San Antonio Medicine September 2016

MEDICINE SAN ANTONIO

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VOLUME 69 NO. 9

MEDICINE SAN ANTONIO

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MEDICAL EDUCATION

FEATURE:

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

TOSA’s Chief Retires after 19 Years of Service Courtesy of TOSA ................................................24

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BCMS President’s Message ...........................................................................................................8 BCMS News..................................................................................................................................10 BCMS Legislative News................................................................................................................12 Business: Ask Your CPA: Business Basics for Medical Practice

by Jim P. Rice, CPA Shareholder..........................................................................................................26 Business: Keep Your Umbrella Handy from Aspect Wealth Management..............................................28 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................30 TMLT Risk Management: Closed Claim Study ........................................................................................32 Business of Medicine: Value-Based Health Care

By Joseph P. Gonzales, MHA, LFACHE ...............................................................................................34 BCMS Circle of Friends Services Directory .............................................................................................37 BCMS Auto Program ...............................................................................................................................43 Auto Review: 2016 Lexus GS-F

by Steve Schutz, MD ...........................................................................................................................44

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4 San Antonio Medicine • September 2016

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VOLUME 69 NO. 9

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

Why I Became A Doctor (and other fairy tales)

By Robert G. Johnson, MD ..................................20

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A New Path to Primary Care: Texas is finding innovative ways to chip away at physician shortage

By Amy Lynn Sorrel, Associate Editor, Texas Medicine ....................................................14

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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 David Schultz, Community Member J.J. Waller Jr., MD, Member

6 San Antonio Medicine • September 2016

PRESIDENT’S MESSAGE

“Balance Billing”

Understanding the real issues, both for the physicians and the patients

By Dr. Jayesh Shah, 2016 BCMS President Recently, at the legislative committee meeting at the Bexar County Medical Society headquarters, there was a spirited discussion in relation to balance billing. The Texas Medical Association did extensive work last year to find out the best practices for Texas physicians and patients on the subject of balance billing and as a result TMA’s socioeconomic committee came back with a consensus presentation.

Health insurance companies are beginning to narrow their networks and are setting limits on payments for services for out-ofnetwork providers because of patients receiving unexpected medical bills. Physicians are concerned for their patients, some who earn less than $10 per hour and end up with a bill for thousands of dollars after a visit to an emergency room. Patients are often surprised with the size of their bills that it causes undue hardship on them.

Physicians believe that patients have a right to be educated on narrow networks before they sign up and start paying premiums to these insurance companies.

TMA research clearly shows that narrow networks and other insurance practices are bearing down on patients in the form of unexpected, out-of-network balance bills. How can this be a physician billing problem?

In a recent TMA survey, about one-in-four physicians said they tried to join a network and, surprisingly, 29 percent received no answer to their request, 32 percent got a payment offer that was too low for them to accept, and only 39 percent received a contract to join the network. So how can this be a physician billing problem?

A 2014 survey of Texas physicians found that 61 percent of physicians found they were listed as being in a network when really they were not, and 56 percent of physicians found instances where they were not listed in a plan when they should have been listed.

So who is responsible for inaccurate directories that mislead patients when are ready to buy particular insurance products?

In both 2014 and 2015 HMO report cards, the Office of Public Insurance Counsel (OPIC) found a growing number of consumer complaints about insurance companies’ “failure to properly disclose provider networks” and “improperly expecting additional payment.”

Appearing before House and Senate committees, the Chair of the TMA Council on Legislation, Ray Callas, MD, laid out medicine’s solution for the surprise bill problem.

8 San Antonio Medicine • September 2016

The following information is from the TMA website https://www.texmed.org/surprise/: • Mandatory increases in state agency oversight of the adequacy of insurer networks.

• Expand the current $500 balance bill threshold for mediation to include all out-of-network physicians, other health care professionals, facilities, and vendors.

• Prior to any preauthorized elective services, require the insurer to inform the patient “about the network status of the facilitybased physicians and others who may participate in their care and bill for services.”

• Similarly, physicians and providers should use a standard form to tell patients which physicians and providers who may be involved in their care “typically practice in the facility where the planned services will occur.”

• Require insurers selling PPOs to include “a clear and conspicuous notice regarding the implications of using or receiving services from an out-of-network physician and the potential for balance billing” on their websites, policy documents, and directories.

• Require insurance brokers and agents to educate consumers on the inherent limitations of the plans they buy, especially their out-of-pocket responsibilities for care provided both in and out of network.

What can you do?

• TMA is asking the county medical societies to make contact with their legislators on this issue prior to September 30.

• Physicians should know and read all the terms of their contracts with insurance companies.

• Educate your patients about the real issue. TMA has developed educational materials for patients that can be printed from the following link-https://www.texmed.org/surprise/.

Regards, Dr. Jayesh Shah

BCMS NEWS

UThSCSA Student Orientation Dr. Jesse Moss, a past president of the Bexar County Medical Society, sits on the floor as he talks with medical students at the University of Texas Health Science Center-San Antonio during Student Orientation Day on August 5.

Dr. gerardo Ortega, a past president of the Bexar County Medical Society, has been honored with a special award by the Baptist health System.

The W.B. Russ, M.D., Award is presented to a physician who exemplifies the qualities that made Dr. Russ a great doctor and a great man.

Russ was a founder of Physicians & Surgeons Hospital which was the original hospital on the site of what became Baptist Medical Center. Russ, who died several decades ago, worked to bring higher quality medical care to the community and his professional work continues to influence medicine in San Antonio to this day.

2016 BCMS Bay Fishing Tournament November 3rd- Nov 4th BAY FIShINg AT ITS BEST Join us for the 2016 BCMS Bay Fishing Tournament! Enjoy bay fishing at its best in Rockport, Texas. Space is limited — please reserve your spot early!

This event is limited to physicians, their spouses, and BCMS Circle of Friends members.

For more information contact: MARK LACHENAUER 4334 N Loop 1604 W, Suite 200 San Antonio, Texas 78249 (210) 301-4372 mark.lachenauer@bcms.org

10 San Antonio Medicine • September 2016

BCMS LEGISLATIVE NEWS

BCMS hOSTS TExAS MEDICAL BOARD On July 27, BCMS hosted Mari Robinson, J.D., executive director for the Texas Medical Board (TMB). Ms. Robinson led a CME presentation on several topics pertaining to the practice of medicine in our state, including physician professional responsibilities. The presentation offered attendees 1 hour of medical ethics CME. Approximately 75 physicians and practice administrators attended.

Among the topics discussed during the hourlong presentation were: legislation passed in the 84th legislative session; regulation issues; the TMB enforcement process and common types of violations.

For local discussion on this and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

Top photo: Mari Robinson, JD, executive director of the Texas Medical Board (TMB) explains the latest on TMB rules on enforcement process during the CME presentation at BCMS on July 27.

Middle photo: Common types of violations was a key topic discussed and presented by TMB’s Mari Robinson, JD. Bottom photo: Executive director of the TMB, Mari Robinson, JD, opened the CME presentation on July 27 with an overview of legislation passed during the 84th Legislative Session.

12 San Antonio Medicine • September 2016

MEDICAL EDUCATION

A New Path to

PRIMARY CARE

Texas is finding innovative ways to chip away at physician shortage

By Amy Lynn Sorrel, Associate Editor Texas Magazine

West Texas is known for its oil fields, but one of its boomtowns is building a new kind of pipeline to stream a steady supply of primary care physicians to the largely rural and underserved area. Midland sits atop one of North America’s largest oil reserves, the Permian Basin, but local educators and hospital leaders say convincing doctors to stay in the patch is often a bust.

To prime the pump, Midland is looking to its own community.

The new well: community college students with an aptitude for a medical career.

“This really is my story,” said Lisa R. Nash, DO, a family physician and associate dean for educational programs at the University 14 San Antonio Medicine • September 2016

of North Texas Health Science Center (UNTHSC) Texas College of Osteopathic Medicine (TCOM) in Fort Worth. She graduated from the medical school after starting her education close to home at Weatherford College and Texas Christian University, then entered rural practice in West Texas postresidency.

“We now understand very well the challenges for rural Texas in recruiting physicians, and predictors for who might really go into rural practice or underserved areas that are not necessarily rural but where there’s need. And one of the best ways to get people into those communities is to train people from those communities because they are the ones most likely to go back there,” she said.

MEDICAL EDUCATION UNTHSC and TCOM are partnering with Midland College and Midland Memorial Hospital on an innovative program designed to grow and keep its own crop of future doctors in the area. The Primary Care Pathway identifies interested, high-achieving community college students likely to be successful in medical school and guarantees them an accelerated pathway to a doctor of osteopathic medicine (DO) degree, focusing earlier and more intensely on primary care. The targeted program allows students to get their undergraduate and medical degrees in seven years versus eight; the first crop of eight students enrolled last fall.

Community college students have valuable experience that doesn’t always make up the typical application sought by medical school admissions committees, Dr. Nash says. But local ties, combined with early exposure to primary care training, create what she describes as a natural fit.

“This is really done in cooperation with the local community and what their needs are in terms of medical services, and we can predictably say in pretty much all of rural Texas the most acute need is primary care,” she said. “It’s just a natural extension taking it back in the pipeline. And if this works, it could be a model replicated many places across the state.”

Thanks in part to several victories the Texas Medical Association and Texas medical schools won over the past two legislative sessions to increase medical education funding, Texas is finding ways to chip away at primary care physician shortages in the nation’s fastest-growing state. More than 5 million Texans — 20 percent of the state’s population — live in designated primary care shortage areas, according to federal statistics. (See “Texas’ Primary Care Profile.”)

The Pathway launched in October 2015 with help from a $350,000 primary care innovation grant, one of several grant programs the 2013 and 2015 legislatures approved to expand availability of undergraduate and graduate medical education (GME) across Texas. In 2015, lawmakers also revived the decades-old Texas Statewide Primary Care Preceptorship Program, a mentorship program that, like the Pathway, gives interested medical students early exposure to primary care by matching them with internists, family physicians, and pediatricians. (See “Medical Education Wins Big.”) “Our need is so great that meeting that need is a goal that is still out there,” said Stacey Silverman, PhD. She is deputy assistant commissioner for academic quality and workforce at the Texas Higher Education Coordinating Board, which oversees the state grants.

The Pathway program, for example, not only shortens the physician pipeline and promotes primary care, but it also “does outreach to a sector of higher education not really picked up yet. We have so many students starting out in community college we need to reach, and this sets a new pathway for community colleges to follow, making it a really innovative model,” Dr. Silverman said. At the same time, she adds, the preceptorship program has shown over the years

that early exposure to primary care plays an important role in swaying medical students’ decisions to choose the specialty.

“It’s a long road, but certainly these programs help us get further down that road in having a positive effect on the physician workforce and education in our state,” Dr. Silverman said.

Community Effort The Pathway model seeks to provide additional opportunities for students from historically underserved communities to attend and succeed in medical school. Selected students enter the pipeline program in their first year at Midland College and benefit from shadowing and mentoring experiences in primary care in the area. After successfully completing an enhanced three-year premed curriculum, students would have automatic admission to TCOM. The basic program structure includes: • Two years of full-time study at Midland College; • One year of full-time study at UNT Denton; and • Four years of study at TCOM. • Two summer clinical internships after their first and second years at Midland College give students firsthand training outside the classroom.

TCOM Dean Don N. Peska, DO, says a number of puzzle pieces fell into place to launch the Pathway.

A Midland County judge who was a member of UNT’s Board of Regents caught wind of the new medical education grants and pushed the idea of partnering with Midland Memorial Hospital on an initiative to get more doctors to the area. Around the same time, Dr. Peska noticed a significant number of applicants who did a portion of their undergraduate education at community colleges around the state. Meanwhile, leadership at Midland Memorial — already a teaching hospital — had close connections to Midland College.

“We saw we had all the components we needed other than putting a medical school there, and we felt we had an opportunity to bring the whole community into this initiative,” Dr. Peska said. “We felt the more we use the community for this, the more successful we would be.”

Some hurdles were encountered in developing the curriculum.

For medical schools to maintain their accreditation, for example, students need at least 90 credit hours to begin their training. Midland College offers only 60 credit hours toward an associate degree and didn’t have the advanced science courses required for TCOM admission.

“But of course, we have an undergraduate school. So we said we could take candidates coming out of Midland, and UNT [Denton] could give them the additional 30 credit hours in coursework we continued on page 16 visit us at www.bcms.org

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design to be successful in medical school,” Dr. Peska said. “To get into medical school, you don’t need the bachelor’s degree. You just need the 90 credit hours.”

TCOM also agreed to waive the Medical College Admission Test for Pathway students.

“We don’t want students to take the exam and fail because their preparation is different, and we recognize and are fairly comfortable with the correlation with Scholastic Aptitude Test [SAT] scores,” Dr. Peska added. “Midland College doesn’t require either, but for this program we ask students who want to enter to take the SAT so we can predict how they will perform on standardized academic exams.”

years. The reasons for creating such programs decades ago were the same that some schools put forth now: addressing predicted physician shortages. Nationally, the Association of American Medical Colleges predicts a shortfall of 90,000 physicians by 2025.

“You can get into some maturity issues when you accelerate too quickly. But we know there have been [accelerated programs] that do just fine, and that’s the reason accrediting bodies don’t require a bachelor’s degree for entry into medical school, just a credit-hours minimum,” Dr. Peska said. Nor is the program for everyone, “but we have a lot of confidence in the rigor they will be facing at Midland College, and we know of no other program anywhere like this.”

Targeted Curriculum

Keeping Close to home

To secure admission to the DO program, the premed students must maintain a 3.5 grade point average — with no grades below a B — in a prescribed curriculum that is heavy in math and science.

In the heart of oil engineering country, Midland College already had a nationally recognized science program, says Margaret Wade, dean of math, science, and kinesiology. In formulating what she describes as a targeted premedical curriculum, “we looked at very standard requirements for medical school,” which include the general biology, anatomy, and organic chemistry courses. From there “we pared down the first two years by giving students the option not to take certain core courses [for an associate degree], like government or history, and enabled them to take more science.”

A faculty member from Midland College’s biology department spends about 10 hours a week identifying and recruiting students to the program. “We want to look for students who’ve already proven they know how to study, took rigorous courses in high school, and can handle heavy loads. We won’t eliminate anyone, but that’s our target audience,” Ms. Wade said, adding that the college has a track record of identifying, mentoring, and transferring successful engineering students to Texas Tech University to complete their studies.

Dr. Peska acknowledges accelerated medical degrees — with mixed success over the decades — are nothing new, and only time will tell if the Pathway strategy works.

A September 2013 New England Journal of Medicine commentary cautions that shortening medical education could mean shortchanging students and the public, but agreed that medical education reforms are necessary. According to the article, in 1974, 33 medical schools had three-year MD programs, most of which disappeared until now as a growing number of schools across the country experiment with the model. The University of Texas System, for instance, is piloting a Transformation in Medical Education (TIME) initiative that aims to better coordinate students’ transition from college to medical school and shorten that total time in school by one to two

Throughout the entire pipeline from undergraduate to medical school, students leave their local community for only three years, Dr. Peska explains. “We want to get them back into the community as quickly as we can because we know the longer we take them out, the more risk of them not coming back.”

UNTHSC also is working with the hospital to develop a primary care residency program to host the students once they graduate.

In addition to helping students save on education costs with a shortened pathway, educators say the grant money provides some enhancements to help meet community college students’ unique needs and improve their likelihood of success. The funds primarily support tuition scholarships, travel, stipends, and program coordination staff, in particular an advisor dedicated to coaching and encouraging the premed students when things get difficult.

Such support, combined with local recruitment and getting students back to their community as quickly as possible, is key to solving some of the challenges Texas faces in getting physicians into rural practice, Dr. Nash says.

From the get-go, rural students face several disadvantages just because they choose a particular educational pathway.

“The challenges are, like me, students don’t come from wealthy families. Most of them have to work and pay their own way through college, so they stay close to home. For a lot of them, that means community college first, followed by a four-year university. And that’s not necessarily the background most medical school admission committees consider the strongest,” Dr. Nash said. Medical schools also look for things like volunteer experience, “which is great. But it takes a lot of time, and most of these kids work through school.”

That doesn’t mean their experience isn’t valuable, she says. But another obstacle is convincing rural students that medical school is an option in the first place.

“Nobody in my family was a doctor, and nobody from my school had gone to medical school. I just remember since I was a little kid wanting to be a doctor,” Dr. Nash said.

16 San Antonio Medicine • September 2016

MEDICAL EDUCATION

Texas’ Primary Care Profile State Population: 26,956,958 Population in Primary Care Shortage Areas: 5,211,605 Active Physicians: 57,502 Primary Care Physicians: 19,234 Active Patient Care Physicians per 100,000 Population State Rank: 42 Active Patient Care Primary Care Physicians per 100,000 Population State Rank: 47 Total Residents/Fellows in ACGME Programs per 100,000 Population State Rank: 22 Total Residents/Fellows in Primary Care ACGME Programs per 100,000 Population State Rank: 32 Note: Texas’ rankings are compared with the other 49 states. A No. 1 ranking goes to the state with the highest value.

Sources: U.S. Health Resources and Services Administration, Association of American Medical Colleges 2015 State Physician Workforce Data Book

After starting at Weatherford College, she got a scholarship to TCU and continued to work on average 24 hours to 30 hours per week, and 16 hours per week through her first year of medical school “until I couldn’t do it anymore. When I graduated, I did a family medicine residency in Fort Worth and went into rural practice and ultimately ended up choosing an academic career and still finding ways to work on rural medicine issues. But for a lot of kids, it never crossed their mind they could do this.”

Seven of the Pathway’s inaugural students are recent high school graduates, and one is an older student who worked after high school.

Many of them would be first-generation college graduates, let alone doctors, “which is exciting,” Ms. Wade added. “You’d be amazed at the community college level at things as simple as, ‘I don’t have gas money for the end of month.’ Now we can step up to the plate with funds, but too often we don’t know about it.”

Early Exposure Educators also agree exposing students to primary care early — and often — is an important factor in their decision to choose the specialty.

In addition to the academic curriculum, for instance, Pathway students complete two summer internships: The first summer, between their first and second years at Midland College, students participate in a clinically oriented program at Midland Memorial to introduce them to basic medical practice and concepts like professionalism and teamwork. The second summer program, when students transfer to UNT Denton, offers hands-on training in clinical skills labs to learn things like how to assess vital signs.

“These are things we expect all applicants to do somewhere along the line, and we are creating the experience for [Midland College students] so they don’t have to go find it,” Dr. Peska said.

In addition to the opportunity to shadow physicians, for example, Midland Memorial is working with the West Texas Area Health Education Center to create a community health coaching program, modeled after a joint project between Angelo State University and Shannon Medical Center in San Angelo. Under supervision of a physician assistant, premed students visit chronically ill patients in their homes, for example, to check on their health status and quality of life, identify possible needs, make sure patients get to their appointments, and report back to the doctors and nurses who coordinate their care.

“We’ll work with premed students at Midland, get them acclimated to a medical environment, and they’ll have some contact with people in the community so when they come back to Midland as a DO, they’ve already gained some valuable experience. And it might help us reduce readmissions in the process,” said Bob Dent. A nurse continued on page 18 visit us at www.bcms.org

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by trade, he is senior vice president and chief operating officer at Midland Memorial and past dean of Midland College’s Health Sciences Division.

Wanted: Primary Care Oil drilling in Midland may be cooling off, Mr. Dent adds, but the boom over the last several years — and Midland’s overall boom-and-bust history — has transformed the once tumbleweed town now in need of more doctors to keep up with the economic and population growth that brought an influx of new workers and businesses. According to U.S. Census data, Midland County’s population increased 10.7 percent from 2010 to 2013, compared with a 5.4-percent population increase for Texas as a whole.

Twenty percent of the county’s population lives in rural areas.

“Our problem is two-fold, and we have to figure out which comes first: making sure the community truly understands the value and importance of seeing primary care doctors on a regular basis and making sure we have enough primary care providers to meet that demand. [The Pathway program] is one way to try and hit all the angles and meet the long-term need of the community,” Mr. Dent said. “People from the big city — West Coast, East Coast — get here, and it’s not what they are familiar with, so they end up leaving. But we’ve found in our medical staff and other clinical staff that if they have a connection to Midland — a family or they were raised here — they stay much longer.”

Embedded in DO training is early and frequent exposure to primary care, a big reason 65 percent of TCOM’s students go into primary care specialties like family and internal medicine and pediatrics, Dr. Peska adds. Large classrooms, divided into small groups, feature advisors largely in primary care. An even larger percentage of students enrolled in TCOM’s rural training track — where Dr. Peska says trainees “really see the diversity of primary care” — go on to choose the specialty.

As a teaching facility, Midland Memorial already hosts an internal medicine residency program through Texas Tech University Health Sciences Center, making it ripe training ground for Midland College students when they return for their clerkships in the final two years of medical school.

Although still early — seven years out — UNTHSC is exploring sponsorship of residency pipelines within the hospital so graduates can stay in Midland. Some hurdles may lie ahead.

For guidance navigating accreditation and challenges with facilitated entry into residency, Dr. Nash plans to reach out to Texas Tech, which offers a Family Medicine Accelerated Track that guarantees students who choose the specialty a residency 18 San Antonio Medicine • September 2016

Medical Education Wins Big Building on 2013 successes and recognizing physician workforce shortages, the Texas Legislature gave another significant boost to undergraduate and graduate medical education (GME) funding in 2015, including: • $53 million for new GME expansion grant programs, a $40 million increase over 2014–15 funding levels; • $7 million for primary care physician pipeline programs: $4 million — or 31 percent — above current funding for the existing family medicine residency program, and $3 million to restart the Statewide Primary Care Preceptorship Program; • A $20 million, or 22-percent, increase in biennial per-resident, or “formula,” funding; • Steady funding for the primary care physician workforce innovations grant program; • An additional $53 million, or 3-percent biennial increase, in medical student formula funding; • Maintained funding for the State Physician Education Loan Repayment Program; • A new loan repayment program for psychiatrists and other mental health professionals; and • Additional money for mental health workforce training programs in underserved areas.

For more information on the GME expansion grants, visit tma.tips/GMEgrants.

MEDICAL EDUCATION

slot and shaves one year off of their medical school training. The program also won a state primary care innovation grant from the Texas Higher Education Coordinating Board.

National Resident Matching Program rules “require you to be all in: If you are going to participate in the match, then all of your positions have to be in the match. The [Pathway] residency is probably going to have to be bigger than what we can fill with local kids,” Dr. Nash explained. The program likely could take advantage of one or more of the GME expansion grants the legislature authorized to promote and support such residency programs, “but there will have to be other spots to comply with accreditation rules and also assure these [Pathway] kids have a spot.”

Preceptorship Revived The Statewide Primary Care Preceptorship Program meanwhile has shown that mentorship and early exposure to primary care specialties have a positive influence on students’ decisions to go into the field.

The program places first- and second-year medical students with practicing internists, family physicians, and pediatricians across the state to immerse them in one of these medical specialties for a summer. The medical students work in practicing physicians’ offices and experience the daily life and work of participating mentor physicians — known as preceptors — who provide direct experience and insight into the clinical and administrative aspects of practicing primary care.

The statewide program cleared a major hurdle, winning back a three-fold increase in funding after the legislature defunded it during a 2011 budget crisis. Lawmakers put $3 million into the program for 2016 and 2017, up from $904,000 the last time it was funded in 2010–11.

Houston internist Robert E. Jackson, MD — one of more than 1,400 preceptors — says students get much more out of the money than a summer stipend, as does Texas, which ranks among the bottom states with the fewest number of primary care doctors serving the population. He is a former governor of the Texas Chapter of the American College of Physicians and a member of TMA’s Council on Legislation.

“We are the front lines, and the legislature woke up and realized how important it is to have enough primary care doctors, and that you can’t just snap your fingers and become one,” said Dr. Jackson, pointing to program data showing participants in the preceptorships tend to choose primary care residencies at higher rates.

Over the past decade or so, the internal medicine and pediatric preceptorships have shown that as many as 38 percent of participating students choose the specialty, compared with national residency entry rates of 9 percent to 24 percent. The family practice

preceptorship — the longest running of the three programs, since 1979 — has attracted as many as 28 percent of participating Texas medical students to the specialty over the years versus 16 percent of nonparticipants.

First-year medical students typically have not decided on a specialty, “and they have really not yet been exposed to that much clinical medicine. What we as mentors try to demonstrate is the joy of the practice of medicine and the breadth and depth of primary care,” Dr. Jackson said, likening the process to detective work. “Patients — all kinds — come to me with a whole bunch of complaints, and it’s so much fun to take care of them, plus it’s an honor and privilege.”

That kind of enthusiasm rubbed off on Navy reservist John DeMis. He knew he wanted to serve his country but, like most medical students, wasn’t sure what kind of doctor he wanted to be when he started at The University of Texas Health Science Center at San Antonio. An internal medicine preceptorship gave him the answer.

“What really struck me was the relationships my mentor had built with his patients. The bread and butter of primary care was made more inspiring by seeing the compassion and empathy you share,” Mr. DeMis said.

His preceptor was a career internist and nephrologist who, from day one of the program, told the students they would be working through lunch. It wasn’t long before Mr. DeMis figured out why: Whether in the dialysis unit, hospital, or clinic, patients brought homemade food and vegetables from their gardens.

“And now that I’m in my third year, I can’t overstate the importance of being able to constantly change gears from different settings.

It was so helpful to be exposed to that early on, and it made me better in third year,” Mr. DeMis said.

Beyond the lessons on labs and charting, however, during those car rides and long days, his mentor also imparted life lessons.

“When you spend this much time together, you don’t just talk about medicine. We talked about things like having a family and making enough money. And I thought, ‘Hey, I can do this,’” Mr. DeMis said. “That was more useful than anything because so often in medical school you’re learning curriculum and diseases and drugs.

But you don’t get to take a step back and see what your life is going to be like. This program totally changed my outlook and made me much more determined in my path to primary care.”

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext.

1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

Amy Sorrel is the associate editor of Texas Medicine, a publication of the Texas Medical Association. This article was first published in Texas Medicine in March 2016. visit us at www.bcms.org

19

MEDICAL EDUCATION

Why I Became a Doctor (and other fairy tales)

By Robert G. Johnson, MD I’ll take flak for this but here goes. The lead story of the May 2015 issue of San Antonio MEDICINE read: ‘Why I Became a Doctor’.

There were five short articles by five different doctors. The first two were entitled ‘Ultimate Altruism’ and ‘A Calling Within My Soul’.

Here’s a smattering of quotes: “endless commitment and dedication”, “a calling, divine or otherwise profoundly metaphysical”, “betterment of the human condition”, “dawning moments of consciousness.” This brought to mind an Instagram that my 18year-old posted of his recent breakfast at IHOP. I wasn’t exactly sure of the food group, but it was smothered in whipped cream and maple syrup.

Before you run me out of town with torches and pitchforks, I’ll admit to agreeing with the above sentiments; it’s just like — you

know — trying to explain marriage to your kid and stopping with the honeymoon. Listened to the conversations in the doctor’s lounge recently? Not much gushing altruism there. The sequel to the article (and the true heart of the matter) should be “Why I Remain a Doctor.”

The third article (by a fellow orthopedist) at least dipped its toe into the lagoon of realism. Its author started by asking if it “is worth all the red tape”, then reminds us of “dealing with insurance companies and (government) regulations on how to run my practice.”

Now we’re getting closer to the real world. Along with my seven partners, we run a small business. We employ over fifty citizens, provide health insurance for them and their families, give out yearly raises and bonuses. Sometimes I find my altruism drowning in a sea continued on page 22

20 San Antonio Medicine • September 2016

MEDICAL EDUCATION continued from page 15

of overhead. The author ends by stating that he “look(s) forward to each day of work.” Big sigh! Maybe I’ve just become tired and cynical, but there are many days (most as I get older) where I’d rather stay home, drink coffee and watch a tree grow.

The only contributor I’ll mention by name is my old friend Fred Olin. As expected, Fred was dry and witty. Starting life as a veterinarian, dealing with all animal forms except people, becoming a doctor simply “expanded my practice by one species”.

There was little fluff or Aunt Jemima’s on the next helping entitled “I didn’t go into medicine for that!” It was cynicism — raw and gritty. In a nutshell, the author was upset with doctors who have sold out to big pharmaceutical companies. You know the scene: Come have an expensive filet mignon while Dr. Benedict Arnold tells you how great a mediocre drug really is. I liked this article the best — no punches pulled. However, the unspoken message remained unsaid: Doctors today are forced (by falling reimbursements and relentless overhead) to seek alternate income streams.

I know what you’re thinking: In the dictionary under curmudgeon, it says ‘see Johnson’. But I sure feel better getting this off my chest. I’d write more but I have an office full of needy patients and a four hour surgery to follow. I jumped out of bed this morning,

22 San Antonio Medicine • September 2016

not because of my enthusiasm for medicine — I had to pee real bad.

So — why did I come into work today: private school tuition, mortgage, *!*## pool repairs? Oh, alright — there was a smidge of altruism…maybe…just a little.

I almost forgot; the title of the article. Why did I become a doctor?

You ready for this? Dr. Zhivago. Saw it twice in the theatre — long before VCR’s. If this is what doctors do and nurses look like Julie Christie then sign me up.

Now that’s all-true-ism.

Robert G. Johnson, MD, is an orthopaedic surgeon, a BCMS member and a frequent contributor to San Antonio Medicine.

DRASTICALLY REDUCED

SOLD

FRESH LOOK

DREAM RANCH!

SOLD

FEATURE: TOSA CHIEF RETIRES

TOSA’s Chief Retires after 19 Years of Service Courtesy of TOSA

Patrick J. Giordano, Chief Executive Officer of Texas Organ Sharing Alliance (TOSA) since 1996, has led the organization through many changes resulting in the ongoing evolution of the federally-designated organ procurement organization covering 56 counties and serving more than six million people in Central and South Texas. This includes San Antonio, Austin, the Rio Grande Valley, Laredo, Waco and San Angelo.

Giordano started out as a hospital volunteer in high school, then trained and worked as a respiratory therapist for eight years, including two years at Walter Reed Army Medical Center when he enlisted in the U.S. Army in the early 1970s.

He earned a Master’s Degree in Hospital and Health Care Administration at the University of Minnesota, followed by multiple executive roles in Southern and Northern California, Kansas City, Oklahoma City and St. Louis before coming to TOSA. After his 19 years of service, focused upon the advancement of lifesaving efforts of TOSA and organ donation in Texas, Giordano has announced his retirement. Before his departure, Giordano discussed the changes, challenges and joys of his work.

24 San Antonio Medicine • September 2016

What drew your interest in working for TOSA, formally the South Texas Organ Bank (STOB)?

The position with the then South Texas Organ Bank represented a compelling area of interest for me professionally with a more focused mission in a field undergoing significant change. I was drawn to those challenges.

What are the biggest changes you’ve seen in donation in your time at TOSA? We basically changed everything about every component and aspect of the organization. In 1997, as well as in today’s world, we had some very heavy regulatory requirements regarding the numbers of

FEATURE: TOSA CHIEF RETIRES donors we needed within very short time frames for compliance. If these metrics were not met within the time frames required, we would have been closed down by the federal government. As a result, not many in Texas or in the field at large thought we had any possible chance for survival. So, as you can imagine, correctly defining problems, relatively fast decision making, acquiring resources and recruiting the right people had to be achieved relatively quickly. This all had to be done in a way to enable us to implement needed changes in time to impact our results.

What, in your tenure, has been the organization’s greatest success?

Watching the organization’s progress in working with hospitals to make donation a normal part of the continuum of care. The key part of this was developing protocols and processes to assure that potential donor cases are evaluated in a timely and appropriate manner. As a result of that success and with the excellent clinical and leadership staff we have assembled at TOSA, this allowed us to improve more processes and eventually become regarded as one of the most productive organizations of our kind in the nation. Many of our practices, how we developed our internal culture, the way we use metrics, and our quality improvement processes are shared in the field and have been cited by national organizations. The bottom line is more organs for more patients on the transplant waiting list.

how has working with donor families and recipient volunteers affected or influenced your work?

They are a blessing beyond description, and we could not do what we do without them. The emotions and life-changing nature of losing a loved one and then knowing they saved someone’s life is an incredible life circumstance. Many people may want to move on after the death of a loved one, which is certainly understandable, but these donor families want to stay involved through the gift of life their loved one gave. They want to celebrate the life which was enabled through the life of their loved one. Together, with the special and lasting gratitude of organ recipients, the volunteers have stories of commitment, survival, and the impact of that gift which are truly inspiring.

What message do you have for TOSA donor families and to the patients on the transplant waiting list in Central & South Texas?

That they are the reason why TOSA is here and why the people who work at TOSA are so committed to providing the best family care possible during such a difficult time for the donor families. We are eternally grateful for their support of their loved one’s gift of life of organ donation.

The patients on the waiting list are the ultimate beneficiary of this gift and we are working 24/7 to see that every potential donor opportunity results in donation. We never, ever stop and we want to see them out of the hospital, healthy and with their families and living their lives. Life is time and we want to play our part in extending their time here.

What would you say to those who are pondering the decision to register as an organ, eye and tissue donor?

It is as easy as ever to register with the Donate Life Texas donor registry. So please do register. In the event you are in a position to donate, you have done a great service to your family by clarifying your wishes with them during a difficult time, and you will save lives.

What are the biggest challenges OPOs face moving forward and what advice would you give them?

There really isn’t enough to room to cover it all in this article, but suffice it to say, and this goes not just for OPOs, but all healthcare organizations: don’t be afraid to challenge the status quo, innovate, hire the best people you can and most importantly treat them with respect. I cannot overemphasize the critical need for healthcare leadership to create and sustain a truly respectful working environment.

In addition, organizations consist of people and people have to keep learning and changing and adapting and then the organization, through this internal culture, will keep operating under the ideals we value and will attain the goals to which we dedicate our work.

OPOs also need to remember that we and the transplant community are a subset of a larger, more encompassing health care delivery system. We need to be cognizant of where we fit in and how well people in healthcare and out in the community, really understand what we do. The communication burden is on us and the more we are communicating and garnering greater understanding, the more support we will see and therefore more donation will happen.

It has truly been a privilege to be part of this great organization and its cause and mission over the past nearly 20 years. I look forward to following TOSA’s continued success and many contributions to the health of our community and beyond.

The Texas Organ Sharing Alliance (TOSA) is one of only 58 non-profit 501(c)(3), independent, federally-designated Organ Procurement Organizations (OPOs) in the United States dedicated to educating and providing organ donation and recovery services to families wishing to donate and to those waiting for a life-saving organ transplant. visit us at www.bcms.org

25

BUSINESS

ASK YOUR CPA

BUSINESS BASICS FOR A MEDICAL PRACTICE

By Jim P. Rice, CPA Shareholder

After 39 years in practice as a certified public accountant, I compiled a list of some business basics for physician practices.

To maximize your profitability, these protocols should be reviewed at least once a year.

Are you doing everything you can to generate new patients? Are you asking other physicians to whom you refer business for referrals?

Are you reassessing procedures that you send to other physicians to see if you could do those services yourself? Is your current location the best place to grow your practice? Are you re-connecting with former patients? Are you re-negotiating contracts with insurance companies or joining a group to re-negotiate on a larger scale? Are you building a marketing brand for your practice?

• Screen patient scheduling to include easily treatable problems between already scheduled appointments. Successful practices derive approximately 20 percent of their revenue from ancillary services.

26 San Antonio Medicine • September 2016

• Make a comprehensive assessment of your expenses and ways to curtail them.

• Have you asked your employees for ideas in this area? Are you having suppliers rebid against other competitors? What about office-sharing with other physicians? Are long-tenured employees overpaid and working less?

• Reassess your employees.

• Do you obtain and retain exceptional employees, and pay them well? You should personally interview all candidates. One of the biggest errors physicians make is putting the wrong people in important positions. A front desk employee can make a life-long

BUSINESS patient or a one-time patient. Train that person well. Finding a great office manager is absolutely critical to your success. Engage an experienced medical consultant to help you find that manager.

• Consider an office retreat with your key people. Regroup and assess everything — away from the office. Take time to prepare for the retreat with an experienced facilitator.

• Clarify stakeholder’s roles. Have all agreements with key employees and fellow owners of the practice clearly written and executed, including buy-sell decisions, employment terms and disability insurance.

• Prevent insider theft and fraud. Embezzlement is very high in medical practices. Reassess your internal controls and the segregation of cash handling duties. Have the bank statements come to your home first and scan the contents each month before giving them to the bookkeeper. Let all your employees know that you are taking an active role in this area. Consider engaging your CPA or medical consultant to review your controls if you strongly suspect a problem.

• Understand your financial statements. Do you know how to interpret the medical practice’s financial data, including the financial statements? Do you get timely financial statements and do you review them timely? Are the financial statements comparable to

the same period for last year and do the financial statements clearly show you the dollars that go to the bottom line for your benefit, after all expenses? Are your patient-receivable balances increasing or decreasing, and why? Ask your CPA to help you and request a statement of cash flow.

• Reassess your choice of advisors. Do you have an experienced CPA, medical consultant, banker and attorney?

• Review your choice of taxable entity for IRS reporting purposes.

Often, an “S” corporation is the most favorable choice, especially with multiple providers • Reexamine the practice’s retirement plan status. Is the retirement plan designed to benefit the key employees more so than others?

Certain types of retirement plans can accomplish this.

Jim Rice, CPA is a shareholder at Sol Schwartz & Associates, P.C. (jprice@ssacpa.com). He has 39 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. Contact Jim at (210) 384-8000 Ext. 112.

visit us at www.bcms.org

27

BUSINESS

Keep your Umbrella Handy From Aspect Wealth Management

In 2015, the U.S. had a record 10.1 million millionaires, up from 9.6 million in 2013. While an increase in personal wealth may bring greater financial flexibility; it may also bring greater liability. Individuals with high net worth, or those who are perceived to have high net worth, may be more likely to be sued. And personal injury claims can reach into the millions.

Umbrella liability insurance is designed to put an extra layer of protection between your assets and a potential lawsuit. It provides coverage over and above existing automobile and homeowner’s insurance limits.

For example, imagine your teenage son borrows your car and gets in an accident, seriously injuring the other driver. The accident results in a lawsuit and a $1 million judgment against you. If your car insurance policy has a liability limit of $500,000, that much should be covered. If you have additional umbrella liability coverage, your policy can be designed to kick in and cover the rest. Without umbrella coverage, you may be responsible for paying the other $500,000 out of pocket, which could mean liquidating assets, losing the equity in your home, or even having your wages garnished.

Umbrella liability insurance is usually sold in increments of $1 million and generally costs just a few hundred dollars a year. It typically covers a broad range of scenarios including bodily injuries, property damage caused by you or a member of your household, even libel, slander, false arrest, and defamation of character.

Deciding whether liability coverage is right for you may be a question of lifestyle. You might consider buying a policy if you: • • • • • • • •

Entertain frequently and serve your guests alcohol Operate a business out of your home Give interviews that may be published Employ uninsured workers on your property Drive a lot of miles or have teenage drivers Live in a manner that gives the appearance of wealth Have a dog, especially if the breed is known to be aggressive Own jet skis, a boat, motorcycles, or snowmobiles

Even if you don’t yet have a tent in the millionaire camp, you may want to consider the benefits of liability insurance. You don’t have to be a millionaire to be sued for a million dollars. Anyone who is carefully building a financial portfolio may want to limit their exposure to risk. Umbrella liability can be a fairly inexpensive way to help shelter current assets and future income from the unexpected.

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 liability insurance, please contact Michael Clark or Jeff Allison at 210-268-1500.

NOTE This is a simplified description of coverage. All statements made are subject to the provisions, exclusions, conditions and limitations of applicable insurance policies. Please refer to actual policy documents for complete details regarding coverage.

28 San Antonio Medicine • September 2016

UTHSCSA DEAN’S MESSAGE

UT SCHOOL OF MEDICINE:

FALL UPDATE

By Francisco González-Scarano, MD

MATCh DAY RESULTS As is our tradition, on March 2, 2016, our graduating students met at the well-known John T. Floore’s Store in Helotes, Texas with their families and loved ones to learn their match results. Below are the number of students who matched to the key specialties.

Anesthesiology (18) Dermatology (5) Emergency Medicine (20) Family Medicine (10) Internal Medicine (31) Neurological Surgery (2) Neurology (8) Obstetrics and Gynecology (15) Ophthalmology (1) Oral Maxiollofacial Surgery (2) Orthopaedic Surgery (9) Otolaryngology (2) Pathology (5) Pediatrics (24) Physical Medicine and Rehabilitation (1) Psychiatry (13) Radiology Diagnostic (8)

WhITE COAT CEREMONY & FAME STUDENTS On July 23, 2016, the incoming class (2020) received their white coats to signify the beginning of their professional career and the start of medical school classes. A total of 223 students were matriculated. For the first time, 25 of them came from the University of Texas at San Antonio (UTSA), as part of the joint UTSA-UTHSCSA Facilitated Acceptance to Medical Education (FAME) Program. This program is a response to the UT System’s request to develop and pilot programs for accelerating the education of physicians. The seven-year curriculum leads to the award of both baccalaureate and Doctor of Medicine degrees. It is a very rigorous program intended help address the growing healthcare needs of Texas and to provide students who are committed to a career in medicine at a relatively early point in their education the opportunity to do so at a faster pace.

EVENTS health Science Center President’s gala – Sept 24 The UT Health Science Center will honor Maj. Gen. (USA ret.)

Joe and Patty Robles at the annual President’s Gala–An Evening of Tribute on Saturday, Sept. 24, at 6:30pm at the Grand Hyatt San Antonio. Honorary chairs for this event are UT System Chancellor William McRaven and his wife, Georgeann. Proceeds from the gala will establish an endowment in honor of Joe and Patty Robles for the Military Health Institute. Contact the office of Institutional Development for tickets at (210) 567-2028.

Radiation Oncology (1) Surgery (12)

Alumni Weekend is October 14-15

Surgery Preliminary (8)

The 2016 Alumni Reunion will be a weekend of events, activities, and fun for the whole family in San Antonio. For more information, please call the Office of Alumni Relations at (210) 567-0242 or email medalumni@uthscsa.edu.

Thoracic Surgery (1) Urology (3) Fifty-one percent matched to Texas residency programs, and 44 students (22%) will stay in San Antonio for graduate training. In the important measure of proportion of students who matched to primary care programs, we counted 82 (41%).

30 San Antonio Medicine • September 2016

AWARDS AND PUBLICATIONS White house Recognizes hepatitis Work The Center for Research to Advance Community Health (ReACH) was recognized in May of this year by the White House

UTHSCSA DEAN’S MESSAGE at its 2016 National Hepatitis Testing Day observance in Washington, D.C. The White House acknowledged the ReACH Center’s initiatives to screen, evaluate and cure chronic hepatitis C virus infection in diverse health care settings serving low-income populations across South Texas.

The Viral Hepatitis Testing Recognition Award given by the U.S. Department of Health and Human Services (HHS) recognizes four ReACH projects that have been conducted since 2012 with funding from multiple federal and state agencies. Dr. Barbara J. Turner, director of the ReACH Center, accepted the honor at the Eisenhower Executive Office Building on the grounds of the White House.

Patient-Centered home Recognition In January, UT Medicine received Patient-Centered Medical Home (PCMH) Recognition from the National Committee for Quality Assurance (NCQA). UT Medicine was cited for our use of evidence-based, patient-centered processes that focus on highly coordinated care and long-term, participative relationships. A patientcentered medical home is a model of health care that places the patient at the center, served by a primary care physician and a health care team who take into account the totality of the individual’s needs. This may include the patient’s family and job situation, health history and spiritual needs. The team can include many other clinicians, including physician specialists, nurses, physical therapists, nurse educators, pharmacists, psychologists and occupational therapists. The NCQA is a private, nonprofit organization dedicated to improving health care quality.

New Software Reveals Viral Mechanism In the February issue of the journal Nature, scientists showed the structure of a protein complex that enables some viruses (similar to HIV) insert their genetic information into cells and permanently infect them. To confirm the discovery, the team of scientists turned to a UltraScan©, a unique software system developed by Borries Demeler, Ph.D., Professor of the Department of Biochemistry. The software delivers sophisticated biological metrics derived from a time-honored scientific process called analytical ultracentrifugation.

Dr. Demeler is a co-author on the paper with researchers from the Salk Institute and Harvard Medical School.

Cardiac Rhythm Warning Researcher Marc Feldman, M.D., Director of Research and Professor of Cardiology, as well as other UT colleagues, patented a technology to help pacemakers better measure cardiac performance.

Their invention, which is being commercialized by Admittance Technologies, will warn patients and doctors of heart problems and prevent pacemakers from activating prematurely. Early warnings will enable cardiologists to adjust a patient’s medications to avoid hos-

pitalizations and ultimately reduce mortality rates from heart failure and arrhythmias.

Dr. Feldman’s research and other work like his is part of the reason the UT System was ranked 4th among the Top 100 Worldwide Universities Granted U.S. Utility Patent Ranking for 2015. The ranking — published by the National Academy of Inventors and Intellectual Property Owners Association — uses data from the U.S. Patent and Trademark Office to highlight the important role patents play in advancing university research and innovation.

Brain Research grant Bess Frost, Ph.D., Assistant Professor of Cellular and Structural Biology, and Hye Young Lee, Ph.D., Assistant Professor of Physiology, were recently awarded a $150,000 grant for brain research from the San Antonio Life Sciences Institute (SALSI). The School of Medicine and UT San Antonio (UTSA) are working collaboratively in the San Antonio Life Sciences Institute, which was established in 2003. Dr. Frost’s expertise is in nucleoplasmic reticulum, the tubular invaginations of the nuclear envelope at the cellular level and the role it plays in Alzheimer’s disease. Dr. Hye Young Lee’s expertise is in using molecular techniques to study neurodevelopmental disorders.

Parkinson’s Disease Researchers in the School’s Barshop Institute for aging and Longevity Studies have described changes in Parkinson’s-affected cells at various stages of the disease, long before any symptoms are evident. The changes are the basis of an article in the April issue of the Journal of Neuroscience. Senior author is Michael Beckstead, Ph.D., Assistant Professor of Physiology. The ultimate goal of the research is a drug to arrest the disease and lengthen the time patients with Parkinson’s can lead healthy, productive lives.

BRCA1 gene Function In a new study published in Nature Communications, researchers from the Cancer Therapy & Research Center (CTRC) provide deeper insight into how the BRCA1 gene functions in normal breast tissue and how its loss results in breast cancer. BRCA1 is known to suppress cancer by repairing breaks in DNA. Lead author Rong Li, Ph.D., a Professor of Molecular Medicine, found that BRCA1 also serves as a limiter or governor on a gene called COBRA1 that regulates breast cell growth.

Francisco González-Scarano Dean, School of Medicine Executive Vice President for Medical Affairs University of Texas Health Science Center San Antonio John P. Howe, III, MD, Distinguished Chair in Health Policy Professor of Neurology visit us at www.bcms.org

31

TMLT RISK MANAGEMENT

Delay in diagnosing cervical spine fracture

By TMLT Risk Management Department This closed claim study is based on an actual malpractice claim from TMLT. The case illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. The ultimate goal in presenting this case is to help physicians practice safe medicine. An attempt has been made to make the material less easy to identify. If you recognize your own claim, please be assured it is presented solely to emphasize the issues of the case.

Presentation and physician action A 79-year-old woman came to the emergency department (ED) of a large hospital after falling down a flight of stairs. The patient complained of pain in her head and neck. The ED physician noted abrasions, hematomas, swelling, contusions, and tenderness in the neck and upper back areas.

The ED physician ordered x-rays and a CT scan of the head. Radiologist A reviewed the films via teleradiology and read the results as negative. The patient was discharged with a diagnosis of head and neck pain, cervical strain, and scalp and forearm contusions. The patient was given a cervical collar.

The next morning Radiologist B over-read the films, and concluded that there was a small, non-displaced fracture involving the facets of C5-6 that was not well seen on the cervical spine images.

Radiologist B called the ED physician currently on duty, notifying him of the findings. After learning that the patient had not been admitted, Radiologist B suggested that someone from the ED notify the patient immediately.

An attempt was made to contact the patient, but without success.

Although the hospital employees were instructed to follow up, the patient was not contacted.

Three days later, the patient arrived at the same hospital by ambulance. She complained of pain and discomfort in her head and neck, and was beginning to develop numbness. While in the ED, it was determined that the patient had a cervical spinal fracture at the C5-6 level, which had been identified on the CT during the first ED visit. The patient was admitted, a neurosurgeon was consulted, and an MRI was scheduled for the next morning.

After returning to her room, the patient experienced a hypotensive episode and was given a bolus of IV fluids. The neurosurgeon’s physician assistant examined the patient and noted normal neurological

32 San Antonio Medicine • September 2016

findings. Surgery was scheduled in 3 days. However, later that afternoon the patient was unable to move her legs and was barely able to move her fingers. The neurosurgeon examined the patient that evening, noting a marked quadriparesis with more weakness in the lower extremities and a sensory loss across her upper chest. He proceeded to perform an emergent anterior cervical diskectomy with decompression at the C5-6 level. Although the surgery was performed without complications, the patient’s neurological condition did not improve and she remained paraplegic with profoundly weak upper extremities. She developed a pleural effusion and atelectasis in the left lung and problems with kidney function.

She was discharged 10 days later to a long-term rehabilitation facility. Her fine motor movement of the upper extremities was minimal, and deep tendon reflexes in her legs were absent. She had 0/5 muscle tone in the lower extremities and 3/5 muscle tone in the upper extremities. While at the rehab facility the patient suffered a number of complications, and a second cervical (C5-6) decompression was necessary. A PEG tube was placed after the patient suffered a CVA. Five weeks later, the patient died due to complications of blunt trauma to the neck, a cervical fracture at C5-6 resulting in traumatic quadriplegia, and complications of a CVA, pneumonia, and sepsis.

Allegations Lawsuits were filed against the ED physicians, the hospital, the neurosurgeon, and both radiologists. The allegations against the ED physicians included failure to properly determine the patient’s condition and failure to contact the patient and have her return to the hospital. Allegations against the hospital included failure to have policies and procedures in place to insure that the patient was contacted and told to return to the hospital. Allegations against the neurosurgeon involved delayed treatment.

The allegations against the radiologists involved failure to properly interpret the x-rays and CT scans from the initial ED visit and failure to properly communicate the correct results. The plaintiffs alleged that had Radiologist A made the correct diagnosis, timely and effective treatment could have been initiated earlier.

Legal implications Given the initial missed cervical fracture, it was difficult to find an expert who was supportive of Radiologist A’s actions. However

TMLT RISK MANAGEMENT

one expert stated that although diagnosis of the fracture was missed, usually 4% of radiological studies are misread, and this is why there is an over-reading process. The findings provided by Radiologist B were reported in sufficient time for the ED staff to contact the patient and have her return to the hospital.

One physician reviewer noted that it was more than 100 hours after the initial fall that the patient developed quadriplegia. He believed an additional injury or event may have been a causative factor.

Disposition Given the difficulty in finding supportive experts, the case against Radiologist A was settled. The hospital and neurosurgeon also settled their cases. The lawsuit against the second radiologist was dropped, and the outcome of the cases against the ED physicians is unknown.

Risk management considerations When several physicians are involved in a single patient’s care, there is greater risk for missed communication among the professionals or with the patient. In this case there seemed to be a chain reaction of missed opportunities initiated when the initial diagnosis of the cer-

vical fracture was misread. Documentation of attempts to communicate the findings to another physician or the patient may have assisted in the defense of this case.

While after-hours teleradiology is standard practice in health care today, a missed diagnosis may have far reaching implications, especially for decisions about patient care in the ED. Radiologists who provide interpretive services from a location other than the hospital where the patient is being treated have unique responsibilities to practice prudently and cautiously, as the effect of injuries may be progressive in nature.

The information and opinions in this article should not be used or referred to as primary legal sources nor construed as establishing medical standards of care for the purposes of litigation, including expert testimony. The standard of care is dependent upon the particular facts and circumstances of each individual case and no generalization can be made that would apply to all cases. The information presented should be used as a resource, selected and adapted with the advice of your attorney. It is distributed with the understanding that neither Texas Medical Liability Trust nor Texas Medical Insurance Company is engaged in rendering legal services. Š Copyright 2012 TMLT.

BUSINESS OF MEDICINE

Value-Based health Care

By Joseph P. Gonzales, MHA, LFACHE

When one thinks about value with respect to health care, it can be part of a line of thought with respect to perspective. Is the perceived value based upon the perspective of the patient, the provider, or the payer? This article will explore various aspects of value-based health care and its intent is to provide some points of discussion for physicians, patients, and insurers.

What Is Value in health Care?

In an article written by Michael E. Porter in the New England Journal of Medicine, Dec. 23, 2010, the discussion of Value in Health Care identified that “…In any field, improving performance and accountability depends on having a shared goal that unites the interests and activities of all stakeholders. In health care, however, stakeholders (limited in this article to patients, providers, and insurers) have myriad, often conflicting goals, including access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction.

Lack of clarity about goals has led to divergent approaches, gaming of the system, and slow progress in performance improvement. Achieving high value for patients must become the overarching goal of health care delivery.”

In Dr. Porter’s discussion, value is defined as the health outcomes achieved per dollar spent. This goal is what matters for patients and unites the interests of all participants in the system. If value improves, patients, payers, and providers can all benefit while the economic sustainability of the health care system increases.

Value can be framed by rigorous, disciplined measurement and

34 San Antonio Medicine • September 2016

improvement of value is the best way to measure system improvement. This all seems understandable, yet “value in health care” seems to escape the ability of all people concerned to define, much less measure and understand.

Value should always be defined around the recipient of care, the patient, and in a well-functioning health care system, the creation of value for patients should determine the rewards for others (providers and insurers) in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. This is the challenge of going from a fee-based system to a value-based system.

For any medical condition, no single outcome captures the results of care. Cost, the equation’s denominator, refers to the total costs of the full cycle of care for the patient’s medical condition, not the cost of individual services. To reduce cost, the best approach is often to spend more on some services to reduce the need for others.

Dr. Porter further opines that the proper unit for measuring value should encompass all services or activities that jointly determine success in meeting a set of patient needs. These needs are

BUSINESS OF MEDICINE

determined by the patient’s medical condition, defined as an interrelated set of medical circumstances that are best addressed in an integrated way. For primary and preventive care, value should be measured for defined patient groups with similar needs. Patient populations requiring different groupings of primary and preventive care services might include, for example, healthy children, healthy adults, patients with a single chronic disease, frail elderly people, and patients with multiple chronic conditions.

The current organizational structure and information systems of health care delivery make it challenging to measure (and deliver) value. Thus, most providers fail to do so. Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes. For example, current measures cover a single department (too narrow to be relevant to patients) or outcomes for a whole hospital, such as infection rates (too broad to be relevant to patients). Or they measure what is billed, even though current reimbursement practices are misaligned with value. Similarly, costs are measured for departments or billing units rather than for the full care cycle over which value is determined. Faulty organizational structure also helps explain why physicians fail to accept joint responsibility for outcomes, blaming lack of control over “outside” actors involved in care (even those in the same hospital) and patients’ compliance.

Today, health care organizations measure and accumulate costs around departments, physician specialties, discrete service areas, and line items such as drugs and supplies — a reflection of the organization and financing of care. Costs, like outcomes, should instead be measured around the patient. Measuring the total costs over a patient’s entire care cycle and weighing them against outcomes will enable truly structural cost reduction, through steps such as reallocation of spending among types of services, elimination of non–value-adding services, better use of capacity, shortening of cycle time, provision of services in the appropriate settings, and so on.

Other Perspectives According to a website of “Wellcentive” (a company that has driven quality improvement, revenue growth, and business transformation for providers, health systems, employers, and payers transitioning to value-based care) “…Value-based care is the intersection of cost and quality. Value-based initiatives shift the care delivery focus from volume to value and redefine financial incentives toward reduced costs. In this model, physicians must think about the entire patient experience among all care settings and be-

tween episodic visits. From a cost perspective, the total cost of care encompasses all spending for the patient — and the patient population as a whole — grouped, benchmarked and analyzed by condition. As the provider mindset shifts to address this model, taking the appropriate steps in terms of patient engagement, technology and workflow are the key first steps to value-based success.”

Another company, Dartmouth-Hitchcock, discusses valuebased care as follows: “…we talk about basing health care on “value, not volume.” What does that mean? In the current feefor-service model of reimbursing providers for health care, physicians and organizations have incentives to ‘do” more. The more tests you order, patients you see, procedures you do, the more money you will make.

One result of this payment based on volume model is enormous variation in rates of procedures and tests such as imaging and screening. As documented by The Dartmouth Atlas of Health Care, there is a 2.5-fold variation in Medicare spending nationally, even after adjusting for differences in local prices, age, race and underlying health of the population. This geographic variation in spending is unwarranted; patients who live in areas where Medicare spends more per capita are neither sicker than those who live in regions where Medicare spends less, nor do they prefer more care. Perhaps most surprising, they show no evidence of better health outcomes.

One way of addressing this variation — and giving patients the care they want and need — is to move to a reimbursement system that is value-based. Dartmouth-Hitchcock speaks of it as “the value equation”: Quality over Cost over Time. For patients, this means safe, appropriate, and effective care with lasting results, at reasonable cost. For providers, it means employing evidence-based medicine and proven treatments and techniques that take into account the patients’ wishes and preferences.

A critical component of understanding value is measurement.

How can we know what works unless we measure our results and track them over time? Any patient considering a procedure should be able to know from their physician what it will cost and what his or her results will be, with firm data, from cost performing that procedure. Without that data, patients lack the tools to make informed choices. We would not accept this absence of information when we buy a car or dishwasher or any other kind of product or service; why should it be acceptable in health care?

A focus of health reform has been to more closely track value measures such as complications, hospital-acquired infections, and readmissions. For example, hospitals now face financial penalties if their rate of readmissions is too high. continued on page 36 visit us at www.bcms.org

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BUSINESS OF MEDICINE continued from page 35

What’s involved in this approach to healthcare?

TEaM TrEaTMENT Organizing care teams of clinical and non-clinical staff under a value-based delivery sets a solid foundation for a value-based setting. Teams track patients throughout their care cycle, and establish a tailored process for patient outreach and engagement. By considering the patient’s experience beyond the office, care teams can take a longitudinal approach to care delivery to meet valuebased care delivery targets.

TEchNoloGy coNSiDEraTioNS Managing the overall health and care delivery for a patient population requires an effective technology solution to effectively collect, aggregate, and analyze patient data. In addition to aiding in predictive modeling and implementing evidence-based care plans, collecting clean, quality data helps strengthen a provider’s reporting to ensure they receive appropriate payments and incentives — while avoiding costly penalties.

36 San Antonio Medicine • September 2016

WorkFloW ThouGhTS Establishing effective clinical workflows — both at the micro and macro levels — ensures clear lines of responsibility, establishes best practices for effectively collecting and reporting on required data, and understanding the comprehensive care requirements for patients and patient populations.

Conclusion Although there are many factors to be considered in the overall discussion concerning a “value-based healthcare system,” keeping the patient as the central focus will be key to the overall success of such a system.

Joseph P. (Joe) Gonzales is an Adjunct Faculty member with UTSA. He has taught in the MBA Program, Business of Healthcare Track. Joe is a Life Fellow in the American College of Healthcare Executives, and has years of experience in healthcare as a hospital administrator in the Army, as CEO of a county hospital in rural Florida, and as a consultant with Deloitte Consulting in DoD and commercial healthcare projects.

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.”

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=kwe qi3TelO8 "Serving to heal, Honored to serve"

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”

BANKINg

BBVa compass (HHHH 10k Platinum 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”

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.

Chris Sherman 210-247-2978 csherman@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

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 Bank-

San 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

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

continued on page 38

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BcMS circlE oF FriENDS SErVicES DirEcTory continued from page 37 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

38 San Antonio Medicine • September 2016

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.”

ELECTRONIC MEDICAL RECORDS

Greenway health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency.

Regional Sales Manager Jason Siegel 512-657-1259 Jason.Siegel@greenwayhealth.com www.greenwayhealth.com

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!”

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 www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”

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”

BcMS circlE oF FriENDS SErVicES DirEcTory hIPAA/MANAgED IT/VOIP/SECURITY

hill country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries.

Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations.

Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

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.” 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) 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 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

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 long-

last 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.

INSURANCE

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.”

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

SWBc (HHH Gold 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 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 catto & catto (HH Silver Sponsor) Providing insurance, employee 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

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BcMS circlE oF FriENDS SErVicES DirEcTory continued from page 39

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

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) 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

40 San Antonio Medicine • September 2016

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 George Gonzales 210-582-9536 george.gonzales@twcable.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 ‘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

BcMS circlE oF FriENDS SErVicES DirEcTory 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”

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.”

PAYROLL SERVICES

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”

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.”

SWBc (HHH Gold 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 Working together to help our clients achieve their business objectives.

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

REAL ESTATE/ COMMERCIAL

robbie casey commercial realty (HHH Gold Sponsor) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done.

Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com

REAL ESTATE/RESIDENTIAL

roslyn casey realty (HHH Gold Sponsor) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key”

kuper Sotheby's international realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge – exceptional results.

Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”

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

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.”

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

visit us at www.bcms.org

41

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

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

Esther Luna 210-690-0700

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

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

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Sandy Small 210-341-8841

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

James Cole 800-611-0176

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

AUTO REVIEW

2016 Lexus GS-F

By Steve Schutz, MD The Germans have the upper hand in the U.S. luxury car wars these days. When it comes to sales volume, Mercedes is first, BMW second, and Audi is fourth and moving rapidly toward possibly taking over the number three spot from former number one, Lexus. And don’t forget Porsche, which is riding a wave of success driven by their two popular SUVs, the Cayenne and Macan.

So Lexus is doomed right? Not by a long shot. They actually had a big 2015, with 344,601 sales, a 10.6 percent increase over 2014, and they’re poised for a similarly strong 2016. A broad lineup of SUVs and crossovers — including the best-selling luxury vehicle on the market, the RX crossover — is the main reason Lexus can’t be counted out, but unbeatable build quality, robust resale value, and excellent customer service certainly help.

44 San Antonio Medicine • September 2016

To their credit, Lexus realized years ago that those bonafides were important but not sufficient to hold the wandering eyes of customers, who have noticed that the Germans (and the Americans and Brits) have also learned how to make reliable vehicles that don’t creak and rattle. So Lexus changed, first with more assertive exterior styling, then with better tech, and now with improved powertrains.

OMG finally! While Mercedes/BMW/ Audi/Porsche have been wowing us for years with turbos, double-clutch transmissions, diesels, hybrids, and even more turbos, Lexus countered with, umm... more hybrids, but that’s kind of it. At the exact time that gasoline became cheaper than bottled water.

Not good timing.

Naturally, Lexus knows all this and are working diligently to correct the problem.

Two years ago they introduced a 2.0 liter

turbo four-cylinder engine, a 3.0 turbo V6 is rumored, and they’ve launched two BMW M/Mercedes AMG-esque F cars, the RC-F coupe and GS-F sedan.

Thank you Lexus! We all understand that the Japanese, like the Americans and English, don’t have autobahns and therefore can’t really compete with the German manufacturers in that arena. But hey, give us something, which Lexus is now doing.

OK, on to the GS-F, which is a nice car but not really a direct BMW M5 or Mercedes E63 competitor. Why not? It has less horsepower — 467 versus 560 and 550, for the M5 and E63 respectively — and much less torque, resulting in slower 0-60 mph times (4.4 sec compared with 3.7 and 3.4 for the M5 and Merc). The reason for that discrepancy is that, instead of a cutting edge twin turbo V8, Lexus is going with a normally aspirated 5.0 liter V8 coupled with an

AUTO REVIEW

8-speed automatic transmission.

For the record, Lexus’ speed/quickness deficiency would be worse if it weren’t for the GS-F’s relatively low curb weight of 4034 lbs, which is less than the 4390 and 4387 lbs that the M5 and E63 weigh.

In the real world, I don’t think those performance differences matter. To borrow a phrase from Coach Greg Popovich, in everyday situations the GS-F drives the way an athletic luxury sedan should, but with a big dab of Nasty, which is what most people are looking for in this segment. Accelerating quickly onto the freeway, tackling a fast curve in the country with confidence, and hustling safely to the hospital when you’re needed — that all matters. And the GS-F does those things well, and it does them with attitude.

It sounds great while it’s doing it, too. As most readers know, turbochargers are the enemy of exhaust sound, and there really is nothing like the howl of a normally aspirated V8 as it approaches the redline. The aforementioned German super sedans are mighty vehicles that can outperform this Lexus, but they

don’t sound any better from behind the driver’s seat, and that’s a big plus for the GS-F. It’s probably worth noting that as fuel economy and emissions regulations continue to tighten, Lexus will almost certainly give the GS-F a smaller engine with a couple of turbochargers. I hope that doesn’t happen soon.

Not surprisingly, the GS-F looks a lot like more pedestrian GS models, which is to say understated except for the wow-look-at-that! grille. I can’t reconcile the totally anonymous rearend with the oh so extroverted face of the GS, but it’s not ugly either.

The inside of the GS-F is a nice place to be, with upscale materials and superb fitand-finish. Some of the upholstery and other trim pieces are brightly colored, giving GS-F owners a reminder that they bought something special, but otherwise it’s pretty standard Lexus fare.

Lexus’ ubiquitous Remote Touch user interface has been updated over the years, but it remains a step behind

Audi’s excellent MMI system, which remains the class benchmark.

The Lexus GS-F wasn’t born with a German spoon in its mouth, but it’s a legitimate alternative to the (faster) BMW M5 and Mercedes E63. Plus it has a wonderful exhaust sound that will make any drive more special.

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

45

THANK YOU

to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of August 26, 2016.

46 San Antonio Medicine • September 2016