Vital Signs October 2012

October 2012 Vol. 34 No. 10Official Magazine of

FRESNO COUNTYFresno-Madera Medical Society

KERN COUNTYKern County Medical Society

KINGS COUNTYKings County Medical Society

MADERA COUNTYFresno-Madera Medical Society

TULARE COUNTYTulare County Medical Society

Vital Signs

See Inside:

CMA’s Practice Resources: CPR

Regional TransportationPlans

Central Valley Cardiology Symposium

See Inside:

CMA’s Practice Resources: CPR

Regional TransportationPlans

Central Valley Cardiology Symposium

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Official Magazine of

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S A N D I E G O

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P A L O A L T O

S A C R A M E N T O

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VITAL S IGNS / OCTOBER 2012 3

Official Publication of

Fresno-Madera Medical Society

Kings County Medical Society

Kern County Medical Society

Tulare County Medical Society

October 2012Vol. 34 – Number 10

Editor, Prahalad Jajodia, MDManaging Editor, Carol Rau

Fresno-Madera Medical SocietyEditorial CommitteeVirgil M. Airola, MDJohn T. Bonner, MDHemant Dhingra, MDDavid N. Hadden, MDRoydon Steinke, MD

Kings RepresentativeTBD

Kern RepresentativeJohn L. Digges, MD

Tulare RepresentativeThelma Yeary

Vital Signs SubscriptionsSubscriptions to Vital Signs are$24 per year. Payment is due inadvance. Make checks payable tothe Fresno-Madera Medical Society.To subscribe, mail your check andsubscription request to: Vital Signs,Fresno-Madera Medi cal Society,PO Box 28337, Fresno, CA 93729-8337.

Advertising Contact:Display:

Annette Paxton,559-454-9331

[email protected]

Classified:Carol Rau,

559-224-4224, ext. [email protected]

ContentsVitalSigns

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

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

MEDICARE NEWS .......................................................................................................................9

NEWS

PRACTICE MANAGEMENT: CMA’s Practice Resources: CPR.........................................................7

AIR QUALITY: Regional Transportation Plans: What You Need to Know ......................................10

BLOOD BANK: Comparative Effectiveness Research in Transfusion Medicine ............................11

32nd Annual Central Valley Cardiology Symposium..................................................................12

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

FRESNO-MADERA MEDICAL SOCIETY .......................................................................................13

• President’s Message

• General Meeting Save the Date: November 7

• Skywatchers of Ancient Mexico: FMMS members only event October 17

• In Memoriam: Charles W. Beam, MD, and Thomas G. Sayeg, MD

• Educational Series and Economic Forum for FMMS members

KERN COUNTY MEDICAL SOCIETY ............................................................................................16

• In Memoriam: Hans Einstein, MD

TULARE COUNTY MEDICAL SOCIETY.........................................................................................17

• Executive Director’s Message

• DumpOnUs.org

Cover photography: “Chapel Bridge" Lucerne, Switzerlandby Cynthia Ginn, RN, CGCS

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

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CMA NEWSContact: CMA legal help line, 800-786-4262 or memberservice@

cmanet.org.

CMS RELEASES STAGE 2 REQUIREMENTSFOR MEANINGFUL USE

The Centers for Medicare & Medicaid Services (CMS) releasedthe final requirements for stage 2 “meaningful use.” The rule is partof a federal incentive program for Medicare and Medicaidphysicians who adopt and achieve “meaningful use” of electronichealth records (EHR), as authorized by the Health InformationTechnology for Economic and Clinical Health (HITECH) Act.

Stage 2 (which will begin as early as 2014) requires physiciansto use secure electronic messaging to communicate healthinformation to patients, as well as to allow patients to view healthrecords online.

The final rule modifies the definition of “hospital-based”physicians to create an application process for physicians todemonstrate that they alone fund their EHR systems and areeligible to receive the incentive payments directly.

The new rule also provides a flexible reporting period for 2014to give providers sufficient time to adopt or upgrade to the latestEHR technology certified for 2014.

The final rule lays out the timelines physicians will have tofollow in order to avoid payment reductions in 2015. Under theprovisions of the HITECH Act and the final rule, physicians whodo not demonstrate meaningful use for 90 consecutive daysbeginning July 1, 2014, will see a 1 percent reduction in Medicarepayments beginning in 2015.

CMA is currently reviewing the final rule and will provideadditional information as it becomes available.

FAQ: HOW FAR BACK CAN PAYORSSEEK REFUNDS OF OVERPAYMENTS?

The California Medical Association (CMA) frequently receivescalls from physicians who are approached by payors to returnmonies allegedly overpaid on claims. Some of the reasons cited bythe payors include changes in eligibility, manual processing errorsor codes/services the payor considers bundled. The frequentquestion is whether there is a statute of limitations on how far backpayors can go.

The good news is that, in most cases, there are limits on how farback a payor can request a refund and there are requirements thepayor must abide by when they believe a refund is due.

One such requirements is that an overpayment refund requestmust be made in writing no more than 365 days after the originalpayment. This applies to payors regulated by both the Departmentof Managed Health Care and the Department of Insurance.

If you believe you have received refund requests outside the365-day period allowed by California law, contact CMA’s memberhelp center for assistance at 800-786-4262 or [email protected].

HHS DELAYS ICD-10 IMPLEMENTATION TO 2014

The U.S. Department of Health and Human Services (HHS)officially delayed ICD-10 implementation by one year, in a final


LAST MINUTE MOVE BY TRIAL LAWYERSTO SCUTTLE MICRA IS THWARTED

In the last days of the 2012 legislative session, a shell bill (SB1528) was gutted and amended in an attempt by trial lawyers toundermine California’s Medical Injury Compensation Reform Act(MICRA). The California Medical Association (CMA) was ableto thwart this move and the bill is dead for this legislative season.

The bill would have artificially inflated medical expensedamages by valuing them on the basis of the retail price of medicalservices provided, not the actual expense to the injured party.Simply put, this would allow trial lawyers to value medicalexpenses at rates much higher than what the physician whoprovided the service is actually paid. The legislation would havescrapped longstanding principles of law that allow an injuredperson to recover as economic medical expense damages onlyamounts actually paid or incurred for medical care and services.

SB 1528 would have artificially inflated economic medicalexpense damage awards and undermined MICRA’s intent toprevent double recovery of these damages. This, in turn, wouldhave increased medical malpractice premiums for physicians,many of whom would be forced to close shop thereby furtherlimiting access to care for all Californians.

Had this bill passed, it would have undermined the state’slandmark MICRA law, which is comprised of a number of differentstatutory provisions all designed to contain costs in medicalprofessional negligence cases while ensuring adequatecompensation for injured persons. MICRA was signed by Gov.Brown in 1975 during his first term as governor.

The next legislative year CMA expects another challenge fromthe same lawyers and we will fight to the end to preserve theMICRA laws.

Contact: Nikki Ragsac, 916-551-2045 or [email protected].

AETNA TERMINATING PHYSICIAN CONTRACTSFOR REFERRING PPO PATIENTS TOOUT-OF-NETWORK FACILITIES

Many physicians have notified the California MedicalAssociation (CMA) that they have received notices from Aetnapurporting to terminate their provider contracts. Aetna claims inthese notices that the physician breached the provider contract byreferring PPO beneficiaries to out-of-network facilities for coveredmedical services.

CMA, along with a coalition of patients, individual physicians,ambulatory surgical centers and local county medical associations,is in active litigation in Los Angeles County Superior Courtagainst Aetna over this exact practice. The lawsuit alleges that,while Aetna is marketing and selling PPO products featuring out-of-network benefits, Aetna is unlawfully retaliating againstpatients who attempt to use their out-of-network benefits andcontracted physicians who refer their patients to out-of-networkproviders and facilities.

In response to the apparent increase in Aetna’s challengedpractices, CMA has developed information and resources to helpindividual CMA members who have received termination noticesfrom Aetna over out-of-network referrals.

Affected physicians are encouraged to call CMA’s legal helpline for assistance. Please see CMA News on page 6


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rule published last week. The delay, firstproposed in April, changes the date ofcompliance for ICD-10 from October 1,2013, to October 1, 2014.

The International Classification ofDisease tenth revision (ICD-10) is a systemof coding created in 1992 as the successorto the previous ICD-9 system. ICD-10 willinclude new procedures and diagnoses,which HHS hopes will improve the qualityof information available for qualityimprovement and payment purposes.

CMA LEADERSHIP WORKING WITHCALIFORNIA CONGRESSIONALMEMBERS TO PLAN FORCONTENTIOUS LAME DUCK SESSION

After the presidential election inNovember, Congress will be back inWashington, D.C., to take up some of themost complex and divisive issues of the day.Included in this will be the 27 percentsustainable growth rate (SGR) cut toMedicare, plus a potential two percentsequestration cut.

Medicine will be competing with a glutof issues that must be addressed by Congressbefore the end of the year, such as whetherto extend a number of expiring programs,including the Bush tax cuts, the SocialSecurity payroll tax cut, and federalunemployment benefit extensions.Congress will also be faced with $1 trillionin government sequestration cuts, set totake effect on January 1, 2013, because ofthe Super Committee’s failure to agree onalternative budget solutions. AlthoughMedicaid is exempt from the sequestrationcuts, Medicare is facing an additional 2percent cut, on top of the 27 percent SGRcut.

California Medical Association (CMA)leaders will meet with congressionalmembers during the August 2012 summerrecess to lay the groundwork for theupcoming lame duck session, which couldbe contentious. Regardless of who wins theelection, 2013 will be an important year forboth Medicare and Medicaid reform issues.It is highly likely that the November-December congressional session willproduce another short-term SGR fix and anew set of politicians will be faced withSGR reform.

Continued from page 5

Please see CMA News on page 7


CMA NEWS

CMA JOINS EFFORT TO MONITORCALIFORNIA HEALTH BENEFIT EXCHANGE

The California Medical Association and the Food & Drug Councilhave joined a statewide alliance that seeks to monitordevelopments in the California Health Benefit Exchange. Thefederal health reform law requires states to launch onlineinsurance marketplaces by 2014.The California Health BenefitExchange primarily will serve individuals and small businesses.

Supporters hope that the exchange will function similar towebsites like Amazon.com and Expedia.com so that users will beable to choose between various health plans through an easilynavigable online store. Officials plan to open registration for theexchange in October 2013. An estimated 4.4 million Californiansare expected to use the exchange by the end of 2016.

The alliance – called the Healthcare Exchange Advocacy andResponsibility Team (HEART) – seeks to ensure that theexchange will lower costs, improve quality and expand health careaccess for residents and supports health plans that offercoordinated, team-based care.

Members of the alliance include:• Businesses and unions;• Health care providers, such as Dignity Health;• Health insurers, such as Kaiser Permanente and Blue Shieldof California; and

• Patient advocates.Lisa Folberg, CMA vice president for medical and regulatory

policy, said that family physicians belonging to CMA who supportthe concept of medical homes as a way to maximize the use ofvarious health care workers and “bend the cost curve” encouragedthe group to join HEART (Sacramento Business Journal, 8/29).

Read more: http://www.californiahealthline.org/articles/2012/8/30/two-groups-join-effort-to-monitor-california-health-benefit-exchange.aspx#ixzz266Sek1Ei

PROBLEMS GETTING PAID?

The California Medical Association’s Center for EconomicServices provides direct reimbursement assistance to CMAphysician members and their office staff.

Reimbursement Help Line 888-401-5911 – One-on-oneeducational and reimbursement assistance to physician membersand their staff

Practice Empowerment – Tools and resources to empowerphysician practices; seminars and toolkits for physicians and theirstaff

Experienced Staff – Staffed by practice management expertswith a combined experience of over 125 years in medical practiceoperations

Need help? Contact CMA’s reimbursement experts at 888-401-5911 or [email protected]

Continued from page 6 CMA’s Practice Resources: CPRCould physicians contract withexchange plans without knowing?

Beginning in 2014, Californiawill begin offering subsidizedhealth care coverage through thestate’s Health Benefit Exchange asrequired by the Patient Protectionand Affordable Care Act.

Contracting with plans offeredthrough the state’s Health BenefitExchange likely brings a host ofnew obligations for physicians, and whether or not to do businesswith exchange plans is a decision that shouldn’t be taken lightly.

Knowing this, it may be unsettling to learn that manyCalifornia physicians could already be signed onto an exchangeplan network due to the way that major insurance plans havestructured their provider agreements.

Many plans’ provider agreements give the provider the opportu -nity to opt in to all of the plan’s product networks or selectively optout of those networks they would rather not take part in.

This is where the contracting can get tricky. Because plans don’t know whether they will have a product on

the exchange or what they will call those products, they are beingidentified in contract addenda under ambiguous names.

For instance, in an addendum – titled Exhibit B – Blue Shieldidentifies its intended exchange provider networks as Commer cialPPO/EPO Networks A, B and C, respectively reimbursing atstaggered percentages of the rates set forward in Blue Shield’sprovider manual.

The word “exchange,” however, appears nowhere in thecontract.

In the above example, the tiered reimbursement approachreflects what is seen in the “metal tiers” for qualified health plans(QHPs) offered under the ex change, meaning plans are settingphysicians up for exchange contracts without explicitly saying so.

With plans’ ability to amend provisions of the contract andprovider manual with relative ease, it’s likely that providers whoopt in to the “all products” clause will soon find themselvesrepresented as part of an exchange provider network, despite theabsence of any discussion of such networks in the contract.

In fact, Blue Shield’s current recontracting effort waslaunched, in part, to insert language in anticipation ofparticipating in the state’s exchange.

To later effectuate any new exchange requirements, the planwould only need to send them along as a state-mandated amend -ment. Generally, unless providers object in writing within 60days of release, the amendment becomes part of the originalcontract.

For this and many other reasons, practices need to ensure allnew and revised contracts are thoroughly reviewed and that allproducts being signed onto are fully understood. CMA continuesto work with exchange stakeholders to address significantconcerns regarding the exchange grace period, monitoring ofnetwork adequacy and clinician-level performance measurementin qualified health plans offered in the exchange.

P R AC T I C E M AN AGMEEN T

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

Winter CME Symposium 2013“The Pursuit of Excellence”

Paul B. Ginsburg PhDPresident, Center for Studying Health System Change

TOPIC: “Healthcare 2013: Report from National Center for Studying Health System Change"

Donald Goldmann MDSenior Vice President,Institute for Healthcare Improvement

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

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

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

Richard “Chip" Davis PhDPresident, Sibley Memorial HospitalJohns Hopkins Medicine

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

Joanne M. Conroy MDChief Health Care Officer, Association of American Medical Colleges

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

Eric Coleman MD, MPHProfessor of Medicine, Head of Division of Health Care, Policy & Research; Director Care Transitions Program, University of Colorado

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

February 6-10, 20132013 Winter Symposium Speakers Scheduled to Appear

Thomas J. Graham MDChief Innovation Officer, Justice Family Chairin Medical Innovations; Vice Chair, Department of Orthopaedic Surgery,Cleveland Clinic

TOPIC: “Great Expectations – Medical Innovationat Cleveland Clinic"

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

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

Brent C. James MD, MStatChief Quality Officer and Executive Director,Institute for Health Care Delivery ResearchIntermountain Healthcare

TOPIC: “The Health Reform Debate HasOverlooked the Physician-Patient Dynamic”

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

TOPIC: “10 Healthcare Trends for 2013"

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CMA URGES CHANGES TOTHE 2013 MEDICARE PAYMENT RULE

The California Medical Association (CMA) has submittedcomments to the Centers for Medicare & Medicaid Services (CMS)on the proposed Medicare Physician Payment Rule for 2013.

Geographic PaymentsIn the letter, CMA expressed extreme disappointment that

the payment rule does not include the geographic practice costindex (GPCI) payment locality update that was recentlyrecommended by the Institute of Medicine (IOM).

“The overall goal for Medicare payment must be paymentaccuracy,” CMA wrote in its letter. “CMS is simply not payingphysicians accurately and is severely underpaying thousands ofphysicians in California each year, which negatively impactsaccess to care in these regions.”

CMA has been working for a decade to convince Congressand CMS to update the payment localities. The IOM reporturged CMS to address the system’s acute payment inaccuracies inpart by updating the physician payment localities and moving toMetropolitan Statistical Area boundaries – the same systemMedicare uses to calculate payments to hospitals.

According to CMS, creating additional payment localities willbe administratively burdensome for the agency. CMA stronglydisagrees with this conclusion, as does the IOM.

Value-Based Payment ModifierWhile CMA supports efforts to improve quality and efficiency,

the association strongly opposes the proposed Value BasedPayment Modifier when applied to individual physicians. Thevalue modifier takes effect in 2015, but will be based on 2013 datafor groups of 25 or more physicians.

The value modifier payment methodology was mandated inthe Affordable Care Act (ACA). While CMA opposed the valuemodifier in the ACA, CMA amendments ensured that thepayments would be risk and cost-adjusted for California’s highercosts. In a nutshell, the rule proposes a system whereby physicianswho successfully report on quality measures and spend less thanthe national average per Medicare patient would be paid more,and physicians with lower quality and higher costs would be paidless.

CMA strongly opposes the proposed value modifier paymentformula unless the current attribution methodology, risk-adjustment methodology and reporting mechanisms forindividual physicians are vastly improved. The data must beaccurate and statistically valid.

CMA supports the value modifier when applied to physiciangroups of 25 or more, but only if they are multi-specialty groupsthat have already successfully participated in the Group PracticeReporting Program.

CMA also opposes the proposed public disclosure of physicianinformation until it is more accurate and physicians are given theopportunity to review the data before it is published, and toappeal and have the data corrected if found to be inaccurate.“Inaccurate information can mislead patients and physicianswithout improving the quality of care or reducing costs,” CMAwrote in its comments.

Nurse anesthetists scope of practiceThe proposed payment rule includes new language that would

permit certified registered nurse anesthetists to furnish and billfor chronic pain management in states where it is within theirscope of practice to do so.

“[Nurse anesthetists] lack the training, education and clinicalexperience to provide chronic pain management care withoutphysician supervision and direction,” CMA wrote in the letter.

Although states have the ability to determine the scope ofpractice of nurse anesthetists and other non-physicianpractitioners, CMA urged CMS to lead and maintain a nationalstandard to protect all Medicare beneficiaries who requirechronic pain management.

Contact: Elizabeth McNeil, 415-882-3376 or [email protected].

MEDICARE TO REQUIRE PRIOR AUTHORIZATIONOF POWER MOBILITY DEVICES

The Centers for Medicare & Medicaid Services (CMS) willrequire physicians in seven states, including California, to obtainprior authorization for motorized wheelchairs and other powermobility devices for Medicare fee-for-service beneficiaries.

While it is being calling a demonstration project, CMS saidprior authorization will ensure the delivery of necessary medicalequipment and should reduce the number of high dollar fraudinvestigations. The demonstration is directed at beneficiarieswho reside in seven states with high populations of fraud- anderror-prone providers: California, Florida, Illinois, Michigan,New York, North Carolina and Texas.

According to CMS, physicians will be required to conductface-to-face examinations of Medicare patients prior toprescribing power mobility devices. Physicians will then berequired to send authorization requests and supportingdocumentation that addresses specific coverage criteria directlyto the durable medical equipment contractor (DMERC), or workwith the durable medical equipment supplier who may submitthe information for pre authorization. The DMERC will reviewthe request to ensure that it meets national and local coveragerequirements and, if approved, provide an authorization numberthat the supplier needs to fulfill the order.

There are a few statutory requirements that must be metbefore the prescription is written. Details of the requirements anda sample checklist are available on the CMS Prior Authorizationof Power Mobility Devices Demonstration web page,http://cal.md/pmd-demo. The checklist and other resources arelocated at the bottom of the page, under downloads.

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

MEDICARE NEWS


A I R Q U A L I T Y

Regional TransportationPlans: What YouNeed to Know

Michelle Garcia,Air Quality Director

Regional Trans port -ation Plans (RTPs) areplanning docu mentsdeveloped by Metro -politan Plan ning Or g -anizations (MPOs)and Regional Trans -port a tion Planning Agencies (RTPAs) incooperation with Caltrans and otherstakeholders. They are required to bedeveloped by MPOs and RTPA’s per Statelegislation, (Government Code Section65080 et seq.) and Federal regulation (Title23 USC Section 134).

The purpose of the RTP is to establishregional goals, identify present and futureneeds, deficiencies, and constraints, analyzepotential solutions, estimate availablefunding and propose investments.

A comprehensive public involvementprogram is an important component fordeveloping a RTP. As Fresno COGundertakes the development of the 2014RTP a major goal of the public outreacheffort is to reach out to nontraditional aswell as traditional audiences to includethem in the transportation planningprocess. This program will help ensure thatenvironmental justice issues such as airpollution are addressed and that inter estedmembers of the public have ampleopportunity to under stand and providemeaning ful input while the RTP is in itsearly stages and through out the planningprocess.

The Fresno Council of Govern mentshas developed a Public Outreach Strategyfor the 2014 RTP/SCS process they will beusing to enlisted public participation andinvolvement. The plan is available on theirwebsite at www.fresnocog.org under thePlanning/Regional Transportation Planpages.

RTP’s are updated every four years, sothis is your opportunity to shapetransportation in Fresno. For moreinformation or to get involved contactMichelle Garcia at [email protected] or559-224-4224 ext 119.


Taking statins with or without the organic compound niacin aretwo frequently prescribed regimens for cardiovascular diseasepatients. But is one protocol better than the other? National Heart,Lung, and Blood Institute, or NHLBI, researchers were particularlyinterested in knowing whether adding niacin helped these patients,and so they randomly assigned more than 3,000 patients to receiveeither the compound or a placebo with their statin therapy. Then,they examined the results. By examining the results of thecomparison study, the NHLBI investigators learned that addingniacin to the statin therapy did not reduce the risk of heart attacksand stroke.

This NHLBI study is an example of comparative effectivenessresearch, or CER, defined as the direct comparison of health careinterventions to determine which work best for what groups ofpatients. All clinical research aims to gather evidence thatultimately will apply to practice, but CER is distinct, said HaroldSox, MD, a professor of medicine at Geisel School of Medicine atDartmouth in Hanover, N.H. He co-chaired the Institute ofMedicine’s, or IOM, Committee on Comparative EffectivenessResearch Prioritization. First, CER compares two or moretreatments or tests that are being implemented regularly in medicalpractice (as opposed to experimental drugs only available throughclinical trials). Plus, research is conducted in community settings,not only academic research centers.

“Frequently, studies are done in patients who are not typical ofthose seen in daily practice or the studies compare treatment witha placebo and not with another treatment,” Sox said. CER allowsthe research community “to be systematic about approaching keytesting and treatment questions,” he noted. It is “a user-drivenscience that seeks to answer questions that make a difference incare,” added Jean Slutsky, PA, MSPH, the director of the Centerfor Outcomes and Evidence at the Agency for Healthcare Researchand Quality, or AHRQ. CER is not new, but the significant federalinvestments over the past few years signal how important it is forhealth care. The American Recovery and Reinvestment Act andthe Patient Protection and Affordable Care Act togethercommitted billions of dollars to CER. In addition, the governmentestablished the Patient-Centered Outcomes Research Institute, or

PCORI, an independent, nonprofit, private entity, to set theCER research agenda. PCORI finalized its research priorities andreleased its first round of funding announcements in May 2012.

How CER Works: As Sox pointed out, CER seeks to providemeaningful answers to questions about commonly used approachesin real-world settings. To achieve results, this methodologyinvolves different types of studies. Barbara Tilley, PhD, the LorneBain professor and director in the division of biostatistics at theUniversity of Texas School of Public Health, explained thatresearchers could explore questions by looking at databases andmedical records and reviewing and combining results of existingstudies or conducting clinical trials. Pragmatic trials, in whichresearchers enroll a broad sampling of patients and look at easy-to-measure outcomes, are another good option for CER, Tilley said.

Barriers to CER Unique to Transfusion Medicine:Transfusionmedicine lacks a strong body of high quality evidence on which to

base CER. The field involves not only transfusion specialists butalso numerous clinicians from other disciplines, so there has notbeen a strong network of investigators focused on the same topics.“Transfusion transcends so many diseases” that it may beoverlooked as a subject for study in itself, said W. Keith Hoots,MD, director of the division of blood diseases and resources atNHLBI. Transfusion medicine research is complicated by“confirmation bias,” said John Roback, MD, PhD, associateprofessor of pathology and laboratory medicine at EmoryUniversity School of Medicine. Because transfusions usually aregiven to very sick people, “when the patient does poorly or diesafter transfusion, we blame their underlying condition, and whenthey improve, we credit transfusion,” he noted. “But we don’ttypically ask whether the transfusion could have contributed totheir death in the first case, or delayed their recovery in the secondscenario.” As another example, Tilley said a patient can beenrolled in a study but not survive long enough to receive atransfusion. This survival bias complicates research findings.

Improving CER: As CER gains traction, more resources areavailable for investigators. Networks such as the NHLBI’sTransfusion Medicine Hemostasis Clinical Trials Network andBone Marrow Transplant Clinical Trials Network and the Centerfor International Blood and Marrow Transplant Research facilitatebroad research.

Improving Care: With health care costs rising, we cannotafford treatments and tests that do not work. . “CER allows you todo large trials with less funding, and the economic situation isgoing to help force that issue.

“[CER] is the kind of research that most directly affects patientcare and public policy. Researchers appreciate that CER offers them“the ability to use their methods to improve clinical care and publichealth,” he added. Sox summed up the need for CER this way: “CERis very much focused on the doctor and the patient in the officemaking a better decision – one that is right for the patient.”

Reference: Boden WE, Probstfield JL, Anderson T et al. Niacin in patients with lowHDL cholesterol levels receiving intensive statin therapy. N Engl J Med 2011: Dec15;365(24):2255-67.

CER EFFORTS UNDERWAY IN TRANSFUSION MEDICINE• Red Cell Storage Duration Study (RECESS): Prospective,

multicenter NHLBI randomized controlled trial looking at theeffect of duration of red blood cell (RBC) storage on clinicaloutcomes for cardiac surgery patients.

• Informing Fresh versus Old Red Cell Management(INFORM) study: International, multicenter study of 25,000patients evaluating the effect of RBC age on mortality followingtransfusion.

• Age of Blood Evaluation (ABLE) trial: Pragmatic,multicenter Canadian trial assessing whether transfusion withfresh RBCs improves mortality among critically ill adults.

• Pragmatic, Randomized Optimal Platelets and Plasma Ratios(PROPPR) trial: Randomized trial, jointly supported by NHLBIand the U.S. Department of Defense, comparing mortality ratesbetween two standard ratios of plasma, platelets and RBCs amongpatients receiving massive transfusions.

B LOOD B ANK

Comparative Effectiveness Research in Transfusion Medicinefrom ‘Comparative Effectiveness Research-Finding Answers in a Sea of Science’, by Dana Trevas, AABB News, July 2012


32nd AnnualCentral ValleyCardiologySymposiumNovember 10, 2012

Madera Municipal Golf Center8:00am-3:30 pm

FEATURED TOPICSAND SPEAKERS

• Endovascular Treatment ofThoracic and Abdominal AorticAneurysms

• Ischemic Heart Disease inWomen: DiagnosticApproaches and Management

• (TAVR) Percutaneous AorticValve Replacement in HighRisk Patients with AorticStenosis

• Current, Evolving and FuturisticTherapies for Management ofAtrial Fibrillation

• Management of VentricularArrhythmias, includingbreakthrough Vent Arrhythmiasin patients with ICD

• Appropriate Triage of ChestPain in the ED: who to refer forworkup, testing and who canbe sent home

Gabriel S. Aldea, MD, FAHA,Section Chief,

Univ. of Washington

Ezra A. Amsterdam, MD, FACC,Professor, Univ. of Calif., Davis

Roger A. Winkle, MD, FACC,Silicon Valley Cardiology

Medical Group

INFORMATION:559-224-4224 x 118 or

[email protected]


Post Office Box 28337Fresno, CA 93729-8337

1040 E. Herndon Ave #101Fresno, CA 93720

559-224-4224Fax 559-224-0276

website: www.fmms.org

FMMS Officers

Sergio Ilic, MDPresident

Ranjit Rajpal, MDPresident Elect

Prahalad Jajodia, MDVice President

Stewart Mason, MDSecretary/Treasurer

Oscar Sablan, MDPast President

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

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

Constantine Michas, MDKhalid Rauf, MD

Rohit Sundrani, MDMohammad Sheikh, MD

CMA DelegatesFMMS President

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

Andre Minuth, MDRoydon Steinke, MDToussaint Streat, MD

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

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

CMA YPS DelegatePaul J. Grewall, MD

CMA YPS AlternateYuk-Yuen Leung, MD

CMA Trustee District VIVirgil Airola, MD

Staff:Sandi PalumboExecutive Director

President’s Message

SERGIO D. ILIC, MD

WE WEAR DIFFERENT HATS

Medical Societies have the difficult task to represent all their members, and as you know, physicianscome in all shades of opinions and have strong beliefs, and we are never wrong. The Society has tosomehow provide an unified opinion on issues that may profoundly divide the members and othersegments of society at large. Take Health Care Reform (ACA). Some members are for a completelysocialized way of delivering medical care and feel the law doesn’t go far enough to accomplish this, whileothers are for a completely different form of delivery and preserving private practice as we know it.

I strongly believe that the FMMS should be more active in presenting positions on issues like thesein a public way through the local media, like The Fresno Bee or through interviews on radio and TV.Health Care Reform is an issue that will affect the health care delivery for years to come, and we needto be more forthcoming with our point of view. We need to make sure the issues are presented in a non-partisan or biased way. If we are going to be relevant, we need to make our opinions known to the public.I hope The Fresno Bee prints the article I sent to them on trying to educate the public about the ACA.

As Dr. Basil R. Besh, MD, Chairman of Orthopedics at Washington Hospital puts it, there are twothings that are driving up medical costs in this country. The first is that there is a disconnect betweenconsumers and payors. Patients demand services and don’t care what the actual costs are because theyare “free.” MRI’s for example. Their insurance pays.

The second is a disconnect between the doctor who prescribes and the payor (hospital or insurance).We prescribe new, very costly medications when older ones are cheaper and just as effective, and wedon’t question the price of a prosthesis etc. I agree with these facts.

Having immigrated from a country that had mostly socialize medicine, I can tell you I didn’t like itthen, and I don’t like it now. There are better ways to reform health care delivery. One way that shouldbe given more consideration is with Health Savings Accounts (HSA). Everyone should have a mandateto have one of them, starting at age 21 or so. That takes care of the above problems and gives theresponsibility to the patient who pays the doctor, the hospital, the medications etc. It is the patient’smoney, so they will spend it wisely.

We wear different hats at different times. Sometimes we are serious; sometimes we are not. One ofour members did not like the wine tasting and dinner social that we had in September because of thedifficult times and the serious issues we are facing that could wipe out private practice as we know it.While this member is right, I feel that life continues, and we can’t stop having an enjoyable evening andsome fun now and then. We are wearing a different hat.

Fresno-Madera

SAVE THE DATEGeneral Membership Meeting

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

Roger Rocka’s Dinner Theater

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

• Benefitting: FMMS Foundation

Includes dinner and show: “Singin’ in the Rain”Sponsorship opportunities: Contact [email protected]


S K Y WAT C H E R S O FA N C I E N T M E X I C O

Downing PlanetariumOctober 17, 2012

This show examines the early culture and history of what is now calledMexico and Central America and their astronomical accomplishments.Skywatchers will take you to colorful cities with their large observatoriesand elaborate temples when they were the ruling centers of greatcivilizations. This exclusive FMMS showing is at the Downing Planetarium,a 74-seat Star Theater under a 30-foot hemispherical dome located on theCSU Fresno campus. Spend a fun and educational-filled evening with yourfamily and guests learning about the importance of astronomicalobservations to these cultures. This show is designed for audiencesgrade six to adult.

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

Tickets & parking passes held at doorConfirmation & directions will be emailed

No food or drinks allowed in theaterInformation: 224-4224 x 118/[email protected]

***Limited Seating = must RSVP to attend


Educational Seriesand Economic Forumfor FMMS MembersOCTOBER 23, 6-7:30PM:“ECONOMIC UPDATE:ELECTION EDITION”

Speaker: Neil Leahey, CIMA®, RegionalVice President Pioneer Investments

Educational objectives:

• Economic market outlook with focuson 2012 presidential election

• Market sector implications for eachpotential election outcome

The Economic Forum is held at TheDaily Grill, Palm & Nees avenues, Fresno.Complimentary hors d’oeuvres andbeverages will be served. Space is limited;RSVP as soon as possible to: CentralValley Physician Benefits: 559-492-9592or info@medicalsocietybenefits. com.

OCTOBER 25, 6-7:30PM:“FINANCIAL PLANNING BASICS”

presented by Eric Van Valkenburg, CLU,CHFC and Amy Nuttall-Zwaan, CRPC,CSNA, Financial Consultants with CentralValley Physician Benefits

This presentation will include:

• Setting financial goals, such asretirement, college and/or estateconservation

• Building a plan around those goals

• Investment Planning

• Risk Management

• Insurance Protection

• Credit Fundamentals

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

Future topics: Nov. 28 & 29, 2012:Under standing Society Security Benefits

Eric Van Valkenburg and Amy Nuttall-Zwaan areRegistered Representa tives with and securities offeredthrough LPL Financial. Member FINRA/SIPC.

Fresno-Madera

Bringing business banking solutions to your community

Come in today and let us get to know you so we can provide your business with the financial resources and tools to help you reach your business goals.

From left to right: Gil Lara 437-3163, Tom Andersen 437-3147, Brian Donovan 437-7628, Frank Gallegos 437-7600

CHARLES W. BEAM, MD55-year member

Charles Beam, MD, a retired radiologist, passed away July 16, 2012, one monthshy of his 91st birthday.

Dr. Beam was born in Montana in 1921. After serving for six years in the USNavy, he received his medical degree from the University of Oregon in 1952 andcompleted his internship and residency training at Santa Barbara CottageHospital. Dr. Beam began his practice in Fresno in 1956 and retired in 1984.

THOMAS G. SAYEG, MD54-year member

Thomas G. Sayeg, MD, a retired general surgeon, passed awayJune 4, 2012, at the age of 90.

Dr. Sayeg was born in Fresno in 1922. He received hismedical degree from the University of California in 1950 andinternship and residency training at Fresno General Hospital.During his residency, Dr. Sayeg served from 1951-1953 in theUS. Army. He began his general surgical practice in Fresno in1957 and retired in 1992.


Kern

2229 Q StreetBakersfield, CA 93301-2900

661-325-9025Fax 661-328-9372

website: www.kms.org

KCMS Officers

Joel R. Cohen, MDPresident

Wilbur Suesberry, MD President-elect

Noel Del Mundo, MDSecretary

Ronald L. Morton, MDTreasurer

Portia S. Choi, MD Immediate Past President

Board of DirectorsAlpha Anders, MDBrad Anderson, MD

Eric Boren, MDLawrence Cosner, MD

John Digges, MDJ. Michael Hewitt, MD

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

CMA Delegates:Jennifer Abraham, MD

Eric Boren, MDJohn Digges, MD

Ronald Morton, MD

CMA Alternate Delegates:Lawrence Cosner, Jr., MD

Patrick Leung, MDMichelle Quiogue, MD

Staff:Sandi Palumbo, Executive Director

Kathy L. HughesMembership Secretary

HANS EINSTEIN, MD February 1923-August 2012

A native of Berlin, Germany, Dr. Hans Einstein grew up in Holland and livedthere until the age of 10. The Netherlands became his home for the next six years.He then traveled onto New York and onto Furman University in South Carolina.

While living in Greenville, SC, Dr. Einstein met Albert Einstein’s son. Thetwo struck up a friendly acquaintance and when Albert Einstein would come tovisit his aon, Dr. Einstein would join them for dinner on numerous occasions. It turned out that theirgrandparents were first cousins.

A graduate of New York Medical College, Dr. Einstein served a rotating Internship at PatersonGeneral Hospital in New Jersey before moving to Bakersfield in 1951. He finished his InternalMedicine Residency at Kern County General Hospital (KMC).

Dr. Einstein was Medical Director at the County Tuberculosis Hospital in Keene, CA for a year,followed by serving as the Tuberculosis Controller for the Kern County Health Department. Aftermore than twenty-five years of practice, he left Bakersfield to join USC School of Medicine as aBarlow Professor of Respiratory Diseases.

In 1988, Dr. Einstein returned to Bakersfield to serve as Director of Medical Education atBakersfield Memorial Hospital. Shortly after, he was named Medical Director. In 1999, Dr. Einstein“Retired” from practice being known as the foremost authority on Valley Fever.

Our medical community has truly lost a great man. As one KCMS member stated “Great physician– yet a very humble human being.”

REMEMBERING HANS E. EINSTEIN, MDPortia Choi, MD

Immediate Past-President, Kern County Medical Society

The last time I saw Dr. Hans Einstein, it was in the beginning of the summer 2012. He was at acommunity event promoting healthy living and the arts. He greeted those who came up to him andgave a warm hand shake, sometimes a kiss and conversation. He was in a wheelchair and with one ofhis daughters. About a month later, he was hospitalized and then, I understand, at home in hospicecare.

I first met Dr. Einstein in 1984 when he took care of my Father at the Barlow Respiratory Hospital,which was affiliated with University of Southern California Medical School. When my father did notimprove he was referred for evaluation to Dr. Einstein. He looked at my father’s chest x-rays andimmediately informed me that the films were typical for coccidioidomycosis pneumonia. My fatherimproved and was cured of his disease under Dr. Einstein’s care.

I met Dr. Einstein again at the Public Health Chest Clinic; and came to understand the enormityof his contribution to medical science. He has provided his expertise and energy in working towarddeveloping a vaccine to prevent coccidoidomycosis (Valley Fever.) Dr. Einstein was very charmingand engaging whenever he spoke about any topic and particularly about Valley Fever. He alsounderstood the politics of achieving a vaccine, and had engaged the various sectors toward thedevelopment of it. He and others were involved in the effort that resulted in the formation of ValleyFever Vaccine Project, a consortium of six academic institutions and four research laboratories, withoversight provided by a committee composed of Kern County-based physicians plus public health andcivic leaders.

Dr. Einstein has been honored in numerous ways. The Kern County Department of Public Health,when they dedicated their new building, named their conference room Hans E. Einstein M.D.Education Center and the semicircular driveway in the front of the building is named Hans E.Einstein, MD Way.

PO Box 1029Hanford, CA 93230

559-582-0310Fax 559-582-3581

KCMS Officers

Theresa P. Poindexter, MDPresident

Jeffrey W. Csiszar, MDPresident-elect

Mario Deguchi, MDSecretary Treasurer

Mario Deguchi, MDPast President

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

Bo Lundy, MDMichael MacLein, MD

Kenny Mai, MD

CMA Delegates:Jeffrey W. Csiszar, MD

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

CMA Alternate Delegates:Laura L. Howard, MD

Staff:Marilyn Rush

Executive Secretary

Tulare Kings


3333 S. FairwayVisalia, CA 93277

559-627-2262Fax 559-734-0431

website: www.tcmsonline.org

TCMS OfficersGaurang Pandya, MD

President

Steve Cantrell, MDPresident-elect

Thomas Gray, MDSecretary/Treasurer

Steve Carstens, DOImmediate Past President

Board of DirectorsVirinder Bhardwaj, MDCarlos Dominguez, MD

Parul Gupta, MDMonica Manga, MD

Christopher Rodarte, MDH. Charles Wolf, MD

CMA Delegates:Thomas Daglish, MDRoger Haley, MD

John Hipskind, MD

CMA Alternate Delegates:Robert Allen, MD

Ralph Kingsford, MD Mark Tetz, MD

Sixth District CMA TrusteeJames Foxe, MD

Sixth District CMA AlternateThomas Daglish, MD

Staff:Steve M. BeargeonExecutive Director

Francine HipskindProvider Relations

Thelma YearyExecutive Assistant

Dana RamosAdministrative Assistant

2012 CMA HOUSE OF DELEGATESOn Saturday, October 13 the CMA House of Delegates (HOD) willconvene in Sacramento C.A. The Tulare County Medical Society(TCMS) has three delegates and three alternate delegates thatparticipate in the democratic process of developing the medicalpolicy of the California Medical Association.

It is time to tip our hats to the local physicians who represent theTCMS as your representatives. Drs. Roger Haley, Thomas Daglish,John Hipskind, Mark Tetz, Robert Allen and Ralph Kingsford are ourcurrent representatives. They volunteer four days of their time tomeet with their colleagues to discuss hundreds of resolutions. Withthat many resolutions, they spend a great deal of other timefamiliarizing themselves with the many debated issues.

Our membership is very fortunate. Most medical societies cannotfill their slots for delegates and alternates who attend the HOD. Ourdelegation is present and participating and many times leading thediscussion. When other societies have vacancies, our alternates areallowed to sit and vote in their absence. It is not uncommon for allsix of our delegates and alternates to be seated the entire meeting.This allows the TCMS to have a strong voice.

Representation at the HOD is divided into ten regional districts.Tulare County is included in the Sixth District, made up of CentralValley counties Kern through San Joaquin. Dr. Roger Haley is theChairman of District VI and works with the Speaker of the House torun an efficient and productive meeting. District VI is fortunate tohave Dr. Haley’s leadership skills.

The HOD also allows participation by mode of practice. Dr.Gaurang Pandya has sat in the last two Houses as a representative ofthe Solo and Small Group Forum. This year Drs. Steven Porter,Andrea Espinosa and Pradeep Kamboj have also been named to theSolo and Small Group forum as delegates and alternate delegates.

Dr. James Foxe has served on the Board of Trustees since the early2000. It had been many years since the TCMS had a physicianelected to the Board of Trustees. Dr. Foxe has served as Chairman ofa number of committees of the Board, most recently theNominations Committee. This is another example of thesignificance of the TCMS members and their contribution toorganized medicine.

Last but certainly not least, as we have previously announced, Dr.Ron Marconi has been selected as the recipient of the Fredrick K. M.Plessner award. This award is given annually to the physician whobest exemplifies the ethics and practice of medicine in ruralCalifornia. This will be done Saturday, October 13 in front of theHouse of Delegates. It is a proud moment when one of our membersis honored for all he has given to our community.

Many times I am asked; what does the Tulare County MedicalSociety do for me? It is with great pride I acknowledge those whoserve on your behalf.

Executive Director’sMessage

STEVE M. BEARGEON EXECUTIVE DIRECTOR

Please see TCMS News on page 18


Classifieds

MEDICAL OFFICES

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

FOR LEASE2701 16th St. – 2,400

Crown Pointe Phase II – 2,000-9,277 rsf.3115 Latte Lane – 5,637 rsf.

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

4000 Physicians Blvd – 5,883 rsf.2204 “Q” Street – 3,200 rsf.

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

SUB-LEASE4100 Truxtun Ave. – Can Be Split

Medical Records & OfficesSprinklered – 4,764 usf.

Adm. & Billing – 6,613 rsf.

FOR SALE1911 17th Street – 2,376 sf.

Crown Pointe Phase II – 2,000-9,277 rsf.Meridian Professional Center – 1,740-9,260 rsf.

9900 Stockdale Hwy. – 2,000-6,000 rsf.

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

Medical office space. 850-3,500 sf atValley Medical Plaza at Herndon, nearSAMC. Rates starting at $1 sf, no triple net.Tenant improvements available. Call Brianat 559-281-1500.FresnoTimeshare. Newly renovated fur-nished office in medical complex. Includesinternet. No minimum. Reasonable [email protected]

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

ANNOUNCEMENT

FOR RENT / LEASE

FOR SALE

MEMBERS: 3 months/3 lines* free; thereafter $20 for 30 words.NON-MEMBERS: First month/3 lines* $50; Second month/3 lines* $40; Third month/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.

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

Individual practice; may be divided & remodeled to suit

Excellent parking andclose to St. Agnes Medical Center

Carl Abercrombie559-227-4658

c: 559-970-9035Jim Abercrombie

530-626-0321

Professional/Medical Office for LeaseCambridge Court

6335 N. Fresno Street, Fresno

NEWLYREMODELED1,200sq.ft. officewith fiveexam rooms

FRESNO/MADERA

TULARE

KERN

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

FOR SALE

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

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

PHYSICIAN/PROVIDED WANTED

FOR RENT / LEASE

HOME GENERATED MEDICALSHARPS DROP OFFVisalia will begin col lectinghome-generated medical sharpsat each of its quarterly Dump On Usevents hosted at the City of VisaliaCorporationyard (335 N.Cain St.).Dump OnUs events are held each January,April, July and October. Medicalsharps include needles, syringes andlancets. All sharps must be placed inan approved sharps container. Limitof 24, 1.4 liter sharps containers (orequivalent) per person. No drugs ormedicines accepted. Service islimited to City of Visalia residentsonly. For additional information,please call the City of Visalia SolidWaste Department at 559-713-4500.

TCMS News

Continued from page 17

Dr. John L. MaffeoMemorial Award &Fundraiser Dinner

October 25, 2012St. Paul Newman Center

Providing support to localprograms for the underserved

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559-255-4300

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