, disguising the true extent of an encounter. While EHR’s deal effectively with ignobly illegible doctors’ handwriting, the great beauty of the fountain pen, ballpoint or roller ball pen was that they were stern and honest editors of content, eliminating ...the healthcare the superfluous and emphasizing true current care. Ink enforced honesty. Sadly multi-page cloned EHR “VALUE” that notes create code creep, with benefit to real quality. Medicare now But let’s return to that even more difficult concept of medical VALUE. My daughter’s boyfriend Matt, now a respiratory therapist at University Hospital in San Diego, in his prior career with the Gemological promotes Institute of America as a gemologist, worked by well-accepted objective criteria for diamonds, the “4 C’s”: represents a of Carat, Cut, Clarity and Color, to generate a reproducible assessment of gem value. In his new career, Matt totally different should understand that the healthcare “VALUE” that Medicare now promotes represents a totally different concept, whose concept, whose intent largely is to restrain cost rather than promote quality. My own professional organization, the American Academy of Neurology, tells me that, “The intent largely Department of Health and Human Services has set a goal of tying 30% of traditional or fee-for-service, is to restrain Medicare payments to quality or value through alternative payment models, such as accountable care cost rather than organizations or bundled payment arrangements by the end of 2016,” and even more in years after that. promote quality. Does that really have anything to do with medical quality or VALUE? Patients truly want quality care, a merger of accessibility, communication, health improvement and empathy, which together generate trust. Closely related is peer respect, that one physician receives from other doctors, the desirability for rendering a second opinion in cases with unclear diagnosis or problematic treatment options. Are not these definitions of quality worth rewarding? Don’t count on HHS caring! Who will define components of “VALUE”? What will be their relative worth? When and how often will measurements be made? How will these assays be conducted? WHY should practitioners condone the financial uncertainty such a system would generate in a private practice setting? HHS and allied commercial payors likely have little interest in quality as a patient might perceive it. One can roughly measure medical quality. To pretend however that such can ever be decimally-accurate goes against the facts of the matter. Health care quality will never become a crystal quantifiable under a 10X loupe. Physicians as much as the next laborer deserve assurance that their medical labor for a service will be recognized primarily related to the amount of time it takes. Similarly surgical or procedural services, where a faster performance may be safer, merit recognition mainly for complexity of the intervention. Regardless of the exact nature of a practice, motivation should remain that the harder one works, the greater the pay. Even salaried physicians should be rewarded for productivity. Beyond that, sharply different reimbursements for identical services in one system versus another need to be corrected to fair and equitable levels. Absent that our best and brightest physicians will flee the treacherous souk of the common medical market and seek refuge in cash only “concierge” practices, Yes, there should be VALUE in facility and physician reimbursement, creation of a calculated incentive to improve quality and efficiency, but only within doctor-accepted limits as a fractional modifier of overall productivity-payment. To concentrate on patient care, physicians need reasonable financial security. Absent such an expectation, our brightest students will look to other professions. A system based on the HHS cost-driven concept of value provides no such motivation. As government and business attempt to garrot the practice of medicine, imposing an onerous new financial order, hospitals and physicians should recall newscaster Howard Beale in the 1976 movie, Network screaming: “I’m mad as hell, and I’m not going to take it anymore!” Author may be reached at Siriusguy @aol.com. MAY 2015 / VITAL SIGNS

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6 MAY 2015 / VITAL SIGNS

CMA takes on public health, Medi-Cal with 2015 sponsored legislation

California Medical Association (CMA) sponsored bills for 2015 include a $2 per pack tax on cigarettes, increasing provider rates for Medi-Cal and establishing a Graduate Medical Education Trust Fund in light of inadequate funding levels from the federal government. SB 591 (Pan) – Cigarette and tobacco products taxes: California Tobacco Tax Act of 2015. This bill is the CMA-led Save Lives Coalition’s legislative strategy to increase the state’s tobacco tax by $2 per pack. The bill would allocate funds raised by the tax to tobacco prevention and education, programs provided by the California Department of Health Care Services (DHCS) and enforcement of tobacco laws. The Los Angeles Times recently editorialized in favor of SB 591. AB 1396 (Bonta) – Tobacco Tax Funding Implementation Medi-Cal. The bill would provide oversight for allocation of the funds raised by the SB 591 (Pan) tobacco tax that are slated for use by DHCS for Medi-Cal. It would require that DHCS meet the federal government mandate that Medi-Cal payments are consistent with certain standards and are sufficient to enlist enough providers to serve eligible populations. It would also require an annual independent assessment of whether Medi-Cal provider rates achieve those standards. SB 243 (Hernandez) and AB 366 (Bonta) – Medi-Cal Reimbursement Rates. Introduced in the 2015-16 California Assembly legislative session, these bills would dramatically improve access to care for Medi-Cal beneficiaries by repealing recent cuts to Medi-Cal provider reimbursement rates; increasing reimbursement rates for most outpatient providers to Medicare levels, for both fee-for-service and Medi-Cal managed care providers; and increasing hospital Medi-Cal rates on a one-time basis and requiring annual increases thereafter. Medi-Cal is one of the lowest paying Medicaid programs in the country. Despite the fact that California now has an estimated 12 million people eligible for Medi-Cal (nearly one third of the state’s population), California pays the third-lowest reimbursement rate in the country (California Healthcare Foundation, March 2014). By the middle of 2016, it is estimated that California’s Medi-Cal population will have grown by over 4.6 million people since 2011. The state needs to ensure that expanded coverage translates into timely access to medical services. Continued on next page

CMA NEWS Continued from page 6 AB 637 (Campos) – POLST forms. This bill would allow nurse practitioners and physician assistants, under physician supervision, to sign Physician Orders for Life-Sustaining Treatment (POLST) forms in an effort to increase utilization and to make a POLST an immediately actionable order. AB 1086 (Dababneh) – Assignment of reimbursement rights. Would require Knox-Keene regulated health care service plans to honor assignment of benefit agreements, thereby sending any payment directly to the out-of-network provider when such an agreement is present. It also requires that assignment of benefits agreements contain certain information that will assist the consumer/patient in determining out-ofnetwork cost exposure. AB 1434 (McCarty) – Health insurance prohibition on health insurance sales: health care service plans. The bill seeks to close an existing loophole that allows Blue Cross of California and Anthem Blue Shield to choose the regulator with which to file their PPO products. This loophole has resulted in the General Fund foregoing more than $1 billion from 2004 to 2011. The bill also requires the Department of Finance, in consultation with DHCS, as a part of the annual budget process, to determine if the implementation of AB 1434 has resulted in increased revenues to the General Fund. If so, the equivalent amount of that increase shall be appropriated to DHCS for the purpose of increasing provider rates under the Medi-Cal program. SB 22 (Roth) – Medical residency training program grants. Establishes a Graduate Medical Education Trust Fund that can receive contributions from private sources in order to provide grants to residency programs in areas with the greatest need. This bill is intended to serve as a vehicle for discussion among various health care stakeholders (physicians, provider groups, hospitals, clinics and health plans) about how to adequately and sustainably fund graduate medical education in light of inadequate funding levels from the federal government. SB 289 (Mitchell) – Telephonic and electronic patient management services.This bill requires health insurance companies licensed in California to pay providers for telephone and electronic patient management telehealth services. Currently, reimbursement for these services vary. Plans often deny physician requests for coverage, depriving patients of a reasonable alternative to face-to-face physician evaluations. SB 563 (Pan) – Workers’ compensation: utilization review. This bill seeks to limit potential conflicts of interest by requiring employers and insurers to disclose payment methodologies for those involved in the process of reviewing and approving, modifying, delaying or denying requests by physicians related to providing medical services to injured workers. It will also look to limit the ability to reopen old cases with lifetime medical awards through utilization review to deny treatment plans that were already approved and settled. SB 781 (Allen) – Emergency room physicians. Because emergency physicians see patients irrespective of their insurance status, they are not guaranteed a certain amount for treatment. This bill would create a system that provides the treating physician fair payment, with the insurer required to pay the amount of the 70th percentile of the Fair Health Database. If either the provider or the insurer disputes the payment, they must enter a mandatory, binding arbitration to determine whether the provider’s charges or the proposed payment by the insurer is “more” fair. For more information on these and other bills of interest to physicians, subscribe to CMA’s Legislative Hot List at www.cmanet.org/newsletters.

New study concludes that vaccine refusal helped fuel Disneyland measles outbreak

A new study conducted by research teams from MIT and Boston Children’s Hospital has concluded that parental resistance to vaccinations played a role in the Disneyland measles outbreak that started in January. The analysis, published in JAMA Pediatrics, showed that the highly contagious disease has spread to seven states and two other countries, largely because parents did not vaccinate their children. The study’s authors used simple math to determine that the vaccination rate among people who were exposed to measles during the outbreak was no higher than 86 percent, and might have been as low as 50 percent. At least 96-99 percent of the population must be vaccinated to establish herd immunity. SB 277 (Pan) is currently moving through the legislature and would remove the option for a personal belief exemption for immunizations, unless medically necessary. The California Medical Association supports the bill, which was recently endorsed by the Sacramento Bee. CMS’ Open Payment Program

The Centers for Medicare and Medicaid Services developed the Open

Payments Program to comply with the Physician Payments Sunshine Act (Sunshine Act). This requires CMS to publicly report data on items of value that are given to physicians and teaching hospitals on an annual basis. Physicians can register in the Open Payments System and review their 2014 CY data beginning Monday, April 6. The official 45-day review and dispute period runs from April 6-May 20. Disputes that are initiated by May 20th will be flagged in the public release on June 30. Physicians can go to the AMA website – www.ama-assn.org for step-by-step instructions on how to register and review their Open Payments data.

IMQ’s Certification Services make tracking CME credits easy

The Institute for Medical Quality (IMQ) offers a continuing medical

education (CME) certification service to make it easier for physicians to track their CME credits. Subscribers can now view and print their transcripts online. They can submit the required documents as email attachments directly to IMQ and enter their data on a submission form that can be downloaded from the IMQ website. The Medical Board of California requires physicians to participate in a minimum of 50 credits from board-recognized CME providers every two years. Thousands of California physicians rely on IMQ’s CME Certification Services to keep track of their credits and to reduce the time and difficulty of a medical board audit by having IMQ verify their CME. If selected for an audit, physicians only need to provide the CME verification they receive from IMQ and their work is done. IMQ’s Certification Services are also recognized by the American Medical Association as counting toward its Physician Recognition Award program. You’ll find more details at http://imq.org/ContinuingMedical Education/CMECertification.

CMA updates physician guide to getting started with PQRS

The California Medical Association (CMA) has just updated the “2015

PQRS and Value-Based Modifier Getting Started Guide,” free for physician members. Please see CMA News on page 15 MAY 2015 / VITAL SIGNS

HEALTHCARE NEWS EHR Coming to the Apple WatcH

It wasn’t very long ago that the idea of digitizing a patient’s long and complex medical history – which involves throwing together a hodgepodge of different kinds of data – seemed like a pipe dream. But just five years after the passage of the Affordable Care Act, not only are health records digital, they can now be worn on the body by doctors and patients like a fashion accessory. This is because startup technology company drchrono Inc., which has made electronic health records available for the iPhone and the iPad, is migrating its product to the new announced Apple Watch. “Just picture a doctor coming down the hallway with his arms full of paper files and devices, who is not really able to engage with anyone,” said drchrono Chief Executive Michael Nusimow. “Now picture that doctor with his hands free, because a lot [of his necessary data] is on his wrist. The wearable health record has become a reality.” Obviously, a physician is not going to be pulling up X-rays and analyzing PET scans on the small screen offered by a wristwatch. But that’s not the point, company founders said. Efforts To Curb Rx Misuse in Calif. Could Be Fueling Heroin Use

A significant rise in the number of patients being treated for heroin

overdoses in California hospitals could be attributed in part to increased efforts to stem prescription drug misuse, Payers & Providers reports. The number of patients being treated for heroin overdoses increased by more than 90% between 2005 and 2013, according to new data from the California Office of Statewide Health Planning and Development. The data show that the number of patients treated at hospital emergency departments for heroin overdoses rose from 1,284 cases, including 298 admissions, in 2005 to 2,449 cases, including 541 admissions, in 2013. In the first half of 2014, California hospitals saw 1,325 patients in the ED and admitted 301 patients for heroin overdoses. Roneet Lev, director of operations at San Diego-based Scripps Mercy Medical Center’s ED, attributed the rise in heroin overdoses in part to efforts to stem prescription drug misuse. Individuals who misuse prescription drugs, such as Oxycodone, often turn to heroin as a lower-cost option when they can no longer obtain opioid pills legally, according to experts.

Enterovirus Could Be Causing Paralysis of Kids in Calif., Other States

Cases of paralysis among children in California and other states could be

associated with a mutated strain of enterovirus D68, according to a UCSan Francisco study published Monday in the journal Lancet Infectious Diseases, the New York Times reports (Saint Louis, New York Times, 3/30). Amid the outbreak, doctors across the country reported a rising number of cases in which children experience arm or leg weakness or complete paralysis, requiring them to be put on ventilators, according to the Washington Post’s “To Your Health” (Eunjung Cha, “To Your Health,” Washington Post, 3/30). Specifically, 115 children in 34 states have developed such paralysis since August 2014, according to the Times. For the study, UCSF researchers examined the genetic sequences of enterovirus D68 taken from 25 children with limb paralysis, 16 of whom had been treated at Children’s Hospital Los Angeles or identified by the California Department of Public Health as early as June 2012.

8 MAY 2015 / VITAL SIGNS

Viruses found in the children were genetically similar and shared mutations resembling those in the poliovirus genome. The researchers determined the viruses to be a new strain of the respiratory illness, called B1, which they estimated to have emerged more than four years ago (New York Times, 3/30). According to “To Your Health,” the mutated strain has just five or six coding differences from more common enterovirus strains, but the mutations were similar to sequencing in the poliovirus or EV-D70, another nerve-damaging virus. Meanwhile, the findings suggested that the B1 strain can affect patients differently, depending on variations in an individual’s biology. However, researchers could not find a definitive link, as no evidence of enterovirus was found in patients’ spinal fluid.

Study: Non-Injury Visits to Calif. Emergency Departments Up

Non-injury visits to California emergency departments have increased

by more than 13% in recent years, according to a study published Monday in Health Affairs, the Los Angeles Times’ “Science Now” reports (Morin, “Science Now,” Los Angeles Times, 4/6). During the study period, visits to the ED for non-injuries increased by 13.4%. Meanwhile, the visit rate for injuries declined by 0.7% (Hsia et al., Health Affairs, April 2015). According to the study, the fastest-growing complex health issues diagnosed in California EDs included abdominal pain; gastrointestinal disease; and nervous system disorders. The study also found that: • Complex medical issue visits outpaced injury visits among patients with Medicaid coverage and private insurance, as well as the uninsured; and • The rate of complex visits equaled that of injury visits among older patients covered by Medicare. “This could reflect an increasing incidence of injury among the elderly as a result of a variety of factors, including increasingly active lifestyles or increasing severity of injury, resulting in the need for growing amounts of emergency care,” according to the study.

70% of Calif. Small Businesses Could See Rate Changes in 2016

Under

the ACA, all health plans must include 10 essential benefits, including hospitalization, prescription drugs, maternity care and mental health treatments. The law’s employer mandate provision stated that any health plans that do not meet all 10 requirements would be canceled at the end of 2014. However, in July 2014, Gov. Jerry Brown (D) signed into law a bill (SB 1446) that gave state businesses with fewer than 50 employees an extra year to obtain ACA-compliant health coverage. If the eligible businesses’ sponsored health plans still do not meet the law’s requirements at the end of 2015, such plans will be canceled (California Healthline, 7/8/14). Patrick Burns, president of the California Association of Health Underwriters, said, “Most of the small group plans that had larger-thanaverage rate increases by switching to ACA plans [instead] grandmothered their plans” to avoid higher rates.

PRACTICE MANAGMENT

Gorillas Under the Fist: The Anitrust Risk in Healthcare Provider Consolidation Daniel O. Jamison, Esq. Dowling Aaron Incorporated

Section 7 of the Clayton Antitrust Act bars mergers whose effect “may be substantially to lessen competition, or tend to create a monopoly.” If violated, undoing the merger is customary. The Affordable Care Act incentivizes consolidation of healthcare providers. Accountable Care Organizations (“ACO”) and nonprofit medical foundations now engulf independent practices. The government justifies the trend based on perceived efficiencies and improved patient care. This trend conflicts with the brute force of the antitrust laws. The federal Ninth Circuit Court of Appeals recently addressed the following Idaho merger. Nampa, located some twenty miles from Boise, is Idaho’s second largest city. Saltzer Medical Group had 16 primary care physicians practicing in its Nampa offices. Saint Alphonsus Health System operated the only hospital in Nampa. Saint Alphonsus also jointly operated an outpatient surgery center with Treasure Valley Hospital Limited Partnership. Saint Alphonsus had 9 PCPs in Nampa. Saint Luke’s Health Systems operated an emergency clinic in Nampa and a hospital in Boise. St. Luke’s had eight PCPs in Nampa. In 2012, St. Luke’s acquired Saltzer’s assets and entered into a five-year professional services agreement with the Saltzer’s physicians. St. Luke’s paid Saltzer $9 million for goodwill. The FTC, State of Idaho, Saint Alphonsus and Treasure Valley sued under Section 7 of the Clayton Act. The parties did not dispute that the relevant product markets were adult PCP services and hospital based ancillary services. The relevant geographic market was crucial. The plaintiffs contended the geographic market was Nampa; the defendants argued that it included Boise and beyond. The relevant geographic market covers where a monopolist could impose a price increase in the proposed market that buyers would pay regardless of the increase. Although one-third of Nampa residents traveled to Boise for PCPs, Nampa was the relevant market. Insurers needed to have Nampa PCPs. Insured patients would not change their behavior such that the one third that already went to Boise would increase. The merger thus posed a threat in the Nampa market that the consolidated entity could demand a price increase from the health plans. In Nampa, the combined entity would have 24 PCPs compared to 9 for Saint Alphonsus in the market. The merger was presumptively anticompetitive. E-mail of St. Luke’s executives also discussed pressuring payors for new agreements; Saltzer executives’ e-mail discussed that they could use the “clout of the entire network.”

In rebuttal, St. Luke’s contended a capitated integrated care system that would improve efficiencies and patient care was pro-competitive. The Ninth Circuit questioned whether there is an “efficiency defense,” but it was insufficient to show that the merger would better serve patients – the The claimed efficiencies must instead rebut government the predicted anticompetitive effects justifies the of the merger. Section 7 was violated for PCP services. trend based Section 7 was not violated for on perceived ancillary services. Proof was lacking efficiencies that Saltzer physicians would and improved improperly label in-house services patient care. as hospital-based or force patients to This This trend travel to St. Luke’s Boise hospital for services that could be provided inconflicts house in Nampa. with the brute Rather than divestiture, St. force of the Luke’s argued that the Court should antitrust implement separate bargaining groups laws with firewalls and anti-retaliation provisions. St. Luke’s also contended that Saltzer could not survive as an independent entity. However, Saltzer employees had testified that Saltzer could survive. The $9 million payment for goodwill ameliorated any financial hardship on Saltzer. Complete divestiture was ordered. Other government guidance provides that if an ACO’s market share is 30% or less, there is an antitrust “safety zone” that invites less government scrutiny. In certain rural settings, the “safety zone” may allow a greater market share. If an entity is outside the “safety zone,” it may encounter a Clayton Act Section 7 challenge. Sections 1 and 2 of the Sherman Antitrust Act prohibit monopolies, attempts to monopolize, conspiracy to monopolize, and combinations that unreasonably restrain trade. They allow recovery of triple the plaintiff’s actual damages and attorney fees. Defendants could be dismantled and face a whopping money judgment. Despite the government’s encouragement of healthcare consolidation, would-be gorillas risk an antitrust haymaker. Mr. Jamison is chair of the Health Law Section at Dowling Aaron Incorporated. His work includes healthcare antitrust cases.

MAY 2015 / VITAL SIGNS

Fresno-Madera Physicians Needed River Way Ranch Camp 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 A.M. Aminian, MD President Hemant Dhingra, MD President-Elect Ahmad Emami, MD Vice President Alan Kelton, MD Secretary/Treasurer Prahalad Jajodia, MD Past President Board of Governors Alan Birnbaum, MD William Ebbeling, MD David Hadden, MD Joseph B. Hawkins, MD Sergio Ilic, MD Trilok Puniani, MD Ranjit Rajpal, MD George Saul, MD Roydon Steinke, MD Connor Telles, MD Cesar Vazquez, MD CMA Delegates FMMS President Don Gaede, MD Brent Kane, MD Brent Lanier, MD Andre Minuth, MD Ranjit Rajpal, MD Oscar Sablan, 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 CMA Trustee District VI Virgil Airola, MD Staff Carol S. Yrulegui Interim Executive Director Doreen Chaparro Physician Liasion

10 MAY 2015 / VITAL SIGNS

Camp physicians needed for one-week duration at River Way Ranch Camp at Wonder Valley, located in the foothills of Sequoia and Kings Canyon National parks. This camp serves youth 7-16 and provides over 70 activities. Physicians will be partnered with a registered nurse to assist in caring for campers. Required to be present in the medical infirmary during designated four, forty-five minute “sick call” and “med call” time periods – and be available in the event of an emergency the RN cannot handle. In exchange for service, room and board provided in addition to physician’s family can attend the camp for no charge and participate in all activities. Dates needed for a physician are: • June 21-28 • June 28-July 5 To inquire: email Ashley@RiverWayRanchCamp.com or call (800) 821-2801 ext. 459. 2015 Summer Clinical Internship Program •U CSF-Fresno Latino Center for Medical Education and Research

Health Professionals serve as mentors and provide clinical exposure and experiences in a clinical setting at least 3 days a week. The mentor will work with UCSF Fresno Latino Center staff in identifying a schedule. To inquire on dates and other information email aallison@fresno.ucsf.edu or call (559) 241-7670.

2015 FMMS Directory Updates CCFMG PHYSICIANS

Charnjeet Brar, MD *PD 290 N. Wayte Ln. 559-499-6562

Ellie Chan, MD *ON *HEM 2335 E. Kashian Ln. #301 559-256-9680

Christopher Downer, MD *OBG 2210 E. Illinois #408 559-443-2694

Nathan Hoekzema, MD *ORS 7235 N. First #103 559-432-2600

Ian Johnson, MD *NS 45 River Park Pl. W. #104 559-320-0530

In Memoriam Edward J. Neufeld, MD 39-year member

Edward Neufeld, MD, a retired surgeon, passed away March 13, 2015 at the age of 79.

Dr. Neufeld was born in Drake, SK, Canada in 1935. He received his medical degree from the University of British Columbia in 1962, completed his internship at Los Angele County Hospital and his residency training at Shaugnessy Hospital in Vancouver, BC. After serving as a general practitioner for two years in Canada, Dr. Neufeld completed a general surgical residency at Valley Medical Center in Fresno. Upon completion of his training, Dr. Neufeld served a medical missionary in Africa for four years. He returned to Fresno in 1972 where he opened his private practice and retired in 1992. Dr. Neufeld is survived by his four children, 13 grandchildren and one great-grandchild.

Fresno-Madera

MAY 2015 / VITAL SIGNS

Kern Michelle S. Quiogue, MD, FAAFP Department of Family Medicine Kaiser Permanente Kern County 2229 Q Street Bakersfield, CA 93301-2900 661-325-9025 Fax 661-328-9372 website: www.kms.org Officers Michelle S. Quiogue, MD President Vipul R. Dev, MD President-Elect Eric J. Boren, MD Secretary Bradford A. Anderson, MD Treasurer Alpha J. Anders, MD Past President Board of Directors Alberto Acevedo, MD William J. Farr, MD Susan S. Hyun, MD Kristopher L. Lyon, MD Betsy Matkovic, MD Mark L. Nystrom, MD Eric A. Peck, MD Edward W. Taylor, III, MD Linda P. Veneman, MD CMA Delegates Jennifer Abraham, MD Lawrence N. Cosner, Jr., MD Vipul Dev, MD John Digges, MD CMA Alternate Delegate Sarah Assem, MD CMA YPS Delegate Cyrus R. Moon, MD Staff Sandi Palumbo Executive Director Kathy L. Hughes Administrative Assistant

President’s Message Given today’s complex system for crafting health care policy, it’s inevitable that major issues in medicine will sometimes be decided in the courtroom.

Understanding this reality, CMA’s Center for Legal Affairs stands ready to defend the rights of California physicians in the courts, while also working to influence policy crafted by the Legislature, regulatory agencies and the private sector. Much of their involvement in the courts consists of amicus curiae or “friend of the court” briefs filed in cases that have the potential to affect the House of Medicine. These cases are often in the Court of Appeal or headed for the Supreme Court, meaning their outcomes could be as equally binding as statutes passed by the Legislature. Other instances call for more direct, and impactful, involvement on members behalf. While ready to defend the rights of physicians in court, CMA’s legal team also works to provide comprehensive education resources to members. Health Law Library Containing over 5,400 pages of up-to-date information on a variety of subjects of everyday importance to practicing physicians, the health law library is the most comprehensive health law and medical practice resource for California physicians. It includes the content from the California Physician’s Legal Handbook, as well as more specialized information on peer review, payor contracting and other topics. Documents are free to members ($2 per page for nonmembers) and are available online in the resource library or by calling the member help center, (800) 786-4262. Legal Information Line The legal information line provides members with information and resources about laws and regulations that impact the practice of medicine. While CMA staff cannot provide physicians with individual legal advice, their health law information specialists, with the support of CMA legal counsel, will help you find legal information and resources on a multitude of health-law related issues, ranging from OSHA requirements to the retention of medical records. This service is free to members (not available to nonmembers). Among the Legal Resources available to members are: • Closing a Medical Practice • Contract Analysis Service • Patient-Physician Arbitration Agreements • Balance Billing Toolkit • Employment of Allied Health Professionals by Medical Corporations • HIPAA Resources: o HIPAA Privacy and Security Rule Training Manual for Physician Office Staff o HIPAA Compliance Toolkit/Priva Plan • OMSS Resources: o Medical Staff Bylaws Analysis Service o Model Medical Staff Bylaws For assistance, call the member help center, (800) 786-4262 or e-mail legalinfo@cmanet.org. BENefits at your fingertips Activate your CMA web account today at www.cmanet.org CMA staff ready to serve you by calling (800) 786-4262

12 MAY 2015 / VITAL SIGNS

April 2015 Membership Recap Active....................................................................................................256 Resident Active Members...........................................................14 Active/65+/1-20hr.............................................................................4 Active/Hship/1/2Hship................................................................0 Government Employed...................................................................4 Multiple Memberships....................................................................1 Retired....................................................................................................63 Total....................................................................................................342 New Members (Pending Dues)..................................................1 New Members (App Pending)...................................................0 Total Members..........................................................................343

Kings

Tulare TCMS General Membership Meeting

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 Jacqueline G. DeCastro, MD Thomas S. Enloe, Jr., MD Michael MacLean, MD Kenny Mai, MD CMA Delegate Ying-Chien Lee, MD Staff Marilyn Rush Executive Secretary

On April 9, Dr. Peter Bretan, MD, FACS, a practicing urologist and transplant

surgeon in Novato shared highlights of life experiences in his professional practice and also in his public service contributions. TCMS members enjoyed listening to his stories collected in his multiple mission trips to the Philippines, where he frequently goes to teach local physicians about kidney Dr. Peter Bretan, Dr. Monica transplantations and laparoscopic guest speaker Manga, TCMS kidney removals. One particular one President of note was how he blindly needed to complete a transplant surgery during a rolling brownout of electricity. Those in attendance saw pictures of patients he treated and their family members, as they often were the kidney donors. He encouraged Dr. Ben & Laurel Brennan physicians to take part in medical mission trips as the experiences often renew the altruism and excitement that led them into medicine. Often times these medical missions provide the last hope for life many of the local residents. It is clear that Dr. Dr. Jerry Jacobsen, Dr. Dan Jones, Bretan lives closely aligned with his retired member TCMS new board mission statement: “In Life, there are member no careers that yield greater rewards than those that help comfort the weary, health the sick and save lives.”

Dr. Ammon Rasmussen and ATSU OMS-II Will Goodrich

TULARE COUNTY MEDICAL SOCIETY

Wine Social May 8, 2015 • Chinese Cultural Center

3333 S. Fairway Visalia, CA 93277 559-627-2262 Fax 559-734-0431 website: www.tcmsonline.org Officers Monica Manga, MD, ABIM President Virinder Bhardwaj, MD President-Elect Raman Verma, MD Secretary/Treasurer Thomas Gray, MD Past President Board of Directors Anil K. Patel, MD Jerry Jacobson, MD Pradeep Kamboj, MD Matthew Kirkman, MD Christopher Rodarte, MD Antonio Sanchez, 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 Membership Dana Ramos Administrative Assistant Lydia Garcia Administrative Assistant

Nurses Day May 16 MAY 2015 / VITAL SIGNS

Tulare Upcoming Events CODING ICD-10-CM WORKSHOP: ADVANCED

savings OF over

79,000

The Medical Injury Compensation Reform Act (MICRA) is California’s landmark law that provides for injured patients and stabilizes medical liability rates. In 2014, California’s trial lawyers launched an attack to undermine MICRA and its protections. With your commitment and grassroots advocacy, Proposition 46 was defeated at the ballot box. Your membership has never been so valuable!

Tuesday&Wednesday, June 16 & 17, 2015 9am-4pm; Visalia Convention Center $169 per person to TCMS physician members and staff

MEDICAL TERMINOLOGY WITH ANATOMY & PHYSIOLOGY Thursday, June 18, 2015 9am-4pm; Visalia Convention Center (Sequoiaupstairs) 303 E. Acequia, Visalia $89 TCMS members This CME-approved course in relevant for providers and practice staff involved in diagnostic and procedural coding. Office managers also are encouraged to attend. Bring a medical dictionary If you have any questions, please feel free to call the Tulare County Medical Society office at 559-734-0393 and ask to speak to Dana Ramos. You may also email her at DRamos@tkfmc.org .

Tulare County physicians are saving an average of $79,046 this year Are you a TCMS/CMA member? 2014 TULARE COUNTY MEDICAL SOCIETY MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

$7,976

$36,865

$24,329

(Non-Invasive)

Tulare County

$28,147

Connecticut

$92,782

$34,700

$170,389

$99,290

District of Columbia

$73,018

$24,010

$147,595

$81,541

New York

$136,398

$36,484

$214,999

$129,294

CT-DC-NY Average

$100,733

$31,731

$177,661

$103,375

$72,586

$23,755

$140,796

$79,046

MICRA Savings

Tulare County Medical Society 3333 S. Fairway, Visalia, CA 93277 Phone: (559) 627-2262 Fax: (559) 334-0090 * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 39, No. 10, October 2014. Annual rates with limits of $1 million/$3 million.

14 MAY 2015 / VITAL SIGNS

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. ANYONE CAN ATTEND! For more information, please contact Tulare County Medical Society at (559) 627-2262 TULARE: Del Lago Park Saturday, May 16, 2015 Topic: FITNESS Registration: 8:00am Walk Time: 8:30am VISALIA: Blain Park, 3101 S. Court St. Saturday, May 9, 2015 8:00 to 9:00 am

CLASSIFIEDS CMA News Continued from page 7 The Medicare Physician Quality Reporting System (PQRS) was federally mandated by legislation and requires physicians to report quality information to Medicare or suffer a fee reduction in 2015. This guide will assist physicians in determining how to proceed with successful reporting. Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.

Health LAw Library

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. FRESNO ANNOUNCEMENT

. University Psychiatry Associates: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC, M-F 8am-5pm. Call 559-320-0580. PHYSICIAN WANTED . On-site urologist seeking FM/IM physician to collaborate wellness programs and referral resources in addition to sexual health/urology practice. Office space available to share in N/E Fresno at 7005 N. Milburn. Call Shelby at 559-277-3963.

FOR LEASE / RENT / SALE

Prime location medical offices, across the street from Visalia Medical Clinic. 2200 sf., 5601 W. Hillsdale Ave., Visalia. Call 559-786-0512. Office space in prime medical location at 220 S. Akers St., Visalia. Perfect for primary care or allergy specialist to open practice in vacated allergist office. Call Shelby at 559-277-3963.

KERN

The

California Medical Association’s (CMA) online health law library contains over 4,500 pages of medical-legal, regulatory, and reimbursement information. ON-CALL documents are free to members and can be found in CMA’s online resource library. Nonmembers can purchase medical-legal documents for $2 per page

TULARE

FOR SALE

Place your next classified here! Vital Signs has over 1,300 monthly readers. Reach physicans just like YOU with your need or want.

1880s Victorian office building, corner lot next to Cancer Center & San Joaquin Hosp. 1200 sf, off-street parking; wheel chair ramp; lobby; secretarial area; 3 offices; conference rm; kitchen; basement; alarm; storage building. $450,000 OBO, 1402 26th St. Bakersfield. Call Don 661327-2367 or Mike 661-747-4553. Well established, turnkey medical weight loss clinic. Over 300 active patients and thousands to build from. Cash business with bariatric computer system. Finance with ProMed Financial. Contact Susan at wtloss4sale@yahoo.com.

MAY 2015 / VITAL SIGNS

VITAL 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.

Proud to be endorsed by the Fresno-Madera, Kern, Kings and Tulare Counties Medical Societies

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