San Antonio Medicine January 2017

SAN ANTONIO

THE OFFICIAL PUBLICATION OF BEXAR COUNTY MEDI

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JANUARY 2017

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VOLUME 70 NO. 1

Dr. Leah Jacobson 2017 BCMS PRESIDENT Election Impact on Medicine SAN ANTONIO, TX PERMIT 1001

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Election Impact on Medicine

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JANUARY 2017

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VOLUME 70 NO. 1

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.

Local perspectives on the 2016 Election’s Impact on Healthcare Polidy By Mike W. Thomas .........14

The Next Chapter of US Health Care

By Alex Kenton, MD .............................................15

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org

Fundamental flaws of Affordable Care Act must be addressed

By Bernard T. Swift Jr., DO, MPH ..........................17 The 85th Texas Legislature Threats Outweigh Opportunities By John Holcomb, MD ................18

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Impact of Election Outcome from a medical student perspective

By Anu Kapadia ..........................................................................................................23

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The Federalization of Health Insurance: ACA Repeal and Replace Implications An Opinion-Editorial by Alan Preston, MHA, Sc.D. ....................................................20

President Trump and Taxes By Jim Rice, CPA ..........................................................24 BCMS President’s Message ...........................................................................................................8 BCMS Alliance.........................................................................................................................................10 BCMS Legislative News ..........................................................................................................................12 BCMS News ............................................................................................................................................26 Women in Medicine .................................................................................................................................28 In Real Time: Part 5 By Rajam Ramamurthy, MD. ...................................................................................30 Book Review: Two books about Rudolph Hess Compared and Contrasted By Fred H. Olin, MD.........36 BCMS Circle of Friends Services Directory .............................................................................................38 In the Driver’s Seat...................................................................................................................................43 Auto Review: 2017 Subaru WRX STI By Steve Schutz, MD ...................................................................44

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member Arthur D. Cortez, MD, Board of Censors Chair George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, DO, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schultz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student

6 San Antonio Medicine • January 2017

PRESIDENT’S MESSAGE

A New Year and New Opportunities for Volunteerism & Community Service

By Leah Jacobson, MD, 2017 BCMS President

Feliz Ano Nuevo, Akemashite Omedetou Gozaimasu, Shana Tova, and Happy New Year! It is with great enthusiasm and anticipation that I write this article.

The year 2017 looks to be exciting — not only for the country and state, but for Bexar County as well. We all anticipate that healthcare is going to change or be influenced by the recent elections, but do not know how. We must be ready. In this edition of San Antonio Medicine, we explore the potential effects of such elections on the future of healthcare. It is also a legislative year for Texas and we will need everyone to help guide legislators with policies that impact the health of our community and the provision of services. We are already hard at work representing the best interest of the physicians of Bexar County. There will be much more information regarding pertinent legislation in future issues of San Antonio Medicine.

As physicians, we take the Hippocratic Oath which includes the words "Do No Harm." This year, I would like for us all to continue to hold true to that oath and add to it "Do MORE Good" — Good for our members, our patients, and the San Antonio community.

I know that we all have very busy schedules, but if we could each find a little more time to do something for others, we could make a big impact. BCMS has more than 4,700 members. If each member volunteered just one hour a month, the community would realize over 56,400 hours a year. If everyone found one hour each week, that translates to greater than 244,400 hours per year! That type of manpower would make a difference.

I want our members to be passionate about the things with which they are involved. The Society would like to help with these endeavors. One way we can help is through our website and Weekly Dose electronic newsletter. If we know about volunteer opportunities, we will publicize them to our members and get more people involved.

We are investigating putting together a volunteer calendar on the website that people can go to with links to events. We also want to host or participate in related community activities, such as blood drives and health fairs. The medical society has a fabulous building which was built to be utilized by its members. We want to celebrate our members’ accomplishments, so we will be looking for ways to 8 San Antonio Medicine • January 2017

do this, including spotlights in San Antonio Medicine, attending openings of medical offices, etc. We need to be more involved in our community. I plan on meeting with government and community leaders to see how the medical society and its members can become more involved. We represent the medical community of Bexar County and therefore, should be involved in decisions that affect us and our patients.

With this in mind, I would like our committees and councils to take the lead with this. Beyond meetings, I think taking on a project or an issue would add another dimension to their work and purpose.

For example, the EMS/Disaster Preparedness Committee could donate time or items to shelters, Red Cross, etc. The Women In Medicine Committee could work with the Battered Women & Children's Shelter, or the Physician Rehab Committee could work with Haven for Hope or veterans. There are so many opportunities to make a difference in other people's lives. I know we already make a big difference in our patients’ and their families' lives, so let’s extend that!

Any organization is only as strong as its members, so I ask you to get involved! The Society is always looking for more membership involvement. There are many ways that you can be involved, including serving on a committee, participating in lobbying on healthcare issues at First Tuesdays in Austin, assisting with fundraising, volunteering at events, etc. We can always find something for you to do!

I am looking forward to representing all the members of the Society as the president in its 164th year. I want all of you to know that I am open to new ideas, projects, etc. We won't know if something works unless we try it! Please feel free to contact me at leahjacobson.bcms2017@gmail.com.

With warmest regards, Leah Jacobson, MD

"Only a life lived for others is a life worthwhile."

— Albert Einstein

BCMS ALLIANCE

BCMS ALLIANCE WELCOMES NEW PRESIDENT FOR 2017 I am excited to be celebrating the centennial year of the Bexar County Medical Society Alliance with you! Our Alliance is one of the oldest in the state of Texas (3rd oldest to be exact). The BCMSA — named the Auxiliary at the time — first met on Oct. 29, 1917 at the Menger Hotel to make surgical dressings for the local Red Cross. From its inception, the BCMSA was organized “to create fellowship among families of physicians and to foster activities in benevolent, philanthropic, charitable, and patriotic endeavors.” A century later, I feel that this statement still fully embodies what we represent.

How do we continue to “create fellowship among families of physicians,” when the definition of the physician family has changed since the founding of the BCMSA during World War I? We recognize that half of graduating medical students are female; many households now have two working spouses (possibly two physicians), and the role of the traditional “housewife” has evolved. While being the spouse of a physician grants us many benefits, there are inherent sacrifices. I joined the BCMSA in 2010 when my husband, Brian, and I moved to San Antonio for his residency. The Alliance proved to be a cornerstone in making San Antonio feel like home in those early, demanding years. The friendships I have gained through the Alliance have always been refreshing to me, as physician families alone understand physicians’ incredibly demanding schedules; these friends never blink an eye when I show up to an event alone or with a very tired husband.

How do we stay true to the pledge to “foster activities in benevolent, philanthropic, charitable and patriotic endeavors” a century after our inception? We have many volunteer opportunities for our members who are interested in serving our community through BCMSA Cares. Our VP of Civic and Philanthropic activities coordinates our “Hard Hats for Little Heads” bicycle helmet giveaways to children at the City of San Antonio’s Síclovía. Texas Medical Association Alliance (TMAA) awarded us the “Dedication to the Mission” award at the AllMed Conference in May 2016 in recognition of our efforts to fit and give away almost 700 helmets! The “Hard Hats for Little Heads” and “Be Wise, Immunize” initiatives are generously subsidized by the TMA Foundation. During 2016, we provided flu and Tdap vaccinations to those in need through events at local men’s and women’s shelters, using grant money awarded to us from the TMA Foundation. Additionally, we raise thousands of dollars in scholarships for university students in Bexar County studying 10 San Antonio Medicine • January 2017

Top Row (L-R) Anne Foster (VP Programs), Jenny Case (Recording Secretary); Middle Row (L-R) Rebecca Husain, Jenny Shepherd (PresidentElect), Lori Boies (President), Valerie Garrison (VP Civic and Philanthropic), Rebecca Husain (Corresponding Secretary); Bottom Row (L-R) Kelly King (Treasurer), Sandra Vela (VP Social).

Pre-Health Professions.

I am honored to serve as the 2017 BCMSA President during our Centennial Celebration. We have something for everyone: special interest groups, book club, activities for young families (I have a 2year-old daughter and love the play dates!), lunch bunch, shopping trips, community service, evening social events (Sips & Dips), bunco, etc. We like to have fun, and it is an organization I am truly excited to lead!

Please mark your calendars for Oct. 28, 2017 for our centennial celebration, “A Century in the Making!” at Neiman Marcus. All proceeds will go towards funding our scholarships. If you are interested in being a sponsor for this event, please contact: bcmsalliance@bcms-alliance.org.

Fondly, Lori Boies, 2017 BCMSA President Please visit our website; www.bcmsalliance.org

BCMS LEGISLATIVE NEWS

BCMS LEGISLATIVE AND SOCIOECONOMICS COMMITTEE WRAPS UP WORK FOR 2016 At the time of this writing, the BCMS Legislative and Socioeconomics Committee wrapped up a year's worth of work on legislative issues discussions and meetings with our state representatives and senators in preparation for the 85th Legislative Session. Committee members ended the year with visits with State Senator Judith Zaffirini (District 21) and State Representative Roland Gutierrez (District 119).

The 85th Texas Legislature will be sworn-in on January 10. Mark your calendars now and make plans to join us for the First Tuesdays visits to the Capitol on Feb. 7, March 7, April 4 and May 2, 2017.

BCMS teams are forming now. If you are interested in participating with your colleagues or if you have a personal relationship with any of our elected officials from Bexar County, then we want to hear from you! Come join us to advocate on behalf of medicine's issues!

To register for First Tuesdays, go to www.texmed.org/firsttuesdays.

For additional information and local discussion on the latest happenings during the legislative session, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, BCMS chief government affairs officer at mary.nava@bcms.org.

PHOTOS ABOVE: TOP - (l-r): David Shulman, MD; Sen. Judith Zaffirini, and Ashok Kumar, MD, pause for a photo during a Nov. 16 reception held in Sen. Zaffirini's honor at Club Giraud. BOTTOM - Rep. Roland Gutierrez (in gray shirt, on right) visits with members of the BCMS Legislative and Socioeconomics Committee on Dec. 7 at the BCMS headquarters.

ATTENTION BCMS MEMBERS: CALL FOR RESOLUTIONS It's not too early to be thinking about BCMS resolutions....

If you have any issues you would like the BCMS Delegation to TMA to consider regarding changes in policy or a stance you would like them to take on a particular issue, please visit www.bcms.org to obtain a sample form you can use to get started now with your draft. The BCMS Delegation to TMA will meet in early February to review any resolutions submitted for consideration. For this reason, the deadline to submit your draft resolutions to BCMS is Tuesday, Jan. 31, 2017.

To submit your draft resolutions or if you need assistance with drafting your resolution ideas, please contact Mary Nava, BCMS chief government affairs officer and delegation liaison at mary.nava@bcms.org.

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ELECTION IMPACT

Local Perspectives on the 2016 Election’s Impact on HEALTHCARE POLICY

By Mike W. Thomas

The election of Donald Trump in November promises to have a profound impact on U.S. healthcare policy in the coming years.

President-elect Trump campaigned on a promise to repeal President Barack Obama’s signature healthcare law — The Affordable Care Act (ACA) — which could leave millions of people without access to health insurance if the Act is not replaced with an adequate alternative. Such a replacement for the ACA has been promised but what it will entail is not clear. The President-elect has indicated that he would like to keep certain aspects of the healthcare law including the rule that insurers cannot turn people away for pre-existing conditions and the rule that allows people to keep their adult children on their healthcare plans up to age 26.

President-elect Trump has selected Republican Congressman Tom Price of Georgia to be his Secretary of Health and Human Services. Tom Price is an orthopedic surgeon who led the House Republicans’ efforts to repeal the ACA for the past eight years.

The American Medical Association issued a strong statement of support for Price by stating that his “service as a physician, state legislator and member of the U.S. Congress provides a depth of experience to lead HHS. “Dr. Price has been a leader in the development of health policies to advance patient choice and market-based solutions as well as reduce excessive regulatory burdens that diminish time devoted to patient care and increase costs,” the AMA said in a statement.

While the key parts may soon be in place for a major overhaul of healthcare policy, congressional Democrats do not plan to give in easily. Democratic House and Senate leaders said they will block efforts to repeal the ACA in its entirety, along with other proposals to rollback expansion of Medicaid and cut Social Security. While some aspects of the healthcare law can be rolled back using the filibuster-proof budget reconciliation process, other key aspects could be blocked by filibusters.

In this issue of San Antonio Medicine we will hear from a number of local doctors, healthcare professionals and medical students on what they expect to see in the coming months as the new political landscape unfolds. We will continue to revisit these issues throughout the year and encourage members to submit their thoughts and comments for possible inclusion in future issues.

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The Next Chapter of U.S. Health Care Speculative Assessment of Where Health Care is Heading after the 2016 Election

By Alex Kenton, MD A great deal of speculation has been made by healthcare experts on what will happen to health care with the incoming Republican Congress and Administration. Indeed, it is difficult to say with certainty what will happen, but my goal is to share my general assessment of where things will go in the next four years so our physician community can prepare.

It’s important to remember that when it comes to health care, all is not won nor lost with the results of state and national elections.

Indeed, there is great opportunity for physicians and patients to successfully navigate this new healthcare world, but for many others there are great challenges. The Affordable Care Act (ACA), the Sustainable Growth Rate fix, and the coming revisions under a new administration will ultimately create some of the most extensive changes we have seen in health care to date. Over the next four years, the changes coming will ultimately lead to a three-tiered healthcare system, which include a limited government-run safety system, a private insurance program, and a cash-based fee-for-service system for those areas not covered by the other two systems. The changes heralded by the incoming Republican leadership will likely solidify the three systems for the foreseeable future.

COVERAGE: It is likely that changes coming to our health care system will result in more people being under-insured or uninsured. Although President-elect Donald Trump intends to work with the Republican Congress to scale back the provisions of the ACA, he intends to protect the legislation which prohibits insurance companies from re-

fusing to insure an individual due to pre-existing conditions, and he intends to maintain the mandate that those who are insured under their parents plans can keep those plans through age 26. Even if full repeal of the ACA and the insurance subsidies are delayed by two to three years, it is likely that premiums will be higher for everyone, perhaps more so than what has occurred already. The result of those higher premiums combined with the repeal of the insurance mandate and associated tax penalties assessed to those who chose to go without insurance will be that many people will choose to be uninsured. Other additional pressures forcing more people to the uninsured or underinsured pools will be the scaling back of the expanded Medicaid provisions, the elimination of subsidies to insurance companies, the reduction of subsidies for individuals, and the removal of many of the price controls and value based initiatives which were all founding constructs of the ACA. The positive result of these changes, however, is that there will likely be the return of a variety of health plans to suit consumer desire. The removal of the Cadillac Tax (a tax on employer-sponsored high-cost benefit plans) will result in the return of more comprehensive plans for those who can afford them, while those who wish for some coverage rather than none will one again have catastrophic coverage models and high-deductible plans as available choices. Selfpay, fee-for-service offerings by physicians and hospitals will flourish under this program, especially with the planned expansion of taxdeferred health savings accounts. It is also likely that some sub-specialty services and concierge services will thrive under this environment. continued on page 16

visit us at www.bcms.org

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MEDICAID AND MEDICARE IMPACT A special note should be made regarding Medicaid. Almost 90 percent of the Medicaid population in Texas is served by managed care Medicaid.

With that said, Medicaid is not on the top priority list for the Speaker of the Texas House or the Lieutenant Governor for the 2018 session. Medicaid falls under Article 2 of the Texas budget, which is the same article under which foster care is funded. Pressure to scale back Medicaid will accrue from Federal cut backs, from the judicial mandate to improve our foster care system, and from the expected decrease in oil revenue. All of these factors, combined with one of the most historically conservative legislature in Texas will make any increase in Medicaid funding highly unlikely. We will expect that the managed care organizations will receive significantly less revenue. The resulting financial losses to managed care Medicaid companies will naturally be passed on to physicians, to hospitals, and to the patient in the form of decreased coverage of conditions, pharmaceuticals, and procedures.

Medicare will also be affected. Speaker Ryan’s plan proposes replacing some of the Medicare coverage with a fixed monetary payment to seniors, which would be used to purchase coverage from private health plans or from traditional Medicare. Coverage of certain conditions, procedures, and pharmaceuticals would also likely be restricted under this change. It is unclear if he can truly push this through since President-elect Trump has previously voiced support to maintain Medicare in its current form.

HOSPITALS AND PHYSICIANS It is estimated by the Congressional Budget Office (CBO) that 22 million people will lose insurance with the last repeal plan offered

by Congress. Regardless of whether this number is accurate, it is likely that tens of millions of people will have a change in their coverage to something less comprehensive. That will translate to significant loss of hospital and physician revenue. For those hospitals and physician groups who rely on insurance or government-run insurance, we anticipate a resulting decrease in investment in resources.

Other methods to sustain financial viability include consolidation of hospital systems, alignment and consolidation of large physician organizations, as well as a continued relocation of physicians and hospitals from rural to urban areas. Patients on Medicaid and Medicare will likely have less hospital and physician access as physi16 San Antonio Medicine • January 2017

cians continue to limit the number of Medicaid and Medicare patients they see.

Such business changes, however, will result in more complaints from those who remain covered under government-run programs and from those who live in rural areas. The outcry will naturally put pressure on our political leaders to push to expand the scope of care to non-physician clinicians. More legislation will be proposed to allow non-physician clinicians to practice an expanded scope of care, unsupervised by the physician. Physicians and organizations offering telemedicine will also likely fill the gap, creating potential competition from outside the state of Texas, but also creating another avenue of opportunity for those with an entrepreneurial streak.

SUMMARY In summary, our political decisions are creating a three-tiered healthcare system consisting of a self-pay healthcare economy, a private insurance healthcare economy, and a government-insured healthcare economy. Although this is not the model we may desire, it is what has been designed with the political choices of both Democrats and Republicans. This three-tiered system is here to stay, by default. Once we all understand that this is where we are heading, physicians — with the help of the Texas Medical Association and the American Medical Association — can successfully navigate these waters.

Dr. Alexander Kenton is a neonatologist who works for Mednax as the medical director at Methodist Children's Hospital. He is the current chairman of the BCMS Legislative Committee and the membership chairman for TexPac.

ELECTION IMPACT

FUNDAMENTAL FLAWS OF AFFORDABLE CARE ACT MUST BE ADDRESSED

By Bernard T. Swift Jr., DO, MPH The election is over. The voters have spoken. Half the country is disappointed in the outcome; but half was disappointed in 2008 and 2012. Whether or not you agree with the outcome, it’s now time to get over it and move forward for the good of the country.

As a nation, we have waxed and waned over the years regarding our governing philosophy. Over the next four years the changes are likely to be substantial with a greater emphasis on growing the economy and less emphasis on social justice.

Healthcare has been one of the major divisive issues of our time.

Polls (if you can believe them now) have consistently reported more than half the country doesn’t like the Affordable Care Act (ACA), although many support the effort to increase the number of Americans who are covered by insurance. The issue is whether or not, as currently written, the ACA is economically sustainable. Whether there is a wholesale “repeal and replace” or “modification” to the ACA remains to be seen. What’s becoming clear is that the early stages of the ACA’s predicted death spiral are beginning to play out.

Unless fundamental change is undertaken, the ACA will not be sustainable in coming years.

We live in a society where it can be argued that the “culture of entitlement” has exceeded the originally intended safety net. The

ACA is one such entitlement that is under fire for its failure to deliver on its many promised benefits, most notably its prediction to “bend the cost curve down.” In fact, costs are rising because the underlying tenets of insurance are not being met. The healthy appear to not be willing to pay the costs of insuring the unhealthy even though mandated to do so via required purchases. It’s that simple.

The great social experiment of the ACA does not appear to be working out very well. Whether we “Repeal and Replace” or “Modify” is immaterial at this point. The fundamental flaws have to be fixed either way.

As of this writing, there is a newly nominated Director of Health and Human Services who will likely have enormous discretion over the direction of policy changes. Tom Price, MD is an orthopedic surgeon who will be on the forefront of identifying a path forward, and his and Congress’ decisions will affect healthcare policy for all of us far into the future. It remains to be seen as to whether or not their ultimate plan will be cost effective, sustainable, and most importantly gain the respect of the public it will serve.

Bernard T. Swift Jr., DO, MPH is an Occupational Medicine physician and is CEO of Texas Med Clinic.

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THE 85TH TEXAS LEGISLATURE

Threats Outweigh Opportunities

By John Holcomb, MD Although the 85th Texas Legislature does not convene until Jan. 10, 2017, Austin traffic is already more bumper-to-bumper than usual with legislators and staff personnel, lobbyists, consultants, and interested citizens creating gridlock on l-35, hoping to influence the outcome of legislation. Looking back at the 84th session, 11,356 bills were offered; 1,203 were ultimately signed into law by the governor, 163 became law without the governor’s signature, and 42 were vetoed. During that session, the Texas Medical Association’s legislative staff actively tracked the progress and status of more than 1,200 bills with potential impact on doctors and patients.

Bills may be pre-filed by Representatives and Senators before the convening of the 85th session. Pre-filing began Nov. 14, 2016 with more than 470 bills filed in the first seven hours. House bills are filed electronically, but the eccentric Senate rules require paper filing. Since the Senate bill numbers are assigned on a first comefirst served basis, and there is political panache in having a bill with a “low number”; one well-known South Texas Senator assigned staff to be in line on the Friday before the Monday morning opening of pre-filing.

The Texas Medical Association, through its Council on Legislation and TEXPAC, and the county medical societies have been watching the legislative landscape over the past year, meeting with legislators in their home districts, and identifying opportunities and challenges to doctors and patients. As is always the case, the challenges far exceed the opportunities. As Texas is a “pay as you go state,” the planned legislative appropriations cannot exceed the Texas Comptroller’s estimate of available revenue, currently estimated at between $110 and $113 billion for the two-year biennium. However overall spending is closer to $220 billion, due to federal “match” payments (for example, Texas Medicaid, which accounts for more than 25 percent of the budget, receives a 59 percent federal match).

18 San Antonio Medicine • January 2017

The current legislature makeup includes 95 Republicans and 55 Democrats in the House, and 20 Republicans and 11 Democrats in the Senate. The Republican members are heavily influenced by the Texas Public Policy Foundation, which is a high-profile conservative policy organization based in Austin. TPPF has warned lawmakers against an “all funds” (state and federal) budget of greater than $218.5 billion, which represents a 4.5 percent increase in the previous budget to account for population growth and inflation, and Republican members are very likely to use this as their target, given the political risk of not looking “conservative enough.”

The most challenging issues facing organized medicine in the 85th session include: • MEDICAID REIMBURSEMENT AND EXTREME ADMINISTRATIVE BURDENS ON DOCTORS: In 2000, 67 percent of doctors in Texas were seeing Medicaid patients; by 2014, participation was down to 37 percent. Of note was the fact that the 2014 participation rate had actually gone up from the 2012 rate of 32 percent. This increase was certainly due to a provision in the Affordable Care Act, which raised primary care reimbursement to Medicare levels for two years (Texas Medicaid pays physicians at about 65 percent of the Medicare rate).

The only other transient increase in participation was seen in 2006 when the participation rate increased from 38 percent to 42 percent as a result of the Frew lawsuit settlement which temporarily raised reimbursement to pediatricians. So, when they say it’s “not

ELECTION IMPACT

EDs, when a patient appears for care based upon the hospital’s “in-network” status, not knowing that the ED physicians are “out-

about the money,” it’s always about the money. Chances of a fix in this session: 0 percent.

• SCOPE OF PRACTICE THREATS: The TMA has a strong track record of beating back scope of practice encroachments from other professions, such as chiropractors wishing to do electromyography and nerve conduction studies, or podiatrists wanting to operate above the ankle. These are relatively easy to defeat. There is a more difficult issue associated with “physician extenders” (PAs, APNs) who are asking for independent practice privileges, owing to the fact that other states have already passed such legislation, and there has not been an avalanche of standards of care problems. Texas is uniquely vulnerable to this threat because of geography, having a large rural population without access to primary care. There are 35 counties in Texas without any doctor, and almost half the counties (125/254) are federally designated “primary care shortage areas.” Chances of our success in this session: 70 percent.

• “SURPRISE BILLING”: This, of course, refers to the common occurrence of a hospital being in an insurance plan’s network, but physicians contracted to the hospital are not. This occurs most commonly in hospital

of-network.” This results in the patient being billed for the balance between the physician’s charges and the insurance plan’s payment to the physician, which may be nothing at all, depending on the plan’s rules. These bills may range from a few hundreds to several thousands of dollars. This is now a high profile issue with considerable coverage from major news outlets (New York Times, Wall Street Journal, NBC, etc.) after a study of this problem was published in the Nov. 17, 2016 issue of the New England Journal of Medicine. This investigation used data from a large insurer covering tens of millions of patients, and found that 22 percent of all patients attending in-network hospital EDs received “surprise” physician bills from out-of-network physicians in those EDs. In Texas, hospitals in the network of the three largest insurers ranged from 21 percent to 56 percent having no in-network ED physicians. Although TMA has offered several approaches to alleviate this situation, it is likely that there will be legislation unfavorable to physicians offered regarding “surprise billing.”Chances of success in this session: 50 percent.

As noted above TMA has a robust bill-tracking system, which allows us to identify legislation as it makes its way through the process, and we are alerted to hearings at which we need to supply physician testimony. Issues to be on the lookout for include bills dealing with telemedicine, the Texas Medical Board which is undergoing “sunset review” this year, potential threats to our existing tort reform protections, and funding for robust public health measures, such as Zika, Ebola, and other challenges.

Those of you interested in any of these issues can access the TMA website (www.texmed.org) for updates. visit us at www.bcms.org

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ELECTION IMPACT

THE FEDERALIZATION OF HEALTH INSURANCE: ACA Repeal and Replace Implications An Opinion-Editorial By Alan Preston, MHA, Sc.D. One of the campaign promises of the Donald Trump administration is to repeal and replace the Affordable Care Act (ACA).

The nation is largely divided on this issue of repeal and replace.

And as one would imagine, the split is along party lines. The 2,400-page legislation is a rather complicated piece of legislation.

As in most legislation, the ACA has parts of it that are helpful and parts that are hurtful. And some of the good or bad of the law depends whether you benefit or not from the law. Beauty is in the eye of the beholder in this case.

When I evaluate the effectiveness of legislation, I first look to see if it will accomplish its objective. Whether I like the objective or not is a separate issue. The name of the legislation is telling and provides a clue to the objective. The Patient Protection and Affordable Care Act. Patient Protection; who are we protecting the patient from? According to the authors of the legislation, the patients were intended to be protected from the big bad insurance companies. What is it that the big bad insurance companies did that required 2,400 pages of patient protection legislation? There are two major complaints by the authors of the legislation: 1. The insurance companies imposed an underwriting technique on individual policies (not group policies sold to employers) called pre-existing condition limitations. The ACA removed 20 San Antonio Medicine • January 2017

this underwriting practice which increased the price of insurance for everyone. Under the old law, if someone was going to purchase individual medical insurance to protect them from a future financial loss, that person would not be covered for certain previously existing medical issues. Contrarily, if you purchase car insurance, they always impose pre-existing conditions.

You can’t get in a wreck prior to purchasing insurance and then ask the automobile insurance company to pay you for an accident that you were in before the insurance went into effect.

Otherwise, everyone would wait to purchase car insurance until they had already been in an accident and not before. It should be obvious to everyone why eliminating pre-existing condition limitations (as happened under the ACA) would not work on individual coverage; unless one wants to pay extremely high rates. Which is where we are now!

2. Per the democrats that designed the ACA, they felt the insurance companies charged too much money for too little coverage and made too much profit in the process. Their solution in the ACA was to mandate a robust insurance plan (the four-minimal essential coverage metal plans) that covered nearly everything. This forced the people in the marketplace to abandon the purchase of what was characterized as low-end insurance policies. And the democrats limited the amount of money an insurance company

ELECTION IMPACT not only made in profit; it also limited the amount it could spend on administrative expenses. This is an unprecedented mandate to limit both the profit a company can make as well as how much it can spend on administrative activities. Whether or not you like an insurance company is not the issue here. This tactic of forcing a company to limit what they can spend on administrative costs should frighten everyone. Your business could be next! And as it turns out, most insurance companies over the last ten years have only made between 3 percent to 5 percent net profit on average.

Thus, if the insurance companies are attempting to charge more to consumers in order to gouge them financially to make huge profits, they are doing a poor job if they only make 3 percent to 5 percent profit.

When the federal government takes on the role of “we know best”, seldom does it turn out well for the recipients of their “wisdom”. Healthcare premiums have increased, making the ACA anything but affordable. And if one cannot afford such a robust mandated insurance product, with extremely high deductibles, then the patient is not protected financially.

Therefore, half of the country would like to see this piece of legislation scrapped. The remaining half are either receiving a premium subsidy or obtaining a real benefit by obtaining insurance for a pre-existing condition that otherwise would have cost that individual dearly. There are those that like the “idea” of “free” healthcare and think somehow that the ACA will evolve into such.

Regardless how one “feels”, Trump has made a campaign promise to repeal and replace the ACA. What will the replacement look like and will the replacement reduce the costs of healthcare? One of Trump’s ideas is to allow insurance companies to compete across state lines in an attempt to make insurance more competitive. A lot of individuals that hear such an idea claim that competition will reduce costs and make things better. In a general rule, I would agree. However, this is an idea I strictly oppose for health insurance. Let me explain.

First, health insurance companies already operate in multiple states to the extent they want to operate in multiple states. Take United Healthcare as an example; they operate in all states in one or more of their product offerings. They contract with over a million physicians and 6,000 hospitals. How would “federalizing” healthcare insurance companies make them more competitive? It would not!

And my objection is the proper role of the Federal Government.

The US Constitution specifically created the Federal Government to be limited and small. Every time legislation attempts to transfer a part of commerce regulated by each individual state to the federal government, we diminish the “States Rights” as guaranteed in the

Bill of Rights in the 10th amendment. Furthermore, I have seldom seen the benefit of “one size fits all”. And mandating that all states have a certain benefit design will certainly increase the cost and limit the 50 incubators of innovation toward product design. To put it simply, this is a classic “power grab” by the federal government to centralize power over 20 percent of our economy. And, since Congress has a dismal approval rating of less than 20 percent, why would we hand over more power to an institution we already distrust?

Furthermore, I hate to be the bearer of bad news; however, healthcare will NOT be affordable in the future, regardless of what the federal or states governments do. I can assure you that healthcare costs will continue to increase year after year. No politician, republican or democrat, will be able to reduce the cost! All is not lost however!

Trump’s other idea is to reintroduce Healthcare Savings Accounts (HSAs). HSAs are not insurance products per se; they help consumers with the out-of-pocket costs they are responsible for.

If I were the architect of the HSAs this is what I would do: First, recognize that healthcare will continue to increase so, make sure that over time consumers are adequately prepared financially to manage the increase. How do we accomplish this task?

Right now, the HSAs have limited contribution levels with too many stipulations. I would remove the maximum amount one can put into an HSA. Let’s face it, deductibles are likely to increase as a way of decreasing the rise in healthcare premiums. I would not make it conditional and tie it to a Qualified High Deductible Health Plan (HDHP). Co-insurance, co-payments, deductibles, and limited and uncovered services are all components of insurance that are the financial responsibilities of the consumers. Thus, consumers will continue to see increases in deductibles and outof-pocket costs. Unlimited contributions to the HSA will prepare consumers for the 1st dollar coverage and limited and excluded items under their insurance. Also, continue to make the contributions tax free and allow the consumer to lower their gross taxable income by the amount of any and all contributions. Allow employers to also lower their taxable income for any matching contributions into the employee’s HSA. Allow the consumer at age 65 to withdraw an amount of money out of the HSA tax free for non-healthcare services. Allow consumers to accumulate an unlimited amount every year with no penalties if they do not spend a penny on healthcare costs. Allow consumers to leave to their beneficiaries, upon death, the amount of the HSA without any estate tax consequences. Allow the HSAs to be portable and attach it to the consumer as it is now; however, also have their employer sponsored insurance product become portable. The healthcare exchanges already exist; thus, it would not be difficult to allow continued on page 22

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ELECTION IMPACT continued from page 21

employees to select an insurance product off the exchange of their choosing as opposed to the employer’s selection.

This last suggestion of allowing the health insurance products to be portable and attach to the employee as opposed to the employer is crucial for many reasons. One is that over time, the employer will no longer dictate to an employee that they must be with insurance company “xyz” when the employee wants to be on the “abc” plan. Insurance companies will think and act long-term to keep the member healthy. They are likely to pay doctors more money in the form of bonuses for improved outcomes of the member as opposed to limiting a doctor’s income to a straight fee-forservice (FFS) model. Doctors should be rewarded for the overall health outcomes of the patient as opposed to a fragmented component. Thus, the incentives would be aligned for the employee, the insurance company, and the doctor to all try to improve the health of the patient since the patient is likely to stay longer on the health plans that perform for the consumer. Right now, it is not uncommon for an employer to change their insurance carrier every three years. Why would the insurance company worry about the long-term health of a member if they will not benefit financially by investing money to improve their health long-term?

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Creating a system that has as the objective long term strategies in improved health, adequate financial savings to manage the increased costs, and aligning the goals and objectives, will go a long way in “protecting” the patient from financial harm when accessing healthcare services. This is an idea I can support Trump in repealing and replacing the failed ACA. Healthcare services and delivery of such are complicated! Let’s keep the regulation at the state level and allow the federal government to act as a facilitator by expanding access and financial protection and not by creating burdens of thousands of pages of restrictions that produce no to little value in a thriving market place. The healthcare market place will thrive if we allow a pathway for consumers to save money in a responsible manner for their first dollar coverage and quit micro managing every aspect of healthcare. Healthcare should not be federalized!

Alan Preston is the executive director of IntegraNet Health, an IPA that helps physicians navigate through the difficult regulatory framework and helps them achieve higher reimbursements from insurance companies.

ELECTION IMPACT

IMPACT OF ELECTION OUTCOME FROM A MEDICAL STUDENT PERSPECTIVE

By Anu Kapadia With the results of the 2016 Presidential Election, there have been many questions that have surfaced. As a medical student, “How does this election impact the medical student experience?” is one that particularly comes to mind.

During the clinical years of medical school, we get to know our patients deeply because we have the luxury of time. This additional time often results in understanding the social stressors our patients experience. Even without the expansion of Medicaid in Texas, I have felt that the Affordable Care Act has given me hope for my patients.

Seeing patients who develop severe complications from what were initially treatable conditions is heartbreaking. Moreover, there are times when you cannot provide treatments because patients are not able to afford it or follow-up. One of the most challenging but rewarding experiences I have had as a student is serving as an advocate for my patients. The joy in advocacy, however, is shaped by what can be done for the patient. As resources and assistance in healthcare decreases, there is less one can do.

In Bexar County, 76,000 residents obtained insurance for the first time because of the ACA after the first enrollment period. That’s a lot of people! We want our patients to live healthy lives, and it is

impossible to do so without access to healthcare. And at the end of the day, sending your patient home with nothing is frankly demoralizing for both the patient and provider.

It is not fair to talk about this topic without addressing that we have encountered patients who are not happy with their healthcare plan. This may be shaped by patients finding it difficult to determine what plan is the right fit for the patient and their families.

That being said, improving on an imperfect system is not the same as the threat to decrease the resources available.

However, while discussing fears and concerns surrounding the future of the ACA, there is also a positive impact this can have on us as medical students. It forces us to talk about how we imagine the future of healthcare in America. How do we increase access to care?

How do we improve the health of our patients from prevention to cure? It is my hope that we take advantage of the frustrations on all ends of the political spectrum to come together and create change in order to enrich the health and wellness of our communities.

Ana Kapadia is a fourth-year medical student at University of Texas Health Science Center at San Antonio.

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ELECTION IMPACT

PRESIDENT TRUMP AND TAXES

By Jim Rice, CPA, Sol Schwartz & Associates

Donald Trump will take office on January 20, 2017 as the 45th President of the United States. When the 115th Congress convenes this January, the Republican Party will be in control of the Presidency, the House of Representatives and the Senate. Whereas there are differences in Trump’s proposed tax legislation and the proposals published by the House Ways and Means Committee, there are still some similarities that lead us to believe that tax legislation is likely to be enacted in 2017.

A political candidate’s proposals can and often do change after taking office, so my discussion here is a broad-brush picture of some of the major tax proposals that Trump has discussed and that likely will be considered by Congress.

Under Trump’s proposal, the individual income tax rates would be lowered. The proposed rates when compared to the 2016 tax rates would look something like this: • 2016 tax rates of 10 percent and 15 percent would be 12 percent under the proposal • 2016 tax rates of 25 percent and 28 percent would be 25 percent under the proposal • 2016 tax rates of 33 percent, 35 percent and 39.6 percent would be 33 percent under the proposal

The tax rates for long term capital gains and dividends would presumably be re-aligned to mirror the proposed rates above with a maximum rate of 20 percent.

Trump has proposed to repeal the Alternative Minimum Tax which currently is generally a flat tax of either 26 percent or 28 percent on taxable income has modified by the elimination of certain deductions. Many taxpayers are subject to the Alternative Minimum Tax. The last time Congress reviewed this tax, there was a vote to provide higher exemptions to reduce the number of affected taxpayers, but there was no effort to eliminate this tax.

President-elect Trump has also proposed to eliminate the federal estate and gift tax. He also proposed that inherited stock and other 24 San Antonio Medicine • January 2017

assets from estates of more than $10 million would not get a tax basis step up, thus making sale of those assets after inheritance subject to potentially higher taxes. Republican members of Congress have criticized this last proposal. Some Democrats are against any repeal of the estate and gift tax.

The Affordable Care Act, also known as Obamacare, had created new surtaxes to help fund certain provisions of the Act. During Trump’s campaign, he made repeal of Obamacare a top priority. Repeal of Obamacare may entail elimination of the surtaxes. These surtaxes include the 0.9 percent additional Medicare tax on high dollar wages and self-employment income and a 3.8 percent Medicare tax on net investment income, including long-term capital gains and dividends. Some of the more recent discussion has been to repeal certain parts of the Obamacare act.

The current corporate tax rate is 35 percent. Trump has proposed to reduce this tax rate to 15 percent. Further, he has proposed extending this 15 percent rate to other businesses such as partnerships and sole proprietorships.

As you can see, there are major tax proposals that will be considered in the next several months. Compromise will surely be the order. No one knows today what those compromises will consist of.

Still, it is good to know what proposed legislation is being discussed and that the climate for taxpayer friendly law changes is excellent.

Is there any tax planning to do right now? If you have the ability to defer income from the tax year 2016 to 2017 or accelerate deductions into 2016 from the year 2017, then you should discuss these options with your tax advisor.

Jim Rice, CPA is a shareholder at Sol Schwartz & Associates, P.C. (jprice@ssacpa.com). He has over 38 years of experience in public accounting. In addition to providing business consultation, financial planning and various other accounting services, Jim specializes in income tax planning and consultation. He works with a high concentration of physician practices and high net worth individuals.

BCMS NEWS

BCMS COO MELODY NEWSOM HONORED The Bexar County Medical Society Chief Operating Officer, Melody Newsom, was recognized as the “Medical Reserve Corp Member of the Year” at the 2016 Alamo Area Citizen Corps Awards ceremony held Nov. 19, 2016, at the Landa Haus in New Braunfels, Texas.

Ms. Newsom received a Public Service Medal and certificate which noted, “Melody’s leadership, guidance and support have been mission critical in securing the roving Medical teams that have assisted the Alamo Medical Reserve Corp and the City of San Antonio during times of exercise and disasters.

She is a gifted leader and a dedicated public servant.”

Melody serves as the staff liaison to the BCMS Emergency Preparedness Committee and has been involved with and has coordinated BCMS’ physician emergency response teams since Hurricanes Katrina and Rita in 2005.

“Melody Newsom has been a key supporter of the Alamo Area Medical Reserve Corp since the inception of the MRC. Her leadership, guidance and support have been mission critical in securing the roving Medical teams that have assisted the Alamo Area Medical Reserve Corp and the City of San Antonio during times of exercise and disasters. Melody is only a phone call away with support through the Bexar County Medical Society to which she plays a vital role in medical response throughout the region as a whole. Without the help of Melody, the medical response in San Antonio and Bexar County would not perform to the level of greatness, compassion and professionalism. All of these qualities do not come with every individual, however Melody Newsom is the leader and gold standard of what a true Emergency Response Medical Professional should be modeled after.”

— Scott Paul, Citizen Corps Coordinator, Bexar County Office of Emergency Management

BCMS OFFICER INSTALLATION HONORING Dr. Leah Jacobson, 2017 BCMS President Lori Boies, 2017 BCMS Alliance President

Saturday, January 28, 2017 Reception 6 p.m. – Dinner and Program 7 p.m.

The Witte Museum, 3801 Broadway St. 26 San Antonio Medicine • January 2017

2017 BEXAR COUNTY MEDICAL SOCIETY

BCMS NEWS

BOARD OF DIRECTORS PRESIDENT Leah H. Jacobson, MD Pediatrics

Gerardo Ortega, MD Vascular Surgery BCMS Foundation President

PRESIDENT-ELECT Sheldon G. Gross, MD Child Neurology

David M. Siegel, MD, JD Internal Medicine 1st Term 2017-2019

VICE PRESIDENT Adam V. Ratner, MD Radiology

Bernard T. “Buddy” Swift, Jr., DO, MPH Occupational Medicine 2nd Term 2016-2018

TREASURER John Robert Holcomb, MD Pulmonary Disease

MILITARY REP. Col. Bradley A. Lloyd, DO Infectious Diseases

SECRETARY Gerald Q. Greenfield, Jr., MD, PA Orthopedic Surgery

MED SCHOOL REP. Ronald Rodriguez, MD Interim Dean, UTHSCSA School of Medicine Urology

IMMEDIATE PAST PRESIDENT Jayesh B. Shah, MD Undersea & Hyperbaric Medicine Rajaram Bala, MD, PA Plastic Surgery 2nd Full Term 2016-2018 Josie Ann Cigarroa, MD Psychiatry 1st Term 2015-2017 Kristi G. Clark, MD Internal Medicine 1st Term 2015-2017 Vincent Paul Fonseca, MD Public Health 1st Term 2017-2019

MED SCHOOL REP. Carlos Alberto Rosende, MD Ophthalmology MED SCHOOL REP Robyn Phillips-Madson, DO, MPH

ALLIANCE REP. Lori Boies, PhD Alliance President BOARD OF CENSORS CHAIR Arthur D. Cortez, MD Neurology, Neuroradiology BOARD OF MEDIATIONS CHAIR Rodolfo Molina, MD Rheumatology

Michael Joseph Guirl, MD Gastroenterology 1st Term 2017-2019

LEGAL COUNSEL George F. "Rick" Evans, Jr.

John W. Hinchey, MD Orthopedic Surgery 1st Term 2016-2018

BCMS CEO/EXECTIVE DIRECTOR Stephen C. Fitzer

John Joseph Nava, MD Family Medicine 1st Term 2015-2017 visit us at www.bcms.org

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WOMEN IN MEDICINE

The 24th Annual Women in Medicine Appreciation Event SPONSORED BY BEXAR COUNTY MEDICAL SOCIETY

Was held on Nov. 17, 2016, at the Omni Colonnade Hotel Special Guest Speaker was Dr. Ruth M. Ruprecht, director of Texas Biomed AIDS Research Program

WINNERS OF THE 2016 WOMEN IN MEDICINE AWARD Dr. Leticia Aguilar – University Medicine Associates (UHS) Dr. Vivian Ayoub – MCCI Medical Group Dr. Julie La Barba – Baylor College of Medicine Dr. Andrea Jean Carpenter – UTHSCSA Cardiothoracic Surgery Department Dr. Priti Mody-Bailey – Community First Health Plans Dr. Siang Ombaba – Star Anesthesia Dr. Pamela Otto – UTHSCSA Radiology Department Dr. Rebecca Romero – UTHSCSA Clinical Neuroimmunology Department Dr. Kristin M. Wilke – ABCD Pediatrics Medical Group Dr. Emily Volk – Baptist Health System Renal Associates Medical Group 100% Large Practice Group – Female Physician Leadership Supporter ~ PHOTO CAPTIONS THIS PAGE LEFT: Women in Medicine Committee Members for 2016 (L-R) Lan-Anh Ngo, MD; Lubna Naeem, MD; Leah Jacobson, MD; Janet Williams, MD; Wendy Kang, MD; Maggie Beato, MD; Melissa Deuter, MD; N. Carol Dornbluth, MD. RIGHT: Women in Medicine 2016 Award Winners (L-R) Back Row — Bushra Yusuf, MD; Jessica Pierce, MD; Melissa Isbell, MD; Lisa Cabrera, MD; Rebecca Romero, MD; Johanna Urena, MD; Judy La Barba, MD; Vivian Ayoub, MD; Emily Volk, MD. Front Row — Andrea Carpenter, MD; Leticia Aguilar, MD; Priti Mody-Bailey, MD; Pamela Otto, MD; Kristen Wilke, MD; Siang Ombaba, MD.

28 San Antonio Medicine • January 2017

WOMEN IN MEDICINE

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FEATURE: IN REAL TIME

Part 5

IN REAL TIME FRONTO TEMPORAL DEMENTIA Caring for the Caregiver

By Rajam Ramamurthy, MD

The loud knock on the door I just closed and the loud voice of a man calling Ma’am! Ma’am! Brought a lump to my throat. I had just come in to grab my purse to follow the ambulance in my car.

The EMT had put ‘N’ in the ambulance and I couldn’t ride with him. Did he arrest, was he bleeding. I stood behind the glass door, my body felt heavy like I was wearing a lead apron. The EMT tech screamed again, ‘Ma’am, could you get the dog out? He climbed in with your husband.’ Seeing me, ‘Patch’ jumped out and the ambulance left.

I had instructed them that ‘N’ should be taken to the University Hospital emergency room, the best in town for trauma care. When

30 San Antonio Medicine • January 2017

I reached the hospital the CT scan was already done, he had IV fluids running and oxygen, via a catheter in his nostril, was at 40 percent. He was not conscious. His breathing was slow and labored but he was maintaining a normal level of oxygen in his blood. They were preparing to X-ray his left shoulder which was enormously swollen.

The blood tests were normal except for a blood pH of 6.8, most patients at that pH are dying or are dead. N had no evidence of heart or lung problems. The slow breathing and the pH prompted a tube in his trachea and a machine to breathe for him. He was sedated and was moved to the medical intensive care unit.

The medical ICU is in the brand new part of the hospital, spa-

FEATURE: IN REAL TIME

cious and beautiful. It was as though a patient who had been in the hospital many times had designed it taking into consideration not

Most of them were young men and women who were putting themselves through college. One was a medical student. N would not let

only what the patient would prefer, but also the needs of the families

them sit, even for a second, demanding any number of things con-

who spend long hours in the hospital with desperately ill patients.

In the midst of intense mental anguish, it is soothing to see an amazing piece of art work and for a few seconds your mind is uncluttered and you are just with that moment. Did I just describe meditation?

My favorite is the ‘Blue Bonnet’ patch high up on a 40 feet wall just outside the front entrance. I would stop and gaze at this beautiful metal sculpture, a patch of blue bonnets by San Antonio artist Riley Robinson. It is so important for the caregivers to take a moment to recharge. I highly recommend reading the references I have given to

stantly. I spoke to each one about N’s condition and that he really does not know what he is asking and to use their judgement. In the morning they would have bonded with N who was happy and called them by their name and they will say goodbye and wish us well and some would hug N before they left. All is well with our profession.

During this period, N hardly slept. They were trying different medications to help with sleep. N complained about frightening dreams. I stayed in the hospital every night. I did not restrict visitors, nor did I make any announcement about the fact that he was hospitalized. He had a constant stream of visitors from the anesthesia department and my department. He spoke to them nonstop. Those who visited N during that period saw him at the peak of his ‘Manic Episode’ which was not considered at that point. It was masked by the other medical interventions needed, such as pain management.

Seven days after the fall he underwent surgery for the shoulder injury. The head of the humerus was fixed to the shaft of the bone with a metal plate and about eight screws. Surgery was performed by one of the best shoulder surgeons, Dr. Dutta, and anesthesia was given by none other than one of N’s colleagues Dr. W. After he was moved to the rehabilitation unit, N’s psychiatric care was attended to by the psychiatry team that covered inpatients. The medications he was on were not helping him. He was getting worse in not being able to sleep and he had unending demands every two minutes to eat, drink, use the restroom, re-adjust the bed, and he would get into the mode of teaching. He made the caregiver sit and draw diagrams of brain or spine or formula and then would explain mostly sensible things to these people who neither had the time nor interest but were very patient.

His inpatient care was coming to an end, he was so unwell. Can he go home in this state? However, the psychiatrist was unwilling to admit him to inpatient psychiatry, not a suitable place for someone who is still high functioning. I made the decision. N needs to be home. He needs his familiar surroundings, he needs Patch, his dog, he needs home-cooked healthy meals, and he needs sleep.

Around this time for logistical reasons his psychiatric care came under the guidance of Dr. Schillerstrom, someone N knew and someone who had done research work with him. N came home after three weeks of hospitalization. Our son was with us and also my sister. It couldn’t have been a better time for N to come home for I had wonderful help. To be surrounded by family and friends is a

fully grasp the caregiver vulnerability, not just for dementia, but for so many other ailments that the spouse has to deal with.

Two of our friends had reached the University Hospital even before I did. A few more arrived with food for all of us. All of them physicians putting their heads together to figure out what caused N’s fall. The shoulder X-ray showed a fracture of the upper end of the left arm (greater tuberosity of the left humerus) with the shoulder being pushed out of the socket. The orthopedic team came and placed the shoulder back in position. N was restless and moved a lot and the joint dislocated again and had to be repositioned. Those two days when he was intubated and sedated were the most peaceful days of the next three weeks he would spend in the hospital. As he was being weaned off the medication N was becoming a difficult patient, constantly demanding, and unreasonable. There was not a moment of peace for the nurses. Now I need warm pads, more medication, bed pan, water, breakfast. He was intimidating. He would ask the residents who came by questions about pain medicines. One night he made them break open 20 warm packs to place on his shoulder. I discussed with the nurses for every shift his diagnosis of FTD and the behavioral aspects of it and that they should treat him and care for him like any other patient and not ‘Dr.N,’ the highfunctioning expert in pain management.

I must digress to write about this profession of health care and the people who choose this as a career — the physicians, the nurses, the nurse assistants, the social workers and even those who are only cleaning the place. The professionalism, the tolerance, the understanding and the kindness that was shown to us just reinforced my belief in this noble profession of health care and those who choose to pursue it. People of my generation often complain about the next generation and how that personal bonding and caring is lacking. We had one-on-one caregivers who are ‘Sitters’ who help the nurses.

continued on page 30

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FEATURE: IN REAL TIME continued from page 28

gift. When it comes to mental illness there is great reluctance to talk about it. I decided to share our trials with our immediate family. I

were out again on the floor as well as all the shoes from the shelves.

My son walked in, and I lost it. Where were the tears the past four

sent an update via email every week in the beginning of N’s illness.

months? Is there such extreme sadness when tears don’t flow?

To hear from his nephews and nieces, many who visited, was good for N. It was also very good for me as caregiver to be surrounded by friends in the city, who were my angels. It is my advice that psychiatric illness should come out of the closet and be handled like any other calamity that befalls a family.

We arranged for a 24-hour caregiver service. N was started on appropriate doses of Sodium Valproate and Risperdal. He refused to take Risperdal as it gave him frightening dreams. N was very energetic and hyperactive. The caregiver who was sent by the agency was a four foot tall women who sat in a chair, mute, and perhaps wanting to run from this scene. Our son will be leaving the following morning and my sister in the afternoon. I walked into our bedroom. N had pulled out all his clothes from his closet and piled them up in the middle of the room, saying you should give all this to Goodwill. I quietly hung them up before anyone could see, I felt embarrassed for him. After 30 minutes I walked back to the bedroom, all the clothes

32 San Antonio Medicine • January 2017

Rajam Ramamurthy, MD, Professor Emeritus. UTHSCSA

Suggested Reading: The Grief Experienced by Spousal Caregivers of Dementia Patients: The Role of Place of Care of Patient and Gender of Caregiver. Marilyn G. Rudd, Linda I. Viney, Carol A. Preston. Int. J Aging Hum Dev, April 1999 Vol 48, Pg 217-240 Caring for loved ones with frontotemporal degeneration: The lived experiences of spouses. Lauren Massimo PhD, Lois K. Evans, PhD, Patricia Benner, PhD, Geriatric Nursing 2013, Vol 34. Published online 2013 May 30.

BOOK REVIEW

Two books about Rudolph Hess Compared and Contrasted

By Fred H. Olin, MD

First, the absolute basic information: On May 10, 1941, Rudolf Hess, the Deputy Führer of the Third Reich flew a Messerschmitt BF110 fighter-bomber from Augsburg, Germany to a spot near Glasgow, Scotland. He had hopes that he could arrange a peace between Germany and Great Britain so that Hitler’s forces could concentrate on the war against the Soviet Union. He did not have Hitler’s blessing or permission.

David P. Green, MD, a local hand surgeon, has written and recently published an “alternative history” book about Rudolf Hess’s flight. He gave me a copy of Rudolf Hess’ Mission: The Flight That Might Have Changed History and I promptly read it. In contrast, Roy Conyers Nesbit, a Briton, and Georges Van Acker, a Belgian, wrote (and published in 1999) a very detailed, factual history of the same event. While I was reading Dr. Green’s book I mentioned it to a friend, who promptly lent the latter book to me. Its title is The Flight of Rudolf Hess: Myths and Reality.

In Dr. Green’s book there are two lists of the characters, one for Part One, “The Flight” and another for Part Two “Barbarossa.”

Part Three, “Consequences” rides along on the others. He separates the individuals who actually existed from the imaginary ones he needed to invent. These are very helpful and aid in keeping the story moving along.

If we make the assumption that the Nesbit/Van Acker book is accurate, then so are the confirmable facts in Dr. Green’s story… after all, Green cited the other book in his extensive bibliography.

The thoroughly plausible sequence of imaginary events laid out in Rudolf Hess’ Mission covers a lot more World War II ground than does “The Flight…” It includes sequences about parliamentary

36 San Antonio Medicine • January 2017

maneuvers that result in the replacement of Winston Churchill as prime minister, Hess’s successful negotiations with the British government to become allies, a German general’s plot (that succeeds) to kill Hitler, German interactions with Soviet military figures and, at the end, a truce between Germany and the USSR, negotiated

by Stalin, his foreign minister Vyacheslav Molotov and Joachim von Ribbentrop, the Third Reich’s foreign minister. The putative reason for the truce is to allow the Russians to attack southward into China and on to Japan. None of this actually happened, but a lot of it is witnessed by one of the imaginary British folks, an Oxford Ph.D. named Roland Cogswell, who has an infallible eidetic memory and is articulate in German. He remembers everything, all the time, and is chosen by the Brits as an emissary/observer to the Reich after their alliance.

Rudolf Hess’ Mission: The Flight That Might Have Changed History is novelized alternative history, with all sorts of imagined conversations between the characters, real and imagined, that carry the story forward. There are some fairly accurate sounding descriptions of real events tossed in, and a few lessons in British history and the personal and family histories of some of the historical people who appear. It is very readable, keeps one’s interest and progresses smoothly and rapidly.

Meanwhile, back in what passes for the real world, we have The Flight of Rudolf Hess: Myths and Reality. The authors have done lots and lots of research in all kinds of archives and, as if to prove their bona fides, include a whole lot more detail than is perhaps necessary. As an example, do we really, really need to know the exact model number and type of the two engines used to power Hess’s

BOOK REVIEW Messerschmitt Bf110E-2/N? The book includes 32 photographs that are nicely illustrative of the text. The final section of the book

ran out of fuel, so he parachuted into Scotland. He was promptly captured, and initially treated as a high-ranking military officer

is spent debunking the many myths about Hess, his flight and his life. Additionally there are a number of informative appendices.

and kept in relative comfort, although he was isolated and pretty much ignored. He was ultimately sentenced to life imprisonment

This book gives us considerable information about Rudolf Hess:

at the Nuremburg Trials. After the trial he was transferred to Span-

He had flown in WWI, was a skilled pilot and had even won an air race around a mountain and gained considerable notoriety for it. He was an ardent disciple of Adolf Hitler, and I had the feeling that he had suppressed his own personality and ambitions just to be able to associate with the Führer. While he and Hitler were in prison after the failed 1923 “putsch” in Munich, Hitler dictated large parts of Mein Kampf for Hess to transcribe. Hess was appointed Deputy Führer when Hitler was elected Chancellor of Germany in 1933.

dau Prison in Berlin, where he lived much of the time as the only prisoner. The Western Allies wanted to let him go after a few years, but the Russians refused. He committed suicide at age 93 by hanging himself with an extension cord. His survivors were his wife, Ilse Pröhl Hess, (1900-1995) and his son, Wolf Rüdiger Hess, (1937-2001) who became an architect.

You should read these two volumes for different reasons: Green’s book is, in its way, escapist literature, and the Nesbit one is all information. I found that they complemented each other, and after reading the second one, I went back to the novelization and read large parts of it with new interest.

At the 1936 Olympics, Hess had spoken briefly with the Duke of Hamilton, a Scot and the scion of the oldest dukedom in Scotland. He somehow came to believe that, in 1941, during and after the Battle of Britain, that there was a serious peace party in the British Government, and that if he turned up at Hamilton’s estate with a plan for alliance that he would be welcomed. It didn’t turn out that way at all, and therein lies the meat of this book. His plane

Fred H. Olin, MD, is a semi-retired orthopaedic surgeon who was born before WWII, but not long enough for him to be able to remember much about it.

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37

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

ACCOUNTING FIRMS 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.”

ACO/IPA

ASSET MANAGEMENT

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”

ATTORNEYS IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com

ARMY HEALTHCARE 5th Medical Recruiting BN (HH Silver Sponsor) We recruit quality men and women who would like to be a part of our team.

SFC Cherie Kirk 210-692-7376 Cherie.k.kirk.mil@mail.mil www.youtube.com/watch?v=kweqi 3TelO8 "Serving to heal, Honored to serve"

38 San Antonio Medicine • January 2017

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions.

From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability,

Appreciation, Adaptability and 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.

Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”

Broadway Bank (HHH Gold Sponsor)

Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Frost (HHH Gold Sponsor) As one of 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 and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area.

Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Regions Bank (HHH Gold Sponsor) VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com

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 some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lot/land, jumbo, and specialized adjustable-rate mortgage loans.

Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Bank of America (HH Silver Sponsor) Bank of America provides people, companies and institutional investors the financial products and services they need to help achieve their goals at every stage of their financial lives.

Courtney Martinez 210-270-5494 courtney.martinez@baml.com Denise Smith 210-270-5058 Denise.C.Smith@baml.com bankofamerica.com Making financial lives better — one connection at a time

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 RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org www.rbfcu.org

CONTRACTORS/BUILDERS /COMMERCIAL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer.

Our model allows you to own your own office space as opposed to leasing.

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up & interior finish out projects. Services include conceptual & final pricing, design-build & construction management. Single-source management from concept to completion ensures continuity through all phases of the project.

Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES Med MT, Inc. (HH Silver 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.”

EMPLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll.

We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals.

Fee-based financial plans offered at discount for BCMS members.

Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”

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!”

e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose.

Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com 165 Elmhurst, Suite B Kyle, TX 78640 Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com

Frost Leasing (HHH Gold Sponsor) As one of 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 and 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.”

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39 www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management” First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

HEALTHCARE REAL ESTATE

SAN ANTONIO COMMERCIAL ADVISORS (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home.

Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com

40 San Antonio Medicine • January 2017

"New Way of Thinking, Caring & Living"

HOSPITALS/ HEALTHCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years.

Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

HUMAN RESOURCES

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we be-

lieve it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

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.”

INFORMATION AND TECHNOLOGIES

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org 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.”

Frost Insurance (HHH Gold Sponsor) As one of 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 and 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.”

INSURANCE

SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com

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.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com Catto & Catto (HH Silver Sponsor) Providing insurance, employee

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

James L. Hayne Jr. 210-222-2161 jhaynejr@catto.com Corey Huffman 210-298-7123 chuffman@catto.com www.catto.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and 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

MedPro Group (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com

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 some of the few agents in the state who 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 (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.

Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET/ TELECOMMUNICATIONS

Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Enterprise Account Executive West Region - Healthcare Sales Leader Medical Market Rick Garza

210-582-9597 rick.garza@charter.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

MARKETING ADVERTISING SEO

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

MARKETING SERVICES

Digital Marketing Sapiens (HHH Gold Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Kareo (HHH Gold Sponsor) The only cloud-based medical office software and services platform purpose-built for small practices. Our practice management software, medical billing solution, practice marketing tools and free, fully certified EHR has helped 30,000+ medical providers more efficiently manage their practice.

Regional Solutions Consultant Lilly Ibarra: 210.714.9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (HH Silver 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.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are 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 “BCMS members receive GPO discounts of 15 percent to 50 percent.”

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

MERCHANT CARD/CHECK PROCESSING Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver nextgeneration technology and help our clients grow their businesses.

Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 41 ‘The true leader in the payments processing industry’

MERCHANT PAYMENT SYSTEMS/CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations.

Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

OFFICE EQUIPMENT/ TECHNOLOGIES

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.

Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”

PAYROLL SERVICES

SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com

42 San Antonio Medicine • January 2017

Working together to help our clients achieve their business objectives.

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.”

SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

PHYSICIANS BUYING GROUP

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

Favorite Healthcare Staffing (HHHH 10K 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.

Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

REAL ESTATE/ COMMERCIAL

CUSHMAN & WAKEFIELD (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

To join the Circle of Friends program or for more information,

call 210-301-4366 or email August.Trevino@bcms.org

Visit www.bcms.org

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS.

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Ancira Volkswagen 6125 Bandera Road San Antonio, TX 78238

Jude Fowler 210-681-4900

Carl Carper 210-681-2300

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Infiniti 12150 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Bill Boyd 210-859-2719

Bill Boyd 210-859-2719

Hugo Rodriguez and Rick Tejada 210-824-1272

Coby Allen 210-625-4988

Bill Boyd 210-859-2719

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Toyota of Boerne 31205 I-10 W Boerne, TX 78006

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Julie Herrera 210-681-3399

Gary Holdgraf 210-862-9769

George Ramirez 210-748-4412

Wayne Alderman 210-525-9800

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX

Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX

Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

Alan Henderson 210-681-6300

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

Richard Wood 210-366-9600

John Wang 830-981-6000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257

North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211

North Park Mazda 9333 San Pedro San Antonio, TX 78216

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

North Park Lincoln 9207 San Pedro San Antonio, TX

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Sandy Small 210-341-8841

North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230

Ancira Nissan 10835 IH 10 West San Antonio, TX 78230

Jarrod Ashley 210-558-1500

Jason Thompson 210-558-5000

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700

James Cole 800-611-0176

Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org

AUTO REVIEW

2017 Subaru WRX STI

By Steve Schutz, MD

Where to begin with the unique and special (but aging) Subaru WRX STI? I don’t know, but, “Get it while you can,” is my summary sentence.

Be warned, though, the STI is loud, has a cramped interior and major league turbo lag, looks too much like a late 1990s car, and gets you a $20,000 interior despite being a $40,000 vehicle. Every time I got into it I wished it had some of the luxury of my Lexus and BMW, but it didn’t. And yet, I absolutely loved every minute I spent driving this car.

Here’s how it would go: close the door — whoa, that’s not an impressive door-closing sound, is it? — and sit in the tight driver’s seat. Look around: lots of so-so plastics and not a lot of elbow room. Start the engine: if I’m being honest, it sounds distinctly agricultural, neither refined nor cool. Drive off 44 San Antonio Medicine • January 2017

and accelerate on a 30 mph-speed-limit street: OMG gurl, this is borrrring... Then hit the interstate: still uninspired until 3500 RPM, and then, Oh Crap, what just happened?!! The STI shows its fangs and just takes off. “Stuff ” just got real is the best way to describe the wow-ness what you feel when the turbo spools up.

To avoid a ticket, I backed off and headed to my favorite quiet mountain road, which is exactly where the STI wanted to be. The sportiest Subaru lunges ahead ravenously on straightaways — when you’re above 3500 RPM, of course — and then grabs the asphalt through turns thanks to its all-wheel drive and front brake-based torque vectoring. Its attitude is always neutral to oversteer-biased, as you’d expect in a car with Rally racing roots. The experience is intoxicating, and if driving this car doesn’t make

you smile, you belong in a Camry.

Some cars like the Mercedes S-class are most at home on the interstate, while others like the Cadillac Escalade excel in suburbia.

The WRX STI, on the other hand, just kills it on low- and high-speed twisty back roads.

One slightly odd side note. Subaru includes a feature in the STI that allows locking of the central differential under cornering to improve performance. Presumably, when you’re really pushing the car this makes a difference (I was not able to tell that things were any different when I hit the button on several occasions during my week with the STI). But the gastroenterologist in me was amused that Subaru labels the switch that activates this feature, “C Diff.” Come on guys, couldn’t you name it something else? Nobody with any medical knowledge thinks good things when they see that term.

AUTO REVIEW

OK, a little cold shower in the form of some important detail: the 2.5 L turbocharged engine in this year’s STI dates back to around 2004, providing 305 HP, which translates to a 0-60 mph time of 4.8 seconds via the only transmission offered, a six-speed manual (Yay!). The turbo lag I alluded to above, which I find so entertaining, is mostly absent from competitors such as the Ford Focus RS, Volkswagen Golf R, and Audi S3, all of which offer more sophisticated drive trains. The Focus RS, for example, is priced just about where the STI is but comes with a more robust 350 HP in addition to a manual transmission.

Subaru already sells the STI with a modern 2.0 liter twin-scroll turbo engine with very little lag, more power, and better emissions/fuel economy/blah blah blah in Japan, and I’m sure it’s “better.” I haven’t driven

that car, of course, but I’m going to say this about it: no way it’s more fun than this aging wonder of a car, which is very much a John McEnroe in a world of Roger Federers.

Anyway, the WRX STI has options galore including advanced features such as blind spot protection, smart cruise control, and park assist. Pick all of those for your spouse’s Lexus RX 450h, but ignore them in this car.

Please. There are other add ons that make sense, naturally, and for those I suggest you call Phil Hornbeak at BCMS headquarters.

He will help you find the perfect WRX STI or any other vehicle you’d like with special member pricing and benefits.

Is the WRX STI sophisticated? No. Is it luxurious? Give me a break. But is it fun?

Hell, yes! Would your humble 53-year-old car reviewer physician want to drive one every day? No, give me a Lexus so I can relax

after working all day, please. But I’ll bet a 35-year-old Steve Schutz would have bought a WRX STI had it been available. (It’s got room for car seats in back!) Thank you Subaru for selling this car. And to potential buyers I’d add: Get it while you can.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

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.

visit us at www.bcms.org

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46 San Antonio Medicine • January 2017