San Antonio Medicine October 2014 by Traveling Blender

MEDICINE SAN ANTONIO

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• ‘Active spectating • Medicaid parity • Patient care • BCMS elections

MEDICINE SAN ANTONIO

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OCTOBER 2014

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VOLUME 67 NO. 10

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

ADVOCACY IN ACTION

The political circus and the physician as an ‘active spectator’ By James Humphreys, MD .........................................12

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Email: editor@bcms.org

Economically viable Medicaid primary care physician payment rates in Texas By Michael A. Battista, MD..........................................14

Physician involvement in advocacy directly affects patient care

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

By Alexander B. Kenton, MD, FAAP .............................16

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Physician as Patient Part 7: What I learned by Jay Ellis, MD ......................................................18 BCMS News ................................................................................................................................23

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Lifestyle: Top Texas spots to view fall foliage by Mauri Elbel ......................................................26 Business of Medicine by Kathleen Carrico, RN, BSN, MBA, and Dana A. Forgione, PhD, CPA, CMA, CFE ................................................................................28 HASA services help improve patient care by Vince Fonseca, MD, MPH, FACPM ..............................30 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ......................................................32 BCMS Circle of Friends Services Directory ..........................................................................................35 Book Review: “A Death in China,” written by Carl Hiaasen and Bill Montalbano, Reviewed by Paula Lyons, MD ................................................................................................40 In the Drivers’ Seat ................................................................................................................................42 Auto Review: GMC Yukon by Steve Schutz, MD ..................................................................................44

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BOARD OF DIRECTORS

OFFICERS K. Ashok Kumar, MD, President Jayesh B. Shah, MD, Vice President Leah Hanselka Jacobson, MD, Treasurer Maria M. Tiamson-Beato, MD, Secretary James L. Humphreys, MD, President-elect Gabriel Ortiz, MD, Immediate Past President

DIRECTORS Josie Ann Cigarroa, MD, Member Chelsea I. Clinton, MD, Member John Robert Holcomb, MD, Member Luci Katherine Leykum, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Adam V. Ratner, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Luke Carroll, Medical Student Representative Cindy Comfort, BCMS Alliance President Nora Olvera Garza, MD, Board of Censors Chair Rajaram Bala, MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom

DIRECTOR OF COMMUNICATIONS Susan A. Merkner

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Diana H. Henderson, MD, Member Jeffrey J. Meffert, MD, Member Sumeru “Sam” Mehta, MD, Member Rajam S. Ramamurthy, MD, Member John C. Sparks Sr., MD, Member Chittamuru V. Surendranath, MD, Member J.J. Waller Jr., MD, Member Jason Ming Zhao, MD, Member

6 San Antonio Medicine • October 2014

PRESIDENT’S MESSAGE

Health literacy:

How to improve patient care and safety? By K. Ashok Kumar, MD, FRCS, FAAFP 2014 BCMS President Health literacy is a major concern to physicians and patients. We all have patients who said they understood our instructions only to learn later that they did not do what we told them in the clinic or hospital. These incidents happen more often than you would imagine! Many patients do not take medicines as prescribed. Sometimes they don’t understand complex instructions, like taking multiple doses of a medication in one day, but many occur because patients did not understand the instructions they received from multiple people: Doctors explain how to take medications during the visit and give them the written prescription. Then the pharmacist gives them verbal and written instructions in a printout and the label affixed to the bottle. In spite of these efforts, patients may not take the medicine as prescribed. There are many anecdotes of patients swallowing the rectal or vaginal suppositories we prescribed. We all want our patients to understand and follow our instructions. Yet, miscommunication and misunderstanding between physicians and patients are common and cause major problems among patients that cost them money, unnecessary suffering, and sometimes avoidable complications. This is a huge patient safety issue that also contributes to escalating healthcare costs. For example, the Institute of Medicine estimates that “nearly half of all American adults, 90 million people, have difficulty understanding and acting upon health information.” Equally concerning, the National Assessment of Adult Literacy estimates nearly 9 out of 10 adults have difficulty using the everyday health information that is routinely available in healthcare facilities, retail outlets, media and communities.1 The Institute of Medicine defines health literacy as “the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions.”2 Health literacy comprises more than one’s ability to read and write; therefore, a patient may be well educated, but may still be unable to understand the health information we provide. Limited health literacy adversely affects a patient’s ability to follow a healthcare provider’s advice and impairs their ability to search for and use health information, adopt healthy behaviors, and act on important public health alerts. It follows that people with limited health literacy are at a disadvantage and may be more likely to succumb to television advertisements of prescription medicines and over-the-counter healthcare remedies. Therefore, health literacy is a crucial factor in improving the health of our patients. The Centers for Disease Control (CDC), National Institute of Health (NIH), Institute of Medicine, American Medical Association, Association of American Medical Colleges and 8 San Antonio Medicine • October 2014

the Centers for Medicare and Medicaid Services (CMS) and various other healthcare and medical organizations support improving health literacy among our patients. The National Assessment of Adult Literacy, Healthy People 2010, and Health Resources Administration (HRSA) highlighted the importance of health literacy to promote health and prevent disease. According to HRSA, factors that contribute to patient’s health literacy include patient–provider communication, patient knowledge of health topics, culture, requirements of the healthcare system, situations, and disabilities. Improving people’s health literacy is a healthcare priority at the national, state and local levels. This task is challenging, but it is certainly an achievable goal when all the governmental agencies, private insurers, and physicians and other healthcare providers make this a priority. As former surgeon general Dr. Richard H. Carmona said, “It is very difficult for clinicians to communicate successfully, but our mission will be marginalized if we do not improve on our efforts to teach our patients critical self-care skills and confirm that they comprehend the plan,” We must communicate with our patients in plain simple language, ask them to repeat our instructions to make sure they understand them, and give them health information brochures written in simple, understandable terms. As healthcare providers and advocates for our patients and communities, we can improve the health literacy of our patients and our communities which, in turn, will improve their health. Let us work harder and make necessary changes in our practices to reach this goal. Physicians and healthcare professionals interested in health literacy can obtain information from many sources. The CDC, NIH and U.S. Department of Health and Human Services websites have abundant information we can use. 1

Kutner M, Greenberg E, Jin Y, & Paulsen C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy (NCES 2006-483). Washington, DC: U.S. Department of Education, National Center for Education Statistics. 2 Institute of Medicine. Health Literacy and Numeracy: Workshop Summary. Washington, DC: The National Academies Press, 2014. Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014 president of the Bexar County Medical Society.

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ADVOCACY IN ACTION

Our key role as active spectators is providing information to legislators to (hopefully) help them make an informed decision on a piece of legislation that is before them.

The political circus and the physician as an ‘active spectator’ By James Humphreys, MD The political process in the United States at the federal level

islative hearings to flag issues for us to address once the session

has certainly been a sorry spectacle of late with ideologically op-

starts. The TMA lobby team is excellent at organizing informa-

posed and uncompromising groups holding enough seats in the

tion for the doctors to see which bills are of concern and which

Congress to effectively paralyze the Legislature to the point that

issues we may be able to get some legislators behind as far as spon-

bills only pass if there is a “must-do-something-right-now” crisis.

soring a bill to correct a problem we have. Additionally, BCMS

Even those bills tend to be a patch or short extension of the pre-

is blessed with our own excellent lobbyist, Mary E. Nava, who

vious poorly working policy rather than any meaningful reform

coordinates with the TMA team and oversees interactions with

or new approach. I certainly share the frustration of my colleagues

the Bexar County legislators.

and despair about that changing for the better anytime soon. I am much more optimistic about the process at the state level, however, and want to invite all BCMS physicians to join me as “active spectators” in our state legislative process.

NUMEROUS ISSUES Over time we have successfully built a number of good working relationships with many of the state representatives and senators

What exactly is active spectating? To me it means being aware

across the state and can fairly readily reach out to them and meet

of both ongoing and upcoming legislative issues and being pre-

with them directly to discuss our issues. The reality is that legis-

pared to offer legislators an educated opinion about bills under

lators are faced with a huge number of issues during any session,

consideration that have an effect on the practice of medicine in

most of which are beyond their expertise. They rely on analytical

Texas. That sounds pretty time-consuming, and it certainly can

information about an issue which is provided to them by their

be; however, BCMS and the Texas Medical Association (TMA)

staff members and by lobbyists and concerned groups that offer

have developed a number of tools to make following the process

them opinions and information on the issue at hand. This is really

and knowing when to chime in substantially easier.

our key role as active spectators — providing information to legislators to (hopefully) help them make an informed decision on a

FLAG ISSUES

piece of legislation that is before them.

Even before the session starts in January 2015, the TMA lobby

How can you be an active spectator? There are a number of

team is meeting with legislators and attending the ongoing leg-

ways, and several of them do not require a large time commitment

12 San Antonio Medicine • October 2014

ADVOCACY IN ACTION

on your part. The BCMS Legislative and Socioeconomics Com-

chance to educate them on our issues. Anyone is welcome to par-

mittee follows developing bills closely and will periodically issue (in

ticipate in First Tuesday sessions, and there will be a number of no-

conjunction with TMA) a “call to action” if there is a need for a lot

tices for the exact dates forthcoming.

of doctors to weigh in on a specific issue. We will notify you of the

We are prepared for the upcoming legislative session and will rep-

problem at hand and provide you with contact information for the

resent the best interests of medicine and our patients, but we can

legislators we need to talk with. Your part would be either to call

always use an additional voice to help us push along good bills and

that legislator to register your concern on the issue or send them an

stop bad ones from becoming law for the state. Either Mary Nava

email (we will even provide a draft email for you).

or I would be happy to speak further to anyone interested about how to get involved and protect your practice and your patients.

FIRST TUESDAYS If you would like to invest a little more time, then you can go to

James Humphreys, MD, is chair of the BCMS Leg-

one of the First Tuesday sessions at the Capitol. These occur on the

islative and Socioeconomics Committee and BCMS

first Tuesday of the month, February through May, when the Leg-

President-elect. Email him at jimhumphreys308

islature is in session. Large numbers of doctors meet at the TMA

@gmail.com.

building in Austin and march over to the Capitol and meet with legislators or their staffers to share information face to face. This can be extremely effective in steering the legislative process. We will

BCMS Chief Governmental and Community Relations Officer Mary E. Nava may be reached at mary.nava@bcms.org.

arrange an appointment with our legislators’ offices and have a

visit us at www.bcms.org

ADVOCACY IN ACTION

It is critical that Texas begin to match the federal government’s payment increase beyond 2014 to protect access to healthcare for millions of low-income Texans.

Economically viable Medicaid primary care physician payment rates in Texas By Michael A. Battista, MD Primary care is critical to ensuring continuity of care for any population, but particularly for vulnerable Medicaid beneficiaries. Low Medicaid payment rates affect provider participation and have historically been considered a barrier to healthcare access. To help improve access, the federal government required that Medicaid payments for certain primary care services and some preventive health services be raised to Medicare levels for the 2013 and 2014 calendar years (known as the Medicaid Primary Care Physician Payment Increase or referred to as the Medicaid Parity Rule). Physicians with a specialty designation of family medicine, general internal medicine, or pediatric medicine currently qualify as primary care providers for the purpose of this increased payment. Furthermore, subspecialists within those designations also qualify for the enhanced payment. The Primary Care Physician Payment Increase is fully federally funded up to the difference between each state’s Medicaid fees in effect as of July 1, 2009, and Medicare fees effective in 2013 and 2014. In other words, there was no additional cost to the states for payments above the amount required by the 2009 rate methodology. Federal funding for this policy. however, will expire Dec. 31, 2014.

MEDICAID ENROLLEES Medicaid is a critical healthcare program for millions of low-income children and for children with special healthcare needs, covering 32 million children nationwide. Half of all Medicaid enrollees across the country are children. In Texas, the Medicaid program is the primary source of healthcare funding for low-income individuals, providing health insurance for 2.36 million low-income children. Children make up nearly 66 percent of Texas’ Medicaid population. According to the Kaiser Family Foundation, nationally Medicaid pays only 66 percent on average of Medicare fees for the same service. In Texas, Medicaid physician fees for primary care services were 60 percent of Medicare fees in 2012. In fact, 35 state Medicaid programs pay higher rates than Texas. Texas Medicaid pays lower physician fees than all of its nearby states, including New Mexico, Oklahoma, Arkansas, Louisiana, Mississippi and Colorado, which 14 San Antonio Medicine • October 2014

have Medicaid to Medicare ratios between 22 and 66 points higher than Texas’ ratio. In Texas, a physician providing primary care treatment to a child Medicaid beneficiary receives only 60 percent of that which would be paid to treat a senior on Medicare for the same illness. Low Medicaid payment rates place an unfair burden on Medicaid providers, resulting in substantial barriers to access to care for low-income Texans. Through the Medicaid Primary Care Physician Payment Increase, the federal government has taken a significant step in an effort to alleviate this burden. Medicaid, however, is a complex state/federal partnership. Not surprisingly, the implementation of the Medicaid Primary Care Physician Payment Increase proceeded with like complexities. States were given flexibility with some aspects of implementation, but were required to submit a Medicaid state plan amendment (SPA) to CMS for approval of the primary care payment increase. If the state’s SPA was not approved by Jan. 1, 2013, the state could increase its fees and wait until the SPA was approved to submit claims for 100 percent federal matching, or it could pay 2012 fees and make supplemental payments to eligible providers once the SPA was approved. Texas was one of the last states to submit its SPA, and it was one of the last states to receive approval in March 2014. According to the Texas Health and Human Services Commission (HHSC), Medicaid managed care payors and Medicaid fee-for-service payors began making supplemental quarterly payments soon after the SPA was approved in spring 2014. Therefore, providers in Texas did not receive the full benefit of the Medicaid Parity Rule until 15 months after it became effective. Even without the delays and uncertainties in Texas, the effect of the policy on provider participation may be constrained by the two-year limit. At the time it was enacted, the scope of the Medicaid Primary Care Physician Payment Increase was reduced to two years as a result of negotiations over its cost. Because the rate increase was temporary, it may not have provided enough incentive for nonparticipating physicians to become Medicaid providers or increase their acceptance of Medicaid beneficiaries. Certainly, the ability to effectively manage Medicaid patients after the increase expired was a consideration of all

ADVOCACY IN ACTION providers. A longer term or permanent increase in Medicaid reimbursement rates might encourage physicians to make additional investments in their practices, such as hiring additional staff, purchasing additional equipment or electronic health records, etc. Unfortunately, federal funding for the Medicaid Primary Care Physician Payment Increase is set to expire Dec. 31, 2014, and the enhanced payments will end unless the Texas legislature decides to continue the policy. Therefore, it is critical that Texas begin to match the federal government’s payment increase beyond 2014 to protect access to healthcare for millions of low-income Texans. We have a unique opportunity right now to continue investing in economically viable payment rates. Nearly all Texas children are eligible for insurance coverage – whether through CHIP, Medicaid or the health insurance marketplace. Yet many providers do not participate in the Medicaid program because of traditionally poor payment rates. The Medicaid Primary Care Physician Payment Increase provides Texas with an opportunity to remove one of the barriers to provider participation in Medicaid. Continuing to incentivize providers along the continuum of care is critical to ensuring real access for Medicaid patients. Texas Medical Association (TMA) remains committed to achieving economically viable payment rates. To that end, TMA adopted recommendations for the state of Texas to maintain the Medicaid Primary Care Physician Payment Increase. In comments submitted to the Texas Health and Human Services Commission (HHSC) on June 23, 2014, TMA urged the state to permanently extend the payment increase be-

yond Dec. 31, 2014, and recognized “it is vitally important to increase the number of physicians participating in Medicaid so that access is not hindered and Texans can get the care that they need.”

HELP NEEDED As an active member of the advocacy team at my organization, Pediatrix Medical Group, I am looking forward to partnering with BCMS and TMA in their efforts to extend the Medicaid Primary Care Physician Payment Increase. Yet, we need your help to gather support for this critical initiative. Share your stories with us. Or, join the BCMS Legislative and Socioeconomics Committee in meetings with members of the Texas House of Representatives and Senate during First Tuesday visits to the Capitol during legislative sessions. Physician participants from around the state wear their white coats to be “lobbyists for a day” and visit with our elected officials from Bexar County in Austin. The First Tuesday program begins on the first Tuesday in February and continues through May during each legislative year. To learn more about participating in our advocacy efforts, or to send in your story, please contact Mary Nava at BCMS, mary.nava@bcms.org, or Darren Whitehurst at TMA, darren.whitehurst@texmed.org. Together, our advocacy work can have a real impact on our practices and our patients. Michael A. Battista, MD, is a member of the BCMS Legislative and Socioeconomics Committee.

visit us at www.bcms.org

ADVOCACY IN ACTION

Human milk use saves lives, saves the state money, and saves payer dollars ... legislative or regulatory help is needed to incentivize hospitals to use motherâ&#x20AC;&#x2122;s own milk or donor human milk and human milk-based products.

Physician involvement in advocacy directly affects patient care By Alexander B. Kenton, MD, FAAP

Many physicians come out of their training without knowledge or desire to participate in government advocacy. They chose their career so that they could take care of patients. Politics, particularly today, can turn many physicians off toward participating. Yet many of these same physicians fail to take into account how they can positively impact patient care on a more global scale by participating in government advocacy. The example below highlights how participation can improve lives for our patients. A common fear unites all neonatologists. Neonatologists are terrified of the disease Necrotizing Enterocolitis (NEC). NEC occurs in approximately 10 percent to 15 percent of Very Low Birth Weight (VLBW) infants. In some instances, NEC can take a perfectly healthy premature baby and in 12 hours devastate the patient.1 If that baby does not die, (NEC has a 50 percent mortality) the alternative is little better, and many survivors of NEC will suffer the longterm consequences of the illness. The complications often encountered include cholestatic liver disease, late onset sepsis, neurodevelopmental delay, and short bowel syndrome, which may necessitate months to years of IV nutrition with the potential need for small bowel transplant and bowel lengthening procedures.2 Those infants who do survive may increase their hospital stay by an average of 60 days. The cost of care for these infants is substantial, with inpatient charges for surgical NEC adding an average of $186,200 per patient. For medical NEC, added hospital charges may reach a mean of $73,700 per patient.

COSTS TO STATE With these costs in mind, in 2010 with 386,000 births of whom 55 percent were covered by Medicaid, surgical NEC cases (127 patients) added charges of about $23 million. Medical NEC cases (360 patients) similarly added charges of $26 million. Although these are charges and not actual costs to the state (the state does not reimburse dollar per dollar), subsequent outpatient costs for these infants directly to the state were also substantial. Each additional 16 San Antonio Medicine â&#x20AC;˘ October 2014

case of NEC cost the state of Texas about $60,000 in outpatient care per case for infants with surgical NEC over a three-year period. A single case of medical NEC will typically cost the state more than $5,000 in outpatient costs over six months. NEC cost the state of Texas $10 million in additional outpatient costs over three years between 2002 and 2005.3,4 It also should be noted that these numbers were derived before the state began to reimburse for small bowel transplants, which can run into the millions of dollars for a single patient. NEC is thought to be caused by a combination of conditions which can lead to impaired bowel wall integrity, including perinatal ischemia, inflammation due to formula feeding, impairment of the development of the normal bowel flora, and a premature infant impaired immune system.2 When human milk is provided to premature infants, however, the development of NEC is drastically reduced. Human milk improves the maturity and integrity of the bowel wall, promotes the establishment of the correct probiotic flora in the bowel, and is not associated with the added inflammatory reaction to the bowel wall that formula may induce. Breast milk improves the resilience of the bowel wall to bacterial invasion and infection, whereas formula is far less protective. Virtually all neonatologists believe that breast milk should be the primary sole source for nutrition of the premature baby. There is now evidence from multiple studies that show that babies fed a combination of human milk and human milk-based fortifier products have far fewer cases of NEC compared to those fed bovine-based milk products.5,6 There are multiple case reports from centers which have virtually eliminated NEC from their units by feeding premature babies a human milk-only diet.7,8 The evidence has become so clear that the American Academy of Pediatrics in 2012 issued the recommendation that all preterm infants should receive human milk, and pasteurized donor human milk, appropriately fortified, should be provided to the infant if a motherâ&#x20AC;&#x2122;s own milk is unavailable or its use is contraindicated.9

ADVOCACY IN ACTION

Unfortunately, many mothers of premature babies are unable to provide their own breast milk due to the distance from home to their baby’s hospital, or due to their medical or social situations. At this time, however, donor human milk and human milk fortifiers are not universally available at all hospitals in the state of Texas. Many hospitals find that the added cost of donor human milk is prohibitive to its use. Preventing NEC does indeed prevent hospital costs, but due to a combination of factors which include the added expense of donor human milk, the low price of bovine-based products, and the ability to receive a higher reimbursement if an infant develops surgical NEC, hospitals often regard donor human milk to be an unnecessary and undesirable added expense. The physicians of the Texas Pediatric Society Committee of Fetus and Newborn, and MEDNAX Inc., participate in a task force to address this issue. In addition to physicians of TPS and MEDNAX, members of the Texas Medical Association (TMA), the Texas Hospital Association (THA), and the Mothers’ Milk Bank in Austin have been exploring a strategy by which hospitals that manage premature babies could be incentivized to use human milk (mother’s own and donor) as the primary nutrition for premature babies. Because human milk use saves lives, saves the state money, and saves payer dollars, the members of this task force have concluded that legislative or regulatory help is needed to incentivize hospitals to use mother’s own milk or donor human milk and human milk- based products. We call this the Texas incentive to improve premature infant survival, care, and cost of care through advancement of the sole use of human milk and milk products for premature infant nutrition.

GENERAL ELEMENTS Although specifics are still being worked out by the committee, the following general elements are to be included: 1. Hospitals that care for premature infants will use mother’s own breast milk or donor human milk and human milk-based products for nutrition for premature infants. 2. Informed consent shall be obtained if formula is to be used for premature infants. 3. A reporting mechanism to DSHS will be developed to confirm that the majority of premature babies at a given hospital are being fed human milk, and that the hospitals have implemented or are participating in established programs to support breast feeding human milk use for premature infants. 4. If the above suggestions are met and the majority of premature infants are fed human milk, an additional financial rider should be provided to hospitals to reimburse the cost of donor milk as determined by average cost assessed statewide by DSHS. We are hopeful that if these recommendations can be implemented in a legislative or regulatory form, that an unusual triple benefit will occur: lives will be saved, the state will save money, and

payers and hospitals also will save money. TMA, TPS and MEDNAX are now working together on taking the next steps to hopefully bring about state-initiated incentives which will make donor human milk the primary alternative nutrition for premature babies and thus save lives and save money. Without the participation in committees, such as the TMA, it would be much more difficult for concerned physicians like ourselves to help develop state guidelines and incentives which can benefit all of our patients on a state or federal level. I am hopeful that the example described here will encourage you to participate in politics for our patients’ benefit.

REFERENCES 1.

Horbar JD, Badger GJ et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999 Pediatrics. 2002;110:143-51. 2. Neu J. W Allen Walker. Necrotizing Enterocolitis. N.Eng J Med. 2011;364:255-64. 3. Ganapathy V, Hay JW et al. Long Term Healthcare Costs of infants who survived neonatal necrotizing enterocolitis: a retrospective longitudinal study among infants enrolled in Texas Medicaid. BMC Pediatrics. 2013, 13:127. 4. Ganapathy V. Hay JW. Costs of necrotizing enterocolitis and cost-effectiveness of exclusively human milk-based products in feeding extremely premature infants. Breastfeed Med. 2012:7(1):29-37. 5. Sullivan S, Schanler RJ, Kim JH, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr 2010;156(4):562.e1-567.e1. 6. Cristofalo EA, Schanler RJ, Blanco CL, et al. Randomized Trial of Exclusive Human Milk versus Preterm Formula Diets in Extremely Premature Infants J Pediatr 2013. Volume 163, Issue 6, Pages 1592-1595. 7. Kenneth Herrmann1,2 and Katherine Carroll3. An Exclusively Human Milk Diet Reduces Necrotizing Enterocolitis. Breastfeeding Medicine Volume 9, Number 4, 2014 a Mary Ann Liebert, Inc. DOI: 10.1089/bfm.2013.0121. 8. Huston K. Markell AM, McCulley EA, et al. Decreasing Necrotizing Enterocolitis and gastrointestinal Bleeding in the Neonatal Intensive care Unit: The Role of Donor Human Milk and Exclusive Human Milk Diets in Infants 1500 g Birth Weight. ICAN: Infant, Child, & Adolescent Nutrition. published online 10 January 2014 DOI: 10.1177/1941406413519267. 9. Eidelman Ai, Schanler RJ and the Section on Breastfeeding Executive Committee. Breastfeeding and the Use of Human Milk. Pediatrics. 2012; 129(3). E827-E839. Alexander B. Kenton, MD, FAAP, is a member of the BCMS Legislative and Socioeconomics Committee.

visit us at www.bcms.org

PHYSICIAN AS PATIENT

Physician as Patient

EDITOR’S NOTE: This is the last in a series of seven articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the BCMS Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness.

What I learned By Jay Ellis, MD I am out from that dark time when I was solely preoccupied

the next performance with grace and dignity.

with my illness. I feel better than I have in years, because the

During my illness, family was always on my mind. My wife and

chronic lymphocytic leukemia was making me progressively more

my mother were my constant attendants, and I cannot compre-

anemic and chemotherapy knocked that back as well. I went from

hend how I would have survived without them. Proverbs tells us,

near death to remission and good health in just six months. It

“It is hard to find a good wife, because she is worth more than rubies.” I will never

feels like a miracle. So, after all I’ve been through, what do I have to show for it? I certainly received an

“The daily life of a (cancer) patient becomes so intensely preoccupied with his or her illness that the world fades away. Every last morsel of energy is spent tending the disease.” — Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer

education in life. I

look at Merrill again without those words coming to mind. My children were a constant source of

guess the first thing I learned was that you cannot do strenuous

joy, and the one item of unfinished business I truly wanted to

exercise with hemoglobin of 8, unless of course your workouts

complete was the opportunity to hold my new granddaughter and

allow for periods of unconsciousness. On a more sober note, I was

pray a grandfather’s blessing over her. I didn’t worry about the of-

forced to ponder those existential questions we put off to a distant

fice, or my group. They would be fine without me. I did ponder

time, like forever.

whether I provided well enough for my wife and family.

The things I thought about most during my illness were faith,

I have been blessed throughout my life with many friends. I

family and friends. Faith allowed me to make some sense out of

would gladly list them all here by name if space permitted and

my illness, knowing that if I didn’t survive I would go to a better

my memory was reliable enough to list them all without error. It

place. As stated before, I had no fear of dying, but I did have fear

was their visits, their calls, their notes, and their bringing food

of being disabled. My wife, Merrill, never liked me saying it, and

that brightened my darkest days. There is an old Russian proverb

she won’t like reading it, but my biggest fear was not being the

that says it is better to have 100 friends than 100 rubles. If that is

man my wife married. I didn’t want my children to remember me

the case, I am rich beyond measure. I will deviate from listing

as a feeble, gasping-for-breath shadow of my former self. There

friends to make just two examples. Dr. Bob Johnson always made

may be a day when that will come, but I wasn’t ready for it then.

time on his Sundays to walk with me in the park. It must have

I passed through the dress rehearsal for old age. I hope I handle

been hard for an athlete of his accomplishments to cut back his

18 San Antonio Medicine • October 2014

PHYSICIAN AS PATIENT

My friends and teammates encouraged me to train to run, even when walking was a challenge. From left: Don Rhine, Dr. Robert Johnson (in back), retired Gen. Ed Rice, Tim Parker, the author and Jimmy Keaton. Courtesy photos

pace to accommodate the efforts of the chemo patient with the

me who have suffered so much more. Some say it's because I lived

hemoglobin of 8. Those walks were the highlight of my week. My

a good life, but I know that canâ&#x20AC;&#x2122;t be true because if it were, there

academy classmates Tim Parker, Billy Nichols and Jim Keaton in-

are living saints around us who would never suffer adversity. Life

sisted on holding my place for our annual run even though the

is not fair, and the rain falls on the just and the unjust. That can't

odds were against me. It was their optimism that planted the little

be it.

seed of hope in my mind that I might come through this and one

As I write these articles and reflect back on what happened, my

day feel well. Their visits and calls were a great break in the mo-

mind returns to small miracles. For our anniversary, Merrill was

notony and they gave the greatest gift of all, the gift of their time.

going to buy me a new wedding band to replace the one that I lost while cleaning the pool. Our friend Alicia heard the story and

MINOR MIRACLES

told Merrill she was going to find the ring. It seemed a well-in-

The most important thing I learned was that there was little

tended wish without any chance of coming true. I had searched

that was unique about my predicament. Others endure as much

the backyard many times. There was not a day when I walked

or more, and if there is anything unusual about my experience it

through the yard that I didn't glance in the pool or at the ground

is that it was brief, and I was fortunate to recover all of my lost

looking for my ring. It never appeared. Alicia and Bob Joyner

function. I marvel that I was so ill at the beginning of the year

came to the house one night, and Alicia walked in the backyard

and feel so well today. Certainly there are lots of reasons for my

with Merrill to check the garden and spotted the ring right next

good fortune. My physician friends tell me that I had great doc-

to her feet. She rushed into the house to give it to me, and I was

tors, great nurses and the advantage of living in the country with

speechless. I had walked past that very spot dozens of times, and

the best cancer treatment in the world. That is all true. My friends

Merrill must have walked past it 10 times that number. How

with a bent toward business remind me that the economics of my

could it just be there that day?

profession allow me access to the best care available. Also true.

The other minor miracle occurred in the early morning hours

My friends at the gym tell me it is because I was in good physical

of Dec. 27. When I awoke with my pneumonia, I knew I was

condition. It allowed me to weather the treatment and my life-

sick, but I didn't realize I was near death. That night what I really

threatening pneumonia. Possibly true as well. I speculate that my

wanted was a glass of water, some Tylenol and to sleep until my

good fortune seems almost unfair when I consider those around

Continued on page 20 visit us at www.bcms.org

PHYSICIAN AS PATIENT

On the left is Tim Parker, and on the right Billy Nichols, my Air Force Academy classmates and airline pilots.

Continued from page 19 alarm went off in the morning. Instead, I found myself sitting on

them in my office. I seldom use the one I own. Until I was asked

the couch staring at my pulse oximeter while it blinked 66 percent.

the question, I never stopped to ponder why I carry one.

To this day, I can't remember how I got my car keys, found my

I own a pulse oximeter for only one reason. When I was in the

way into the garage, opened my bag and pulled out the pulse

military we conducted humanitarian trips to South and Central

oximeter. Maybe it was my anesthesiology training leaping from

America. I then made one trip with my church to Guatemala.

my unconscious to check my ABCs. No. I was hypoxic, confused

These trips always reminded me why I became a physician and

and had trouble forming thoughts. I don't know what prompted

gave me a renewed sense of purpose. Just before the last trip, I pur-

me to get the pulse oximeter.

chased a pulse oximeter so I would always have one no matter

What is even more interesting is why I have a pulse oximeter. If

where I might practice. Had I not had this pulse oximeter, I would

you ask the average anesthesiologist, they don't own one. Several

have gone back to bed on Dec. 27, and Merrill would have found

people have asked me why I do, because there really is no need for

me cold and stiff later that morning.

us to carry one. They are everywhere in the hospitals. We have

20 San Antonio Medicine â&#x20AC;˘ October 2014

Did the Almighty place the pulse oximeter there so that I would

PHYSICIAN AS PATIENT

Last item on my bucket list: to hold this little girl and pray a blessing over her.

Looking for balloons.

survive this event? Why me and for what purpose? For those who

does one decide which activities are wastes of precious time and

don’t believe, the jokes practically write themselves. “Little miracles

which ones serve a special purpose? I’m going to try not to over-

are now available from Amazon.com. Plus, if you are an Amazon

analyze. I’m not going to win a Nobel Prize, and I’m not going to

Prime member, your heavenly missive arrives with free shipping!”

end world hunger. I’m going to have to settle for just trying to be

It is hard for me to believe, even as I write this. I shared the story

a better physician, a better husband, a better son, a better father,

with Richard Fetchik in the doctor’s lounge one day. After I

and a better man. I had plenty of time to think over the past six

thanked him for taking care of me, he reminded me that people

months, and I found it to be a useful endeavor. Bob Johnson asked

think the voice of God manifests only in the burning bush or the

me if I was ever short of things to think about, and the answer is

booming voice. Richard reminded me that sometimes God speaks

no. One of the things I thought about was all the things that were

in whispers.

taken from me during my illness. One of the great ways to learn

If that is the case, then I have a new task. I have to figure out

the value of something is to lose it. I can dance with my wife again,

what I’m going to do with this very special gift of extra time. How Continued on page 22 visit us at www.bcms.org

PHYSICIAN AS PATIENT

Continued from page 21 and the Baptists are right. Dancing does lead to other things. I can enjoy food and drink, and now have to watch my weight instead of forcing myself to eat. Mostly, I treasure the small blessings I took for granted. My daughter called one day with a story about my grandson. He was walking home from school and found a balloon. This unexpected discovery prompted him to declare it “the best day ever” of his three years on earth. So I’m going to push away from the keyboard to go for a run. I don’t need to run, but now that I have the capability again, I want to take advantage of it. I want to use the gifts returned to me to their full benefit. I want to enjoy the little pleasures of life that I missed so deeply. If I’m lucky, on this run, on this day, I might find a balloon. Date night with Merrill after I am found in remission.

22 San Antonio Medicine • October 2014

BCMS NEWS

SAVE THE DATE Oct. 2-3: BCMS Fishing Tournament. Sponsored by Gateway Mortgage Group LLC, Stefen Brooks, RMLO, NMLS #229142. Departs from Rockport. Oct. 16: BCMS Auto Show, 5-9 p.m. BCMS office parking lot. 6243 IH-10 West. Buffet and cocktails; new model vehicles; family and friends welcome. Nov. 1: Women in Medicine Appreciation. 11 a.m.-3 p.m. Omni Hotel at the Colonnade. Guest speaker, networking, shopping, fashion show. For information, go to www.bcms.org.

IN MEMORIAM E. Rubin Bernhard Jr., MD, age 82, died Aug. 25, 2014. Dr. Bernhard, a family practitioner, was a BCMS member and 1985 BCMS president.

CORRECTION In the story, “The ‘A’ Word: Any Baby Can helps families facing an autism diagnosis by offering hope and support,“ published in the July 2014 San Antonio Medicine, the author misidentified Steve Trevino. His job title is architectural designer/muralist.

New Texas Select Committee on Health Care Education and Training created By Mary E. Nava, MBA, Chief Governmental and Community Relations Officer

Some exciting news for the state's healthcare sector: Texas House Speaker Joe Straus announced in a news release July 24 the creation of a new committee -- Select Committee on Health Care Education and Training -- which will examine the healthcare workforce and the growing needs of this sector, along with preparing more students for healthcare industry careers. Chairing the committee will be Rep. Susan King (R-Abilene), a nurse and wife of TMA President Austin King, MD. In addition, San Antonio State Rep. Justin Rodriguez (D-125) is among those selected to sit on the committee. The 84th Legislative Session kicks off in January.

Drs. Vijay and Malathi Koli hosted a reception in their home Aug. 23 honoring State Sen. Leticia Van de Putte (District 26), who is running for lieutenant governor. Pausing for a photo were (standing, from left) Dr. Jayesh Shah, Mary Nava, Dr. Vijay Koli, Dr. Michael Battista and Dr. Rajam Ramamurthy; (seated, from left) Dr. Malathi Koli, Van de Putte, the senator’s daughter, Dr. Nichole Van de Putte, and Dr. Janet Realini.

ALSO IN THE NEWS Dr. Rodolfo Molina was appointed to the Texas Department of Insurance Advisory Committee for Standardized Prior Authorization of Prescription Drug Benefits. Dr. Molina, a rheumatologist in private practice, is a member of the BCMS Legislative and Socioeconomics Committee. For more information, contact Mary Nava at mary.nava@bcms.org.

visit us at www.bcms.org

BCMS NEWS

Kumamoto delegation visits San Antonio Delegates from the Kumamoto City Medical Association visited San Antonio Aug. 23-27 as part of the BCMS sister-city agreement. The 17 Japanese visitors attended a reception and dinner at Oak Hills Country Club, visited with BCMS staff members, and toured the University of Texas Health Science Center at San Antonio and other local medical facilities. For more photos of the delegatesâ&#x20AC;&#x2122; visit, go to www.bcms.org.

Greeters at the San Antonio International Airport were on hand Aug. 23 to welcome a delegation of visitors from the Kumamoto City Medical Association in Japan.

Delegates from the Kumamoto City Medical Association visited the BCMS office Aug. 25.

Kumamoto City Medical Association President Dr. Keisuke Fukushima addresses guests at Oak Hills Country Club during a dinner Aug. 24 in honor of the Japanese guests.

24 San Antonio Medicine â&#x20AC;˘ October 2014

BCMS NEWS

BCMS 2015 Candidates In accordance with the Bexar County Medical Society bylaws, the following slate of candidates was presented for 2015 on behalf of the BCMS Nominating Committee. Official ballots were mailed to BCMS members on Sept. 14. Ballots must be completed and received in the BCMS office, by mail or in person, by no later than 5 p.m. Oct. 14. The candidates provided biographical information regarding their nominations, which has been edited here for space. To read their complete biographies, visit www.bcms.org.

Jayesh B. Shah, MD, CWS, FAPWCA, FCCWS, FUHMS, FACP Candidate for President-elect Dr. Jayesh Shah has been a practicing physician in San Antonio for the past 14 years, and has served BCMS for the past 10 years on various committees. He is the current BCMS vice president. Dr. Shah is one of the Texas alternate delegates to the American Medical Association. He has served on several TMA committees. He is past president of the American Association of Physicians of Indian Origin. He is a true physician rights advocate and is active on medical issues at the national and state levels. He is knowledgeable of issues caused by uninsured, underinsured, Medicaid and Medicare, and the delivery of healthcare in Texas. Dr. Shah is board certified in internal medicine, wound management, and in undersea and hyperbaric medicine.

Leah H. Jacobson, MD Candidate for Vice President I have been actively involved with BCMS and organized medicine since I entered medical school in 1990. I feel it is important to work for both physician and patient advocacy, and the betterment of healthcare for all. In addition to BCMS, I am a member of the San Antonio Pediatric Society, Texas Pediatric Society, Texas Medical Association and American Academy of Pediatrics. I have had the privilege to serve on the board of directors for BCMS for six years, as well as be a member of the delegation to TMA for more than 10 years. I am an adjunct clinical associate professor in the UTHSCSA Department of Pediatrics and Family Practice. For the past 10 years, I have worked in private practice in San Antonio.

Maria M. “Maggie” Tiamson-Beato, MD, FAAP Candidate for Treasurer Maggie graduated from the University of Santo Tomas Medical School in Manila, Philippines, and completed her pediatric residency at Mount Sinai School of Medicine in New York. After 10 years of private practice, she joined the U.S. Air Force Medical Corps, and then joined the South Texas Center for Pediatric Care. Currently, she serves as BCMS secretary and was treasurer of the San Antonio Pediatric Society. She is a clinical assistant professor at UTHSCSA and an active member of the American Academy of Pediatrics. Her vision for BCMS is to strive for continued growth in membership by helping fellow practitioners realize the importance of belonging to a dynamic medical society which helps promote the profession’s best practices.

Adam V. Ratner, MD Candidate for Secretary Dr. Adam V. Ratner is chair and a co-founder of the Patient Institute. He received his undergraduate degree from Harvard College and his MD degree from the University of Texas Southwestern Medical School. He was a Sarnoff Fellow for Research in Cardiovascular Science while in medical school. He performed his postgraduate training in diagnostic radiology and was a Felix Bloch Fellow for MRI research at Stanford University. He was in the private practice of radiology for almost 20 years prior to co-founding the Patient Institute. He currently serves as a clinical professor and deputy chair for strategic development and socioeconomics in the Department of Radiology at the University of Texas Health Science Center at San Antonio. visit us at www.bcms.org

LIFESTYLE

TOP TEXAS SPOTS TO VI EW

Story and photos by Mauri Elbel Towering cypress trees splashed in gold and crimson fringe the cool, clear waters of the Frio River on a brilliant autumn afternoon in Garner State Park (www.tpwd.state.tx.us/state-parks/garner). Just an hour and a half from downtown San Antonio, the air is brisk and the surrounding backdrop paints a perfect-picture scene of autumn in Texas. Fall is my favorite time to visit this area of Texas, where soaring mesas and carved limestone cliffs form the backdrop to the vivid colors which come alive in the Hill Country this time of year. Sitting on the southwestern edge of the Edwards Plateau, Garner State Park is a 1,774acre oasis of tranquility nestled in the unique sub-region known as the Balcones Canyonlands, where fall colors, cooler camping weather and fewer people combine to create big reasons to visit. October and November are ideal for fall foliage hikes along trails such as the short but steep halfmile climb leading to White Rock Cave, ideal for explorers of all ages and skills. But Garner State Park isn’t the only nearby spot where fall beauty can be seen in 26 San Antonio Medicine • October 2014

fall foliage

all its glory. All throughout the Lone Star State, Texas state parks provide some of the best places to view fall’s vibrant hues. Soak in the season’s colors with a visit to Garner or one of these nine other areas:

Lost Maples State Natural Area From Garner State Park, Lost Maples State Natural Area is less than 30 miles away and offers one of the most fabulous fall foliage spots in Texas –– the Lost Maples foliage report is updated weekly online from October through November. A true Hill Country haven, these roughly 2,200 acres are graced with towering bigtooth maples, rugged limestone canyons, pristine streams and plateau grasslands. As leaves turn the color of fire, fall from the trees and decorate the ground with a spectacular autumnal covering, thousands gravitate to this state natural area each fall to hike the 11 miles of trails lining the banks of the Sabinal River and weaving through dense woods and rocky outcroppings as well as camp, picnic, birdwatch and fish. More at: www.tpwd.state. tx.us/state-parks/lost-maples.

Pedernales Falls State Park At Pedernales Falls State Park, about an hour and a half from downtown San Antonio, trails wind through hills sprinkled with oaks and junipers, forming a gateway to the wooded areas filled with pecan, elm, sycamore, walnut and hackberry trees. On the terrace adjacent to the river, ash, buttonbush and cypress grow, creating a diverse tree population that reveals autumn’s bold colors to those who go looking. “Upon first glance, Pedernales Falls State Park appears to offer little in the form of colorful fall foliage as the uplands around the entrance and park headquarters are dominated by evergreen, ash, juniper and live oak,” said John Alvis, assistant park superintendent. “The often overlooked beauty can be found along the river with the warm orange and yellow hues of the cypress as it is reflected off of the clear tranquil waters of the Pedernales. Intermixed with the deciduous red and post oaks, the views along the river can be striking.” The best time to view fall color at Pedernales State Park is typically November –– come for the day or stay overnight at one of its campsites. More at:

LIFESTYLE

While the following Texas parks are located a bit further away from San Antonio, their famous fall colors make the drive well worth it:

www.tpwd.state.tx.us/state-parks/pedernales-falls.

Colorado Bend State Park Colorado Bend State Park is an adventurer’s playground, boasting 32 miles of multiuse routes and opportunities for primitive camping, hiking, mountain biking, caving, fishing, bird- and wildlife-watching, and swimming or paddling down the Colorado River. November is one of the best times to visit this state park, making the nearly three-hour trip from San Antonio well worth it. “We had some nice colors last year,” said Jason Hairston, interim park superintendent. “Though the majority of trees in our park are cedar, we do have some hardwoods like oak, elm and pecan.” More at: www.tpwd.state.tx.us /stateparks/colorado-bend.

Hill Country State Natural Area Each fall, Hill Country State Natu-

ral Area draws in the overflow from Lost Maples due to the gorgeous fall colors on offer every November. Around 40 miles of multiuse trails weave through the rugged terrain southwest of Bandera, leading guests through a secluded back country environment of valleys, streams and limestone hills. Just over an hour’s drive from downtown San Antonio, midNovember through December are ideal months to visit Hill Country State Natural Area. That’s the time red oaks boast crimsons, oranges and browns; escarpment black cherry trees show off their golds; and flame-leaf sumac blaze in reds and browns that contrast with the greens of the live oaks and mountain cedar, said Hill Country State Natural Area’s Leanne Beauxbeannes. Beautiful autumn weather also provides the best opportunities for camping, hiking, biking and horseback riding, she said. More at: www.tpwd.state.tx.us/state-parks/ hill-country.

Brave the road trip to Davis Mountains State Park (www.tpwd.state.tx.us/stateparks/davis-mountains; 403 miles from San Antonio) to see beautiful warm fall hues juxtaposed by the grays and teals seen on gray oaks and mohr oaks, said Jason R. Singhurst, plant ecologist/botanist for TPWD’s wildlife diversity program. “The hardwood slope forests at Caddo Lake State Park (www.tpwd.state.tx.us/stateparks/ caddo-lake; 386 miles from San Antonio) include orange hues of sugar maple, purple foliage of red maple and yellow hues of sweetgum.” Head to Lake Mineral Wells State Park (www.tpwd.state.tx.us /state-parks/lake-mineral-wells; 252 miles from San Antonio) to witness striking orange, red and yellow fall foliage colors as post oaks and black jack oaks change color. Lying in the heart of the Texas Panhandle is the second-largest canyon in the nation, Palo Duro Canyon State Park (www.tpwd. state.tx.us/state-parks/palo-duro-canyon; 500 miles from San Antonio) where rugged landscapes and brilliant colors combine for a stellar time to visit each fall. “Palo Duro Canyon has amazing displays of yellow foliage of cottonwoods and willows along the Prairie Dog Fork of Red River,” Singhurst said. Visit Martin Dies Jr. State Park (www.tpwd.state.tx.us/stateparks/martin-dies-jr; 316 miles from San Antonio) located at the edge of the Big Thicket National Preserve to see a beautiful blend of fall colors. “Martin Dies State Park has amazing oranges, yellows and purple fall foliage displayed by American beech, hickory, sweetgum and maple,” Singhurst said. visit us at www.bcms.org

BUSINESS OF MEDICINE

Minimizing the cost of physician preference items By Kathleen Carrico, RN, BSN, MBA, and Dana A. Forgione, PhD, CPA, CMA, CFE

A major force driving national healthcare priorities is the need for healthcare organizations and physicians to do more, with less, and improve quality at the same time. That is, improve clinical outcomes while working within the constraints of lower healthcare reimbursement. Physicians and value analysis professionals within the hospital supply chain play a vital and strategic role in bringing together both clinical quality and cost reduction for many Physician Preference Items (PPIs). While estimates vary, hospital operating expenses range from 15 percent to 25 percent of total cost. Of this, 60 percent of supply costs are made up of PPI (ECRI Institute, 2009). Vendors have a long history of promoting PPI starting in medical schools where physicians become familiar with using certain items and develop lifetime product or brand loyalty. Manufacturers invest significant time and money to promote personal relationships with physicians to help maintain brand loyalty. This marketing approach contributes to even stronger physician preference, maintains and expands market share, and helps to maintain profitability for the manufacturerâ&#x20AC;&#x2122;s products. This is especially relevant to the procurement of surgical equipment and supplies.

ACTIVE ROLE NEEDED To help control costs, it is important for physicians to take an active role in value analysis decisions regarding supplies and equipment. Value analysis does not mean the least expensive item is selected. Rather, products are reviewed for evidence-based outcomes and weighed against the outcome-benefit to the patient. Often, a vendor will cite the benefits of reduced length of stay, lower infection rates, or improved clinical outcomes. But value is weighed against actual outcomes and requires consideration of the total cost of care. There are several important key processes that enable physicians and value analysis professionals to work effectively toward longrange, cost-effective care, that is process-focused, evidence based, and value driven. These include: 28 San Antonio Medicine â&#x20AC;˘ October 2014

1. Engagement: Become engaged in the supply chain. It is imperative that the supply chain and value analysis process work in collaboration with the physician. Overall value should carry significant weight in the selection of a PPI. By working together with value analysis professionals and teams, physicians can have early, meaningful input regarding clinical requirements, and can avoid adverse surprises. Collaboration can work strongly in the favor of both the physician and the healthcare institution to drive down the costs of clinical PPIs. 2. Data: Identifying and using salient data can make a significant difference in discerning true clinical improvements versus vendor claims of improvements that come at a higher cost. With todayâ&#x20AC;&#x2122;s information technology, tracking outcomes using electronic tools such as ECRI (www.ecri.org), Hayes Research (www.hayesinc.com/hayes), Crimson Analytical Data (www.advisory.com/technology/crimson) or other comparable programs, should be an integral part of the evidence-based PPI selection. 3. Alternatives: Review all the options. Be willing to consider how costs and outcomes compare across alternatives. Since branding is such an effective tool to promote product loyalty, rely more on blind studies of products whenever possible, and be open to generic supplies with documented outcomes. 4. Standardization: The value analysis process has the best opportunity to obtain lower negotiated prices when multiple product variations can be narrowed down to one or two. Working with the value analysis team to standardize PPIs as much as possible provides leverage to help drive pricing down and also reduce inventory carrying costs. Once again, collaboration between physicians and value analysis professionals is key! 5. Reimbursement: Understanding the impact of the PPI on charges, reimbursements and clinical outcomes will help shape the negotiation process. The ability of a hospital to successfully meet its operational demands when performing procedures with a negative-value to the bottom line is unsustainable. It is impor-

BUSINESS OF MEDICINE

tant for physicians to understand and weigh the current supplychain cost of a procedure. Often standing orders and preference cards are outdated, and contribute to needless additional costs. By working with the value analysis team, improved utilization and standardization can make a significant difference in balancing quality, access and cost. 6. Collaboration: Sharing viewpoints on desired outcomes, patient safety concerns, comfort-level with a product, and supplier support and service experience can help other supply chain and value analysis team members to appreciate and strive to meet these needs. With a shared perspective, these attributes can be better represented in the strategic and operational goals of the healthcare organization. Often education and training services can be negotiated as part of the overall expectations when converting products. Working with the value analysis professional, physicians can help drive these important aspects of a purchase decision that may otherwise be overlooked.

CONCLUSION Overall procedural cost, outcomes and physician preferences play a vital part in driving down costs in the healthcare organization, and throughout the entire U.S. healthcare system. The active participation of physicians early on, and continuing throughout the review and ne-

gotiation process, can have a significant impact on procuring high quality supplies at reasonable prices. It is important for physicians to help drive this process through collaborative effort that will result in overall improved healthcare value, by considering both the clinical and financial data, and weighing it by the best available evidence.

REFERENCE ECRI Institute, (2009). News Release â&#x20AC;&#x201D; Wasting Millions on Purchases Based on Physician Preference? Accessed Jul. 28, 2014 at: www.ecri.org/press/pages/ Physician_Preference_Items.aspx. Kathleen Carrico, RN, BSN, BS, MBA, has worked in healthcare for more than 30 years. She has served in various positions, including ICU, labor and delivery, surgical operations manager, and most recently in value analysis in the supply chain at University Health System. Dana A. Forgione, PhD, CPA, CMA, CFE, is the Janey S. Briscoe Endowed Chair in the Business of Health at the University of Texas at San Antonio. He is also an adjunct professor in the School of Medicine, Department of Cardiothoracic Surgery, the Department of Pediatrics, and in the School of Public Health, all at the University of Texas.

visit us at www.bcms.org

HASA

HASA services help improve patient care By Vince Fonseca, MD, MPH, FACPM

A few years ago, Healthcare Access San Antonio (HASA) set out to create a set of services to share clinical information across providers with the patient's consent, privately and securely. In July 2014, HASA, the Health Information Exchange (HIE) for Bexar and 21 surrounding counties in South Central Texas, became the first HIE in Texas and only the fourth in the nation to achieve full accreditation with the Texas Health Information Exchange Accreditation Program from the Electronic Healthcare Network Accreditation Commission and the Texas Health Services Authority. HASA services include ProviderAssist to exchange key clinical information such as discharge summaries; a patient portal for patient’s online access to their health information and secure messaging; and HASAFacts for reports on your patients, such as ED visit or hospital discharge notification. We realize that patients seek health services in many places, not just in one doctor's office. Coordinating care is extremely difficult if you do not know the services other providers have delivered to your patients. What is the status of services in the United States to support these needed functions? The Office of the National Coordinator's report released in August 2014, National Health Information Exchange and Interoperability Landscape, summarizes the trends and status of HIT activities in the nation. EHRs are now used by 78 percent of providers, and 65 percent of providers have collected meaningful use Stage 1 bonuses, as of February 2014. Stage 2 puts stronger emphasis on health information exchange and patient engagement.

o Medication lists: 34 percent o Medication allergy lists: 34 percent • 50 percent receive discharge summaries routinely, but only 25 percent receive them electronically

Patient Engagement • Two-thirds could provide clinical summaries to patients for each visit; about 55 percent routinely do this (Stage 1 measure) • 60 percent could provide educational resources for patients’ specific conditions, about 45 percent routinely do this (Stage 2 measure) • 50 percent could exchange secure messages with patients; about 30 percent routinely do this (Stage 2 measure) • 40 percent could provide patients with the ability to view online, download or transmit information from their medical record; about 30 percent routinely do this (Stage 2 measure) • Staff physicians were more likely to use patient engagement features than those in private practices

Hospitals • 57 percent could exchange information with ambulatory providers outside of their organization

Health Information Exchange • 39 percent of providers are able to exchange information to any other provider o 35 percent were able to exchange information with providers within their affiliated groups or hospitals o 14 percent were able to exchange information with providers outside of their affiliated groups or hospitals o Staff physicians more likely to exchange than those in private practices • Physicians exchange different types of data: o Lab results: 36 percent o Imaging reports: 34 percent o Problem lists: 33 percent 30 San Antonio Medicine • October 2014

• 40 percent could exchange information with hospitals outside of their organization • Types of data exchanged by hospitals: o 57 percent lab results o 55 percent radiology reports o 42 percent clinical care summaries o 37 percent medication history • 51 percent able to query patient health information electronically • 41 percent able to send and receive secure messages containing patient health information to and from external sources

HASA

• Routine ED visit notification to PCP o 45 percent routinely notify PCPs inside their system o 25 percent routinely notify PCPs outside their system

Patients • 28 percent were offered online access to their medical information; of these, o 46 percent viewed the information offered to them o 44 percent shared their online data with someone else o 39 percent downloaded their online data o 11 percent transmitted their data to app or PHR

Labs • 67 percent have capability to send structured lab results to EHR; o Of these, 80 percent actually sent structured lab results to an EHR • 47 percent of physicians have capability to incorporate structured lab results into EHR • 93 percent of hospitals incorporate structured lab results for more than 40 percent of patients admitted to inpatient or ED

Behavioral Healthcare Providers • 25 percent able to exchange key clinical information with other providers • 28 percent of BH provide summary of care record for transitions of care HASA now has clinical information for more than 1.1 million unique patients and a set of services to help you improve the care for your patients by providing exchange services, a patient engagement portal and a reports portal. The most recent information on the status of exchange and patient engagement in the United States shows that we still have significant gaps. HASA provides a way to help close them and support you in caring for your patients. Vince Fonseca, MD, MPH, FACPM, is the director of medical informatics at Intellica Corp., and the medical advisor for Healthcare Access San Antonio (HASA), the local Health Information Exchange (HIE) provider authorized by the state of Texas to create a community-based, regionwide HIE in Bexar County and 22 surrounding counties. Visit www.hasatx.org.

visit us at www.bcms.org

UTHSCSA DEAN’S MESSAGE

PRIMARY CARE CENTERS: Answering the challenge By Francisco González-Scarano, MD We have just opened our newest outpatient office at 3939 Medical Drive, which will offer comprehensive, integrated primary care as a part of our new UT Medicine Primary Care Center. This is a major step in a new approach to addressing the growing healthcare needs of our city, which is a challenge being faced by communities everywhere. Our new facility is also a step further toward our goal of creating a patient-centered, integrated healthcare organization, with primary care as the foundation of our large multispecialty practice. The Primary Care Center is rapidly growing and is adopting the Patient Centered Medical Home (PCMH) model, an important structure for supporting a healthy community throughout all our primary care practices. According to an article in the Annals of Family Medicine (Nov. 12), by 2025 visits to primary care providers will increase by approximately 100 million/year. This study estimates that the United States will need another 52,000 primary care physicians (PCPs) and other providers to meet this need. Their calculations cited population growth and advancing age as the most significant drivers, with increases in the number of insured contributing about 20 percent to this rise. The U.S. Department of Health and Human Services predicts we will be short by approximately 20,000 PCPs. The American Association of Medical Colleges estimates the shortage at 46,000 PCPs by 2020. Regardless of the numerical differences, the studies all agree that we are facing a significant and potentially dangerous shortage of primary care providers. And, of course, the greatest impact will be on the vulnerable and underserved populations, exacerbating an existing problem. Beyond the equation of patient-to-physician ratios, many of you know there are substantial business obstacles to running a successful primary care practice. Many practices face an unsustainable workload, with physicians adding hours and business days to meet the growing needs of their patient base. Proper reimbursement for “cognitive” services is a continual challenge, worsened by the growing requirement to perform increasing amounts of unreimbursed work. Lately, more physician assistants and advanced practice nurses provide primary care; these efforts 32 San Antonio Medicine • October 2014

expand the healthcare workforce. Physician recruitment is an ongoing challenge, and only recently have we started to see a small upward trend in the number of MDs applying to primary care residency programs.

CMS INCENTIVES The federal government has developed some innovative solutions to this growing demand, and like many hospitals and medical school practice plans, UT Medicine has joined the list of organizations that have enrolled in the “Delivery System Reform Incentive Payment” (DSRIP) program. The DSRIP program, which is funded by the Centers for Medicare and Medicaid Services (CMS) as part of an initiative to improve care access and quality/outcomes in Texas and California, is based on the goal of reducing the overall cost of healthcare through efficiencies in processes that ultimately result in a healthier population. Analysts and economists surmise that DSRIP program payments may ultimately replace all traditional supplemental payment programs used in most state Medicaid programs. The DSRIP program is integrated with what is known as the “1115 Waiver” program, which Texas applied for and received in December 2011. The details are beyond the scope of this article, but the waiver is for Section 1115 of the Social Security Act of July 13, 2011. It waives certain Medicaid requirements and replaces previous funding with two new pools of federal funding, including payment for uninsured patients as well as incentives for quality and cost-control metrics. With a focus on prevention, health promotion, care coordination, and chronic disease management, the new model of primary care is the foundation for building a healthier patient population and decreasing the total cost of healthcare. Our new office on Medical Drive is designed to do just that – improve how we deliver care so that it is better for everyone involved. Heading up our Primary Care Center is Dr. Sara Pastoor, who was recruited from a highly successful career in the U.S. Army. She is now focused on transforming primary care at UT Medicine and expanding the primary care presence in the San Antonio com-

UTHSCSA DEAN’S MESSAGE

munity. Dr. Mariana Munante, medical director for the new clinic on Medical Drive, is a graduate of our family and community medicine residency program, an experienced physician leader and patient centered medical home champion. “We are entering into a new era of healthcare delivery,” Dr. Pastoor says. “Along with opening this new venue, we are using a primary care strategy that will transform the status quo at UT Medicine, leading our organization to become an integrated healthcare system with a strong foundation of primary care that is focused on improving the health of the community, enhancing the experience of care, and controlling healthcare costs.” The new office is based on a patient and family-centered perspective that takes into account additional determinants of health -- including socioeconomic influences, cultural or religious beliefs, health literacy and patient self-management skills, as well as other barriers to better health. We will be tracking metrics around quality measures and plan to qualify for DSRIP funds by demonstrating better outcomes. We also will be offering services to under-insured and under-served patient populations.

REIMBURSEMENT OPPORTUNITIES We know that strong primary care is the platform for the promotion of healthy behaviors, early detection and prevention of disease, as well as effective disease management. In turn, care planning and coordination with specialists and other providers are the cornerstones of the new model of primary care. To better support this new model financially, the goal is to develop new reimbursement opportunities that pay for improved performance on quality measures and to incentivize care coordination activities, resulting in decreased healthcare spending by keeping patients healthier. Our emphasis on evidence-based prevention and proactive processes that improve the effectiveness of care will be the pivot point for improving performance on these measures – all of which have a strong influence on the patient’s well-being and the cost of healthcare as a whole. Our new Medical Drive clinic, under the leadership of Dr. Munante, will include a team of three physicians, as well as nurse practitioners, physicians assistants, nurse case management services, and other highly qualified medical professionals. We will care for patients of all ages, and will have a psychologist for counseling and behavior-related health problems, a PharmD for medication counseling and management, and a licensed nutritionist on site – all working together to assist patients as an integrated team to improve disease management and prevention through better health literacy, effective self management, and adoption of healthier be-

haviors. We will offer well-child visits, as well as treat minor injuries and illnesses in children. This includes vaccinations and school/sports physicals. We also will have Quest diagnostics onsite for lab tests. The electronic medical record (EMR – UT Medicine uses EPIC), will play a crucial role as we look to share not just health information, but the responsibility for patient care among the primary care team. EPIC supports our move into an era of electronic patient management to ensure proactive, integrated, evidence-based care for every patient. The EPIC system, which is used by many large health systems in the United States, has proven to be an ideal tool for this and is now fully deployed throughout most UT Medicine sites. EPIC also will play an important role in performance measurement and reporting for the Primary Care Center. “MyChart” is a patient portal that is incorporated into EPIC. This portal allows patients to communicate with their physicians and other staff, complete pre-appointment history collection or health risk assessments, access their laboratory results, and request prescription refills and appointments, all through a secure, webbased electronic platform. MyChart is part of our effort to recruit patients as an important member of their healthcare team; encouraging patients to use this tool in their healthcare has great potential for improving outcomes, streamlining processes, and making healthcare more affordable and personal. Diabetes self-management classes provided by the San Antonio Metropolitan Health District, as well as other programs designed to promote better health and healthier habits, also will be available in the Medical Drive venue and will be available to the un-insured and the under-insured. At UT Medicine, our goal is to create sustainable, accessible and affordable healthcare by implementing a healthcare delivery model designed around the patient, who ultimately, will be the best measure of our success as we work to build a true patientcentered medical home as the foundation of an integrated healthcare organization. Join me in congratulating Dr. Pastoor and the entire Primary Care Center team at UT Medicine as they work to bring the future of primary care into the present in San Antonio. Dr. Francisco González-Scarano is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu. visit us at www.bcms.org

34 San Antonio Medicine â&#x20AC;˘ October 2014

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

• ACCOUNTING Anderson, Johns & Yao CPAs (HH Silver Sponsor) We strive to provide a professional and friendly atmosphere for all your accounting and financial needs Ann Yao, CPA/PFS, 210-696-9400 yao@ajycpa.com www.ajycpa.com San Antonio based CPA firm with 30 plus years of experience Padgett Stratemann & Co. LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally-owned CPA firms, providing sophisticated accounting, audit, tax, and business consulting services. Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com Offering Service. More Than Expected. On every engagement. Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA, 210-384-8000, ext 112 jprice@ssacpa.com www.ssacpa.com Dedicated to working with physicians and physician groups

have over 150 years of combined experience providing exemplary representation for clients. Eric Pullen, 210-222-9494 EPullen@pulmanlaw.com

• BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with 5 core values; Attention, Accountability, Appreciation, Adaptability & Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett, 210-343-4556 jeanne.bennett@amegybank.com Karen Leckie, 210-343-4558 karen.leckie@amegybank.com www.amegybank.com Community Banking Partnership

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance. BB&T offers banking services to help you reach your financial goals and plan for a sound financial future Ed L. White, Jr. 210-247-2985 ewhite@bbandT.com www.bbandt.com

• ATTORNEYS Cox Smith Matthews, Inc. (H Bronze Sponsor) The largest Texas law firm headquartered in San Antonio and one of the top 25 largest Texas law firms. Dan G. Webster, III 210-554-5500 dgwebste@coxsmith.com www.coxsmith.com Pulman, Cappuccio, Pullen, Benson & Jones (H Bronze Sponsor) The attorneys at Pulman, Cappuccio, Pullen, Benson & Jones, LLP

BBVA Compass (HHH Gold Sponsor) A multinational banking group providing financial services in over 30 countries,and to 50 million clients throughout the world. Commercial Relationship Manager Zaida Saliba, 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie, 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com Working for a better future

Broadway Bank (HHH Gold Sponsor) Broadway Bank is a full service personal and commercial bank with a specialized Healthcare banking team committed to supporting our medical community. We offer 40 convenient locations in San Antonio, Austin and surrounding areas. Ken Herring, 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com We’re here for good.

Crockett National Bank (HHH Gold Sponsor) Crocket National Bank is a leading Texas community bank specializing in mortgage, ranch and commercial real estate lending providing superior customer service and competitive financial products. Lydia Gonzales, 210-384-9304 lydiagonzales@crockettnationalbank.com www.crockettnationalbank.com Doing what we promise.

Frost (HHH Gold Sponsor) As one the largest Texas-based banks,Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses. Lewis Thorne, 210-220-6513 lewis.thorne@frostbank.com www.frostbank.com Frost@Work provides your employees with free personalized banking services.

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com Baptist Credit Union (HH Silver Sponsor) It is Baptist Credit Union’s mission to meet our members needs by providing extraordinary service, quality financial products, and personal financial education. Sarah Chatham 210-525-0100, ext 201 memberservices@baptistcu.org www.baptistcu.org We commend your dedication to the health & wellbeing of our community. Cadence Bank (HH Silver Sponsor) Cadence Bank is a full-service financial institution serving commercial, consumer, treasury and wealth-management clients in Texas and the Southeast. Margarita Ortiz, 210-764-5500 maggie.ortiz@cadencebank.com Steve Edlund, 210-764-5573 steve.edlund@cadencebank.com http://cadencebank.com Explore Cadence Bank’s innovative financing options and treasury management solutions. Citi Commercial Bank (HH Silver Sponsor) Chris McCorkle 210-408-5014 christopher.a.mccorkle@citi.com www.citi.com Continued on page 36

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Firstmark Credit Union (HH Silver Sponsor) Address Your Office Needs. Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs. Competitive rates, favorable terms, and local decisions. Gregg Thorne, SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org St. Joseph's Credit Union (HH Silver Sponsor) A Credit Union providing savings, checking, IRA, club, and CD accounts. Plus, Auto, signature, Lines of Credit, MasterCard and Real Estate Loans. Debra Abernathy, 210-225-6126 lending@sjcusatx.net www.sjcusatx.com Better Rates on Auto loans, Signature loans and Platinum MasterCard Jefferson Bank (H Bronze Sponsor) Full service bank specializing in mortgages, wealth management & trusts. Ashley Schneider 210-734-7848 ext 7848 aschneider@jeffersonbank.com www.jeffersonbank.com Security Service Federal Credit Union (H Bronze Sponsor) Business financing, specializing in low interest commercial real estate transactions Luis Rosales, 210-845-8159 lrosales@ssfcu.org BCMS members can get up to half a percent off the origination fee

• CONTRACTOR/ BUILDERS Huffman Developments (HH Silver Sponsor) Steve Huffman, 210-979-2500 Shawn Huffman, 210-979-2500 www.huffmandev.com San Antonio Retail Builders (HH Silver Sponsor) Specializing in remodeling/finish out of medical offices. H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com Next 6 months Architectural Space Plan / Rendering No Cost or Obligation

• CUSTOM HOMEBUILDING

Diamante Custom Homes (HHH Gold Sponsor) Experience your new custom homebuilding process through San Antonio’s leading designbuild firm. Over two decades of streamlining the balance between your budget and your dreams. The name you know from the builders you trust! Keith Norman, 210-341-6430 knorman@diamantehomes.com www.diamantehomes.com Special promotions for all BCMS members – call us today!

• EDUCATION

• CATERING

Alpha Bilingual Preschool (H Bronze Sponsor) Our mission is to provide young children with an integral early education in a Spanish immersion environment. Tania Lopez de Pelsmaeker 210-348-8523 tldp@hotmail.com Give your children the gift of speaking a second language.

Corporate Caterers (H Bronze Sponsor) Ricardo Flores, 210-789-9009

• ELECTRONIC MEDICAL RECORDS

Texas Farm Credit (H Bronze Sponsor) Rural, homestead and acreage lending. Tiffany Nelson, 210-798-6280 www.texasfcs.com

Heavenly Gourmet Catering (H Bronze Sponsor) 210-496-9090 www.heavenlyg.com

Greenway Health (HHH Gold Sponsor)

36 San Antonio Medicine • October 2014

Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency. Jason Siegel 512-657-1259 jason.siegel@greenwayhealth.com www.greenwayhealth.com

• FINANCIAL SERVICES

Northwestern Mutual Wealth Management Company (HHHH Platinum Sponsor) Comprehensive Financial Planning Insurance and Investment Planning Estate Planning and Trust Services. Eric Kala CFP, CLU, ChFC, Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction,confidence, and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com Get what you deserve… Maximize your Social Security benefit!

Frost Leasing (HHH Gold Sponsor) As one the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses.

Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com Commercial leasing for a doctor’s business equipment and vehicle. Platinum Wealth Solutions of Texas LLC (HH Silver Sponsor) Comprehensive financial planning firm who assists medical professionals to protect their income, their wealth, their practice and legacy. Tom Valenti, 210-998-5023 tvalenti@jhnetwork.com Eric Gonzalez, 210-998-5032 ericgonzalez@jhnetwork.com www.platinumwealthsolutionsoftexas.com Understanding the uniqueness in the financial life as a physician. Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning. Robert C. Cadena, 210-342-2900 robert@retirementsolutions.ws www.retirementsolutions.ws Bold Wealth Management (H Bronze Sponsor) Comprehensive Investment Advisory and Retirement Planning Services for Businesses and Individuals. Richard A. Poligala, 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com Complimentary no-obligation retirement plan review to BCMS members

• GOLF TPC San Antonio (H Bronze Sponsor) 18-hole championship golf courses designed by two of golf's most innovative architects, Pete Dye and Greg Norman. Matt Flory, 210-491-5816 www.tpcsanantonio.com

• HEALTHCARE CONSULTING TNT Healthcare Consulting LLC (H Bronze Sponsor) We want physicians to concentrate on what they were trained

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY to do, treating patients. Tom Tidwell, CMPE 210-861-1258 Thomas.tidwell@att.net Let TNT healthcare consultants evaluate your practice and improve efficiency and cost.

• HOSPITALS/ HEALTHCARE SERVICES

First Choice Emergency Room (HHH Gold Sponsor) Nacogdoches Road 24-hour 210-447-7560 Tezel Road 24-hour 210-437-1180 www.fcer.com Check in online – free, easy, fast!

Select Rehabilitation of San Antonio (HHH Gold Sponsor) At Select Rehabilitation Hospital of San Antonio, we provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck, 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com/ Offers patients a higher degree of excellence in medical rehabilitation.

South Texas Sinus Institute (HHH Gold Sponsor) The South Texas Sinus Institute is a state of the art facility dedicated to in-office Balloon Sinuplasty using the unique Painless Sinuplasty Anesthetic Linked Method. Sue Musgrove, 210-225-5666 stsisue@gmail.com www.southtexassinusinstitute.com. We will offer convenient same day or lunch appointments to BCMS members.

Warm Springs Medical Center Warm Springs Thousand Oaks Warm Springs Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate,expert care during the rehabilitation process & support recovery through education & research. Central referral Line 210-592-5350 Joint Commission COE Elite Care 24 Hour Emergency Center (HH Silver Sponsor) We are a fully equipped emergency room open 24 hours a day and 7 days a week, staffed by experienced emergency physicians. We provide the same level of emergency medical care that you would receive in a hospital ER. Clemente Sanchez, 210-269-8028 csanchez@elitercaremarketing.com Rosie Clark, 210-771-0141 rclark@elitecaremarketing.com www.elitecareemergency.com Get seen by an experienced physician within 10 minutes. Methodist Healthcare System (HH Silver Sponsor) Palmira Arellano, 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Seasons Hospice and Palliative Care (HH Silver Sponsor) Deb Houser-Bruchmiller 210-471-2300 dhouser@seasons.org www.seasons.org Southwest General Hospital (HH Silver Sponsor) Southwest General Hospital is a 327-bed, state-of-the-art hospital located in San Antonio, Texas. Southwest General offers comprehensive healthcare services. Craig Desmond, 210-921-3521 Elizabeth Luna, 210-921-3521 www.swgeneralhospital.com

• HUMAN RESOURCES

Employer Flexible (HHH Gold Sponsor)

Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page. John Seybold, 210-447-6518 jseybold@employerflexible.com www.employerflexible.com BCMS members get a free HR assessment valued at $2,500. Pinnacle Workforce Corp HR. Services (H Bronze Sponsor) Dan Cardenas, 210-344-2088 dancardenas@pinnacleworkforce.com

• INFORMATION TECHNOLOGY

Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Stephanie Stephens, 210-332-4924 sstephens@dahill.com www.dahill.com Allison Royce Business Technologies (H Bronze Sponsor) Business Technology Provider, specializing in HIPAA Compliant Managed IT Services and IT Support since 1993. Jeff Tuttle, 210-564-7000 jtuttle@allisonroyce.com www.allisonroyce.com PitCrew IT Services (H Bronze Sponsor) Provides reliability for your business computers or network, enabling you to operate smoothly. Eric Murcia, 210-547-0305 eric@pitcrewit.com

• INSURANCE

Blue Cross Blue Shield of Texas (HHH Gold Sponsor) Edna Pérez-Vega, 210-558-5162 Edna_Perez-Vega@bcbstx.com www.bcbstx.com

Frost Insurance (HHH Gold Sponsor) As one the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment, insurance services to individuals and businesses. Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com Business and personal insurance tailored to meet your unique needs.

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Donnie Hromadka 512-338-6151 dhromadka@humana.com www.humana.com Nationwide Insurance Joel Gonzales Agency (H Bronze Sponsor) What matters to you, matters to us! Joel Gonzales 210-314-7514 gonzj8@nationwide.com www.nationwide.com/jgonzales Texas Drug Card (H Bronze Sponsor) The Texas Drug Card program is a FREE statewide Rx assistance program available to all residents. Todd Walker 512-569-5547 twalker@texasdrugcard.com http://texasdrugcard.com/index.php

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• INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH Platinum Sponsor) Texas Medical Liability Trust is a physician-owned health care liability claim trust, providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 14,000 doctors in all specialties who practice in all areas of the state. TMLT is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, the Dallas, Harris, Tarrant, and Travis County Medical Societies. Patty Spann, 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended Partner of the Bexar County Medical Society.

Medical Protective Medical Malpractice Insurance (HHH Gold Sponsor) Medical Protective, the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Thomas Mohler 512-213-7714 thomas.mohler@medpro.com www.medpro.com

Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the Texas Medical Association Insurance Trust (TMAIT) helps physicians, their families, and their employees get the insurance coverage they need. James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org We offer BCMS members a free insurance portfolio review.

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are one of the few agents in the state that specialize in Medical Malpractice and all lines of insurance for the medical community. Katy Brooks, CIC, 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com Serving the medical community. The Doctors Company Medical malpractice insurance (HH Silver Sponsor) We relentlessly defend, protect and reward the practice of good medicine. As the patient safety industry leader, we proudly offer a comprehensive selection of CME opportunity and risk-mitigation resources. Kirsten Baze, 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com

• INTERNET/ TELECOMMUNICATIONS Time Warner Cable Business Class (HH Silver Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community. Rick Garza, 210-582-9597 Rick.garza@twcable.com Time Warner Cable Business Class offers custom pricing for BCMS Members.

• MARKETING SERVICES Phiskal LLC Marketing and Promotion (H Bronze Sponsor) A leading edge marketing and development firm using proprietary Artificial Intelligence engines to enhance your presence with websites, apps & database applications. Sundeep Sadheura 210-865-4520 Sunnys@phiskal.com HTTP://PHISKAL.COM/

38 San Antonio Medicine • October 2014

• MEDICAL BILLING AND COLLECTIONS SERVICES

DataMED (HHH Gold Sponsor) Providing your practice with the latest compliance solutions, concentrating on healthcare regulations affecting Medical Billing and Coding changes allowing you and your staff to continue delivering excellent Patient Care. Anita Allen (210) 892-2333 aallen@datamedbpo.com www.datamedbpo.com BCMS members receive a discounted rate for our billing services. Commercial & Medical Credit Services (H Bronze Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda, 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com Make us the solution for your account receivables. PriMedicus Consulting Inc. (H Bronze Sponsor) A physician-founded and built company, dedication to your success. Sally Combest MD., 877-634-5666 s.combest@primedicusconsulting.com www.primedicusconsulting.com PriMedicus Consulting for the Health of Your Practice. Urgent Care Billing Solutions, LLC (H Bronze Sponsor) UCBS provides superior practice management services and revenue optimization services to the healthcare community in a virtual office environment. Ann DeGrassi, CMIS 210-878-4052 adegrassi@ucbillingsolutions.com www.urgentcarebillingsolutions.net

• MEDICAL SUPPLIES & EQUIPMENT

the largest worldwide distributor of medical supplies, equipment, vaccines, and pharmaceuticals serving office based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com/medical BCMS members receive GPO discounts of 15%-50%. McKesson Medical-Surgical (H Bronze Sponsor) MCKESSON is a leading distributor of Medical Supplies and Equipment. Karan Cook, 210-573-2117 karan.cook@mckesson.com

• PAYMENT SYSTEMS/ CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by 250-plus business associations. Tanner Wollard, 979-219-9636 Tanner.Wollard@e-HPS.com http://www.heartlandpaymentsystems.com/ Lowered cost for American Express; next-day funding.

• PUBLICATION MANAGEMENT FIRM Traveling Blender (H Bronze Sponsor) Publication Management Firm Janis Maxymof, 210-413-9731 janismaxymof@gmail.com 10% discount on display advertising in magazine for Circle of Friends members.

• PRINTING SERVICES SmithPrint (H Bronze Sponsor) SmithPrint offers custom printing, branding, graphic design, signage and more! Robert Upton 210-846-5268 Robert@smithprint.net http://www.smithprint.net/ New customers: 10% discount on print materials at SmithPrint.

• REAL ESTATE/ COMMERCIAL Henry Schein Medical (HHHH Platinum Sponsor) From alcohol pads and band aids to EKG’s and Ultrasounds, we are

Cano and Company Commercial Real Estate (HH Silver Sponsor)

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Experienced and respected commercial real estate representation. We specialize in office leasing, property acquisition, and commercial real estate investment. Dennis Cano, Agent 210-731-6613 www.canoandcompany.com Dennis@canoandcompany.com Effective commercial real estate solutions for your practice and investments. Newmark Grubb Knight Frank (H Bronze Sponsor) Commercial Real Estate Darian Padua 210-804-4841 Dpadua@ngkf.com Stream Realty Partners (H Bronze Sponsor) Carolyn Hinchey Shaw 210-930-3700 cshaw@streamrealty.com www.streamrealty.com

• REAL ESTATE/ RESIDENTIAL Kuper Sotheby's International Realty (HH Silver Sponsor) Joe Salinas III, 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge, exceptional results. Embrace your new life ... I'll help you become a connoisseur!

Becky Aranibar Realty Group Keller Williams (H Bronze Sponsor) Offering Real Estate Services to the San Antonio Medical Community. Carlo G. Aranibar, MBA, 210-862-4022 BARgrouptx@gmail.com www.beckyaranibar.com Offering free comparative market analysis to determine your home's value.

• REAL ESTATE/ INVESTMENTS Texas Premier Capital (HH Silver Sponsor) A real estate development company offering and managing real estate investment funds in the South Texas area. H.B. Newman 210-446-4793 brett@texaspremiercapital.com Rick Carter 210-367-7909 rick@texaspremiercapital.com www.texaspremiercapital.com

• REGULATORY COMPLIANCE Hildebrand Regulatory Compliance (H Bronze Sponsor) HEDIS, Accreditation, PCMH, ICD10 Patricia Hildebrand, 432-352-6143 Pati.Hildebrand@HildebrandHealthcare.com www.hildebrandhealthcare.com

• RESEARCH STUDIES/ BIOTECHNOLOGY

ICON Development Solutions (HHHH Platinum Sponsor) We are a respected clinical research organization that has an extensive reputable history in diabetes research. Depending upon the current studies, ICON may establish working relationships with local physicians. Your expertise may be invaluable to our efforts to identify subjects Dr. Dennis Ruff 210-283-4572 dennis.ruff@iconplc.com www.iconplc.com Find out how ICON can help your Practice.

• STAFFING SERVICES

Favorite Healthcare Staffing (HHHH Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency, and protect their revenue cycle!

Brian Cleary 210-301-4362 BCleary@FavoriteStaffing.com www.favoritestaffing.com/public/medicalsocieties/bexar_count y/bexarcounty_index.aspx Favorite Healthcare Staffing offers preferred pricing for BCMS members.

• TRANSCRIPT SERVICES Med MT, Inc. (H Bronze Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records. Ray Branson 512-331-4669 branson@medmt.com www.medmt.com The Med MT solution allows physicians to keep practicing just the way they like.

As of September 15, 2014

For more information, call 210-301-4366, email August.Trevino@bcms.org or visit www.bcms.org.

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Contact BCMS today to join the 100% Membership Program!

Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA Village Oaks Pathology Services/Precision Pathology WellMed Medical Management Inc. *100% member practice participation as of September 15, 2014. visit us at www.bcms.org

BOOK REVIEW

A Death in China

“

Reviewed by Paula Lyons, MD

Meet Emperor Qin Shi Huangdi, builder of great roads and

the party. Friends betray friends who discuss poetry at dinner.

the Great Wall, standardizer of Chinese currency and language,

But legions of young people will not obediently follow the

centralizer of Chinese government. He proclaimed himself “Son

straight party line, and a new revolution is brewing. This story

of Heaven” around 221 B.C., and buried alive more than 400

takes place several years before the real-world events of Tianan-

wise men and scholars who disagreed that he was immortal. A

men Square, but Hiaasen’s story shows the writing on the wall.

few years later, his mortality caught up with him, and he was

Investigating his friend’s disappearance, Stratton is assisted by

interred in an elaborate tomb with his celestial army. Today the

an American news correspondent (who wears many other hats)

Qin ruins are an archeological prize, where the Terracotta Army

and the Chinese niece of his disappeared friend. On the surface

stands guard still.

she is a proper citizen who follows the rules; but underneath, the

In the novel “A Death in China,” written by Carl Hiaasen and

niece is part of the burgeoning youth revolution. The story chases

Bill Montalbano, the ruins bring together Chinese American Dr.

characters from Peking to a small, distant village where Stratton

David Wang, educated art historian, teacher and writer in the

meets up with the ghosts of his tragic Viet Nam war-era mission

United States, with his brother, deputy minister of arts and culture

and then back to the United States for the final showdown.

Wang Bin. When Dr. Wang refuses to help his brother transport

The story that takes place in China is relatively staid and serious

important artifacts out of China to the United States, he disap-

compared to the outrageous and crazy Hiaasen-style action on the

pears and is proclaimed dead. In China for an art history tour,

other side of the ocean. Beloved author Hiaasen and distin-

David Wang’s good friend, former student and previously tortured

guished foreign correspondent Montalbano entertain us from start

Viet Nam veteran Tom Stratton will not accept that his friend

to finish. “A Death in China” is a thoroughly enjoyable read.

would succumb to “Death by Duck.”

Without spoiling all the twists and surprises, I am happy to reas-

It seems that believable information is hard to come by in China in the early 1980s when changes in politics were starting

sure that history holds its own, politics will never change, death is final, greed does not pay, and love triumphs.

to brew to the surface. Everything is a secret. The art and cultural progress that followed the Cultural Revolution seem to

BCMS member Paula Lyons, MD, practices ur-

have lost their importance. Hardline Communist leaders are re-

gent care and occupational medicine at Texas Med-

placing any government worker who is not fully committed to

Clinic.

40 San Antonio Medicine • October 2014

visit us at www.bcms.org

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Porsche Center 9455 IH-10 West

Gunn Honda 14610 IH-10 West (@ Loop 1604) Ancira Chrysler 10807 IH-10 West Cavender Audi 15447 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Ram 10807 IH-10 West * Gunn Infiniti 12150 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Dodge 10807 IH-10 West BMW of San Antonio 8434 Airport Blvd.

Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Jeep 10807 IH-10 West

Ancira Elite Motorcars 10835 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

Ingram Park Auto Center 7000 NW Loop 410 Cavender Toyota 5730 NW Loop 410

Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

Ancira Kia 6125 Bandera Road

* Mini Cooper The BMW Center 8434 Airport Blvd.

* Ancira Volkswagen 5125 Bandera Rd.

Batchelor Cadillac 11001 IH-10 at Huebner Cavendar Cadillac 801 Broadway

Cavender GMC 17811 San Pedro Ave.

42 San Antonio Medicine â&#x20AC;˘ October 2014

* North Park Lexus 611 Lockhill Selma

Ingram Park Nissan 7000 NW Loop 410

* The Volvo Center 1326 NE Loop 410

visit us at www.bcms.org

AUTO REVIEW

GMC Yukon

refreshed but not completely redone

By Steve Schutz, MD Eight years after the last generation Yukon launched, GMC has introduced a new version for 2015. While the new model represents an extensive update, it's more accurate to call it a re-skinning with extra attention paid to the interior, rather than a complete renewal. That's probably a smart move for GM. After all, it's not like there's much competition in the full-size SUV market. There's GM with their Yukon/Tahoe/Escalade and Yukon XL/Suburban/Escalade ESV models, and then not much else. Sure, Ford still makes the slow-selling Expedition/Navigator twins, and Lexus, Infiniti and Mercedes offer niche competitors for luxury buyers, but really, GM owns this segment. So why take chances? 44 San Antonio Medicine â&#x20AC;˘ October 2014

While it probably wonâ&#x20AC;&#x2122;t matter to buyers, it should be noted that the newest Ford Expedition can be had with a modern turbocharged V6 that combines plenty of passing and towing power with best-in-class fuel efficiency, while the new Yukon offers just two carryover V8s. For the record, the base 5.3 L engine puts out 355 HP (16 mpg city/23 mpg highway for 2WD versions), and the Denali-only 6.2 L power plant provides 420 HP (15 mpg city/21 mpg highway 2WD).

MORE CONTEMPORARY EXTERIOR The 2015 Yukon at least looks new thanks to a crisper, more origami-like design. Tumblehome, the tapering of the

upper sides of a vehicle toward the roof best appreciated when you look at it head-on, has been reduced. Surprisingly, that change, which gives the truck a more boxy appearance, does more to make the Yukon look contemporary than anything else. There are many other changes as well, such as artfully shaped headlights, an updated grille, and an attractive crease in the sheet metal that runs from just behind the front fenders to the rear of the truck. Although the new exterior will garner most of the attention, it's inside the Yukon where GMC engineers seemed to have spent the most time. Two generations ago, the Yukon had an interior that was uninspiring, with hard plastics and ugly colors. The last version was much improved, and the latest

AUTO REVIEW

one is better still. Areas where your elbows rest are soft, the seats are comfortable even on long trips, and every surface, button and switch feels solid and built to last. The ergonomics inside the Yukon are good, too, though not as clearly excellent as interior quality. Like everyone, GMC has moved to a central screen that controls everything from the HVAC to navigation to the audio system. GM uses touch-screen technology rather than a knob on the center console, and that's fine, but you spend a lot of time moving between the various functions on the screen when it used to be possible to simply turn knobs and push buttons to do the same thing. At some point, all cars and light trucks will have user interfaces that make doing everything you need to do easy. Until that day arrives, we will need to deal with every manufacturer's different version of imperfection. As with the last Yukon, driving the 2015 version is a generally pleasant experience. Marvelous on the open road, good on back roads, and not much fun in town describes what it's like to live with this big rig. The ride is smoother than before, but this is a large ve-

hicle that can't hide its mass. Parking and maneuvering are much easier in a sedan or crossover, as the many full-size GM SUVs with dings and paint stripes on the rear bumpers remind us. Of course, the upside of having a giant SUV is tons of space inside, and the Yukon doesn't disappoint in that department. Optional power-operated third seats fold down with the push of a button, and if you fold the second row down, too, you get a huge flat floor onto which you can load or stack just about anything. I spent much of my time with the Yukon moving my son out of his college dorm room, and all that space was welcome indeed.

CONSIDER A DENALI A quick aside: before you finalize your purchase, test drive a Yukon Denali with the more powerful engine. The 5.3 L motor is adequate for everyday use, but for towing a trailer, hauling kids plus their gear on a road trip, or just climbing up hills, the extra oomph you get from the 6.2 L engine is something you will appreciate often. Not surprisingly, a more polished truck

with a new exterior and premium interior doesn't come cheap. While Yukon pricing starts at around $47,000, expect to pay closer to $60,000 by the time you option your rig out. BCMS Auto Program director Phil Hornbeak will get you the best deal possible, but don't expect a Kia price tag. (At least it's built in Texas.) While more a refresh than a complete redo, the 2015 Yukon is clearly better than it was and will give current owners plenty of reasons to trade in their old trucks. New engines and transmissions will make the big Yukon even more appealing, but theyâ&#x20AC;&#x2122;re probably two years away. Steve Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org. visit us at www.bcms.org

46 San Antonio Medicine â&#x20AC;˘ October 2014