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VOLUME 70 NO. 10
MEDICINE SAN ANTONIO
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San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.
OPIOID CRISIS
Opioids: The Reversal of the Pendulum By Brian Boies, MD ........................................14
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Editor: Mike W. Thomas Email: Mike.Thomas@bcms.org
Managing Long-term Opioid Therapy in Today’s Risk-Concious Climate By Maxim S. Eckmann, MD and Ameet Nagpal, MD, MS, M.Ed ........................18
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BCMS President’s Message ....................................................................................................8 BCMS Legislative News...................................................................................................................10 BCMS Alliance News .......................................................................................................................12 Financial Planning for a Special Needs Child By David K. Alvarez, CFP ............................................24 Feature: The Virtuous Mission: Exploring the Bioethical Obligation of Interprofessional Healthcare By Ammar Navid Saigal, MPH, MD Candidate (2018)..................................................26 Business: Ransomware: A Tale of Two Sites By David A. Schulz, CHP, CIPP ...................................29 BCMS News: Hurricane Harvey .......................................................................................................33 Physician Practices: WellMed Medical Group By Mike W. Thomas...................................................36 BCMS Circle of Friends Directory.....................................................................................................38 In the Driver’s Seat...........................................................................................................................42 Auto Review: 2017 Ford F-150 Raptor By Steve Schutz, MD .........................................................40
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San Antonio Medicine • October 2017
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative James E. Remkus, MD, Board of Censors Chair Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student
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San Antonio Medicine • October 2017
PRESIDENT’S MESSAGE
Hurricane Harvey/ Disaster Relief By Leah Jacobson, MD, 2017 BCMS President In light of the recent tragic events revolving around Hurricane Harvey, I decided to focus this article on the BCMS and physician involvement in the emergency operations. I cannot thank Dr. David Cohen, chair of the BCMS Emergency Preparedness Committee, and Melody Newsom, BCMS Chief Operations Officer and staff liaison for the committee, enough for their many hours of coordination and long days at the San Antonio Emergency Operations Center (EOC). Most of you may not be aware of this, but BCMS remains involved in ongoing efforts to plan for such events as Hurricane Harvey. It is imperative that all factions- police, fire, medical, etc., be ready to go when needed. A big thanks also goes out to all the BCMS members, physician non-members, nurses, and allied health professionals who quickly volunteered their services. Almost 500 people responded to our call for volunteers and assistance. BCMS, in combination with University Health System (UHS) and the military at SAMMC, were able to successfully staff three evacuee shelters on an around-the-clock basis. Another thanks has to go out to the Metropolitan Health Department staff for their support, and the firemen and policemen who offered their assistance in special circumstances. Many of the Gulf Coast evacuees that we saw in the shelters had multiple chronic medical conditions and had forgotten their medications. Many also just wanted someone to talk to or check on them- they would ask for tylenol or aspirin, an ice pack, a blood pressure or sugar check. At the Centennial shelter (where I volunteered) there was a large homeless population, and many of the evacuees had mental health issues. It was a very helpful addition to have volunteers from the Center for Health Care Services (CHCS) Crisis Care Center on-sight so quickly. If you are interested in getting more involved in these circumstances, you may join the BCMS Emergency Preparedness Committee and/or become a member of the Alamo Area Medical Reserve Corps (MRC) which is coordinated through the City of San Antonio's Metropolitan Health Department. The MRC is a partner program of Citizen Corps, a national network of volunteers dedicated to ensuring hometown security. Citizen Corps, along with the Corporation for National and Community Service, and the Peace Corps are all part of the President's USA Freedom Corps, which promotes volunteerism and service throughout the nation. MRC units are community-based and function as a locally-organized group of volunteers, medical professionals and others, who promote healthy living, prepare for and respond to emergencies. MRC volunteers supplement existing local emergency and public health 8
San Antonio Medicine • October 2017
resources. MRC volunteers include physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists. Other community members, such as interpreters, chaplains, office workers and legal advisors, can fill other vital support positions.
WHAT CAN MRC VOLUNTEERS DO? •
• • • • • •
Promote disease prevention, eg. distributing mosquito dunks to the community to prevent insect-borne diseases, such as Zika and West Nile viruses. Improve health literacy by distributing information at health fairs. Eliminate health disparities Enhance public health preparedness Assist local hospitals and health departments with surge personnel needs. Participate in mass prophylaxis, vaccination exercises and community disaster drills. Train with local emergency response partners.
HOW CAN THE MRC BENEFIT THE COMMUNITY? •
• • • • •
Bolster public health and emergency response infrastructures by providing supplemental personnel Enable communities to meet specific health needs Allow local communities more autonomy, less reliance on state and national resources Give community members the opportunity to participate in developing strategies to make their communities healthier and safer Provide mechanisms for information sharing and coordination between all partner organizations Provide a dialogue between emergency management and public health agencies.
Register with the Medical Reserve Corps at: www.sanantonio.gov/Health/EmergencyManagement/Volunteer Education/MedicalReserveCorps.
We hope that we will not experience such an event any time in the near future, but if so, I know that San Antonio/Bexar County and BCMS are ready to meet the challenge. Please think seriously about how or what you can do to help make a difference. Sincerely, Leah H. Jacobson, MD, 2017 BCMS President
BCMS LEGISLATIVE NEWS
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San Antonio Medicine • October 2017
BCMS ALLIANCE NEWS
BCMSA Centennial Celebration and Scholarship Fundraiser!
The Bexar County Medical Society Alliance is excited to celebrate its 100th anniversary in October 2017! Our centennial marks 100 years of giving back to our community and providing strength and support to the medical family. Every year, the BCMS Alliance, in conjunction with the BCMS Foundation, provides generous scholarship monies to exemplary students in Bexar County. As we celebrate 100 years, please join us for our Centennial Celebration Allied Health Scholarship Fundraiser, which will help fund scholarships for students preparing for careers in an allied health field. This “party for a cause” will take place on Oct. 21, 2017 at 6 p.m. at Neiman Marcus La Cantera. Our “birthday party” will be complete with food, champagne, a mixologist, live music, an overall good time, and of course, dessert! Through community sponsors, including our Presenting Sponsor CHRISTUS Santa Rosa Health System, and ticket sales, we are planning for a very profitable event that will fund our ability to give thousands of dollars in scholarships to well-deserving allied health students in Bexar County! All BCMS and BCMSA members and their guests are invited to join us on the night of October 21st! Tickets are $100 per person, and 100 percent of all ticket sales will fund scholarships. For tickets, please contact our Centennial Celebration Chair Rebecca Christopherson (cell: 210-387-9544) or simply write a check for the number of tickets you would like with a note of the attendees. Send the check made out to the BCMS Foundation (BCMSA Centennial in Memo Line) to Rebecca at 11323 Caliza Crest, Boerne, Texas 78006. I cannot wait to celebrate 100 years of giving back to the community and friendship between medical families with you! All the best, Lori Boies 2017 Bexar County Medical Society Alliance President bcmsalliance@bcms-alliance.org
THANK YOU TO OUR SPONSORS
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San Antonio Medicine • October 2017
Find us on the web:
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www.bcmsalliance.org
OPIOID CRISIS
The Reversal of the Pendulum By Brian Boies, MD
Opioid Addiction:
Opioids are mu receptor agonists, meaning that they offer pain relief by primarily binding to those receptors in the brain and spinal cord. These same receptors, however, also exists in parts of the brain that are not directly related to pain perception, namely the reward centers that, when activated, are responsible for the euphoria of the opioid class of medications (1). This euphoric effect drives human behavior with continued use of the drug though classic conditioning mechanisms (2). Tolerance of the analgesic and euphoric effects develops relatively quickly, requiring more frequent dosing intervals and increased doses than previously needed, but other aspects of tolerance develop more slowly, such as respiratory depression, making a rapid dose escalation a dangerous proposition (3,4). In time, patients develop physical dependence with opioids, experiencing withdrawal symptoms such as nausea, vomiting, chills, and agitation if abruptly decreased or stopped, or if a mu receptor antagonist such as naloxone is administered. Contrast this to addiction. Addiction is more of a disease process, with compulsive, continued use despite harm, cravings, and reduction of social, occupational, or recreational activities (5). This occurs in a smaller percentage of people who are exposed to opioids, but can last much longer than tolerance or physical dependence — on the order of months to years. Genetics may play an important role 14
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in developing addiction to opioids; other contributory factors include, but are not limited to, age and social situations. Addiction, tolerance, and dependence together can lead to patients taking increasingly higher dosages of opioids in a quickly escalating pattern. The eventual result is commonly overdose. Opioid overdoses were the direct cause of death in over 28,000 people in 2014, with over half of those deaths being from prescription opioids (6,7). Furthermore, in 2015, the number rose to over 33,000 people in just that year alone (8). Statistically, that correlates to 91 people a day that die from opioid overdose, and many of those are from physician written prescriptions. Physicians have played a substantial role in this epidemic; how did we get here?
Back to the Beginning:
Alleviating pain is a common goal amongst the majority of physicians. Considering that pain complaints are one of the top reasons for primary care physician visits across the country, and with more than 30 percent of Americans having some form of chronic or acute pain (9), it’s understandable how the opioid epidemic started. The acute pain relieving properties of opium and its derivatives have been well known for millennia, just as the addictive potential of these drugs has been well documented throughout history and extending
OPIOID CRISIS even into relatively modern times as seen during the Opium Wars in China and with the rates of morphine addiction after the Civil War and World War I. Because of this well-known risk of addiction, physicians trained well into the 1970s and 1980s were taught to avoid these medications for chronic non-cancer pain if possible and to use the lowest doses needed when required. This training changed in the 1990s. In 1995, Dr. James Campbell presented, in his presidential address to the American Pain Society (APS), the idea that pain should be evaluated as a vital sign. This dramatically changed the way health care providers, and patients, thought about pain. Pain became the fifth vital sign — being elevated from a noteworthy concern, to the ranks of objective signs, such as heart rate, blood pressure, respiratory rate, and temperature. One can see the problem — pain, defined through the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” (10) a purely subjective experience, became a focus for providers everywhere. Maybe this alone would not have convinced providers to drastically change their prescribing habits — to prescribe medications they were historically taught were addictive and should not be used for chronic non-cancer pain. But combined with the release of OxyContin in 1996, and a national marketing campaign to “inform” physicians about its “non-addictive” potential, things quickly changed. OxyContin, a long-lasting formulation of oxycodone which is an opioid approximately 1.5 times as potent as oral morphine, was released by Purdue Pharma into the United States in 1996. That year, the new drug had earned $48 million in sales, and by the year 2000, that number was $1.1 billion (11). This increase was accounted for by the liberalization of opioid prescribing habits by physicians who were being told that this was an ideal drug for non-cancer pain with non-addictive potential (12). The pharmaceutical company claimed this was supported by scientific literature, and often quoted the “Porter and Jicks” article, among others, in industry-sponsored physician education seminars. Back up to 1980 — a single paragraph “Letter to the Editor” was published in the New England Journal of Medicine (NEJM) by Dr. Hershel Jick and Jane Porter which laid the groundwork for the future dramatic change in opioid prescribing over 15 years later. The letter in its entirety is below: “Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two pa-
tients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” (13) The indiscriminate conclusion was that the development of addiction was rare in patients without a history of addiction. This fivesentence letter, given without any further information beyond its two references, gave pharmaceutical companies the ammunition they needed to cause an opioid reformation; this gave them “medical evidence” that addiction was extraordinarily rare in most patients. Numerous papers began to reference the article, infamously known now as simply, “Porter and Jick”, without noting that the article referred only to hospitalized patients who received medications from a trained provider — not at all analogous to self-administration on an outpatient basis (14). As noted in the letter, these patients vaguely received “at least one narcotic preparation,” with no mention of total dose, dosing intervals, pain being treated, or duration of treatment. The generalization of this letter to a chronic pain population at home taking opioids for low back pain represented a complete misrepresentation of the information provided, and those conclusions were far beyond what the original authors intended to communicate to the medical community. An article in the New England Journal of Medicine (NEJM) published this year identified 608 citations of “Porter and Jick” in medical journals since its publication (14). About 72 percent of these authors cited it as “evidence that addiction was rare in patients treated with opioids,” and over 80 percent did not mention that the document referred to hospitalized patients. Not surprisingly, a large spike in the rate of citation was noted after the introduction of OxyContin in 1996. In 2007, the manufacturer of OxyContin and three company executives pled guilty to criminal charges that they misled prescribers and patients by claiming that it was less addictive, and therefore less subject to abuse and diversion, than other opioids (15). By this time, however, much of the damage had been done. Drug users had long since learned to crush the controlled-release tablet to allow instant access to its highly concentrated opioid dose, as much as 160mg of oxycodone in a single tablet, to abuse in their intake method of choice, be it ingesting, snorting, or injecting the drug. An abuse-deterrent formulation of OxyContin was introduced in 2010 with the intent to make it more difficult to solubilize, but “abuse-deterrent” does not necessarily mean “abuse-proof.” A study in 2012 in the Journal of the American Medical Association (JAMA) looked at the effect of the abuse-deterrent form of OxyContin in patients with opioid dependence who were entering treatment programs in the United States (16). While the abuse of OxyContin as the primary drug decreased from approximately 35 percent of responders to 12.8 percent within almost two years of the new forcontinued on page 16
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OPIOID CRISIS continued from page 15
mulation being released, abuse of other prescription drugs, such as fentanyl and hydromorphone, increased from 20.1 percent to 32.3 percent. Heroin use also doubled during that time, and was cited as being “easier to use, much cheaper, and easily available” (16).
Battling the Epidemic:
To battle addiction and the opioid epidemic, the Centers for Disease Control and Prevention (CDC) has released guidelines for the prescription of opioids in 2016 (17). These include such ideas that acute pain typically requires three days or less or less of opioids, with rarely more than seven days needed, and that nonpharmacologic and nonopioid pharmacologic therapy are preferred for chronic pain. A study published this year in 2017 noted that, in patients who are opioid naïve and cancer-free who received a prescription for opioids, the highest probabilities of continued opioid use at one and three years were those who were initiated on long acting opioids, followed by those who started on tramadol (18). This same study noted that the risk of chronic opioid use increased with each additional day of medication supplied starting with the third day, with a risk of chronic use that doubled after a second prescription is given to a patient; these data support the recommendations noted above from the CDC about limiting prescriptions for acute pain. Also, the CDC recommends that prescription drug monitoring programs, which give clinicians information on how often, from whom, and what controlled substances are being filled by patients, and urine drug testing should be used routinely on patients whom are undergoing long-term opioid therapy (17). Not only does this allow for evaluation of other medications that may have interaction with opioids, such as benzodiazepines, but also gives a helpful screening tool to combat divergence of opioids and use of illicit sub16
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stances. Modern urine drug screens can determine which metabolites and/or parent compound is present in the urine, so other opioids, be them illicit or prescribed, can be discovered if taken in conjunction with the prescribed medication. Lack of the prescribed opioid in the urine, especially when taken regularly, can be a strong indicator that diversion has occurred. Given that evidence shows most people abusing prescription opioids received them for free from a relative (6), regular use of these tools can hopefully limit diversion and recreational opioid use.
Treatment of Addiction:
Treating addiction can prove challenging to say the least, especially when many of these patients have legitimate reasons for pain. In general, treatment with opioid agonist therapy is more effective than abstinence, detoxification, or non-pharmacologic approaches alone (19). Opioids such as methadone and buprenorphine can reduce relapse rates by providing patients with reduced cravings, prevention of withdrawal symptoms, and maintenance of opioid tolerance, thus decreasing the euphoric effect from more commonly abused opioids
OPIOID CRISIS like oxycodone or heroin if used concurrently. These medications can also cause withdrawals from suddenly discontinuation, just like other opioids, but this can be beneficial by encouraging continuation of the maintenance therapy. Opioid receptor antagonists like naltrexone have been used as well, but with less encouraging results (19). These patients need to be motivated to abstain from using opioids, as cessation of naltrexone will not precipitate withdrawals like with opioid agonist therapy. This leads to poorer adherence to the treatment, and thus higher rates of relapse. Counseling and therapy groups are helpful treatment options as well, with approaches such as motivational interviewing, cognitive behavioral therapy in either an inpatient or outpatient setting being shown to reduce relapse. Typically, these approaches work best in conjunction with pharmacologic methods to enhance outcomes and results (19).
Conclusions:
The opioid epidemic, while now recognized as a significant problem in the United States, continues to grow yearly. Though opioids themselves can be useful for a variety of pain conditions in patients with specific diagnoses, their use should be limited to those cases where other options have been attempted unsuccessfully. Using appropriate monitoring, such as urine drug screens and prescription access databases, is highly recommended. Attempts should also be made to use the lowest doses possible, and wean the patient when treatment has failed or is no longer needed. Unfortunately, prescription opioids are many normal people’s first foray into addictive substances, and many times, this occurs unintentionally after an injury or surgery for which opioids were prescribed, perhaps for longer than recommended with the newest guidelines. Without proper education and precautions, many of these people begin to misuse the medications and eventually become addicted. Ultimately, physicians should be the first line of defense by limiting their prescribing to appropriate cases for the good of our patients and their families. Dr. Brian Boies is an Assistant Professor in the Department of Anesthesiology at the University of Texas Health Science Center at San Antonio (UTHSCSA), and is board-certified in both Pain Medicine and Anesthesiology.
Works Cited:
1. Volkow, N.D. and A.T. McLellan, Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. New England Journal of Medicine, 2016. 374(13): p. 1253-1263. 2. Miguez, G., M.A. Laborda, and R.R. Miller, Classical conditioning and pain: conditioned analgesia and hyperalgesia. Acta Psychol (Amst), 2014. 145: p. 10-20. 3. Hill, R., et al., Ethanol Reversal of Tolerance to the Respiratory
Depressant Effects of Morphine. Neuropsychopharmacology, 2016. 41(3): p. 762-73. 4. Ling, G.S., et al., Differential development of acute tolerance to analgesia, respiratory depression, gastrointestinal transit and hormone release in a morphine infusion model. Life Sci, 1989. 45(18): p. 1627-36. 5. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders. 5th ed. 2013, Washington, DC. 6. Centers for Disease Control and Prevention. Opioid Overdose: Prescribing data. [Web page] 2016 December 20, 2016 [cited 2017 July 3]; Available from: https://www.cdc.gov/drugoverdose /data/prescribing.html. 7. Rudd, R.A., et al., Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014. MMWR Morb Mortal Wkly Rep, 2016. 64(50-51): p. 1378-82. 8. Rudd, R.A., et al., Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep, 2016. 65(5051): p. 1445-1452. 9. Johannes, C.B., et al., The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain, 2010. 11(11): p. 1230-9. 10.Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain, 1979. 6(3): p. 249. 11.OxyContin Marketing Plan, 2002. 2002, Purdue Pharma: Stamford, CN. 12.Van Zee, A., The promotion and marketing of oxycontin: commercial triumph, public health tragedy. Am J Public Health, 2009. 99(2): p. 221-7. 13.Porter, J. and H. Jick, Addiction rare in patients treated with narcotics. N Engl J Med, 1980. 302(2): p. 123. 14.Leung, P.T.M., et al., A 1980 Letter on the Risk of Opioid Addiction. New England Journal of Medicine, 2017. 376(22): p. 2194-2195. 15.Meier, B. In guilty plea, OxyContin maker to pay $600 million. New York Times, 2007. 16.Cicero , T.J., M.S. Ellis , and H.L. Surratt Effect of Abuse-Deterrent Formulation of OxyContin. New England Journal of Medicine, 2012. 367(2): p. 187-189. 17.Dowell, D., T.M. Haegerich, and R. Chou, CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA, 2016. 315(15): p. 1624-45. 18.Shah, A., C.J. Hayes, and B.C. Martin, Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States, 2006-2015. MMWR Morb Mortal Wkly Rep, 2017. 66(10): p. 265-269. 19.Tetrault, J.M. and J.L. Butner, Non-Medical Prescription Opioid Use and Prescription Opioid Use Disorder: A Review. Yale J Biol Med, 2015. 88(3): p. 227-33. visit us at www.bcms.org
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OPIOID CRISIS
MANAGING LONG-TERM
OPIOID THERAPY IN TODAY’S RISK-CONSCIOUS CLIMATE By Maxim S. Eckmann, MD and Ameet Nagpal, MD, MS, MEd
PAIN: A SYMPTOM AND A DISEASE
A portion of the population that experiences severe acute pain or injury will go on to experience persistent pain long after apparent healing of damaged tissues, for months or even years (1). This pain serves no useful function in terms of recovery, and it is exceedingly frustrating and distressing for patients, patients’ families, and health care professionals. Persistent pain and subsequent costs have quietly become an epidemic in the industrialized world. In the United States, direct and indirect costs likely exceed $500 billion annually, placing major stress on the U.S. health care system (2). The growth in the chronic pain patient population has been followed by an epidemic of prescription opioid addiction and overdose deaths due to the high exposure rate of patients to opioids while under medical care. The field of pain medicine has evolved in recent years to try and understand the pain “continuum” as a disease entity rather than a symptom alone. The FIGURE 1 mechanisms of persistent pain are numerous. Altered nervous system processing and response to stimulation are likely at the core of many chronic pain syndromes (3). Diverse treatments include allopathic and homeopathic medicine pathways, exercise and physical modalities, diverse drug classes, psychological therapies and sometimes procedures directed at diseased tissues or neural structures. Sometimes pain cannot be cured, but can be managed like a chronic disease. Due to the relative youth of the pain medicine specialty and pertinent established science, there still are not enough comprehensively trained pain specialists in the country. The specialists we do have are finding some syndromes or individual cases difficult to treat, even with their considerable expertise. Thus, almost 18
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all physicians and non-physician providers, including those in primary care, inpatient care and surgery — just to name a few — should adapt to the current climate and seek understanding of harm reduction and risk management when dealing with patients with difficult pain problems.
LONG TERM OPIOID THERAPY FOR PERSISTENT PAIN
Opioids, being relatively flexible, tolerable, potent and familiar options for physicians, have long been a mainstay of treating moderate to severe acute pain. In the 1990s, pain societies advocated for more continued on page 20
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OPIOID CRISIS continued from page 18
aggressive treatment of severe pain and a movement away from “opioidophobia.” (4) Those recommendations, intended especially for terminally ill or cancer patients, became broadly applied to non-terminally ill patients as well. These patients had a much longer lifespan and thus longer opportunity to develop drug misuse problems while on opioid therapy. Based on increasing awareness of potential problems such as tolerance, abuse and addiction with prescription pain medications, as well as unintended or intentional diversion of the medications to others, the societies now recommend a new culture of risk assessment, drug monitoring and continual reevaluation (5) (Figure 1). The Centers for Disease Control and Prevention (CDC) has generally recommended against long courses of opioid therapy if at all possible, recommending that opioids be prescribed no longer than three to seven days beyond initial surgery or injury. However, many pain societies have voiced concern for restrictions inherent in this recommendation. Somewhere in the middle, a balance must be found between potential benefit and harm.
RATIONAL STRATEGY FOR OPIOID USE: REDUCING OPIOID BURDEN UP FRONT
Opioids do have side effects such as respiratory depression and constipation, and long-term health consequences including tolerance, increased pain, abuse/addiction, sex hormone suppression, stress hormone suppression and sleep cycle disruption (6). Physicians and non-physician licensed providers will likely prescribe opioids eventually, so the unique properties and issues in opioids create a need for organized and logical management to minimize patient harm, reduce liability and adhere to regional regulations and practice standards, while also providing analgesia to patients in need.
Establishing a diagnosis
Although pain is a disease process of itself, currently it is still widely recognized as being secondary to a primary disease by both insurance payers, clinicians and state medical boards. Use of pertinent history, physical exam and testing or imaging can support clinician knowledge and recognition of painful conditions. The importance of establishing a likely diagnosis for chronic pain will aid in the prognosis of an expected recovery course and in the planning of specifically directed treatment, if applicable. Physicians 20
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TABLE 1
should be aware of the syndromes they commonly treat and any relevant evidence-based recommendations by their professional societies (7).
Patient Education
Patients should be made aware of the typical course of the disorder that is likely causing pain and the most beneficial initial measures that should be employed to manage the symptoms. This reduces the anxiety of uncertainty, which can feed into worsening pain experiences and potentially lead to an exhaustive search of more expensive medical care, where it may not be helpful. Coping skills should be assessed and actively augmented with counseling if they appear insufficient. For example, most acute low-back pain resolves in a matter of weeks to months, and opioids have less strong evidence for use in acute low-back pain than many other medications (7). If opioids are used, patients should be fully informed of the long-term health consequences, as well as the possibility that their provider may remove the use of opioids if problems exceed benefit. Patients should also receive education on maintenance of mobility and proper motivational attitude following acute low-back pain.
Bringing all Tools to Bear (…Before Opioids)
Non-pharmacologic therapies (including education) should be employed prior to or in conjunction with pharmacologic management.
OPIOID CRISIS For example, superficial heating is a simple, safe and usually effective treatment for low-back pain (7). Some available patient literature shows heat treatment speeds recovery from back injury (8). Therapies that are safe, patient-applied and minimally expensive should always be preferred, because more expensive treatments may yield no better results. When drugs are needed for more distressing or debilitating pain, providers should consider the wide array of classes and the pain receptors upon which these drugs act (Table 1). For example, membrane-stabilizing medications like carbamazepine are more specific for neuropathic pain conditions like trigeminal neuralgia. While opioids could also work, they would probably be less efficient. Yet severe pain from a long bone fracture would probably need a base therapy of opioids in conjunction with other techniques. If well tolerated, using “adjunctive” medications in conjunction with opioids can improve the durability of the therapy and operate in therapeutic windows of both (or more) pain medications. Also, the patient may be a candidate for referral to a pain specialist or surgeon for definitive treatment or interventional pain procedures such as joint or spine injection.
RATIONAL STRATEGY FOR OPIOID USE: A CYCLE OF EVALUATION AND MONITORING
There are many reasons why opioids will be necessary for pain management. Some pain conditions are so severe in intensity that opioids are needed even in the presence of comprehensive multimodal therapy. Sometimes clinicians become part of a medical continuity of pain care because patients may have been established on opioids in a recent hospitalization or the clinician inherits the patient from another practice. At other times, patients may be specifically referred for management of opioid therapy. Opioids are considered controlled substances by the Drug Enforcement Agency (DEA) because they have the potential for abuse, addiction and subsequently illegal use and redistribution (diversion). Opioids are not the only forms of controlled substances. For example, benzodiazepines and powerful hypnotic medications are controlled as well. Notably, the Food and Drug Administration has placed a black-box warning on the co-administration of benzodi-
azepines and opioids concurrently due to increased risk of accidental overdose. At the minimum, rationale for co-administration of these two drug classes should be very well documented and managed by pain specialists, if possible. As opioids are widely needed and prevalent in clinical practice, physicians are exposed to potential liability or reprimand if prescribing practice falls well outside the intent of the DEA and state agencies to limit the diversion of prescription medications, which are the leading source of drug abuse and drug overdose fatalities in the US (9). Fortunately, the bar for demonstrating responsible prescribing is very achievable with proper knowledge and processes. Peer reviewers are much less likely to find fault with a practitioner who documents well the rationale and monitoring steps taken for a patient on opioids. If a judicious practitioner chooses to prescribe opioid therapy for chronic pain management (chronic opioid therapy), there are several steps that should be taken in order to meet the standard monitoring process. Many of these are documented in Chapter 170 of the Texas Medical Board Rules, the CDC Guidelines for Opioid Prescriptions and other published guidelines for urine drug screens (10, 11, 12). These processes occur first with the evaluation, which should include obtaining all pertinent medical records, a thorough history and physical examination, ordering of necessary laboratory and imaging studies, and consultation or referral to a specialist if necessary. Once the evaluation is complete, the patient should sign a “Controlled Substance Agreement,” or CSA, with the prescriber. This should outline the risks associated with prescription of opioids and the rules that
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OPIOID CRISIS continued from page 21
the patient should follow when taking these medications. These include: not obtaining pain medication from another prescriber or individual, not using illicit substances, taking the medication as prescribed, random monitoring, and being compliant with the rest of the treatment plan. Discontinuation of opioid therapy due to non-compliance with the treatment plan should be addressed in the CSA. Recent evidence suggests that it may be prudent to restrict driving in patients who are prescribed opioids, and this may be placed in the CSA as well, but this data is controversial (13). Once the patient has been placed on chronic opioid therapy, monitoring with random urine drug screens and pill counts is recommended (12). Periodic review of the patient’s diagnosis, appropriateness for therapy and patient compliance should be made. Improvements in functional status and pain states should be noted, and if the individual patient is not improving in both function and pain, re-evaluation is warranted. In Texas, we have a robust Prescription Monitoring Database Program (PMP or PMDP) that should be utilized periodically to ascertain if a patient is obtaining prescriptions from other providers (14). If necessary, psychological evaluations should be provided either at the evaluation stage, during the monitoring process or both.
CONCLUSION
A stigma has been attached to chronic pain patients for a long time. There is now a stigma on providers, as well. It is fair to say that part of the preconceptions that our society has about prescribers of opioids for chronic pain is based upon poor judgment by the provider regarding the evaluation and monitoring process of patients who are otherwise being treated appropriately with these addictive medications. Safe opioid prescribing involves selecting the right patients and monitoring them for signs of abuse, misuse, addiction and diversion over time.
REFERENCES
1. Holmes A, Williamson O, Hogg M, Arnold C, O'Donnell ML. Determinants of chronic pain 3 years after moderate or serious injury. Pain Med. 2013 Mar;14(3):336-44. 2. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012 Aug;13(8):715-24. 3. Krames ES. The Role of the Dorsal Root Ganglion in the Development of Neuropathic Pain. Pain Med. 2014 Mar 18. 4. Agency for Health Care Policy and Research (AHCPR), Clinical Practice Guidelines, Acute Pain Management, Feb 1992-Dec 1994. 5. Chou R, et. al.; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. J Pain. 2009 Feb;10(2):113-30. 6. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl 22
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7.
8. 9. 10. 11. 12. 13. 14.
J Med 2003;349:1943-53. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK; Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91. Burton K, et al. The Back Book, 2nd ed. The Stationary Office, UK, 2002 July. Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38. Texas Medical Board Rules, Chapter 170, Authority of Physicians to Prescribe for the Treatment of Pain www.cdc.gov/drugoverdose/prescribing/guideline.html Owen GT, Burton AW, Schade CM, Passik S. Urine drug testing: current recommendations and best practices. Pain Physician. 2012 Jul;15(3 Suppl):ES119-33. Nagpal A, Xu R, Pangarkar S, Dworkin I, Singh JR. Driving Under the Influence of Opioids. PM R. 2016 Jul;8(7):698-705. https://texas.pmpaware.net/
ABOUT THE AUTHORS:
Max Eckmann, MD, is an associate professor and medical director of pain medicine in the Department of Anesthesiology at The University of Texas Health Science Center at San Antonio, now doing business as UT Health San Antonio. Dr. Eckmann is board-certified in both pain medicine and anesthesiology by the American Board of Anesthesiology. As a fellowship program director, Board Member of the Texas Pain Society and an active planning participant in national organizations such as the American Society of Anesthesiologists and American Society of Regional Anesthesia and Pain Medicine, Dr. Eckmann has an up-to-date perspective on medical and legal trends in his specialties and how those interact with other medical and surgical specialties. Ameet Nagpal, MD, MS, MEd, is an assistant professor and medical director of UT Health San Antonio Pain Consultants. He is board-certified in pain medicine and physical medicine and rehabilitation by the American Board of Physical Medicine and Rehabilitation. Dr. Nagpal is the associate program director of the UT Health San Antonio Pain Medicine Fellowship. He is highly active with the Spine Intervention Society as a speaker and volunteer for their Evidence Analysis Committee and Education Division, and with the American Association of Physical Medicine & Rehabilitation as a speaker and volunteer on their Self-Assessment Committee. He also spends a significant portion of his administrative time working with undergraduate medical students as a course coordinator, discipline coordinator and Curriculum Committee member.
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FINANCIAL PLANNING
FINANCIAL PLANNING FOR A SPECIAL NEEDS CHILD By David K. Alvarez, CFP If you are reading this article, chances are you have a friend or family member that is caring for a special needs child. In the United States alone, recent estimates show that about one of every six children (roughly 15%) aged 3 to 17 have one or more developmental disabilitiesi. The Centers for Disease Control and Prevention defines Developmental Disabilities as “a group of conditions due to an impairment in physical, learning, language, or behavior areas. These conditions begin during the developmental period, may impact dayto-day functioning, and usually last throughout a person’s lifetime.”ii The challenges for parents or guardians are many and may seem insurmountable, from daily care and maintenance to the financial cost of rehabilitation or treatment. This creates a significant need for financial planning. Parents of a special needs child often struggle to plan for their own retirement as well as the long-term needs of the child. Thankfully there are several steps they can take to mitigate fi24
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nancial risk and ensure their loved one will always receive support and care, even when they are no longer around to provide it.
Guardianship
When special needs children turn 18, they are legally adults. If they are not able to care for themselves or live independently, the parent needs to apply for guardianship.iii The Texas Guardianship Association defines a guardianship as “a court-supervised administration for a minor or for an incapacitated person.”iv This is an important first step, and should be considered along with who would care for the child (or adult) if the parents are not able to do so. In addition to consideration of an ideal future guardian, steps for appropriate care of that child should be diligently specified in writing. These instructions should include the child’s medications, routines, interests, fears, family members, close friends, and any other details that will
FINANCIAL PLANNING allow a future guardian the best opportunity to maintain the quality of life the child currently maintains.
Retirement Planning
Financial planning can be a challenge for parents of special-needs children, especially when thinking of their own retirement. How do you pay for the child’s care when you are retired? The first option everyone should consider is government assistance. Disabled children up to age 18 can receive Supplemental Security Income (SSI) from Social Security along with Medicaid if their parents meet the program's low- income and asset requirementsv. After the child turns 18, they should be able to qualify for these benefits on their own. This underlines the importance making sure assets and beneficiaries are titled correctly. Along with SSI and Medicaid, special needs families should consider Social Security Disability Insurance (SSDI). SSDI pays benefits to adults with disabilities (if the disabilities began before the adults turned 22 years old). SSDI is also available for a child if one of the parents is deceased or if one of the parents is already receiving Social Security retirement or disability benefits. Additionally, most folks saving for retirement are aware of the benefits of saving money in a qualified retirement plan or an individual retirement account (IRA). Parents of special needs children should consider adding an ABLE account to their savings plan. In 2014 Congress passed the Achieving a Better Life Experience (ABLE) Act which allows for the creation of tax-advantaged savings plan for the disabled. Earnings and withdrawals for qualified expensesvi are federal and state tax free. Also, assets below $100,000 in the ABLE account will not be counted as a resource for SSI and Medicaid testing. Over 20 states have created ABLE accounts and most of those states do not have residency requirements.
Estate Planning
Recent polls show more than half of Americans do not have a willvii. While this may be problematic for most, with a special needs child this can be a tragic mistake. Parents of a special needs child absolutely should create a will and consider including a special needs trust with an appropriate trustee as well as a guardian for the child. All assets intended to be passed along for the benefit of the special needs child should go into the trust. If done properly this will ensure the child won't lose government benefits such as SSI or Medicaid. When looking at their assets, parents and guardians sometimes overlook accounts where the child be listed as a beneficiary (e.g. IRAs, Retirement Plans, Life Insurance, Transfer on Death, etc.) If those assets are intended to benefit the child, it is important to designate the special needs trust, not the child outright, as the beneficiary. If these assets end up in the name of the child individually, the child may lose access to government benefits. Another benefit of a special needs trust is that assets in the trust should be protected from “creditors and predators” if the child is ever sued.
Communication
All this planning can add a tremendous amount of value, but it can also be rendered ineffective if the plan is not communicated with and understood by all family members and loved ones who care for the child. For example, parents of a special needs child recently informed us that their parents (grandparents of the special needs child) transferred money into a 529 plan for their child. The child will likely not be attending college, and those funds can only be used for qualified college education or rolled over to a different child’s 529 plan. The family could have used help paying for the child’s expenses related to the medications, physical therapy, and daily tutoring. If a special needs child has wealthy family members who would like to help financially, writing a check or funding a 529 may not be the most efficient way to do so because those would be subject to federal gift taxes. There are likely educational or medical expenses that the family members would be able to pay directly, which would not qualify as a taxable giftviii. It may make sense to have a family meeting to explain the plan or regular email updates to communicate any recent or important changes. The challenges of caring for a special needs child can be daunting. A financial planner with experience in special needs planning can introduce you to the appropriate service organizations, attorneys, and accountants, and will partner with them to make sure the optimal plan is put in place for you and your family. A well designed financial plan should put you in a position to achieve your retirement goals and ensure your child always receives the highest quality care, love, and support. David K. Alvarez is a Certified Financial PlannerTM professional with Intercontinental Wealth Advisors, LLC a boutique wealth management firm that is headquartered in San Antonio and recently celebrated its 35th anniversary. The primary focus of David’s work is the Healthcare and Non-Profit communities. David serves on the Board of Directors for the Blood and Tissue Center Foundation and the San Antonio Public Library Foundation. He may be reached at (210) 271-7947 or dalvarez@intercontl.com. i Boyle CA, Boulet S, Schieve L, Cohen RA, Blumberg SJ, YearginAllsopp M, Visser S, Kogan MD. Trends in the Prevalence of Developmental Disabilities in US Children, 1997–2008. Pediatrics. 2011; 27: 1034-1042 ii www.cdc.gov/ncbddd/developmentaldisabilities/index.html iii In some states, guardianships are called conservatorships. In Texas they are called guardianships. iv http://texasguardianship.org/guardianship-information/faqs-2/ v The Social Security Administration has an online Benefit Eligibility Screening Tool https://ssabest.benefits.gov/ vi List of Qualified Disability Expenses available on the social security website: https://secure.ssa.gov/poms.nsf/lnx/0501130740 vii Gallup poll based on telephone interviews conducted May 48, 2016 http://www.gallup.com/poll/191651/majority-not.aspx viii https://www.irs.gov/instructions/i709/ch01.html visit us at www.bcms.org
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FEATURE
THE VIRTUOUS MISSION:
Exploring the Bioethical Obligation of Interprofessional Healthcare By Ammar Navid Saigal, MPH, MD Candidate (2018) The global medical landscape continues to evolve toward interdisciplinary patient care out of necessity. The World Health Organization warns of the public health burden that will be experienced by billions due to the projected shortage of approximately 13 million health workers by the year 2035. [1] Healthcare systems around the world must employ multilateral strategies to palliate the growing need for medical professionals. One increasingly common strategy is the integration of physician and mid-level provider services in medicine. There are numerous practical benefits of doctors working together with nurse practitioners, physician assistants, and other allied health specialists. However, this workplace arrangement can create 26
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unfortunate competition among physicians and mid-level practitioners with respect to overlapping patient management. This essay seeks to provide insight into the mutual bioethical obligation between these two types of health professionals by analyzing sources of discord stemming from this heterogeneous clinical arrangement. Recognizing this obligation and defining clinical responsibilities will allow providers of all levels to coordinate the provision of their services with maximal efficiency. Considering the growing need for access to health services, it is critical that mutual respect and collaborative efficiency be established. Recognizing this reality is a necessary part of the virtuous mission that physicians and mid-level providers alike
FEATURE
have committed themselves to. The virtuous mission represents the bioethical dedication to compassionate caretaking that all health professionals must learn to value above their own private interests in order to maintain the highest standards of care. The Association of American Medical Colleges advises that compensating for the national shortage of physicians will require “efficient use of all health professionals on the care team.” [2] Addressing this issue on a worldwide scale has produced an unprecedented surge of hybridized care teams. [3] For the purpose of ensuring the effective flow of patient information and clinical tasks, it is now more important than ever to understand the differences between physician-level and mid-level practice. Mid-level health workers have been successfully taking care of patients around the world for over a century. [4] Various categories of these professionals exist today with different amounts of medical education and certification. These workers are generally trained in history-taking, patient counseling, performing physical examinations, and/or prescribing medication. Although their scope of practice is generally narrower than that of physicians, they widely render autonomous health services and thereby partially alleviate the burden of physician shortages. According to the U.S. Bureau of Labor Statistics, these workers constitute over half of the entire national healthcare workforce. [5] Their proliferation has reshaped the modern clinical environment. The conflict between health practitioners of different levels is born partly from the belief of some doctors that the relatively lesser extent of mid-level educational training should subjugate mid-level providers to physicians when it comes to clinical decision-making. Another cause of animosity that can arise from physicians toward other providers is the perception that mid-level care diminishes the patient-doctor relationship by usurping physician responsibilities. This worry of some physicians may extend to concerns about the patient-doctor relationship being so disrupted that it is eventually rendered obsolete. [6] At the same time, mid-level practitioners do not always take kindly to being viewed as inferior caregivers. The American Academy of Nurse Practitioners has repeatedly condemned the use of terminology such as “non- physician provider” and “allied-health provider”, citing derogatory connotations that do not reflect the advanced care delivered to patients on a daily basis by licensed mid-level practitioners across the country. [7] These are some of the main sources of conflict among healthcare providers with differing credentials attempting to care for the same patients. In light of these competitive tensions, it is important not to forget that taking proper care of sick individuals is the common, utmost
priority of healthcare teams. The utility of mid-level health workers in facilitating the clinical duties of the physician is undeniable in this endeavor. Consider a patient with sickle cell disease. The care of this patient will typically involve nurses, nurse practitioners, respiratory therapists, social workers, and counselors managing the difficulties of caring for a child with a chronic illness. Having these colleagues available to attend to various duties can enable the physician to direct highly-organized patient management.[8] On the other hand, a sense of entitlement to decision-making regarding patients will only brew discontent between providers with overlapping job descriptions. Physicians and mid-level health workers should instead strive for gratification by realizing that synchronizing their efforts provides quality care that is greater than the sum of its parts. Neutralizing competitive attitudes between doctors and mid-level providers is necessary to promoting “well-being for all at all ages” by the year 2030 as outlined in the United Nations Sustainable Development Goals. [9] Mid-level health services are widespread and provide patients with more healthcare options in addition to facilitating physician duties within integrated settings. Multidisciplinary collaboration within patient care should be viewed as an opportunity to optimize the quality of medical services rather than being dwelled upon as an impediment to further clinical advancement. As healthcare workers our goal is to promote the general welfare by ensuring that our patients receive optimal medical attention. Accomplishing this objective will be our collective contribution to improving the standards of living for those in need. This includes the resolution of occupational disputes that run counter to our common goal by adversely impacting the quality of care provided. Integrated clinical environments may cause health workers to lose sight of the specifics of workplace roles, but the virtuous mission of healthcare renders this concern trivial compared to whether or not patients are being properly attended to. The true caregiver is the individual that safeguards health interests of patients - regardless of his or her degree of educational achievement – as dictated by the basic bioethical principles of autonomy, beneficence, non-maleficence and justice. Physicians and mid-level providers should therefore always aim to uphold the virtuous mission of healthcare. In an era where healthcare is constantly evolving to meet the needs of patients, the virtuous mission will ultimately guide humanity to the rescue. Ammar N. Saigal is a fourth-year medical student who is currently studying to become an Orthopaedic Surgeon at the UT Health San Antonio Joe R. & Teresa Lozano Long School of Medicine. continued on page 28
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FEATURE continued from page 27
Bibliography 1)
WHO. (2014, May 20). Global health workforce shortage to reach 12.9 million in coming decades. Retrieved from World Health Organization, http://www.who.int/mediacentre/news/ releases/2013/health-workforce-shortage/en/ 2) Physician Supply and Demand Through 2025: Key Findings. Retrieved from American Association of Medical Colleges, https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough202 5keyfindings.pdf 3) Rowland, P. (2013). Core principles and values of effective team-based health care. Journal of Interprofessional Care, 28(1), 79–80. doi:10.3109/13561820.2013.820906 4) Lehmann, U. (2008, July ). Mid-level health workers: The state of the evidence on programmes, activities, costs and impact on health outcomes. Retrieved from World Health Organization, http://www.who.int/hrh/MLHW_review_2008.pdf 5) What is Allied Health? Retrieved from Health Professions Network, https://www.healthpronet.org/docs/1342_AH_BrochU pdate_06.pdf
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6) 7)
8) 9)
Laguë, G. (2008). Do nurse practitioners pose a threat to family physicians? Canadian Family Physician Use of Terms Such as Mid-Level Provider and Physician Extender. (2015). Retrieved from American Academy of Nurse Practitioners, http://www.aanp.org/images/documents/publications/useofterms.pdf Elements of successfully integrating a mid-level provider into practice (2005). Journal of Oncology Practice, 1(3), 93–94. doi:10.1200/jop.1.3.93 SDGs: Sustainable development knowledge platform. Retrieved from World Health Organization, https://sustainabledevelopment.un.org/topics/sustainabledevelopmentgoals
BUSINESS
RANSOMWARE:
A Tale of Two Sites By David A. Schulz, CHP; CIPP
Name of Covered Entity
Individuals Affected
Breach Submission Date
Type of Breach
ABCD Pediatrics, P.A.
55,447
03/26/2017
Hacking/IT Incident
Urology Austin, PLLC
279,663
03/22/2017
Hacking/IT Incident
Source: U.S. Department of Health and Human Services: Office for Civil Rights When two nearby healthcare practices appear on the HIPAA breach site for ransomware attacks within days, it is time to review this digital epidemic. San Antonio Medicine is grateful that both practices, ABCD Pediatrics and Urology Austin, were forthcoming about their experiences, how they withstood the onslaught. Ever since Hollywood Hospital made headlines last year by paying blackmail to regain access to its encrypted patient files, paying the perpetrator has become a common response. Here are two examples of
enhanced resistance; medical education relies on case studies of successful outcomes. Such outcomes tend to begin with “situational awareness.” At Urology Austin, Site Manager and IT Director Layton Smith noticed the system being monitored — surveilled — for weaknesses. He immediately contacted their managed services IT company, GCS Technologies, a managed services company handling security for 450 companies in Central Texas. Smith says, “GCS’s team got them — continued on page 30
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the perpetrators – locked out of the system, and immediately began remediating the issue.” GCS found Urology Austin services going offline because of encryption, and their monitoring software began raising the red flags. GCS employs a multi-tiered approach to security, with no less than six or eight products employed at all time to monitor traffic and data usage. “What took it from existential to only catastrophic,” says GCS Technologies President Joe Gleinser “was an image-based backup solution.” Image-based backup is a process for a computer or virtual machine to create a comprehensive copy of its operating system and all the data associated with it, including the system state and application configurations. It’s all saved as a single file that is called an image. This is far more extensive — and utilizes more resources — than typical file backups, where each file (which could include the poisonous malware) is incrementally uploaded to the reserve copy. Urology Austin does a weekly image and relies on daily incremental backups, so they’re never than six days away from a stable reset point. “At the end of the day, we were able to recover fully and the practice was seeing patients more quickly,” says the GCS president. Closer to home, a similar story unfolded when an employee of ABCD Pediatrics discovered that a virus gained access and began encrypting ABCD’s servers. The encryption process was slowed significantly by recently updated antivirus software. Upon discovery, ABCD immediately contacted its IT Company, and servers and computers were promptly moved offline and ana30
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lyzed. ABCD’s IT Company identified the virus as “Dharma Ransomware,” a variant of an older ransomware virus called “CriSiS.” These virus strains typically do not exfiltrate (“remove”) data from the server; however, it could not be ruled out. Also, during the analysis of ABCD’s servers and computers, suspicious user accounts were discovered suggesting that hackers may have accessed portions of ABCD’s network. ABCD’s IT Company successfully removed the virus and all corrupt data from its servers. Secure backup data stored separately from ABCD’s servers and computers (“off-site backups”) were uncompromised by this incident. As a result, no confidential information was lost or destroyed, including protected health information. Nor did the attack mature to the point of ABCD receiving ransom demands or other communications from unknown persons. Concerned that interlopers may have been on the server for a limited period, ABCD Pediatrics advised more than 55-thousand patients of the incident, per HIPAA regulations. Urology Austin sent 279-thousand letters advisory level (see sidebar, “The Law.”). Between the costs for advisories and client credit protection where, it’s critical to have cyber incident insurance, both companies advised. And the breach is only the opening refrain of what can be a long sad song: “Once a breach is identified by the Department of Health and Human Services, the Office for Civil Rights gets interested,” says Clifford Robertson, JD. Speaking recently to the Bexar County Medical Society, he detailed the process by which any breach is likely to open the practice to a complete HIPAA compliance audit.
BUSINESS
He reviewed a number of corrective action plans mandated by the Office for Civil Rights, whose post-breach review will begin by examining the practice’s most recent risk assessment, IT logs and personnel policy and procedure guide training records. “One unencrypted laptop left unattended in a car,” said Robertson, “has brought down whole enterprises.”
Tips to Staying Safe in Your Own Data
Crucial to successful responses in both cases was a close relationship with their IT managed services provider. Making sure your practice’s MSP is aware of and responsible for all of HIPAA’s Security Rule mandates, particularly regarding anti-malware updates, software patches and monitoring IT assurance should be part of its business associate agreement. GCS’s Joe Gleinser says he is asked for the best advice to those new to the business: “First, recognize the magnitude of the risk and build a multi-layered shield. Unfortunately, I don’t see ransomware taken seriously at the Executive Level, but perhaps that might change as more stories get told.” Staff training of new security threats and email policies is vital to an enhanced immune system. Says Gleinser, “We’ve responded to more than eighty-five ransomware attacks since January 2016. Almost every case has been caused by a phishing attack through email.” Unfortunately, despite strong immune systems, viruses still find a path to infect otherwise healthy systems. An incident response plan is needed to deal with a chaotic and calamitous situation. Adrian P. Senyszyn, JD, who serves as attorney for ABCD Pediatrics, and is an expert on cyber incidents, speaks to the need to preserve evidence. “You need to help prove the low probability of compromise to pro-
tected health information.” First, he advises, disconnect: have your IT company disconnect your network from the Internet, the more quickly, the better. Investigate and document the incident immediately. Make sure IT staff accurately document their findings in an incident report that should be signed and dated. Screenshots or photographs taken by cell phones will help document evidence. Treat everything as though it was a crime scene … it is. If possible, have the MSP maintain the infected IT system in a digital sandbox, neither shutting it off nor wiping it clean. By wiping the malware from your system, you are likely destroying the evidence that proves the ransomware did not exfiltrate data to cyber criminals Determine the scope of the incident by identifying and documenting which networks, systems, or applications were affected; the name of the virus or malware; and the origin of the incident or vulnerability that caused it. Staff should document information related to the attack in separate incident reports that are signed and dated. You also should consider whether a forensic investigation of your computers and servers would be appropriate. Besides your IT manager, there are two other names at the top of your disaster-recovery call sheet: contact your medical professional
THE LAW: Ransomware is a HIPAA reportable incident, regardless of whether PHI was removed from the system. The Office for Civil Rights (OCR) of Health and Human Services (HHS) has made it clear: with 4,000 daily attacks, it is a serious threat that exploits “human and technical weaknesses” and “The presence of ransomware (or any malware) on a covered entity’s or business associate’s computer systems is a security incident under the HIPAA Security Rule.” (FACT SHEET: Ransomware and HIPAA - HHS.gov)
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T’wasn’t the Iceberg that killed the Titanic’s Passengers. It was Poor Policy and Training. Accidents happen; Tragedy doesn’t have to. Decisions that caused the death of two-thirds of the 2200 passengers were made a thousand miles away, and five years earlier than the ship left dry dock • Begin with "Technological Hubris" - From the boardroom to the docks, the Design Committee of Major Construction firmly believed that the “Water Tight Compartments” made it impossible to sink. (Never, ever say "Never.") • "Safeguards" were all Technical, not Personal and Physical • Only 20 lifeboats instead of the 60 that would have had room for all 2100 passengers. • There was negligible staff training — boat lowering of was NEVER drilled. • There were NO passenger evacuation drills — the only one scheduled was cancelled the day of the crash. • Of the 20 lifeboats: o Only 18 were launched o 2 Sank in the process o Most boats were half filled o 700 survivors of the 2200 passengers o The com officer was still using outmoded CQD ... Not SOS adopted in 1905 o Nor were the emergency flares and rockets understood to be anything but fireworks by nearby ships ... that could have rescued the passengers. So when HIPAA calls for an annual Risk Assessment and analysis of office safeguards, don't think "CMS" or "HHS" ... Think of the RMS Titanic and the 1500 passengers who trusted in the "Can't never happen here" doctrine. It can. It does. And if Policies and Processes aren't followed ... It Will!
liability carrier – and make sure your cyber liability insurance covers the costs of ransomware removal, forensic investigation, breach notification, OCR investigation, and fines and penalties. And if you don’t already have one, retain a lawyer who has handled HIPAA incidents. If an attack was successful, is there someone at your company that knows how to acquire bitcoins to pay the ransom? An attorney would — as well as determining the risk of not paying the ransom at all. Recent trends show less-honor 32
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among thieves: first payments can simply be the ante to an ongoing game you’re bound to lose. David Schulz, certified information privacy and certified HIPAA professional, is Executive Director and CEO of Cyber Risk Associates, LLC, compliance specialists for small and boutique healthcare practices and associates in the San Antonio area. He is a community representative on the BCMS Communications/Publications Committee.
BCMS NEWS
Hurricane Harvey was one of the worst storms to hit Texas in more than 20 years. In addition to the damage caused by its initial impact near Rockport, the storm wreaked even more devastation in the Houston area where it stalled and, over a six-day period, dumped a record 51 inches of rain — the most ever in the continental U.S. Harvey caused an estimated $75 billion in damage. More than 450,000 people have requested assistance from the Federal Emergency Management Agency (FEMA). More than 72,000 people had to be rescued during the storm and another 30,000 needed tempo-
rary shelter. The Bexar County Medical Society recruited 207 of its physician members and 370 other medical personnel volunteers to provide medical services for the benefit of displaced Hurricane Harvey evacuees. Working with Metro Health, the BCMS volunteers provided 24hour medical coverage beginning August 25 at a number of shelters set up in San Antonio. The Chair of the BCMS Emergency Preparedness Committee, Dr. David Cohen directed the efforts, supported by BCMS staff continued on page 34
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member Melody Newsom. By August 31, the shelter situation in San Antonio was winding down and Metro Health was in the process of closing down the Centennial and Kazen shelters. Most of the shelter populations were shipped back home via bus, but those remaining were transferred to the shelter at Harland Clark where the population grew to more than 300. BCMS volunteers were told to expect as many as 2,000 evacuees during this time. Much of the work at this point involved logistics of transferring supplies to the remaining shelter. Dr. Junda Woo, with Metro Health, set up a medical station at the responder shelter housing first responders and bus and truck drivers. Epidemiologists were brought in after a rumor started about a possible bug outbreak. The Harland Clark shelter grew to 433 people by Sept. 1. There would have been more, but several buses trying to bring people from coastal communities couldn’t find routes west past Nome, Texas. Melody Newsom said the population at Harland Clark was extremely complimentary of how well the shelter was running and how it was organized. 34
San Antonio Medicine • October 2017
“We spent the last couple of days making sure everyone knew their new shelter assignment,” Newsom said. “I’ve talked to a few of the physicians and they were very pleased with how organized the medical clinic is and said there is plenty of room. It seems to be a positive experience for most.” More than 1,000 patients had to be transported to hospitals across the state in the wake of the hurricane and one of the biggest challenges statewide was 650 dialysis patients needing care in Beaumont. But things were under control in San Antonio where Roger Pollok with Metro Health boasted about the work of the medical volunteers. Once the majority of the evacuees were sent back, Kazen Middle School shelter was reopened and was staffed with our medical volunteers. The other shelters were closed and evacuees were consolidated once again. All remaining evacuees were eventually transferred to Kazen. One person was diagnosed with pneumonia and was being treated with antibiotics and a nebulizer by Dr. Donald Gordon. “I can’t imagine having pneumonia and living in a shelter,” Newsom said. “Thank God for our volunteers!”
PHYSICIAN PRACTICES
PHYSICIAN PRACTICES WellMed Medical Group By Mike W. Thomas
EDITOR’S NOTE: This is the first in a series of articles for San Antonio Medicine that will look at local physician practice groups.
CARLOS HERNANDEZ, MD
RICHARD WHITTAKER, MD
Since 2002, WellMed Medical Group has grown exponentially, from a single clinic in San Antonio to more than 200 across Texas and Florida, and now has plans to open more clinics in Indiana and Ohio. Today, WellMed has more than 5,000 primary care and specialist locations and more than 12,000 providers in its network serving more than 310,000 patients annually. What is the secret to that successful growth? Carlos Hernandez, MD, president of WellMed, says it is due to their focus on the senior population dependent on Medicare and a company philosophy that adheres to providing “fee for value” rather than “fee for service.” “The fee-for-service model is fragmented,” Hernandez said. “It is uncoordinated and expensive.” The fee-for-value model, by contrast, is set up to provide rewards for doing the right thing, not just for doing something, he said. “We get paid for taking care of our patients, not for providing a service,” he said. At WellMed, the primary care physicians are playing quarterback and directing all of the patient’s care, Hernandez said. That way the patients get the right care at the right time for the right reasons. This, ultimately, is less expensive with no duplicative testing and provides better results, he says. 36
San Antonio Medicine • October 2017
SUSAN LEE, MD
Hernandez says fee-for-value will be the wave of the future in healthcare if we are ever going to get a handle on rising costs. “The cost of healthcare in the U.S. is more expensive than anywhere else,” Hernandez said. “The outcomes are worse too, because we charge for technology, not outcomes. Where it is going now, everyone is tired of paying for care that doesn’t deliver good results.” Richard Whittaker, MD, chief medical officer for WellMed Medical Group, said a culture of taking care of the whole patient is at the core of their success. Making sure all the physicians that join WellMed are immersed in that culture is key to continuing that success in the future, he adds. “We look for people who fit our values,” he said. “Everyone goes through behavioral-based training. It’s a robust onboarding process that takes one-to-two weeks. It’s important to get a good fit from the beginning so that there is a low-rate of turnover. Training is a significant investment in the value-based care model.” Whittaker said the market is very competitive right now for hiring good people out of medical school so they must offer an excellent benefits package to capture the best candidates. Doctors who work at WellMed should like working in teams and collaborating with colleagues when treating patients. If they don’t like structure, then this may not be the place for them. Here, they
PHYSICIAN PRACTICES will likely see fewer patients in a day and spend more time with each one as a result, he said. “It allows us to have deeper relationships with our patients,” he said. Dr. Susan Lee, chief of central clinical programs at WellMed, said since the Medicare Advantage Plan requires the primary care physician to manage all aspects of a patients care, it was determined that a group effort would be best. “We knew that if we took on the full risk and responsibility for the care of the patient, we could find ways to provide better benefits with those funds,” she said. “If we could arrange to give them more timely care, that would help prevent emergency room visits down the road.” The bottom line was that by focusing on preventative care they were able to generate savings that could be reinvested back into the care model. It actually costs less to provide better care, she said. Coordination of care requires a lot of effort. Without that coordination it can create a lot of problems for the patients and expensive redundancies. “If they see a specialist, we make sure we have access to that information and our hospitalist calls to set up a person-to-person conversation with the clinic doctor,” Lee said. “This way we can see at a glance all the things that can be overlooked in a busy practice.” WellMed creates a registry or data list of patients to make sure that no one is missing quality health metrics, Lee said. “If I was in private practice on my own, I wouldn’t have a team of nurses around me helping with all of this vital coordination of care,” she said. When these things are overlooked it leads to patients be readmitted for more expensive care, she adds. “Our goal is to see all of our patients within three days of discharge to make sure they got everything they need,” she said. “Our aggressive approach has been shown to prevent the need for readmissions and overall better results for our patients.” Recently, WellMed earned the Gold Seal of Approval for Ambulatory Health Care from The Joint Commission, the nation’s oldest and largest standards-setting and accrediting health care body. WellMed also received the Primary Care Medical Home (PCMH) Certification, an additional designation earned by select ambulatory health care organizations. “I think the dream has been realized in what we have accomplished,” Lee said. “For us it is not about how many patients we see in a day, but how well we take care of them. The most expensive care is delayed or deferred care – like not changing the oil in your car. I think we have proved what we set out to do.”
WELLMED MEDICAL GROUP, P.A. Founded in 1990 CORPORATE HEADQUARTERS: 8637 Fredericksburg, Ste. 360 San Antonio, TX 78240 Phone: 1-888-781-9355 (WELL) Website: www.wellmedhealthcare.com Social media links: • Facebook.com/WellMed • LinkedIn.com/WellMed • YouTube.com/WellMed1 • www.linkedin.com/company/wellmed-medical-managemen PRESIDENT AND/OR LEAD PHYSICIAN Chairman & CEO – George Rapier III, MD President, WellMed Medical Group – Carlos O. Hernandez, MD WellMed staff physicians in San Antonio have privileges at all Baptist Health System and Methodist Healthcare System hospitals. 401K, savings and retirement plan options, paid leave, dental, vision, medical, paid holidays, options for disability and life insurance, competitive compensation program and work-life balance program, multiple incentive opportunities WellMed is a pioneer of the ACO model and continues to practice today under the nationally recognized WellMed Care Model. WellMed Medical Group operates as a primary care and multispecialty practice specializing in senior health care. OUR PHYSICIANS ARE CERTIFIED IN VARIOUS SPECIALTIES INCLUDING: • Dermatology • Geriatrics • Cardiovascular Disease and Interventional Cardiology • Family Medicine • Family Practice • Hospital Medicine • Internal Medicine • Neurology • Osteopathic Medicine • Palliative Care • Pain Management • Podiatry and Podiatric Surgery • Rheumatology • Wound Care WellMed accepts new Medicare/Medicaid patients WellMed is covered by Texas Medical Liability Trust WellMed accepts multiple, Medicare Advantage health plans in different markets as payers for patient services. IN BEXAR COUNTY WE ACCEPT: • Original Medicare • Cigna Health Spring • Amerigroup • United Healthcare • Superior / Centene
visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.
ACCOUNTING FIRMS RSM US LLP (HH Silver Sponsor) RSM US 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@rsmus.com www.rsmus.com “Offering service more than expected — on every engagement.” Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACO/IPA
IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com
ASSET MANAGEMENT
Avid Wealth Partners (HHHH 10K Platinum Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's com-
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San Antonio Medicine • October 2017
mitted to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
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. 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”
The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Manage-
ment in North America for 2017 by Euromoney."
ATTORNEYS
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Employment & Labor Mario Barrera 210 270 7125 mario.barrera@nortonrosefulbright.com Life Sciences and Healthcare Charles Deacon 210 270 7133 charlie.deacon@nortonrosefulbright.com Real Estate Katherine Tapley 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation. Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Common & Not-So Common Legal Ailment”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
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. Rick Tatum richardt@ozonabank.com www.ozonabank.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
RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org 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 Frost (HH Silver 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.”
BUSINESS SERVICES
New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com
CONTRACTORS/BUILDERS /COMMERCIAL
Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction. Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com
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 shuffman@huffmandev.com Lauren Spalten 210-667-6988 lspalten@huffmandev.com www.huffmandev.com
FINANCIAL SERVICES
Avid Wealth Partners (HHHH 10K Platinum Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor Specializing in Investment Management and Fee-Based Financial Planning 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction,
confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@ aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose. Managing Partner Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com
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. 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”
RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for
continued on page 40
visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39
each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org
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”
HEALTHCARE TECHNOLOGY The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney." First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE REAL ESTATE SAN ANTONIO COMMERCIAL ADVISORS (HH Silver Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation,
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San Antonio Medicine • October 2017
RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."
HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home. Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"
HOSPITALS/ HEALTHCARE SERVICES
Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years. Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery. Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire 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 mipeck@selectmedical.com Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
INFORMATION AND TECHNOLOGIES
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
pany 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 Mortgage Kristie Arocha 210-255-0013 karocha@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
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
INSURANCE/MEDICAL MALPRACTICE
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services com-
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 physi-
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY cians 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
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” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor)
Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
INTERNET TELECOMMUNICATIONS
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
MEDICAL BILLING AND COLLECTIONS SERVICES 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.”
“20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”
OFFICE EQUIPMENT/ TECHNOLOGIES
PROFESSIONAL ORGANIZATIONS
Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes. Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”
PAYROLL SERVICES
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
PRACTICE CONSULTANTS
New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only). Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com
The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, non-profit, R&D, healthcare delivery, professional services and more! President Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”
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 www.bcms.org 41 41 visit usus atatwww.bcms.org
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS.
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
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
Pete DeNeergard 210-680-3371
Hugo Rodriguez and Rick Tejada 210-824-1272
Coby Allen 210-625-4988
Abe Novy 210-496-0806
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
Northside Ford 12300 San Pedro San Antonio, TX
David Espinoza 210-912-5087
Sean Fortier 210-681-3399
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
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
Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300 KAHLIG AUTO GROUP
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
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Daniel Jex 210-684-6610
Frank Lira 210-381-7532
Richard Wood 210-366-9600
John Wang 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
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
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
Scott Brothers 210-253-3300
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
James Cole 800-611-0176
Ed Noriega 210-561-4900
Matt Hokenson 210-764-6945
Sandy Small 210-341-8841
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
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43
AUTO REVIEW
2017 Ford F-150 Raptor By Steve Schutz, MD
44
San Antonio Medicine • October 2017
AUTO REVIEW You don’t have to look hard to find cars
or trucks with understated and elegant de-
Fox shock absorbers, and the Raptor’s frame
is strengthened over the regular F-150’s with
word. I was concerned that it would hunt for
And yet, according to Car and Driver,
because, in everyday driving, the transmission
sign. Any Audi sedan qualifies as do their
additional welds and stronger shock mounts.
class is another one, and I’d add the new
those beefy shock absorbers, which stiffen
S90, and Cadillac CT6. There are many
extension to prevent bottoming out during
new Q5 and Q7 SUVs. The Mercedes ELand Rover Discovery, Ford Fusion, Volvo
as they near both full compression and full
more of course, and I applaud the stylists
severe off-road driving, are also softer in the
vehicles. I admire them all.
everyday conditions is softer than it would
who penned these tastefully good-looking
And then there’s the Ford F-150 Raptor.
Festooned with armor-like body “enhancements” and aggressive styling elements ga-
lore, the Raptor is as tastefully elegant as a
The 10-speed transmission is worth a
middle of their travel so that the ride in
be otherwise.
You’d be forgiven for looking at the Rap-
tor and saying, “Sure, the trail-busting sus-
gears in normal driving, and it didn’t. That’s usually shifts up and down two gears at a
time. Naturally, transmissions like this one are
becoming ubiquitous because of emissions and fuel efficiency requirements, so we’d bet-
ter get used to them. But unlike continuously variable transmissions that lack any sort of
charm, Ford’s 10-speed is pleasant to experi-
ence, although it was a little strange to look
at the dashboard at one point and note that I
pension has been tweaked for improved
was in 8th gear at 35MPH.
be rough, right?” Actually, no. I expected a
many options and option packages, space
demographic: outdoorsy guys, 30-45, in
commuting to work was a quiet and com-
in detail. All Raptors come with a 5.5 ft bed,
certainly gun enthusiasts. And UFC fans too,
Raptor’s off road chops — which I didn’t
perCrew (four real doors) configuration. As
tuxedo t-shirt at the opera. In a world of
Jason Garretts it's a Conor McGregor, and
yet it works because it appeals to its target shape, maybe hunters, probably fisherman,
come to think of it. Strong sales validate
Ford’s decision to create this brawny spinoff of the uber-popular F-150.
In case you're curious, no the Raptor
doesn't work for me. I could happily own a
manners on normal roads, but it’s still gonna
harsh ride and totally didn’t get it. Instead,
fortable affair. I’d read so much about the
test, by the way — that the single biggest
The 2017 Ford Raptor is an automotive
150, sure, but otherwise the on-road driving
450HP 3.5L turbocharged V6 EcoBoost en-
Raptor differs from a standard F-150 visually
10-speed automatic transmission. While it’s
signia, black fender flares over all four wheels, prominent underbody skid plates, charcoal 17-inch wheels, and huge knobby tires.
To their credit, Ford made sure the Rap-
guess that makes it a good all-arounder, as-
natural to worry about the V6 when you re-
duty suspension features beefy (3” wide)
road despite all that off-road ability. So I suming you’re looking for a pickup with a
design that’s about as subtle as a Who Farted
member that Raptors used to come with
tank top.
makes 39 more HP and 76 lb-ft of torque
vehicle, call Phil Hornbeak at 210-301-
“honkin” 6.2L V8s, the new engine actually more than the previous motor. Fuel econumm...ok
sure maximal off-road mastery, that heavy-
tell all that by looking at it, of course, but
gine coupled with a yes-you-read-that-right
heavy-duty suspension and higher profile its standard F-150 brethren. In order to en-
extrovert that’s a monster off road. You can
the Raptor is also surprisingly civilized on
omy has climbed from an embarrassing
tires, the Raptor sits three inches higher than
or whatever other vehicle is right for you.
All Raptors now come with 4WD and a
tor is much more than an F-150 with body cladding. Thanks to a raised and bolstered
always, Phil Hornbeak at BCMS headquar-
road noise than you hear in a standard F-
how comfortable the ride was. There’s more
never buy a Raptor. It’s just too OTT.
is: big black grille with a gigantic FORD in-
and either a SuperCab (extended cab) or Su-
ters stands ready to help you find a Raptor
experience is similar.
For the record, a partial list of how the
limitations prevent us from discussing them
surprise for me when I drove this truck was
standard F-150 — a tastefully designed
pickup if there ever was one — but I’d
While the Ford Raptor is available with
12MPG
city/16MPG still
pretty
highway
to
a
If you’re in the market for this kind of
4367.
Steve Schutz, MD, is a board-
embarrassing
certified gastroenterologist who
with 4WD and a similar but less potent 3.5L
1990s when he was stationed here
15MPG/18MPG. (For the record, an F-150 EcoBoost
V6
manages
city/23MPG highway.)
17MPG
lived in San Antonio in the
in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.
visit www.bcms.org 45 45 visit us us at at www.bcms.org
46
San Antonio Medicine • October 2017