July 2014

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: Surviving Covered California Recommendations for Optimal Blood Use Be a Key Legislative Contact

Vital Signs

July 2014 • Vo V Vol. l. 36 No. 7

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

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2 JULY 2014 / VITAL SIGNS

Vital Signs Official Publication of Fresno-Madera Medical Society Kings County Medical Society Kern County Medical Society Tulare County Medical Society July 2014 Vol. 36 – Number 7

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

Contents NEWS

AFFORDABLE HEALTHCARE ACT: Surviving Covered California.....................................................5

BLOOD CENTER: AABB’s List of Recommendations for Optimal Blood Use...................................7

LEGISLATIVE NEWS: Your Voice is Key to Our Success in the Capitol: Be a Key Contact................8

HEALTHCARE NEWS..............................................................................................................10

The “Other” Trial Lawyer Health Care Proposition.....................................................................10

CLASSIFIEDS..........................................................................................................................19 TULARE County Medical SocieTY.......................................................................................11 • HIPPA and Your Vendors

• Coding Book News

• Walk With A Doc

Kern County Medical Society...........................................................................................13

• Medical Missionary Journey: Part One

Fresno-Madera Medical Society......................................................................................14

• President’s Message

• Legislative Meeting with Assemblyman Jim Patterson

• Walk with a Doc

Kings Representative TBD 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 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

Cover Photograph: “ Abandoned Dock,” Galapagos Islands

By Newton Seiden, MD 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.

JULY 2014 / VITAL SIGNS

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A former employee sued me for wrongful termination.

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. FMMS, KCMS and TCMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are: A Helpline staffed by experienced employment defense attorneys.

Any manager, officer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

For more information on these important benefits, and the special FMMS, KCMS and TCMS First-Time Buyers Program, please contact Mercer at: 800-842-3761 or email us at CMACounty.Insurance.service@mercer.com

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim.

Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

EEO compliance training for managers/supervisors. An internetbased training program, compliant with California law, provides supervisors with sexual harassment training.

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

Optional Wage and Hour Defense Coverage. (Subject to additional premium.)

Ask about our First-Time Buyers Program.

65457 (7/14) Copyright 2014 Mercer LLC. All rights reserved. • 777 S. Figueroa St., Los Angeles, CA 90017 www.CountyCMAMemberInsurance.com • CMACounty.Insurance.service@mercer.com

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • 800-842-3761

AFFORDABLE HEALTHCARE ACT

Surviving Covered California Provided by California Medical Association

Covered California reports that nearly 1.4 million individuals have enrolled in exchange plans, which significantly surpasses original targets, making it critical that physicians and their staff know what to expect from these products. To help answer some of the more common questions, the California Medical Association (CMA) offers this information to assist physician practices in surviving this major change in health care.

How can I identify whether an exchange patient is in months two or three of the grace period? Enrollees who receive federal premium subsidies to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums.

Insurance ID cards for exchange enrollees do not indicate whether the enrollee is subsidized. Current enrollment trends, however, predict that 88 percent of those with exchange coverage will be subsidized and receive the three-month grace period. In other words, those with a Covered California logo on the ID card will most likely will have the three-month grace period.

In the first 30 days of the grace period, federal law requires plans to pay for services incurred, but in months two and three of the grace period plans can pend and deny claims. So it will be extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible. If the patient is in months two or three of the grace period, the health plan should indicate that coverage is inactive or otherwise suspended.

CMA queried Anthem Blue Cross, Blue Shield of California and Health Net, which account for approximately 75 percent of the total Covered California enrollees, on exactly what to look for in eligibility verification to identify patients who are in months two and three of the grace period. They report the following: Plan Name Grace Period Eligibility Status Indicator (Days 31-90 of grace period)

network. Confusion around these off-exchange products, also called “mirror” products, has resulted in a number of practices unknowingly seeing patients out-of-network for products that use a narrowed exchange provider network, as these ID cards will not have the Covered California logo. The issue is specific to just Anthem Blue Cross and Blue Shield of California, because they are the only two plans offering narrowed networks.

Sample Blue Shield ID Card

Blue Shield mirror products (bought off of the exchange but utilizing the exchange provider network) will list one of the following product names on the patient ID card: • Basic PPO/EPO • Enhanced PPO/EPO • Get Covered PPO/EPO • Preferred PPO/EPO • Ultimate PPO/EPO. Sample Anthem Blue Cross ID Card

Anthem Blue Cross Inactive pending investigation Blue Shield of California Pended Health Net Eligibility suspended

Unsubsidized exchange patients and those with a mirror product are not entitled to the 90-day federal grace period, rather they only receive the 30day grace period called for under state law.

What are my options if a patient presents with inactive coverage on account of the grace period? Practices should have policies in place regarding how they will handle patients who are in months two or three of the grace period. Patients should ideally be made aware of this policy in advance. If a patient’s eligibility verification comes back indicating his or her coverage is not active, the practice should treat the situation as they would any other patient who has had a lapse in coverage. For non -emergent services, patients may be given the option to either pay cash at the time of service or reschedule to a later date when their coverage is effective. The office policy should include how patients will be triaged to determine whether their condition is emergent or urgent and the policy should be approved by the physician.

How can I identify the off-exchange, or “mirror,” products that are sold outside of Covered California but utilize the narrowed exchange provider networks? Practices must review patient ID cards and eligibility information closely to identify whether the practice is in or out of network for that particular plan. Every plan offered in the exchange must also be offered outside of the exchange, using the same provider

Anthem Blue Cross mirror products (bought off of the exchange but utilizing the exchange provider network) will list “Pathway” (network name) on the bottom of the card. The product names for mirror products, which appear on the top of the ID card are: • Anthem Core DirectAccess (EPO/PPO) • Anthem Essential DirectAccess (EPO/PPO) • Anthem Essential Guided Access (HMO) • Anthem Preferred DirectAccess (EPO/PPO) • Anthem Premier DirectAccess(EPO/PPO) • Anthem Premier Guided Access (HMO) If you see these product or network names on the Anthem Blue Cross Please see next page JULY 2014 / VITAL SIGNS

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New Career Opportunities Available

KERN

FRESNO

FAMILY MEDICINE FACULTY

FAMILY MEDICINE FACULTY

Clinica Sierra Vista is seeking a Board Certified Family Medicine Physician to serve as faculty for the Rio Bravo Family Medicine Residency Program. Full and part-time teaching positions available!

Make a difference in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary offered.

Federal loan forgiveness may be available for qualified applicants.

Clinica Sierra Vista is seeking a Board Certified Family Medicine Physician to serve as faculty for the Sierra Vista Family Medicine Residency Program. Full and part-time teaching positions available!

Make a difference in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary offered.

Federal loan forgiveness may be available for qualified applicants.

Interested applicants may contact Clinica Sierra Vista

(661) 979-0812

6 JULY 2014 / VITAL SIGNS

Covered California Continued from page 5 or Blue Shield of California patient ID cards, it indicates the patient only has access to the narrowed exchange network. Again, these are the only two plans currently offering narrowed networks. The other nine plans generally offer their full network to exchange and mirror product patients.

Given the confusion and varying product/network names, CMA submitted a letter to Peter Lee, Executive Director of Covered California, and the Exchange Board of Directors, recommending Covered California develop new requirements of plans to clearly identify mirror products on patient ID cards, among other things.

What options are available for Covered California/mirror product patients who are having trouble finding in-network providers and/or facilities to provide care?

CMA has received a number of complaints about patient access to care issues, mainly in the narrowed networks offered by Anthem Blue Cross and Blue Shield of California. In fact, in a recent CMA survey of physicians’ experiences with exchange plans, more than half of physician respondents indicated that they have experienced difficulties finding an in-network physician or hospital to which they can refer their Covered California patients.

Patients who are having trouble finding an innetwork physician or facility are encouraged to file a complaint with the Department of Managed Health Care’s Help Center at 888-466-2219.

When calling, patients should indicate they have a Covered California plan and cannot find an in-network physician/facility that is reasonably accessible.

In addition to contacting the health plan, we ask that physicians and practice staff who are experiencing difficulties finding in-network providers notify CMA of the issue so that we may raise it with Covered California and the appropriate regulator. Issues may be submitted to our physician helpline at 888-401-5911 or economicservices@cmanet.org.

Still have questions? Visit CMA’s exchange resource center at www.cmanet.org/exchange. At the resource center, you may download CMA’s comprehensive exchange toolkit, “CMA’s Got You Covered: A Physician’s Guide to Covered California, the state’s health benefit exchange,” as well as a other CMA exchange resources. CMA members and their staff also have FREE access to our reimbursement helpline at 888-401-5911 or economicservices@cmanet.org.

BLOOD CENTER Choosing Wisely

AABB’s List of Recommendations for Optimal Blood Use Patrick C. Sadler, MD, Medical Director, Central California Blood Center

AABB (formerly American Association of Blood Banks) has issued its list of five recommendations that will assist in the evaluation of the need for transfusion of blood and blood components. The list, which was developed as part of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely campaign, highlights evidence-based recommendations that promote appropriate patient blood management, and was explained in an April 24 AABB press release. “If you look at the literature, as much as one-quarter of transfusions are probably unnecessary,” said Jeannie Callum, MD, FRCP, an AABB board member and associate scientist at Sunnybrook Health Sciences Center in Toronto. “Education is needed to inform physicians that they can use less blood and blood components and have equal or better patient outcomes.” The list of recommendations incorporates five key messages: • Don’t transfuse more units of blood than absolutely necessary; • Don’t transfuse red blood cells for iron deficiency without hemodynamic instability; • Don’t routinely use blood products to reverse warfarin; • Don’t perform serial blood counts on clinically stable patients; and • Don’t transfuse O-negative blood except to O-negative patients and in emergencies for women of child-bearing potential of unknown blood group.

According to AABB President Graham Sher, MD, PhD, the AABB board decided that joining the Choosing Wisely campaign was a sound opportunity to raise awareness about appropriate blood use beyond AABB’s own membership. The Choosing Wisely campaign’s goal of promoting appropriate use of tests and procedures matched with AABB’s strategic initiative focusing on patient blood management, stated the press release.

The Choosing Wisely campaign aims to promote conversations between physicians and patients that lead to informed and effective care choices that are supported by evidence, free from harm, and truly necessary. More information about AABB’s Choosing Wisely list and other patient blood management efforts can be found at http://bit.ly/QIJrrF. (Source: ABC Newsletter, 4/25/14)

JULY 2014 / VITAL SIGNS

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LEGISLATIVE NEWS Legislative Key Contact Program Your Voice is Key to Our Success IN THE CAPITOL

Health care reform, medical liability and insurance regulations are just a few of the vital issues being debated and voted on by decision-makers in Sacramento.

CMA has some of the best lobbyists, lawyers and other advocates in the Capitol, but the most powerful weapon in advancing the cause of physicians and their patients is you. Hearing from a physician with experience from the frontlines of medicine can make all the difference for a legislator facing a complicated health care issue.

Join the Fight to Protect Medicine Every cause needs powerful champions. That means you.

You don’t have to be a political expert or know a legislator directly to serve as a Legislative Key Contact. You just need the desire to make an impact, and CMA will give you the rest.

Quick and Easy CMA will provide you with all the tools you need to quickly and effectively deliver your message to legislators, from talking points to sample letters.

Strength in Numbers Organized medicine is strongest when more individual physicians speak up and are heard. The stronger we are, the greater the opportunity for success.

Campaign Insider Get all the latest infomation on upcoming elections and candidates running for office.

Capitol Insider You will get the latest insider information on legislation as it moves through the Capitol.

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Become a Key Contact Today!

Call 916-444-5532 or email grassroots@cmanet.org

LEGISLATIVE KEY CONTACT APPLICATION CONTACT INFORMATION Your office address will be used for providing matching legislator information. The program now supports email outreach only (we are no longer able to fax LKC Alerts), so please provide an email address that you check frequently.

Physician Name:_____________________________________________ CMA ID: _________________________________ Office Address: ______________________________________________________________________________________ Office City: ________________________________________ ZIP: _____________________________________________ Office Phone: ______________________________________ Office Fax: ________________________________________ Email: ___________________________________________ Specialty: _________________________________________ Component Medical Society:__________________________________ Political Party: ________________________________ TYPE OF PRACTICE o Solo/Small Group (1-4 Drs.) o Administrative

o Medium (5-150 Drs.)

o Academic/Faculty

o Alliance

o Large (150-1,000 Drs.)

o Govt. Employed

o Hospital Based

o Very Large (1,000+ Drs.) o Medical Student

o Retired

Name of Organization/Medical Group ______________________________________________________________________ Medical Staff Affiliations _______________________________________________________________________________ ELECTED OFFICIALS YOU KNOW Please indicate federal representatives and state legislators you know - even if they do not represent the district in which you practice or reside. See codes below for describing your relationship with the elected official.

Name(s)

Types of Relationship

________________________________________________

_______________________________________________

________________________________________________

_______________________________________________

________________________________________________

_______________________________________________

________________________________________________

_______________________________________________

Types of Relationship: CNST: constituent; NEI: neighbor; SOC: social acquaintance; FRI: friend; CON: campaign contributor; FUND: attended a fundraiser; MTG: met at a meeting; SUP: campaign supporter; *=immediate access to elected official: OTH: other (please specify) Please submit completed form to the Legislative Key Contact Program: MAIL: CMA, 1201 J St., Ste. 200, Sacramento, CA 95814 • EMAIL: grassroots@cmanet.org • FAX: 916.444.5689 JULY 2014 / VITAL SIGNS

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HEALTHCARE NEWS Dooley Discusses CALIFORNIA Health Reform

During the “Health for Tomorrow” conference at UC-San Francisco,

Diana Dooley, secretary of California’s Department of Health and Human Services and chair of the Covered California board, discussed the challenges and successes of implementing health reform in the state, KQED’s “State of Health” reports.

Dooley said that changes called for under the ACA -- including coverage expansion, payment and delivery reforms, and prevention and wellness initiatives – have prompted “disruptive innovation” in the health care industry. The changes mean that officials “can’t completely predict what the result is going to be,” she said.

Officials now are focusing on expanding provider networks, but Dooley said, “It’s going to take us a couple years at least to settle into a different relationship between the doctors, the plans, the hospitals and the referral systems for care.”

Doctor Counseling Program Bill Shelved

Last month, the Assembly Committee on Appropriations held back a bill (AB 2346) that would have created a statewide counseling program for physicians with mental health or substance misuse issues, the Los Angeles Times reports.

The bill, by Assembly member Lorena Gonzalez (D-San Diego), would have established a voluntary and confidential program for doctors in the state. The California Medical Association supported the bill. However, the measure was opposed by trial attorneys and consumer groups, which took issue with the confidentiality provision.

California Receives Largest Share of Multistate GSK Settlement

California Attorney General Kamala Harris (D) said the state will receive the largest share of a multistate settlement with British drugmaker GlaxoSmithKline over allegations of illegal marketing tactics, the San Francisco Chronicle reports (Lee, San Francisco Chronicle, 6/4).

In 2012, the U.S. Department of Justice announced a $3 billion settlement agreement with GSK to resolve allegations that the company broke U.S. laws in marketing several products. Under the agreement, GSK paid the settlement and pleaded guilty to misdemeanor criminal charges for illegally marketing antidepressants Paxil and Wellbutrin and for failing to report the safety data on diabetes drug Avandia.

The agreement was said to be the largest health care fraud settlement in U.S. history (California Healthline, 7/5/12).

In the latest settlement announced last month, GSK has agreed to pay a total of $105 million to 44 states and the District of Columbia over allegations that the company promoted certain drugs for unapproved uses. The drugs in question included Advair, an asthma drug; Paxil; and Wellbutrin (Berkrot, Reuters, 6/4).

Under the agreement, GSK is banned from paying health care providers to promote its products and from giving sales representatives incentives to promote the drugs for unapproved conditions. Harris said that California will receive $7.1 million of the settlement (San Francisco Chronicle, 6/4).

However, GSK did not admit any wrongdoing as part of the settlement (Reuters, 6/4).

Measles Cases Reach Highest Level in 14 Years, CDC Says

CDC has announced that of last month, there have been 288 confirmed cases of measles in the U.S. in 2014, the largest number since the disease 10 JULY 2014 / VITAL SIGNS

The “Other” Trial Lawyer Health Care Proposition on November Ballot Threatens Provider Reimbursement AND Access to Care

There is more than one proposition on the California ballot this

November that threatens health care providers and patients. The same groups pushing to change the Medical Injury Compensation Reform Act (MICRA) – “Consumer Watchdog” and their trial lawyer allies – are also pushing a separate measure that would give the state Insurance Commissioner sweeping new power over health care benefits, rates and co-payments for individuals and small groups.

The California Medical Association (CMA) is part of a coalition opposed to the measure, along with a broad group of county medical societies, specialty societies, hospitals, health plans, labor and small businesses.

CMA President Dr. Richard Thorp explained why so many provider groups are opposing the measure: “This initiative threatens physicians’ ability to provide the care that patients need by giving a single elected politician – the Insurance Commissioner – vast new power over health care benefits and rates. With recent cuts to the Medi-Cal program, we are already seeing the devastating impact it can have on patient access to care when politicians cut reimbursement rates below the cost of providing care. Additional cuts would result in an even more difficult time for patients that need care the most.”

Even worse, this measure gives a politician new power over benefits too. The last thing doctors and patients need is a politician having more power to interfere with what treatments are or aren’t covered – those decisions are best left to the exam room.”

Beyond these flaws, the insurance initiative has a hidden agenda – allowing trial lawyers and the sponsors to file costly new health care lawsuits. They buried a provision in the fine print that allows them to “intervene” in the regulatory process created under the Initiative and file lawsuits if they don’t like the results. In doing so, they can pocket millions of dollars in so-called “intervenor fees” – as much as $675/hour. In fact, the proponents have already received more than $11.5 million from a similar provision used in auto and home insurance regulation.

Many business groups and taxpayer organizations also oppose the measure because it sets up a costly, duplicative new bureaucracy, when California already has multiple regulators overseeing health care.

For more information or to sign up to oppose this measure, visit www.stophighercosts.com. was considered eradicated in the country, the Los Angeles Times’ “L.A. Now” reports (Brown, “L.A. Now,” Los Angeles Times, 5/29).

The number of cases this year is larger than the number of cases in the first five months of any year since 1994, according to CDC (Viebeck, The Hill, 5/29). CDC noted that nearly all the cases were connected to foreign travel by unvaccinated individuals and that about 90% of all patients with measles had not been vaccinated or did not know their vaccination status (Mehrotra, Wall Street Journal, 5/29).

Please see Healthcare News on page 12

Tulare HIPAA and Your Vendors Tim Torian, Torian Group, Inc., www.toriangroup.com

HIPAA’s updates have expanded the requirements of business associates. A “business associate” is a person or entity

that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. If you have not already addressed this issue, you may need to create or update written agreements with many of your vendors.

Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; benefit management; practice management; and re-pricing. Business associate services are: legal; actuarial; accounting; consulting; data aggregation; management; administrative; accreditation; and financial. These are non-employees that create, receive, maintain, or transmit protected health information (PHI). Examples of Business Associates include IT professionals, vendors such as software companies, bookkeepers, accountants, trainers, consultants, and other contractors that have access to the practice’s PHI. Business associates are responsible for their subcontractors, and they must comply with security and breach notification rules. Healthcare providers are liable for the actions of BAs who are agents, but not for those that are independent contractors. Here are some steps to take to assure compliance and limit your exposure: Implement or Update Security Policies and Procedures. A security breach poses the most significant risk for employers and business associates. Most settlements announced by HHS have involved a security breach. Six have resulted in settlements exceeding $1 million. Employers and business associates should implement or update policies and procedures to ensure compliance with the HIPAA Security Rules. It must be in writing. Review the basics and update your documentation. Make sure you are conducting the required risk assessments and addressing the findings in a written plan. Make sure your designated security officer is actually executing your security policies and plan. Consider outsourcing the IT portion of your assessment and corrective action if you don’t have the expertise.

Enter Into or Update Business Associate Agreements. For the first time, business associates are required to enter into business associate agreements with their subcontractors. The business associate agreements may not require significant changes for legal compliance purposes. However it is important to address potential liability for HIPAA violations. A significant number of privacy and security breaches involve a vendor. Do you have the updated Business Associate Agreement on file? Have you verified that the agreement does not disclaim responsibility? Are you confident in your business associates? The Business Associate Agreement must identify if the associate subcontracts with other individuals or groups. For example, if the medical office contracts with an IT professional and the IT professional subcontracts a computer technician and a breach occurs, who is responsible?

When writing or revising associate agreements, there are several critical elements to include: • Insurance – Ask if your business associates carries adequate liability insurance, and whether it covers a security breach.

• Security plan summary – A copy of the technical evaluation goes into the contract - requiring that the BA have adequate security, and be able to provide a written assurance of the security of protected data.

• Incident response – How long does it take the BA to respond? How long does it take them to protect? How long does it take them to remediate? Those types of questions all go into the contract. A 10 or 15 day time limit to disclose a security breach will give you time to do your own assessment and disclosure within the required 60 days.

In some cases you may need to educate those you contract with on these requirements. Covered health plans are not required to update their existing business associate agreements until September 22, 2014.

A sample Business Associate Agreement is provided by the Department of Health and Human Services: www. hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html.

Update or Implement Privacy Policies and Procedures. Employers that have previously implemented HIPAA policies and procedures will need to update them to address regulatory changes. Changes in the last year include the new standard for determining whether a security breach has occurred and new procedures regarding requests for access to PHI in electronic form.

Conduct Training. Employees need to be informed of the changes to HIPAA regulations that are relevant to their job functions. At the same time, employers and business associates can take advantage of the opportunity to provide refresher training.

The core of HIPAA compliance is good security practices. The burden of documentation and good planning are worthwhile considering the alternative. For more information is available at www.toriangroup.com/compliance.

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

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.

JULY 2014 / VITAL SIGNS

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Tulare 2015 Coding Book News

It is that time again to start purchasing

coding books. Order your 2015 editions of CPT, ICD-9, ICD-10, and HCPCS through us. We are offering extraordinary discounted rates and free shipping directly to your office.

Please contact Dana Ramos, Provider Relations to order or obtain more information: 559-734-0393 or dramos@ tkfmc.org.

Tulare County Medical Society presents

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.

TULARE Del Lago Park, Tulare, CA Saturday, July 26, 2014 8:00am to 9:00am VISALIA Riverway Sports Park, Visalia, CA Saturday, July 12, 2014 8:00am to 9:00am Who can attend: ANYONE For more information, please contact Tulare County Medical Society at (559) 627-2262

12 JULY 2014 / VITAL SIGNS

Healthcare News Continued from page 10 Of the 288 reported cases of measles, 43 individuals were hospitalized and none died.

Of the cases in which the origins of the disease could be traced, CDC reported that 22 cases were contracted in the Philippines, two in China, six in India and the remainder in 15 other countries.

In an “unusual twist,” more than half of the confirmed cases were found in patients ages 20 or older, the New York Times reports. The number could have included adults whose parents did not vaccinate them when they were children, CDC Director of Immunization and Respiratory Diseases Anne Schuchat said (McNeil, New York Times, 5/29).

The U.S. areas with the most measles cases include: • Ohio, with 138 confirmed cases; • California, with 60 confirmed cases; and • New York, with 26 confirmed cases.

The biggest outbreak, centered in the Amish community in Ohio, is a result of a high rate of unvaccinated residents. According to the Washington Post’s “To Your Health,” officials are not sure how the Amish community contracted the disease, but Schuchat noted they believe people traveling to conduct faith-based work in foreign countries might be involved (Bernstein, “To Your Health,” Washington Post, 5/29).

Ca Whooping Cough Diagnoses Triple 2013 Rates, DPH Data Show

More than 1,700 cases of whopping cough were reported in California between January and April – more than three times the number of cases during the same period in 2013, according to state Department of Public Health data released Friday, the AP/Sacramento Bee reports (AP/ Sacramento Bee, 5/16).

The outbreak of whooping cough this year has led to 77 hospitalizations, with the majority of cases in children ages three months or younger.

Two infants have died after being diagnosed with the illness – the first whooping cough deaths in California since 2010.

According to the Contra Costa Times, this year there have been at least: • 17 reported whooping cough cases in San Mateo County; • 19 reported cases in Solano County; • 27 reported cases in San Joaquin County; • 50 reported cases in Contra Costa County; • 56 reported cases in Alameda County; and • 82 reported cases in Santa Clara County

(Tsai, Contra Costa Times, 5/16).

DPH Director Ron Chapman said, “The last peak in California was in 2010, and now we are concerned that the recent increase in reported cases suggests that another cyclical peak is beginning” (DPH release, 5/16).

CMS, ONC Propose Rule To Extend, Alter Meaningful Use Timeline

Last month, CMS and the Office of the National Coordinator for Health IT announced a proposed rule that would give providers an additional year to upgrade electronic health record systems to meet reporting requirements for Stage 2 of the meaningful use program, Modern Healthcare reports (Conn, Modern Healthcare, 5/20).

The agencies noted that the proposed timeline change comes in response to stakeholder feedback about needing more flexibility. The proposed rule acknowledges that many software vendors have had difficulty upgrading their EHR products, receiving certification and upgrading customers’ systems in time to attest to the meaningful use program (Goedert, Health Data Mgt., 5/20).

The proposed rule would provide additional flexibility by allowing eligible professionals, eligible hospitals and critical access hospitals to use the 2011 Edition certified EHR technology or a combination of 2011 and 2014 Edition certified EHR technology for the 2014 EHR reporting period (Sullivan, Healthcare IT News, 5/21).

Providers would be able to attest to meaningful use under the 2013 reporting year definition and use the clinical quality measures from 2013.

Also providers scheduled to begin attesting to Stage 2 in 2014 who have run into vendor problems could use 2014 Edition certified EHR technology to meet the 2014 Stage 1 objectives (Gregg, Becker’s Hospital Review, 5/20).

The agencies noted that the proposed changes are “for 2014 only.” In addition, the agencies noted that providers seeking to qualify for Medicaid meaningful use in 2014 “must adopt, implement or upgrad e to 2014 Edition [certified EHR technology] only” (Health Data Management, 5/20). They specify, “In order to avoid inadvertently incentivizing the purchase of an outdated product that cannot be used to demonstrate meaningful use in a subsequent year… A provider would not be able to qualify for a Medicaid incentive payment for 2014 for adopting, implementing, or upgrading to 2011 Edition CEHRT or a combination of 2011 and 2014 Edition CEHRT” (CMS proposed rule, 2014).

Kern Kings Guest Editorial

Medical Missionary Journey 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 Alberto Acevedo, MD 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 Vipul Dev, MD John Digges, MD Lawrence N. Cosner, Jr., MD Staff Sandi Palumbo Executive Director Kathy L. Hughes Administrative Assistant

Thomas R. Larwood, MD with Portia Choi, MD The following article is a remarkable human interest story of Dr. Thomas Larwood’s life. It was first published in Levan Humanities Review, Volume 2, Issue 1 (2014). Over the next few months, we will continue with his story.

PART I Why did I become a medical missionary? My background gives clues. My maternal Grandfather was a Methodist Minister in Iowa and my Mother was a church organist and choir director. It’s too far back to count, but my paternal great, great Grandparents were Presbyterian missionaries to the Nez Perce, a Native American tribe whose territory covered parts of Washington, Oregon, and Idaho. On the way, my great-great-Grandmother, Eliza Hart Spalding, along with Narcissa Whitman became the first two Caucasian women to cross the Rockies.

Many of our family’s activities were church related, as were most of my closest friends. We had several visiting missionaries stay at our home, which helped bring the world to us. The road to becoming an Eagle Scout was a help.

Of the many influences, the simplest answer was in Isaiah, Chapter 6 Verse 8: “Also I heard the voice of the Lord, saying, ‘Whom shall I send, and who will go for us?’ Then said I, ‘Here am I, send me.”

In the ninth grade I decided to become an aeronautical engineer but while a freshman at Fresno State, I became doubtful about spending the rest of my life with numbers, so I talked to my Dad about it. He, a civil engineer and later a teacher, was not given to telling me what to do but rather would ask questions to help me find my own answers. He asked me what I was most interested in. I thought a bit, and then replied, “Science and people.” Then he wondered what that might add up to. The thought of my going into medicine had never seriously crossed my mind but it seemed to fit. The idea stuck and I became a pre-med student, never to look back.

After two years in college, I was drafted in 1944 and spent two years in the Navy Hospital Corps, which made me a better doctor later. Near the time of my discharge from the Navy, I was due to give the sermon at my home church in Fresno for Youth Sunday. On my way from the Oakland Naval Hospital, I stopped by for a brief visit at the Methodist Youth Conference being held at Monte Toyon near Aptos. I was struck that evening by Dr. Day’s talk in which he asked, “Are you going to invest your life or just spend it?” That night I felt that I had been called, so declared to the Methodist Board of Missions, my desire to be a medical missionary. The decision was enhanced by Gordon Seagraves’s book, “Burma Surgeon,” more so when he visited our church. Also by Albert Schweitzer, an accomplished interpreter of Bach on the organ, who became a physician and spent the rest of his life in Africa, with amazing results.

Following my last year of pre-med at UC Berkeley, I attended the U.S.C. School of Medicine. You might say it was a trial run for the future when I went on a Methodist Youth Work Camp in Mexico the summer after the first year of med school. Wally Duncan, a pre-med student from Indiana, who spoke no Spanish, and I walked around the countryside with two Mexican nurses, who spoke no English, giving smallpox vaccinations. My Spanish sure improved!

The rest of the guys were building a new playing field and basketball court at the school, constructing all from local materials with men from the community.

The fiesta that followed was participated in and enjoyed by all! My take-home message was that you do things with people, not for them.

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

Authors can be reached at trlarwood@bak.rr.com or ssportia@aol.com.

JULY 2014 / VITAL SIGNS

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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 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 Roydon Steinke, 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

14 JULY 2014 / VITAL SIGNS

President’s Message Another Reason for Attracting Physicians to the Area

In addition to the obvious need for more practicing physicians in our area to take care of patients, here’s another

reason to consider.

According to a couple of recent reports (The State Level Economic Impact of Physician Report (IMS Health, March 2014 and US Bureau of Economic Analysis: Current-Dollar GDP by State, 2012) California physicians not only have a positive impact on the health of their patients and communities, but also support the health of their local and state economies. We do this through the creation of jobs with their related wages and benefits, purchases of goods and services and large-scale support of state and local tax revenues.

These studies, conducted by IMS Health on behalf of the American Medical Association (AMA), demonstrate the significant level of support the physicians generate for California’s economy.

California National Total Patient Care Physicians 85,943 720,421 Jobs: 398,273 3,336,077 Total direct Jobs Supported by Physician Industry1 Total Indirect Jobs Supported by Physician Industry1 585,717 6,632,265 Total Jobs Supported by Physician Industry1 983,990 9,968,342 Average Jobs Supported by Each Physician including his/her own1 11.5 13.8

Sales and Revenue: Total Sales Revenue Generated by Physician Industry1 % of Total GSP/GDP2

$162.6 Billion 8.1%

$1.6 Trillion 10.2%

Wages and Benefits: Total Wages & Benefits Supported by Physician Industry1

$88.1 Billion

$775.5 Billion

$7.8 Billion

$65.2 Billion

Local and State Revenue: Total Local & State Revenue Generated by Physicians1

1. The State Level Economic Impact of Physicians Report (IMS Health, March 2014) 2. US Bureau of Economic Analysis: Current‐Dollar GDP by State, 2012 •••••

CMA’s Key Contact Program Current issues affecting physicians and patients are being decided in the legislative arena at a fast pace. While CMA has effective legislative advocates in the Capitol, there is no substitute for the legislator hearing from local physicians who have first-hand knowledge about how issues affects patients or the delivery of health care.

See pages 8-9 in this issue of Vital Signs for information on CMA’s key contact program and how to sign up. I urge all of you to participate. As a key contact you would be asked to communicate with the legislator of your choice.

CLASSIFIEDS

Fresno-Madera Members Meet With Assemblyperson Patterson

­­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

Fresno-Madera Medical Society

Legislative Committee Chair John Nelson, MD (left) discusses with Assemblyperson Patterson a bill he recently advocated against, AB 1215 and the effectiveness of grass-root campaigning that included motivating patients to write letters.

Assemblyperson Jim Patterson, a new member of the Assembly Health Committee, met with members of the FMMS Legislative Committee last month to discuss the future of health care delivery and current issues and bills of importance to medicine, including the support of: AB 2458: Funding for Primary Care Residency Programs AB1805: Restoring the Medi-Cal reimbursement cuts SB1000: Sugar-Sweetened Beverages Safety Warning Act. In addition to the above bills, the physicians emphasized the need to preserve physicians’ private practices and giving patients a choice on how to access care.

PHYSICIANS: Looking for ways to: • Add more physical activity to your lifestyle?

• Be a role model and inspiration to your patients and your community?

• Spend more time with your family and friends?

Consider volunteering ONE HOUR every month or two in the Fresno-Madera Medical Society’s: WALK WITH A DOC Program This walking program is risk free and requires no preparation. Physicians just need to: SPEND A SATURDAY MORNING: •P resenting a 2-3-minute presentation on the health benefits of walking from the perspective of your specialty • Leading a 45-50 minute walk around Woodward Park in Fresno or Town & County Park in Madera • Answering potential questions from the walkers Encourage patients to take steps to improve their health

FRESNO: JULY 26

Woodward Regional Park Sunset View Shelter Registration 7:15am Walk Event 7:30am-8:30am

MADERA: JULY 12

Town & Country Park Pavilion Area Registration 7:15am Walk Event 7:30am-8:30am

Ready to Volunteer?

For a schedule of dates and times Call the FMMS office: 559-224-4224x110 or send email to receptionist@fmms.org

Find us on Facebook: Fresno-Madera Medical Society

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

ANNOUNCEMENTS Fresno Gastroenterology welcomes boardcertified physicians Dr. Paul Hanchett and Dr. Vivek Mittal. Referrals appreciated. Call 559323-8200 or Fax: referral to 559-323-9200.

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.

FOR LEASE Office space at Chestnut/Herndon. Build to suit.

1,200 sf. Call 559-287-3279.

Medical office. 1,000sf, up to 2,500 sf at NE corner First/Herndon & NW corner First/Bullard; starting at $1 psf++ by owner. Call 559-824-9966 or 559-930-4297.

PHYSICIAN WANTED .

Spruce Multispecialty Group of Fresno, committed to the private practice of medicine, is recruiting a BE/BC IM, Rheumatology or Pulmonary specialist. Contact Rathin at 559-289-9518 or tharathin@gmail.com.

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

MEDICAL OFFICES FOR LEASE 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.

1150-1160 Lerdo Hwy, Shafter 1,766 to 3,793 sf.

9300 Stockdale Hwy. – 3,743 sf.

9330 Stockdale Hwy. – 5,754 rsf.

9900 Stockdale Hwy. – 2,085 sf.

500 Old River Rd. #185 – 3,071 sf.

SUB-LEASE 4100 Truxtun Ave. – 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.

JULY 2014 / VITAL SIGNS

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