MEDICINE
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MEDICINE
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GERIATRIC CARE
Alzheimer’s Association provides recommendations for primary care providers By Margaret J. Barron, Executive Director of the Alzheimer’s Association, San Antonio & South Texas Chapter .................................................16 The Unique Health Care Needs of the Baby Boom Generation By Robert M. Kruger, MD, FACP................................20
BCMS President’s Message ...........................................................................................................8 BCMS Legislative News................................................................................................................10 BCMS News..................................................................................................................................12 Feature: Heroes in Scrubs by David A. Schulz .......................................................................................24 Business: San Antonio Kidney Disease Center Benefits from Network Investments. .............................26 BCMS New Member Welcome Casino Night ..........................................................................................28 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................30 Business of Medicine: A Choice: Taxable or Tax-Free in Retirement? From Aspect Wealth Management .......................................................................................................33 BCMS Circle of Friends Services Directory .............................................................................................35 In the Driver’s Seat...................................................................................................................................39 Auto Review: 2016 Lincoln MKX, By Steve Schutz, MD..........................................................................40
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Early Diagnosis: The Value of Knowing By Margaret J. Barron, Alzheimer’s Association ........18
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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.
In Real Time: Fronto Temporal Dementia By Rajam Ramamurthy, MD .......................................14
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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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BOARD OF DIRECTORS
ELECTED OFFICERS Jayesh B. Shah, MD, President Sheldon Gross, MD, Vice President Leah Jacobson, MD, President-elect James L. Humphreys, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary Adam V. Ratner, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John W. Hinchey, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Jennifer Lewis, BCMS Alliance President Roberto Trevino Jr., MD, Board of Censors Chair Jesse Moss Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director Alice Sutton, Controller
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Fred H. Olin, MD, Member Esmeralda Perez, Community Member Jaime Pankowsky, MD, Member J.J. Waller Jr., MD, Member
6 San Antonio Medicine • July 2016
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PRESIDENT’S MESSAGE
MACRA is coming. Are we ready? By Dr. Jayesh Shah, 2016 BCMS President With the repeal of the sustainable growth rate (SGR) now behind us, we thought our struggles were over. But before we could celebrate our victory, MACRA (Medicare Access and CHIP Reauthorization Act) is suddenly here. Congress passed this legislation to completely reform the way Medicare makes physician payments. The goal of MACRA is to provide better care with lower cost. It focuses on quality, cost, technology improvement and practice improvement. The stated main goal is to decrease administrative paperwork for physicians, according to the acting administrator for the Centers for Medicare and Medicaid Services (CMS). The proposal currently plans to implement performance measurements for both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM), which start on Jan.1, 2017. While these regulations are not final, the proposed rule was published in April 2016 and CMS is actively listening to our concerns. Mr. Andy Slawit, CMS acting administrator, was at the American Medical Association meeting in June 2016 echoing many of our concerns. Physicians should continue to post their comments and concerns on the website at www.cms.gov before the comment period ends in July 2016. The final rule is to be published by October 2016. MACRA is an innovative model with new approaches, including models of medical home and specialty models to reduce cost. MACRA sunsets three of the existing quality programs — including PQRS — into a single, aligned quality improvement program. If a physician chooses the Alternative Payment Model, then the requirement is decreased. MIPS allows additional opportunity for bonus payments. According to the information on the CMS website, $500 million are assigned as bonus funds for the first six years. First reporting is not due until 2018. Adding new regulations without improving the infrastructure will cause more frustration to physicians. MACRA’s theoretical goals are hard to translate into the reality of private practice. Physicians feel that the measures are more an exercise of compliance than of quality improvement. It could lead to some unintended consequences of physician burnout and the closure of some small practices.
The Texas Medical Association’s MACRA position paper www.texmed.org/macra/ specifically asks CMS to: • Exempt physicians who have no possibility of earning more than it costs them to report data, and not force physicians into unacceptably risky payment models. 8 San Antonio Medicine • July 2016
• Establish objective and timely measurement and reporting systems that are simpler and less costly than those currently required. The focus should be on improving care for all Medicare patients, not creating yearly physician winners and losers that affects payment two years after care has been delivered. • Use quality metrics that capture those activities that are under the physician’s control and have been shown to improve the quality of care, enhance access-to-care, and/or reduce the cost of care. The focus should be on metrics that are the most meaningful to a practice and its patients, not on what will result in the best “score.” • Give physicians, who want to shift to value-based care, enough time to make this transition in a way that benefits their patients and does not cause undue collateral damage to their practices. • Require electronic health record vendors to build and maintain products that meet federal specifications rather than forcing physicians to buy and constantly upgrade expensive and oftenbulky systems.
Here is what all physicians should do. PREPARE YOUR PRACTICE: All physicians and practice managers should review all the modules on the steps to transition their practice so the practice can meet the challenges of value-based care. https://www.stepsforward.org/ PREPARE YOUR PRACTICE. There are steps you can take now to prepare for the transition to MACRA next year, such as participating in a qualified clinical data registry that streamlines reporting processes. MACRA TOOL KIT: AMA has prepared a Tool Kit for all physicians to get prepared for MACRA. To access the MACRA tool kit and additional resources and information please visit https://www. ama-assn.org/go/medicare payment. TMA PRACTICE EDGE: Texas Medical Association has started TMA Practice Edge which will allow small practices and specialty physicians to align themselves and form clinically-integrated networks and ACO’s with very little upfront cost. Please review the following website for details. www.tmapracticeedge.com. Stay involved and stay strong. We need strong physician leadership to overhaul this healthcare system. Regards, Dr. Jayesh Shah
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BCMS LEGISLATIVE NEWS
BCMS MEMBERS ATTEND LEGISLATIVE RECEPTIONS By Mary E. Nava, BCMS Chief Government Affairs Officer
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BCMS physician members recently attended receptions honoring State Representative John Lujan (Dist 118) on June 1, U.S. Senator Ron Johnson (WI), also on June 1, State Representative Diego Bernal on June 2 and Congressman Will Hurd on June 6. With this being an election year, there are numerous opportunities for physicians to meet and visit with elected officials on issues of importance to medicine. For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, committee liaison and chief government affairs officer, at mary.nava@bcms.org.
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1. (l-r) State Representative Diego Bernal (Dist 123) visits with BCMS members Alex Kenton, MD and Rudy Molina, MD at a reception held in his honor at Club Giraud on June 2.
2. (l-r) State Senator Jose Menendez (Dist 26), Alex Kenton, MD, Rudy Molina, MD and Congressman Joaquin Castro (TX-20) discuss issues of the day during a June 2 reception at Club Giraud honoring State Rep. Diego Bernal. 3. Event hosts, Drs. Alex and Candace Kenton, pause for a photo with Congressman Will Hurd (center) during a reception held at their home in honor of Congressman Hurd on June 6. 10 San Antonio Medicine • July 2016
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BCMS NEWS
SISTER CITIES INTERNATIONAL (SCI) RECOGNIZED THE BEXAR COUNTY MEDICAL SOCIETY WITH ITS 2016 LONGEVITY AWARD Sister Cities International (SCI) recognized the Bexar County Medical Society with its 2016 Longevity Award on Tuesday, June 14. The organization is celebrating its 60th Anniversary this year. Pictured from L-R are Dr. Neal Gray, Dr. Alfonso Chiscano, BCMS CEO Steve Fitzer, District 8 Councilman Ron Nirenberg, BCMS President Dr. Jayesh Shah, Mary Kane, president and CEO of SCI, Tom Quigley, chairman of SCI, Dr. Roberto San Martin, Dr. Gerardo Ortega, BCMS COO Melody Newsom, Hiroko Fay, Japanese translator, and Brissa Vela, BCMS membership director.
BCMS EMERGENCY PREPAREDNESS COMMITTEE TAKES PART IN HURRICANE EXERCISES
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2 1. Mock evacuees arrive at the mega shelter in San Antonio 2. Dr. David Cohen, chair of the BCMS Emergency Preparedness Committee evaluates a "real" patient during the DSHS hurricane shelter exercise.
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3. Dr. Sonny Arkangel teaches hurricane volunteers about things to watch for during the hurricane exercise.
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GERIATRIC CARE
IN REAL TIME
Part 1
Fronto Temporal Dementia By Rajam Ramamurthy, MD
This narrative was written originally in real time in the form of a diary on pieces of paper, notebooks, on blank pages in books I was reading as and when I had to unburden myself. I would write late in the night when I couldn’t bear it anymore as the world was caving in on me. Dementia creeps in stealthily, most of us including physicians don’t think of it for a long time, we don’t know much about it. It devastates not one but many lives. I was busy cooking a couple of special dishes. We were going to have three couples, dear friends, at our home to savor pastries we had brought back from our trip. We had just returned from a trip to India, Cambodia and Vietnam. We were at a big gathering the previous day when I ran into these close friends. Then, around 10 a.m., the phone rang. Our close friend who had traveled with us and was also invited to the party, asked if I could go to their house which was just two minutes away, to discuss ‘N’ my husband (for this writing I will use this name). A chill ran through me and I knew what was coming. We sat and
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talked for about an hour. At the gathering the previous day, N made an inappropriate sexual comment to one of our female physician friends. She was already very shaken after just escorting another mutual friend who left the gathering very perturbed as N had made a similar comment to her. N, a well-respected, extremely high-functioning professional and one of the leading experts in the country in his field, must have had one too many to drink, she said. I did not think so. Fear was choking me and I did not know what I was afraid of. Our friends with whom we travelled in Cambodia and Vietnam thought that throughout the trip N’s behavior was bizarre. I agreed. He was careless, would walk away from the rest of us on his own, he ate way too much to my embarrassment and he left our hotel room open with the luggage and lost a $6,000 camera. I canceled the party. We decided to meet that evening; just N and I and our friends who are like family to us. We confronted N head on. He clearly remembered conversing with these ladies but had no recollection of saying anything inappropriate.
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GERIATRIC CARE Before we set out on our trip, N had visited Korea for a week. Was it jet lag, lack of sleep, or the medication Melatonin he usually takes before and after international travel to combat jet lag. N started talking about not being able to sleep at night, bad dreams and a voice talking to him. His sleep problem has been going on for about a year. Before all this began, you could set your clock by the time N would go to bed at 11 p.m. and wake up at 5 a.m. Many times I had suggested a sleep study. He had consulted a sleep specialist and I quote the answer; “Rama, I can take your money and do a sleep study but it will not give you any answers for your sleep problem.” All of us came to the conclusion that N must take time off and have some investigations. N refused to see a psychiatrist. He did see one last November at my insistence. I was concerned about his comments, conversation and jokes that had inappropriate sexual overtones. N said the psychiatrist mostly talked about himself and his health issues and said, and I quote, “N, you are a 72-year-old man in a 40-year-olds body. You deserve to have your urges fulfilled.” He also charged $500 for two sessions and would not give a receipt. We thought a neurologist would be a good place to start. On Monday, my first phone call was to the neurologist, a person who I trusted immensely. I felt comforted when she agreed to see N the very next day. After retiring about a year ago, my routine (which
was interrupted frequently) was to do my yoga and sit and try to write for a couple of hours. This is a big part of the reason for my retiring plus the pull for wanting to spend more time with our three grandchildren. N maintained his enthusiasm to teach and treat pain patients and I was eagerly waiting for the day when he came to the comfortable point of wanting to retire. Each individual reaches this point at their own pace. Around 11 a.m. I received a call from N’s colleague. He said that N was looking very tired and it would be a good idea for him to take a couple of weeks off and rest. He was talking constantly, the fellows were confused and concerned about some of the comments he made. He kept talking about him being Buddha, Shankara (A Hindu Saint) and Jesus. He told them that he can teach them to meditate and become enlightened. His jokes had sexual overlays and some of his statements had no factual basis. Should I go and get him? Should he drive? Do I call him and discuss the issues. He did mention the other day that his VW Prius was racing at 100 miles per hour. Then I saw N drive in. Rajam Ramamurthy, MD, Professor Emeritus UTHSCSA.
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Alzheimer’s Association PROVIDES RECOMMENDATIONS FOR PRIMARY CARE PROVIDERS By Margaret J. Barron, Executive Director of the Alzheimer’s Association, San Antonio & South Texas Chapter
The Alzheimer’s Association offers guidance to assist health care providers in detecting cognitive impairment as part of the Medicare Annual Wellness Visit. As of January 2011, an Annual Wellness Visit is available for all seniors who are Medicare eligible. The benefit was added in the Affordable Care Act, and its purpose is to develop strategies with patients to manage their health as well as screen for select conditions. Checking for cognitive impairment is part of the visit. Prior to Alzheimer’s Association recommendations, there has been no comprehensive guidance on how to assess for cognitive impairment in the primary care setting. During the visit, the health care provider can use the recommended tools and assess patients’ responses as well as evaluate family members’ information. These tests along with vital patient history, self-reported concerns and clinician observations make up the first step in determining the need for further evaluation. As baby boomers turn 65 years old, they advance into an age of greater risk for developing Alzheimer’s disease. The Medicare Annual Wellness Visit could increase timely detection and diagnosis of Alzheimer’s to allow people affected and their families to better adjust current lifestyles, engage in learning about care and support, and plan for the future. In developing the recommendations, the Alzheimer’s Association convened a group of experts to survey the current literature and build consensus around an effective, practical and easy process. In addition to the range of tools identified, the recommendations suggest questions to include in the required Health Risk Assessments that patients must provide for the visit. The recommendations allow physicians to efficiently identify patients with probable cognitive impairment while allowing flexibility to choose a cognitive assessment tool that works best for you and your patients.
The Cognitive Assessment Toolkit contains: • The Medicare Annual Wellness Visit Algorithm for Assessment of Cognition, incorporating patient history, clinician observations, and concerns expressed by the patient, family or caregiver; • Three validated patient assessment tools: the General Practitioner Assessment of Cognition (GPCOG), the Memory Impairment Screen (MIS) and the Mini-Cog. All tools: › Can be administered in 5 minutes or less › Are equal to or superior to the Mini-Mental State Exam (MMSE) for detecting dementia › Are easily administered by medical staff members who are not physicians › Are relatively free from educational, language and/or cultural bias; • Three validated informant assessment of patient tools: the Short Form of the Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE), the Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) and the GPCOG; • The “Alzheimer’s Association Recommendations for Operationalizing the Detection of Cognitive Impairment During the Medical Annual Wellness Visit in a Primary Care Setting,” as published in the journal Alzheimer’s and Dementia.
For general information on the Medicare Annual Wellness Visit, go to alz.org/AWVfacts. More information on the recommendations can be found at alz.org/hcps. To receive a free Physicians Outreach Packet, please call the Alzheimer’s Association San Antonio and South Texas Chapter office at 210.822.6449.
The Alzheimer’s Association is the world’s leading voluntary health organization in Alzheimer’s care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research; to provide and enhance care and support for all affected; and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s. For more information, visit alz.org.
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Early Diagnosis: THE VALUE OF KNOWING By Margaret J. Barron, Executive Diredtoor fo the Alzheimer’s Association, San Antonio & South Texas Chapter
On a daily basis, I have at least one person say to me that they wish they had known about the Alzheimer’s Association when their loved one was battling Alzheimer’s disease or another dementia. It is disheartening to hear this over and over again because I know for every single voice I hear, there are probably hundreds more going through the same thing, thinking they have to face Alzheimer’s alone. As the Executive Director of the Alzheimer’s Association San Antonio and South Texas Chapter, my role is to make sure families are introduced to the Alzheimer’s Association and community resources as soon as possible after diagnosis. However, we are only reaching a small percentage of those with Alzheimer’s or other dementias because too many individuals are not receiving a proper diagnosis. The issue of disclosure of a dementia diagnosis and what is best for patients and families has been debated around the world over the past two decades. Literature reviews continue to show that clinicians who suspect dementia often do not disclose or document a formal diagnosis. As a result, approximately 50 percent of patients with dementia have no documentation of diagnosis in their medical records. A recent study of caregivers’ experience with the diagnostic process reported that it took two years after the initial physician visit for some patients to receive a dementia diagnosis. Caregivers also reported a 18 San Antonio Medicine • July 2016
sense of reluctance among doctors to disclose the diagnosis. Physicians have cited many barriers to diagnosing dementia, including doubts about the value of diagnosis given limited treatment options, concern over risk of misdiagnosis and lack of knowledge of local dementia support services. However, based on published data, perceptions that disclosure of dementia diagnosis is not preferred or causes psychological distress among individuals and family members should be challenged. A survey of public perceptions and awareness of Alzheimer’s disease was conducted by the Harvard School of Public Health and commissioned by Alzheimer Europe through a grant provided by Bayer. The survey found that a majority of patients want to know if they have Alzheimer’s disease: • Nearly 89 percent of Americans say that if they were exhibiting confusion and memory loss, they would want to know if the cause of the symptoms was Alzheimer’s disease. • Of those aged 60 and over, 95 percent say they would want to know. • Over 97 percent say that if they had a family member exhibiting problems with memory loss, they would want them to see a doctor to determine if the cause was Alzheimer’s.
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An early and documented diagnosis leads to better outcomes for individuals with Alzheimer’s and their caregivers: • A formal diagnosis allows individuals and their caregivers to have access to available treatments, build a care team, participate in support services and enroll in clinical trials. • Participating in planning early in the disease process allows individuals with Alzheimer’s to create advance directives regarding their care and finances – so that their wishes can be carried out when they are no longer cognitively able to make such decisions. • Early diagnosis also allows individuals with the disease and their caregivers to better manage medications, receive counseling, and address driving and safety issues in advance. • Undertaking the diagnostic process early potentially allows cognitive impairment to be reversed in some people. Research suggests that the cognitive impairment in nine percent of individuals experiencing dementia-like symptoms is due to a potentially reversible cause, such as depression or a vitamin B12 deficiency. Primary care physicians are the important gatekeepers to assessment and treatment and a respected link/referral to community resources. Support, services, and education for patients with dementia and their family members/caregivers are freely available in the community. For caregivers whose loved ones receive a diagnosis, some have informed us that their doctors did not know about available services. Instead, caregivers found out about us through a friend, neighbor, social worker or by researching online. Disclosure of diagnosis and knowing about the Alzheimer’s Association from early on in the diagnosis can reduce caregiver stress, increase the quality of life for people with dementia, empower caregivers and connect them to important resources. For most caregivers, simply knowing they are not alone and that the Alzheimer’s Association is there for support is enough.
For more information go to alz.org. visit us at www.bcms.org
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The Unique Health Care Needs of the Baby Boom Generation By Robert M. Kruger, MD, FACP
Imagine a conversation between a doctor and two different patients regarding medical treatment. “I don’t know doc — that’s too many choices. You decide which is the best one for me and I’ll go with it.” “Thanks, doc, for your thoughts. Let me research this on the internet and I’ll get back with you with my decision.”
These conversations about the same choice come from patients who bring distinct values and experiences to the medical decisionmaking process. The second patient was from the Baby Boom generation and the first one was from the generation before. Each looks differently to their physician for help. Through greater understanding of our patients’ backgrounds, doctors can better serve the needs of these two very diverse generations. I am both a Baby Boomer and a geriatric internal medicine physician. I have taken care of our parent’s demographic and my own. I experienced first-hand the social and technological changes which influenced my generation. We are unique from those who came before us or who arrived after us. The Baby Boom generation includes the huge 76 million population block, born in the United States in the post-World War II era, from 1946 to 1964. As the Baby Boomers grew, traditional social norms were redefined and tremendous advances in technology occurred. In 2016, they turn 52 to 70 years old. Boomers are better educated and more affluent than generations before. But they are ageing and are redefining geriatric care.
To appreciate the changes brought about by the Baby Boom generation, it’s important to look more closely at the generation before. The parents of the Baby Boomers were the Greatest Generation, born between 1901-1924, and the Silent Generation, born between 1925-1945. Both of these were influenced by World Wars I and II and the Great Depression. They grew up in an age of austerity and 20 San Antonio Medicine • July 2016
sacrifice. They were taught to use everything, share, and don’t waste anything. They looked to the government for protection and to restart the depressed economy. The country drew together and as a nation, won the wars and restored the economy. This population worked as a team, respected authority and trusted the government. The Baby Boomers were born into the post-World War II era where societal values we redefined and technology advanced at a fast pace. This generation was influenced by the Vietnam war, the civil rights movement, Kent State, space travel, modern music, and the age of computers. Television brought world and national events into our living rooms, and helped reshape society. This population learned to question authority, pursue the right of individuals and apply technology to their advantage. The Baby Boomers also started taking responsibility for their own health. In the 1970’s, jogging and exercise became popular. They watched their cholesterol, never started smoking, joined health clubs, and made healthy lifestyle choices. How can doctors today apply Boomer characteristics to optimize their health? If doctors who take care of the Boomers understand their unique motivations and experiences, they might be able to communicate more efficiently, improve their overall health, and guide them back into making healthy living choices.
PROFESSIONAL RELATIONSHIP ISSUES Early on, Baby Boomers learned to distrust authority, whether that was the government, an institution, or the person in charge. Doctors who can deal with their patients in a collaborative manner
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might motivate them to achieve better compliance with treatments and health care practices. This may require extra time during an encounter to discuss the specific thoughts and needs of the patient. Some medical offices employ HIPAA-compliant patient portals to optimize communication with their doctor. These provide a layer of health-care security lacking in regular email, texts, tweets, or Facebook. In some instances, patients might need to be reminded that collaboration does not render them a colleague. Doctors possess training and experience far beyond that of a layman and ultimate responsibility for medical decision-making rests entirely on the physician.
PATIENT’S RIGHTS ISSUES A fundamental pursuit of the Baby Boom generation was to respect the rights of each person as an individual. People must be able to express their opinions and deserve to be heard. In this regard, doctors should make patients aware of their own responsibility to take control of health care decisions by preparing and maintaining advanced directives, and discussing healthcare preferences with their family.
TECHNOLOGY AND HEALTH CARE CONSUMERISM ISSUES Pharmacologic companies often target the affluent BabyBoomer population with medical treatments. Consumers are bombarded with commercials offering a treatment for erectile dys-
function, depression, chronic pain, memory medications, stopsmoking aids, and gastrointestinal problems. Physicians may need to teach their patients not to believe all they see on television or read on the internet.
HEALTHY AGING ISSUES The Baby Boom generation introduced many healthy lifestyle innovations which are accepted as commonplace today. They jogged, avoided tobacco, and watched their weight and cholesterol. But over the years, affluence breeds corpulence and obesity is putting Boomers at risk of increased health hazards. Doctors should remind their Baby Boomer patients of the importance of trimming down, getting proper rest and exercise, and maintaining proper balance in life. To sum it up, the influence of the Baby Boom generation has been profound in the modern-day transition of American society. This generation is healthier and more active than their parents and is living longer. Doctors willing to understand Boomer motivations and reflect a willingness to partner-up with these patients may bring about a healthier and more active geriatric population over the decades before us. Dr. Robert M. Kruger is a geriatric internal medicine consultant at Wilford Hall Ambulatory Surgical Center. He is Clinical Associate Professor of Medicine at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
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GERIATRIC CARE
BACK TO THE
FUTURE The Return of the House Call By David Cavazos, Practice Manager at DAYS The American economy can no longer sustain the continued rise of healthcare costs. There is, however, an emergent practice from the early 20th century that is both making a comeback and having an impact on healthcare cost reduction. I am referring to a group of doctors and mid-level practitioners that are now armed with modern technology (mobile X-rays, sonograms, EKG’s, ultrasound, IV infusions of antibiotics, etc.) and visit their patients where they live — be it a home, an apartment, a facility or personal care home. These primary care physicians are improving the healthcare and quality of life of a segment of the population that keeps increasing yearly. I refer to the increasing geriatric population with multiple diagnoses that find it hard to have to wait hours at a time to be seen in a doctor’s office. These include demented patients with behavioral problems, paraplegic and quadriplegics on respirators and many more. This is a segment of society where seeing a doctor can be quite difficult. Home visits provide a more accurate picture of the patient’s conditions, compliance, social support and functional needs. Most physicians have no idea of the social environment that their patients live in. Going on our 7th year of practice, working for Doctor At Your Service (DAYS) has been rewarding in more ways than one. Most patients and their families truly appreciate this type of service. Dr. Antonio Cavazos, Jr., owner and a physician of DAYS, is often asked to have a cup of coffee or breakfast while on a home visit. Patients 22 San Antonio Medicine • July 2016
often respond better to a candid conversation with the doctor than to an antidepressant. Sometimes holding a patient’s hand can be more effective than a shot of morphine. Whether or not the patient is a smoker is no longer a check box but an odor. The home environment is often the best indicator of one’s health. I recently had the opportunity to meet Dr. Thomas Cornwell, past president of the American Academy of Home Care Medicine, at the AAHCM annual conference. Dr. Cornwell is one of the nation’s leaders and researchers of home care medicine. His research paper, Home Care Medicine’s Perfect Storm, provided me with the national statistics and cost savings data for this article.
The geriatric population is rapidly increasing and so are the costs associated with their care. At least 1 million seniors are permanently homebound and an additional 2 to 3 million are disabled and have a difficult time getting to a doctor’s office. U.S. healthcare spending reached $2.9 trillion in 2013 representing 17.4 percent of the Gross Domestic Product. Those over the age of 65 are the most rapidly growing population and are also associated with the highest healthcare costs. A crisis is approaching due to an aging population, medical cost inflation that exceeds economic growth, and the lack of a comprehensive strategy for care of people with advanced chronic
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GERIATRIC CARE
illness. A paradigm shift is needed to care for this aging population or the costs will continue to increase as our society ages. The sickest patients (10 percent of the Medicare population), those with five or more chronic conditions, drives more than half of Medicare costs. These patients are also the target population of home visiting practices (Cornwell, 2015). Prevention of ER visits and hospitalization is the goal of home visit medical groups and it seems to be working. The cost of one ER visit is equivalent to around 10 home visits. Data published in the New England Journal of Medicine in April 2009 revealed that 20 percent of Medicare hospital discharges were readmitted within 30 days and 34 percent within 90 days. Half of the 30-day readmitted patients had not seen a physician since their hospital discharge. Attempts to reduce readmissions with Medicare home health (nurses, therapists, social workers, aides) were generally not successful, with readmission remaining high around 28 percent. In contrast, home care medicine by doctors, nurse practitioners and physician assistants has shown to have a profound effect on both reduced readmission and healthcare costs. A study by Naylor, published in the Journal of the American
Geriatric Society in 2004, showed that house calls for three months post-hospitalization cut readmission by more than half (23 in the house call group versus 63 in the control group). Figure 2 below shows the tremendous cost savings. The home visit intervention stopped at three months but benefits continued for an additional three months, with over 50 percent reduction in readmission in cost versus the control population. No further benefits were seen in the 6-12 month period, showing the need for continued long term home visits. Restoring the doctor-patient relationship is of paramount importance. The potential of home medicine has barely been tapped. With all the technological advances, home visits offer effective treatment and improve the quality of life of the aging population while decreasing the number of ER visits, hospitalizations and readmissions after discharge. This field is wide open and I encourage doctors both young and old to consider entering this emergent practice. David Cavazos, Practice Manager – Doctor At Your Service (DAYS), Phone: 210-771-5622, dcavazos@doctoratyourservice.com.
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FEATURE
Heroes in Scrubs By David A. Schulz The U.S. Army Medical Department Museum at Fort Sam Houston represents the rarest gem of specialty museums. Visitors of all stripes, ages and interests, regardless of background, leave here with more than a gift shop bag. They carry with them a profound appreciation for the contributions of the Army Medical Department both to survival under the extremes of combat as well as to general healthcare. Most of all, it inspires a new perspective on the courage and valor in practicing medical science in the most calamitous of circumstances. Beginning with the creation of the U.S. Army in 1775 and its accordant Medical Corps, exhibits reach back to the republic’s earliest days. Dozens of display cases featuring hundreds of artifacts depict 24 San Antonio Medicine • July 2016
multiple storylines, starting with the phlebotomy of bloodletting to release “bad humors” with leeches or those new-fangled mechanical substitutes. Or follow progress in disease prevention in mass populations, from smallpox inoculations in 1777 ordered by General Washington from Valley Forge. Or chart the history of general anesthetics, the implementation of triage, or the development of emergency evacuation vehicles from the hoop-topped wagon ambulances of the 19th century to the evac choppers in use since the close of World War II. Then take a walk through a glistening Korean Warera Hospital Rail Car! It becomes quickly obvious how tightly the histories of warfare and medicine intertwine, and at their heart are stories of the people
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FEATURE At Left, a display of a MASH surgical team in action. Below right, a helicopter used to transport patients from the battlefield and between medical facilities.
who do remarkable and glorious things in extreme circumstances. Fan of M*A*S*H? Spend time with the 555th Forward Surgical Team, “Cheatin’ The Reaper,” recently back from Afghanistan. Or bask in the tale of the Warrior Dentist, Dr. Benjamin Salomon, finally awarded the Medal of Honor 60 years after he stood a rearguard action during the Battle of Saipan, allowing the safe evacuation of the wounded, killing at least 98 enemy troops before being killed himself. The storyline that will bring me back soonest is that of the U.S. Army Veterinary Corps. Recognition of the need for veterinary expertise had been evolving since 1776 when General Washington directed that a “regiment of horse with a farrier” be raised. But this summer marks their Centennial anniversary as a component of the Medical Department, organized on 3 June 1916 in preparation for the European Conflict. With the large number of horses and mules required for overseas service with the American Expeditionary Forces, a professional corps to care for sick and injured animals was needed, and more than 2,000 vets saw active military service during World War I. Army veterinarians ensure the health of military working dogs and assist with host-nation related animal emergencies. Veterinary staff advisors also play key roles regarding issues involving chemical and biological defense. Because “an army travels on its stomach,” the Veterinary Corps continues to have significant impact on operations by assuring low food borne illness rates, conducting inspections and approval of safe food sources around the world. While not on the traditional tourist agenda — requiring more planning and effort than typical — the Army Medical Department Museum combines our heritage in military and healthcare leadership creating a unique attraction in which every citizen can take pride. It’s a family staycation activity that will inspire conversation, distinctive memories and revisits.
VISITING THE MUSEUM: A PRACTICAL GUIDE Visiting the AMEDD Museum takes planning and effort, but not cost! The museum is free, parking is plentiful, and while primarily in-
tended for members of the Department, it is open to the public, suitable for general audiences, and very supportive of older school groups that call ahead (210-221-6358). It makes a great field trip for the whole family during summer break; go to the Museum, then pick up lunch, head downtown and picnic in Hemisfair Conservancy playgrounds, another under-appreciated gem. It will be a day the kids will long remember. The museum address is 3898 Stanley Road, but for newbies to Fort Sam (like me) navigating to the best access began at Broadway and Burr Road until it met up with Harry Wurzbach Road, going down Wurzbach but stopping short of the fort’s entry gate to check in at the Visitor Center on Scott Road. It’s just off Wurzbach, to the left, prior to the gate checkpoint.
HOURS Hours are 10-4 Tuesday-Saturday; and while it’s free, remember something for the plate: this museum is supported by a private foundation that enables improvements and enhancements. David Schulz, a certified HIPAA and privacy professional, appears in publications throughout Texas and the country since 1982. CEO of Cyber Risk Associates, a member of the BCMS Circle of Friends, he currently focuses on cyber security, privacy and HIPAA breach threats, but writes on subjects from entertainment, food trends, and cool museums — any topic concerning the intersection of technology and lifestyle. visit us at www.bcms.org
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BUSINESS
San Antonio Kidney Disease Center Benefits from Network Investments Healthcare providers are working to increase the quality of patient care, reduce costs and ensure regulatory compliance by leveraging network-delivered clinical and business applications. However, moving mission-critical healthcare applications to the network increases bandwidth and reliability requirements. Not surprisingly, a 2016 survey of IT leaders finds that improving speed and performance are the top drivers for network investments.i The San Antonio Kidney Disease Center Physician Group P.L.L.C. (SAKDC) is a medical practice that has made strategic investments to ensure its network infrastructure stays ahead of the curve. Founded in 1978, SAKDC is one of the largest nephrology practices in Texas with 30 physicians and 100 employees working in 15 satellite clinics to serve thousands of patients across the region. Three years ago SAKDC relied on legacy T1 connections to link its locations. As data traffic from its patient management system, scheduling and electronic health records (EHR) surged, the practice’s communications arteries became clogged. Frustrated physicians and support staff demanded a better solution. Philip Moya, SAKDC’s IT director, spearheaded the shift to high-performance network connections using fiber-optic and cable modem solutions. In addition to increasing bandwidth, SAKDC needed to meet key network reliability and business continuity objectives. Following an in-depth technical evaluation, SAKDC chose to create an Ethernet Private LAN linking clinics to its main office data center via two paths. The primary connection is a fiber-optic circuit that links 13 remote clinics at speeds up to 100 Mbps. Secondary connections are provided by cable modems. Should the fiber connection go down at any location, the cable modem establishes a virtual private network (VPN) link back to the data center to maintain connectivity and continuity. “We did not want one single point of failure at any of our sites,” Moya explained. “It would have done no good to put fiber and cable modems at each of our clinics and to just have one connection here at the main office. So we were adamant about having two separate paths into the building.” The way the circuits are configured, Moya adds, it “would take two simultaneous 18-wheelers [hitting poles] in two different part of the city to take us out.” Like all healthcare practices, SAKDC must comply with HIPAA privacy and security requirements. The configuration of the Time Warner Cable Business Class (TWCBC) solution is instrumental in supporting those efforts. Moya explains that “nobody else’s data touches our network; our data doesn’t touch 26 San Antonio Medicine • July 2016
Philip Moya of San Antonio Kidney Disease Center has established two paths to connect clinics to the data center.
anybody else’s network. We backhaul all of our Internet access through our main site, which runs through our filters. [If we] have to failover off the private network onto the wide-open Internet …everything’s encrypted.” From a security standpoint, the SAKDC network is built to such a high standard that Moya says, “Passing the ‘Data in Motion’ portion of a HIPAA audit… would be very easy.” When it comes to network performance, an ounce of prevention has provided a pound of cure for SAKDC. Thanks to its new network infrastructure, Moya says that keeping healthcare information flowing “is just a non-issue.”
About Time Warner Cable Business Services Time Warner Cable Business Services, a division of Time Warner Cable, offers a full complement of business communications tools to small, medium and enterprise-sized companies under its Time Warner Cable Business Class brand. Its Internet, voice, television, network and cloud services are enhanced by award-winning customer service and local support teams. Through its NaviSite subsidiary, Time Warner Cable Business Services also offers scalable managed services, including application services, enterprise hosting and managed cloud services primarily in the U.S. and U.K. Time Warner Cable Business Services, founded in 1998, serves approximately 750,000 business customers throughout Time Warner Cable’s service areas. i “2016 State of the Network Study,” Network World For more information, visit https://business.timewarnercable.com/
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visit us at www.bcms.org
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CASINO NIGHT
2016 NEW MEMBER WELCOME
CASINO NIGHT The Bexar County Medical Society welcomed its newest members with a Casino-themed party on June 1 at University of the Incarnate Word.
The Bexar County Medical Society Foundation awarded scholarships to five area high school students.
Dr. John Nava looks over his hand at one of the Blackjack tables.
28 San Antonio Medicine • July 2016
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CASINO NIGHT
Dr. Bernard Swift rolls the dice.
BCMS COO Melody Newsom and Controller Alice Sutton sold additional chips throughout the night.
Jason Siegel with Greenway Health and Christian Escamilla with BBVA Bank were gambling hard at the New Member Welcome event. BCMS President Dr. Jayesh Shah and his wife Neha are seated next to Escamilla.
Circle of Friends member Anna Gross with ICS (center) enjoys some blackjack next to Dr. Alex De Jesus (on the right) and his daughter, Amarilis De Jesus (on the left).
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UTHSCSA DEAN’S MESSAGE
UT SCHOOL OF MEDICINE UPDATE: BRAINMAP CHANGING THE WAY WE STUDY NEUROSCIENCE By Francisco González-Scarano, MD
Researchers around the world can count on a definitive resource
any brain disorder.
when analyzing the structure and function of the human brain;
In a clinical setting, a physician might scrutinize an MRI to in-
that tool is located within the UT School of Medicine in San An-
vestigate the cause of a patient’s persistent headaches. But for re-
tonio (SOM), and it is called BrainMap (http://brainmap.org).
searchers undertaking a statistical analysis, BrainMap offers a wealth
BrainMap is furthering our understanding of virtually every brain
of data comparing patients from around the world, with extensive
disorder, from psychiatric conditions such as depression, bipolar
meta-data coding and rigorous, ongoing quality control. Approxi-
disorder, schizophrenia and PTSD, to autism and neurological
mately 700 peer-reviewed journal articles are now based on the in-
diseases such as Parkinson Disease, multiple sclerosis, Alzheimer
formation contained in BrainMap.
Disease and more.
BrainMap is continuously being updated. The database collects
As one of the most extensive databases for brain research any-
the results of brain-related experiments, showing effects and their
where in the world, BrainMap provides software and tools to share
corresponding stereotactic coordinates, along with meta-data in-
neuroimaging results and enable meta-analytic studies of human
cluding size and intensity of effects, the location of the study, details
brain function and structure in healthy and diseased subjects.
on patient population, the types of imaging used, experimental-de-
Rather than a collection of images, BrainMap is a compilation of
sign details, and more.
more than 4,000 published, peer-reviewed functional and structural
The database allows researchers to search all published studies for
neuroimaging papers collectively reporting more than 15,000 ex-
a given disorder and compute the most consistent findings. This
periments that map areas of the brain using three-dimensional x, y,
electronic compilation allows researchers to reorganize and analyze
z coordinates, yielding data that offers a range of applications much
data in very sophisticated ways to try and understand disease
more than any group of images. This compilation of qualitative and
processes, to develop biomarkers of diseases and to examine the net-
quantitative data from thousands of published studies gives re-
work properties of brains.
searchers around the world ready access to information on virtually
30 San Antonio Medicine • July 2016
BrainMap is frequently used to see whether a particular pattern
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UTHSCSA DEAN’S MESSAGE
of brain activity extends across multiple types of experimental chal-
treatment trials using transcranial magnetic stimulation (TMS) in
lenges. For example, a scientist who wants to learn about the brain
post-traumatic stress disorder (PTSD) and major depressive disorder.
areas engaged by social cognition can search the database for differ-
This meta-analytic network modeling approach is now being used
ent experiments relating to this question. The researcher accesses the
to design neuromodulatory treatments for other disorders as well,
dataset and collects all the information, looking to determine simi-
including chronic pain, tinnitus and auditory verbal hallucinations
larities and differences.
in schizophrenia.
BrainMap data also helps determine whether activation or atrophy
BrainMap was created in 1988 by Peter Fox, MD, Professor of
in certain brain areas is specific to one disease or common across
Radiology, Psychiatry, Neurology and Physiology. Fox is also the Di-
multiple diseases. Consider the focus of recently published research
rector of the Research Imaging Institute (RII), a department-level,
looking for certain areas of the brain that may be affected by multi-
research-dedicated component within the School. Fox created the
ple psychiatric disorders. Prior to the advent of databases such as
BrainMap as a way to apply standard coordinates to a collection of
BrainMap, answering this question would be a massive undertaking.
brain images for research purposes. The project was in the design
Comparing multiple independent experiments produces much more
phase when he was recruited to direct the RII at its inception in
rigorous results with far greater efficiency.
1991. Fox led the charge for researchers to assign three-dimensional
Researchers using BrainMap determined that multiple psychiatric
x, y, z coordinates to locations within the brain. While his belief in
disorders, including schizophrenia, major depressive disorder, bipo-
using Cartesian coordinates to create maps of the human brain was
lar depression, and obsessive compulsive disorder all were associated
initially met with skepticism, it soon became the prevailing standard
with cortical atrophy in the anterior insula and anterior cingulate
and has forged BrainMap into the powerful resource that it is today.
gyrus bilaterally. Further, they demonstrated using BrainMap that
Fox has been at the helm of improvements and additions to it ever
these regions formed a closely integrated functional network1. As a
since, building it up to a resource composed of data from more than
result, there’s now an awareness of the need to redefine psychiatric
130,000 subjects. Accessible online at BrainMap.org, the site pro-
disorders in diagnostic criteria to better match their biology.
vides free software that allows researchers to access the database, con-
BrainMap is also key to advances in some pre-operative mapping.
duct their own searches and analyses, and even add their own data
For example, studies have identified which areas of the brain are en-
for review and possible inclusion into the database. The result is the
gaged in different tasks. BrainMap sorts this information in an ap-
continuous addition and updating of information on virtually all
plication that allows physicians to look at any brain area to help in
brain diseases.
planning regions to avoid during neurosurgery.
In addition to overseeing BrainMap, Fox’s expertise in brain func-
Another area of growing significance is connectomics, the study
tion, brain imaging, and using images to explore both brain diseases
of the brain’s information transfer properties. BrainMap is further-
and normal function has led the RII to become one of the nation’s
ing our understanding of the movement of information through
preeminent neuroscience imaging centers.
the brain and the information architecture of the brain, or connec-
The RII is a research resource maintaining its own grant portfolio
tomic modeling. This is useful in studying abnormalities that affect
and operates as an “open door” laboratory, providing access to in-
not a region or structure of the brain, but a particular communica-
vestigators from other departments and institutions. Its mission is
tion network.
to perform basic, clinical and translational research using noninva-
Many conditions are now being examined as network disorders.
sive, biomedical imaging methods for measuring the structure and
For example, connectomic research in non-human primates by
function of living organisms, with the highest priority given to neu-
Mahlon Delong and colleagues at Emory University was fundamen-
roscience research.
tal in motivating the use of deep-brain stimulation for Parkinson
BrainMap is furthering our understanding of the most challenging
Disease. Connectomics mapping using diffusion tensor imaging by
diseases of our time. Using the database, Fox is currently assisting
Helen Mayberg, also at Emory, informed the first clinical trials of
with research on multiple sclerosis, commonly understood as a dis-
deep-brain stimulation in major depressive disorder. In a similar way,
order of the brain’s white matter. However, MS also affects gray mat-
Brainmap-based modeling has informed ongoing neuromodulatory
ter structures in an anatomically non-random pattern, as was Continued on page 32 visit us at www.bcms.org
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UTHSCSA DEAN’S MESSAGE Continued from page 31
recently reported in the journal Brain by Steenwijk2, a discovery
taking place within our various programs, responses range from sur-
substantiated in an as-yet-unpublished study by a medical student,
prise to astonishment that such developments are underway here in
who confirmed the cortical atrophy pattern using BrainMap and ex-
San Antonio. The BrainMap is an excellent example of that. It’s also
tended this to identify the network connectivity patterns and be-
yet another illustration of how faculty and facilities within the
havioral functions of these regions. These findings are being followed
School are shaping and advancing the world’s collective medical
up with clinical analyses by Dr. Rebecca Romero, a faculty member
knowledge.
in the SOM Department of Neurology. The database is so accessible and efficient that it is used not only
Francisco González-Scarano Dean, School of Med-
by senior neuroscientists, mathematicians and statisticians, but also
icine Executive Vice President for Medical Affairs Uni-
by students. For example, German medical school students are ex-
versity of Texas Health Science Center San Antonio
pected to conduct research projects. As a result, that country has the
John P. Howe, III, MD, Distinguished Chair in
most published papers using BrainMap meta-analysis.
Health Policy Professor of Neurology.
While BrainMap is used by researchers across the globe, it is also driving newly emerging treatments here at home. Led by Fox, re-
References:
searchers from the School are now creating partnerships with private
Goodkind et al., JAMA Psychiatry 72(4): 305-315 2015.
caregivers in San Antonio to roll out neuromodulatory treatments,
Cortical atrophy patterns in MS are non-random and clinically
a development in its early stages that will continue to grow. In the course of informing others of the research and advances
32 San Antonio Medicine • July 2016
relevant. Steenwijk et al., Brain 139:115-126 (2016)
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BUSINESS OF MEDICINE
A Choice: Taxable or Tax-Free In Retirement? Some retirement plans are allowing Roth Conversions From Aspect Wealth Management Forty years ago, the Stanford marshmallow experiment explored self-control by offering preschoolers a choice: Take a marshmallow immediately and get only one or wait to take a marshmallow and get two. Some chose the first option; others the second. Soon, participants in some 401(k), 403(b), and 457 plans may be faced with a comparably difficult choice. In its most abbreviated form the decision boils down to this: Do you want taxable or tax-free income when you retire? Recent legislation has made it possible for plan sponsors to allow plan participants to convert their Traditional employer-sponsored retirement plan accounts into Roth accounts. Participants may either continue to make Traditional pre-tax contributions to their plans, let their assets grow tax-deferred, and receive taxable distributions during retirement or they can pay taxes today, let their assets grow tax-free, and take tax-free distributions as long as certain requirements are met.[i]
Traditional and Roth 401(k) Plan Options The type of employer-sponsored retirement plan account you have — Traditional or Roth — determines how the money you save in the plan may be taxed today and in the future. Typically, contributions to Traditional retirement plan accounts are made with before-tax dollars so these contributions can reduce your current taxable income. Any earnings in Traditional accounts grow tax-deferred until withdrawn, which generally is at retirement. Currently, distributions from Traditional retirement plan accounts are taxed as ordinary income. Savings in Roth retirement plan accounts, on the other hand, are made with after-tax dollars so they do not reduce taxable income today. However, any earnings in these accounts grow tax-free and qualified distributions are federally tax-free. Roth retirement plan contributions have been around for less than a decade and were relatively slow to catch on when they were first introduced. As a result, if you started saving in a retirement plan at work more than five years ago, it’s likely all or most of your contributions were made to a Traditional plan account. Since 2007, the number of employers allowing Roth contributions has grown from 11 to 50 percent, according to a 2013 study from Aon Hewitt. In 2013, about 30 percent of plans that offered Roth contribution op-
tions also allowed in-plan Roth rollovers or conversions. Another 16 percent of plan sponsors are expected to add the feature by the end of 2014.
Roth In-plan Conversions In-plan Roth conversions are not new. Since the Small Business Jobs Act passed in 2010, plan participants who qualified to take distributions — generally meaning they had reached retirement age, were retiring, or were leaving their employer — were eligible to convert all or part of a Traditional plan account into a Roth account. That changed with the American Taxpayer Relief Act of 2012 (ATRA) which makes it possible for full or partial conversions to take place without a qualifying event, as long as the plan sponsor allows it.
Is a Roth Conversion Right for You? The idea of having tax-free income in retirement can be appealing, but Roth conversions are not right for everyone. Here are some things to consider when weighing the pros and cons: • Current and future tax brackets: If you’re young and expect your tax bracket will increase over time, a Roth may make sense, especially if your tax bracket in retirement is likely to be higher than it is now. If you expect to be in a lower tax bracket in retirement, a Roth may not be for you. • Higher tax bill this year: Roth conversions require you to pay income taxes on any amounts converted in the year of the conversion. You should have non-retirement plan savings available to pay these taxes so you don’t incur withdrawal penalties. • Required Minimum Distributions (RMDs): If you won’t need the assets in your plan account and would like to avoid RMDs after you reach age 70½, a rollover into a Roth Individual Retirement Account (IRA) may be a good choice since Roth IRAs do not require withdrawals until after the death of the owner. Roth 401(k) accounts are subject to RMDs. Continued on page 34 visit us at www.bcms.org
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BUSINESS OF MEDICINE Continued from page 33
• Inheritance and estate plans: Since RMDs are not required if you have a Roth IRA, rolling Roth plan assets into a Roth IRA may allow you to provide your heirs with tax-free income over their lifetimes, as well as years and years of potential tax-free growth. Aspect Wealth Management has managed portfolios for the Bexar County Medical Society for over 15 years. As a member of the society, if you would like a complimentary review of your portfolio tax strategies, please contact Michael Clark at 210-268-1520.
Sources: http://www.aon.com/attachments/human-capital-consulting/2013_report_Trends-Experience-DC- Plans_Highlights.pdf http://www.forbes.com/sites/ashleaebeling/2014/01/03/the-in-plan-401kroth-conversion-strategy/ http://www.irs.gov/pub/irs-drop/n-13-74.pdf
http://www.irs.gov/Retirement-Plans/Retirement-Plans-FAQs-regardingRequired-Minimum-Distributions http://www.forbes.com/pictures/mjh45kmmj/4-youre-leaving-money-tograndkids-4/ http://www.reuters.com/article/2013/01/24/us-column-miller-rothconversion- idUSBRE90N0P520130124
The opinions voiced in this material are for general information only and are not intended to provide specific advice or recommendations for any individual. To determine which course of action may be appropriate for you, consult your financial advisor prior to making an investment decision. [1] Roth account distributions may be tax-free and penalty-free as long as you’ve had the account for five or more years and you are age 59½ or older, disabled, making a qualified first-time home purchase, or deceased.
http://www.forbes.com/pictures/mjh45kmmj/1-your-federal-rate-isheaded-up-4/
The above material was prepared by Peak Advisor Alliance.
http://www.forbes.com/pictures/mjh45kmmj/3-you-wont-need-your-iraat-70-12-4/
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
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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
Amegy Bank of Texas (HHH Gold Sponsor)
Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com
Frost (HHH Gold Sponsor)
Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com
IBC Bank (HHH Gold Sponsor)
Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com
Ozona Bank (HHH Gold Sponsor)
Chris Sherman 210-247-2978 csherman@bbandt.com
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)
VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com
Greenway Health (HHH Gold Sponsor)
Jason Siegel 512-657-1259 Jason.Siegel@greenwayhealth.com www.greenwayhealth.com
Firstmark Credit Union (HH Silver Sponsor)
e-ESI
Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org
( Gold Sponsor) Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com
RBFCU (HH Silver Sponsor)
FINANCIAL SERVICES
CONTRACTORS/ BUILDERS/COMMERCIAL
Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor)
210-945-3800 nallen@rbfcu.org www.rbfcu.org
Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com
RC Page Construction, LLC (HHH Gold Sponsor)
Brandi Vitier 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
ELECTRONIC MEDICAL RECORDS
EMPLOYEE BENEFITS
Huffman Developments (HHH Gold Sponsor)
Regions Bank (HHH Gold Sponsor)
Ray Branson 512-331-4669 branson@medmt.com www.medmt.com
Jennifer Dooling 210-270-5226 jennifer.dooling@baml.com Courtney Martinez 210-419-2643 courtney.martinez@baml.com
Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com
The Bank of San Antonio (HHH Gold Sponsor) BB&T (HHH Gold Sponsor)
SSFCU (HHH Gold Sponsor)
Med MT, Inc. (HH Silver Sponsor)
Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com
ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES
Eric Kala, CFP, CLU, ChFC Wealth Management Advisor 210-446-5752 eric.kala@nm.com www.erickala.com
Aspect Wealth Management (HHH Gold Sponsor) Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com
Frost Leasing (HHH Gold Sponsor)
Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com
Continued on page 36 visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Continued from page 35
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor)
Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/d epartments/health-care-administration
HEALTHCARE REAL ESTATE
San Antonio Commercial Advisors (HHH Gold Sponsor) Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com
Kylyn Stark 210-978-4110 kstark@elitecareemergency.com www.elitecareemergency.com
Methodist Healthcare System (HH Silver Sponsor)
Palmira Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com/
Select Rehabilitation of San Antonio (HH Silver Sponsor)
Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com
HUMAN RESOURCES
e-ESI (HHH Gold Sponsor)
HIPAA/MANAGED IT/VOIP/SECURITY
Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com
Hill Country Tech Guys (HHH Gold Sponsor)
Employer Flexible (HHH Gold Sponsor)
Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/
John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com
HOSPITALS/ HEALTHCARE SERVICES
INFORMATION AND TECHNOLOGIES
Southwest General Hospital (HHH Gold Sponsor)
Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 simperial@iasishealthcare.com www.swgeneralhospital.com
Henced (HHH Gold Sponsor) Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com
INSURANCE
210-220-6412 bob.farish@frostbank.com www.frostbank.com
Humana (HHH Gold Sponsor)
Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
SWBC (HHH Gold Sponsor)
VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com Ad Valorem Tax Advisor Nikki McNish 210.376.2316 nmcnish@swbc.com www.swbc.com
Catto & Catto (HH Silver Sponsor)
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) Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Central referral line 210-592-5350
Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 jisgitt@tmait.org www.tmait.org
Elite Care Emergency (HH Silver Sponsor)
Marketing Liaison Dlorah Martin 509-592-7998 dmartin@elitecareemergency.com Marketing liaison
36 San Antonio Medicine • July 2016
Frost Insurance (HHH Gold Sponsor) Bob Farish
MedPro Group (HHH Gold Sponsor)
Thomas Mohler 512-213-7714 thomas.mohler@medpro.com Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor)
Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com
The Doctors Company (HH Silver Sponsor)
Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com
NORCAL Mutual Insurance Co. (HH Silver Sponsor) Patrick Flanagan 844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com
ProAssurance (HH Silver Sponsor)
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)
Darin Anderson 210-563-5230 Darin.anderson@twcable.com
IT SUPPORT/VOIP/ CLOUD SERVICES
ICS (HHH Gold Sponsor)
Daniel Simons 210-581-9020 daniel.simons@ics-com.net Robert Foehrkolb 210-225-5427 rfoehrkolb@ics-com.net www.ics-com.net
MARKETING ADVERTISING SEO
Henced (HHH Gold Sponsor) Rainey Threadgill 210-647-6350
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Rainey@henced.com www.henced.com
MARKERTING SERVICES
Digital Marketing Sapiens (HHH Gold Sponsor) Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com
MEDICAL BILLING AND COLLECTION SERVICES
MERCHANT PAYMENT SYSTEMS/CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor)
Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com
OFFICE EQUIPMENT/ TECHNOLOGIES
Commercial & Medical Credit Services (HH Silver Sponsor)
Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com
PAYROLL SERVICES
SENIOR LIVING
Ronel Uys 210-805-8200, ext. 10105 ruys@dahill.com www.dahill.com
Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com
Legacy at Forest Ridge (HH Silver Sponsor) SWBC (HHH Gold Sponsor) Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com
Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com
STAFFING SERVICES
PHYSICIANS BUYING GROUP Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) CASA Physicians Alliance (HHH Gold Sponsor)
Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com
Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com
Kuper Sotheby's International Realty (HH Silver Sponsor)
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHHH 10K Platinum Sponsor)
Roslyn Casey Realty (HHH Gold Sponsor)
Dahill (HH Silver Sponsor)
Kareo (HHH Gold Sponsor)
Regional Solutions Consultant Lilly Ibarra: 210.714.9815 lilly.ibarra@kareo.com www.kareo.com
REAL ESTATE/ RESIDENTIAL
Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net
Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com
REAL ESTATE/ COMMERCIAL CASA Physicians Alliance (HHH Gold Sponsor) Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net
SAN ANTONIO COMMERCIAL ADVISORS (HHH Gold Sponsor) Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com
MERCHANT CARD/ CHECKPROCESSING Firstdata/Telecheck (HH Silver Sponsor)
Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com
Robbie Casey Realty (HHH Gold Sponsor)
Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com
To join the Circle of Friends program or for more information, CALL 210-301-4366, EMAIL August.Trevino@bcms.org VISIT www.bcms.org visit us at www.bcms.org
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Ancira Chrysler 10807 IH-10 West Gunn Acura 11911 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Ancira Dodge 10807 IH-10 West Cavender Audi 15447 IH-10 West
* Gunn Infiniti 12150 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Ingram Park Auto Center 7000 NW Loop 410
North Park Mazda 9333 San Pedro Ave.
North Park Subaru at Dominion 21415 IH-10 West
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne
Cavender Toyota 5730 NW Loop 410
Ancira Jeep 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of San Antonio 9600 San Pedro Ave. Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)
Northside Ford 12300 San Pedro Ave.
Cavender GMC 17811 San Pedro Ave. Batchelor Cadillac 11001 IH-10 at Huebner
Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Chevrolet 12602 IH-35 North
North Park Subaru 9807 San Pedro Ave.
* North Park Lexus 611 Lockhill Selma North Park Lexus Dominion 21531 IH-10 West Frontage Road
Ancira Nissan 10835 IH-10 West Ingram Park Nissan 7000 NW Loop 410
North Park Toyota 10703 SW Loop 410
* Ancira Volkswagen 5125 Bandera Rd. North Park VW at Dominion 21315 IH-10 West
Gunn GMC 16440 IH-35 North
* Fernandez Honda 8015 IH-35 South
* North Park Lincoln/ Mercury 9207 San Pedro Ave.
Ancira Ram 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Gunn Honda 14610 IH-10 West (@ Loop 1604)
visit us at www.bcms.org
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AUTO REVIEW
2016 Lincoln MKX By Steve Schutz, MD In 2000, Lincoln sold 193,009 vehicles in the U.S. and claimed the title of best-selling luxury automotive brand in this country. Fifteen years later, they have been passed by BMW, Lexus, Mercedes, Audi, Acura, Cadillac, and Infiniti and sit eighth in that important competition for sales preeminence. While many of those years have seen Lincoln be unable to mount a successful strategy, the last three have shown a coherent plan that seems to be working. No, Lincoln’s not going to topple No. 1 BMW anytime soon, but it’s worth noting that Lincoln’s U.S. sales went from 94,474 in 2014 to 101,227 in 2015, a 7 pecent increase. What is this coherent plan? Lincoln executives haven’t revealed much in the way of details, but news reports indicate that the idea is to benchmark Lexus ride comfort and interior quiet, focus on the dealer experience 40 San Antonio Medicine • July 2016
— again, like Lexus — and design their vehicles to look less dramatic and more understated than their competitors (unlike Lexus, ironically). Oh, alphanumeric titles like MKZ or, the crossover I’m reviewing today, MKX, are going away, and real names are coming back. Hooray, I love names! While cars called 328i and S550 are fine with me, I miss names I could remember without googling like Legend, Futura and Eldorado. OK, on to the MKX, a compact crossover SUV clearly aimed at the hugely popular Lexus RX 350. Based loosely on the Ford Edge, the MKX seats four comfortably and five in a pinch, and is a nice alternative to the RX. Don’t focus on the exterior design too much though, because as noted above, that, like the name, is going to change in the next couple of years as Lincoln moves away from
the horizontal waterfall grille currently featured on all of its vehicles and replaces it with a more traditional grille. Nevertheless, the MKX looks like what you’d expect a contemporary luxury crossover to look like, which is to say upscale but understated. Would it be smart to make Lincolns more interesting, stylistically? Maybe, but if I were in charge of Ford’s luxury brand, I’d do exactly what they’re doing, which is to go with a more low-key design language and focus on quiet, quality, and the ownership experience. The interior is also tasteful and (mostly) user-friendly, but a little bland. The materials are excellent with soft touch surfaces and a nice look, but I’d prefer more personality. As it stands, it looks like a mix of Ford and Lexus — and the result is as good as what you’ll see in the Lexus RX — but I’d like to
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AUTO REVIEW
see more originality in future generations. I’d also like to see a better infotainment user interface. The current one is intuitive and logical, but the small screen and (too) busy menus are downers. Driving the MKX is, no surprise, a lot like the RX 350. There’s very little road or engine noise unless you’re really hustling, and the ride is geared for comfort, not sport. It’s all very Lexus like, which is usually a problem for enthusiasts but shouldn’t be. I’m an enthusiast, but even I don’t want to be, umm, enthusiastic all of the time. Honestly, after a long day working and scoping (from 7:305:30, or later, sometimes much later) I don’t want a demanding car. At all. I want a quiet cocoon where I can relax and make a few phone calls. I’m betting there are more than a few physician readers out there who are with me. A Lexus or Lincoln is a good thing, especially if the dealer is going to help make my life peaceful in other ways. And that appears to be the case at Lincoln.
Their first serious effort at making the ownership experience special is the Lincoln Black Label program. Available with the MKZ, MKX, and MKC, the Black Label program includes vehicle pick-up and drop-off for service, car washes anytime, annual interior/exterior detailing, test drives at your home or office, and access to unique culinary experiences at select restaurants. I like all of this, especially the pick-up and dropoff for service. I use that perk regularly for my Lexus, and it’s great. In the morning I leave my key and a credit card with the receptionist at my office, and in the afternoon, the key is on my desk, and I can walk out to my serviced (and cleaned) car and drive home. Why only Lexus and Lincoln are focusing on this type of customer pampering is beyond me. Average transaction prices for MKX crossovers are expected to be around $45,000-$50,000, which will get you a well equipped vehicle with a turbocharged eco-
boost V6 engine. As always, Phil Hornbeak will helpfully guide you through the buying process. My only 2 cents here is to order yours the way you want it as long as you get the ecoboost engine. I’m happy to see Lincoln growing again. Ours is a competitive luxury automotive marketplace where you need brains, guts, and a good plan to succeed. After several years of wandering, Lincoln is moving in the right direction. I hope they continue to grow. 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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