San Antonio Medicine December 2017

SAN ANTONIO

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VOLUME 70 NO. 12

MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

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A Brief History of Charitable Hospitals in San Antonio

By J.J. Waller, MD ..............................................18

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

Medicare for All Might Mean Misery for Most

By Alan M. Preston, MHA, ScD ..........................24

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

BCMS President’s Message ............................................................................................................8 BCMS Alliance News ................................................................................................................................10 BCMS Legislative News ............................................................................................................................12 Feature: Vatican Speech: Pornography and the Developing Brain: Protecting the Children

By Donald L. Hilton Jr. MD, FAANS, Adjunct Associate Professor of Neurosurgery, UTHSCSA ..............28 Legal Ease: Driving While Intoxicated during a “No Refusal” Weekend, What do I do?

By George F. “Rick” Evans, Jr., General Counsel, BCMS........................................................................32 BCMS News: Women in Medicine Event...................................................................................................34 BCMS Circle of Friends Directory ..............................................................................................................38 In the Driver’s Seat ....................................................................................................................................42 Auto Review: 2018 Nissan Armada By Steve Schutz, MD ........................................................................44

PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net

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VOLUME 70 NO. 12

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

Patient Protection and Affordable Care Act: Find What’s Missing, Keep What Works, Fix What’s Broken From Texas Medical Association ....................... 20

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Reimbursement Primer

By Alan M. Preston, MHA, ScD ..........................14

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San Antonio Medicine • December 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 • December 2017

PRESIDENT’S MESSAGE

A Year to Remember

By Leah Jacobson, MD, 2017 BCMS President It is hard for me to believe that this year is almost over. I am proud of the many things we have accomplished this year. *We attempted to bring the Medical Society into the modern era by launching the BCMS app in February, and having the first electronic ballot for the BCMS general elections this Fall. *We engaged more actively with our city leaders and community partners, by co-sponsoring one of the mayoral debates along with the Hispanic Chamber of Commerce in March, partnering with Metro Health in the Tobacco (T-21) Campaign this Fall, participating in the joint County/City Opioid Task Force, and promoting our agenda with City Council members. *BCMS continued its active involvement on a State level, lead by Mary Nava, during the 85th State Legislative session. We had many members each month attend the First Tuesdays. We maintained ongoing relationships with our local legislators with committee and individual meetings. BCMS and TexPac, along with TMA, successfully held the first (and hopefully annual) Legislative Forum. *On a financial note, most of the first floor of the new BCMS building was leased this year with two new tenants moving in this Fall. Also, we, as a Board of Directors, invested BCMS funds to help solidify the Society's financial future. *At the TMA level, BCMS successfully promoted the election of Dr. Jennifer Rushton to the position of AMA alternate delegate at TexMed in May 2017. Five BCMS members were also selected for this year's TMA Leadership College (the most ever!). *With the opening of the new University of the Incarnate Word School of Osteopathic Medicine, BCMS forged a new academic relationship. Both UIW and UT-Health have been great partners in sponsoring BCMS events this past year. I thank them and look forward to continuing these relationships. There was also the re-development of an ad hoc committee to address such needs- the BCMS 8

San Antonio Medicine • December 2017

Academic Collaboration Ad Hoc Committee spearheaded by Dr. Adam Ratner. *We had many events, some recurring and some new. With the recurring events, such as the New Member Welcome/Anniversary Event, Women in Medicine 25th Annual Event, and the Auto Show, we tried different venues which I felt were a great success. As for new adventures, the Publications Committee held a terrific writers' workshop in conjunction with Gemini Ink, and we partnered with UHS to hold an ethics seminar put on by the Texas Medical Board. *BCMS members helped support the health of their community by participating at the San Fernando Health fair and the Shavano Park Health fair. Members also provided 24-hour medical care to the evacuees of Hurricane Harvey that were brought to shelters in San Antonio. *Current projects revolve around the development of a new Leadership series for BCMS helmed by incoming president, Dr. Sheldon Gross, and additional cooperation between the BCMS Alliance as they celebrate their centennial year. We are also actively working to revise the BCMS By-Laws.

I would like to thank the members of the BCMS Executive Committee- specifically, Drs. Gross, Ratner, Shah, Holcomb, and Greenfield, for their support and guidance this year, as well as the Board of Directors. A big thanks also goes to the BCMS staff, in particular Steve Fitzer, Melody Newsom, Brissa Vela, Mary Nava, Mike Thomas, Alice Sutton, and August Trevino for their great job running the BCMS. I would like to thank the members of the Medical Society for allowing me to serve as your president. It has been an honor and a privilege.

We tried some new things. I saw some new faces — I consider that a win!

With Warm Regards, Leah H. Jacobson, MD FAAP 2017 BCMS President

BCMS ALLIANCE NEWS

Our Centennial Year!

By Lori Boies, 2017 BCMS Alliance President As 2017 draws to a close, I am honored to have served as your 2017 Bexar County Medical Society Alliance President.

We have done a lot of great things in 2017! Every month, we had a wide range of social events that included dinner clubs, book clubs, Lunch with Littles, Sips and Dips, cooking classes, our General Meeting Programs, and the list goes on. In ad-

dition to our busy social calendar, we also gave back to our community in a variety of ways! We raised money for almost 1000 bicycle helmets through TMA’s Hard Hats for Little Heads program, which we gave out to area children free of charge. The BCMSA received a $2500 grant from the TMA Foundation to partner with SA Metro Health to help provide HPV vaccinations. For Doctors’ Day, we raised $2600 for Project Brave, a local domestic violence awareness organization in memory of Dr. Casey Mitchell Drawert. Additionally, the BCMSA partnered with a local Alcoholics Anonymous chapter to provide free literature to physician’s offices.

This year marked an important milestone for the Bexar County Medical Society Alliance – our Centennial! We celebrated 100 years of fostering friendships among medical families and promoting education and wellness in Bexar County at a scholarship fundraiser and party at Neiman Mar-

L to R - 2018 President-Elect Rena Baisden, 2015 President and Centennial Celebration Chair Rebecca Christopherson, 2017 President Lori Boies, and Centennial Celebration Committee Member Mary Anne Roman

cus. One hundred and fifty guests enjoyed our “party with a purpose” and over $40,000 was netted to provide scholarships to college students pursuing a career in an Allied Health Profession. The BCMSA also unveiled the Sandra Vela Memorial Scholarship in honor of Sandra, one of our board Centennial Celebration Chair Rebecca Christopherson with Sandra Vela's family members, who passed in 2017. A special thank you is due to to announce the creation of the Sandra Vela Memorial Scholarship. our sponsors for making the event possible and allowing us Alliance provides to both the medical family and to our community! to net over $40,000!! We would like to thank our Presenting Sponsor, The Alliance would like to the thank the BCMS staff led by CEO Christus Santa Rosa Health System; Gold Sponsors: HEB, RiverCity Steve Fitzer and board for all of their support during our 100 years!!

Cardiovascular, Medtronic; Valet Sponsor: Barrett Jaguar and Dr. Leah Jacobson deserves recognition for her amazing job of Maserati; Silver Sponsors: Noah Oviedo & Robert Trevino, Clay leading the BCMS board during 2017 as President. I would like to Davenport, South Texas Renal Care Group; Bronze Sponsors: Brian thank my board for their hard work and help this year, and I am exand Lori Boies, Texas MedClinic, Frost Bank, and South Texas Carcited for the vision of 2018 Bexar County Medical Society Alliance diothoracic & Vascular Surgical Associates. I also want to give a President Jenny Shepherd as she leads us into the next 100 years! heartfelt “Thank You” to BCMSA Past President and Centennial Celebration Chair, Rebecca Christopherson. Without her vision, our event would have never been possible!!

As our 100th year concludes, I am proud of everything that the 10

San Antonio Medicine • December 2017

All the best, Lori Boies, 2017 Bexar County Medical Society Alliance President

Find us on the web: bcmsalliance.org

BCMSAlliance.org/

BCMS LEGISLATIVE NEWS

BCMS LEGISLATIVE NEWS BCMS members have been active this past month meeting with local political leaders and pushing issues to improve the health of the community.

Pausing for a photo with Texas State Representative Tomas Uresti (Distirct 118) on Oct. 24 at the Quarry Golf Club were (l-r): BCMS President, Leah Jacobson, MD; Mary Nava, BCMS chief government affairs officer; Alex Kenton, MD, BCMS chair of BCMS Legislative and Socioeconomics Committee; Uresti; Jenny Shepherd, BCMS Alliance president-elect; and John Shepherd, MD.

Dianna Burns-Banks, MD, past president of BCMS and a pediatrician in private practice offers remarks during the Oct. 19 press conference on CHIP, hosted by the office of Congressman Lloyd Doggett (TX-35); (standing with Dr. Burns-Banks).

Daniel Deane, MD (at podium) testifies in support of Tobacco 21 during the Oct. 26 hearing of the City Council's Community Health and Equity Committee.

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

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San Antonio Medicine • December 2017

PUBLIC FINANCING

REIMBURSEMENT PRIMER

By Alan M. Preston, MHA, Sc.D. he word “reimbursement” conjures up and provokes a lot of emotions for providers of healthcare. What should a physician, hospital or pharmaceutical company be paid for their respective service or product?

Are they paid too little or too much? If you are the one paying the bill, you may think it is too much. If you are the one receiving the payment, you may think it is too little. Who is “right”?

To some degree, the marketplace is constantly attempting to figure the answer as to what is the appropriate amount and methodology of payment. Medicare is one of the largest payers for many physicians (not so much for pediatricians). Traditional Medicare does not enter into a bargaining session with physicians. Their contract is a contract of adhesion; take it or leave it! Because of the monopolistic nature of Medicare, they dictate the coverage and pricing of physician services, procedures, hospital stays, and other services performed on a Medicare patient. Other third-party payers have looked at Medicare as the “benchmark” for setting pricing policies for similar covered services on their list of covered services. We call that regressing to the mean in healthcare services pricing.

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San Antonio Medicine • December 2017

Depending on what insurance company you have contracted with, the methodology of payment may be very different from a typical Fee For Service (FFS) reimbursement scheme. Even a “typical” FFS payment is no longer “typical.” Physicians often describe the amount of FFS payment they receive from a Managed Care Organization (MCO). Since Medicare is such a large payer, the MCOs tend to gravitate toward the mean payment for a given CPT code.

Thus, physicians typically describe their reimbursements as a percentage of Medicare. The range is typically 80 to 110 percent of Medicare reimbursement on an FFS from an MCO. Some FFS arrangements are tied to the productivity of the physician. In these arrangements, coding and complexity of the services provided are key factors that go into this type of reimbursement.

Years ago, Medicare created the Resource-Based Relative Value Scale (RBRVS). Many group practices pay their physicians on such a system. The RBRVS is tied to a conversion factor that is multiplied by a CPT code base amount to achieve the reimbursement to a physician. The RBRVS is a fair system since it takes into consideration the acuity and complexity of patients seen by the physician. The

PUBLIC FINANCING challenge that a group practice had when they hired a physician and paid a salary to the physician is that there was no incentive by the salaried physician to properly code the patient’s condition, particularly if the patient had a higher acuity when presenting. The documentation for a higher acuity patient is quite robust, and if you are a physician on a salary, it will not impact your income if you code at the appropriate higher level or simply code at a lower level. For the group practice, however, it can make the difference between profitability or loss!

Larger practices often have the capability to enter into risk contracts with MCOs. There are many iterations regarding risk contracts. Some group practices take on full capitated contracts, while other simply take risk for their professional services. Capitation is a monthly payment, usually based on a per member per month (PMPM). The per-patient fee is tied to the level of services the group negotiates with an MCO. As a full capitated risk contract suggests, the group is responsible for inpatient/outpatient hospital care, ambulatory surgical centers, prescriptions drugs, mental health, DME, specialty services, and PCP services. In other words, the group is essentially taking on the risk of the MCO when they enter into a full-risk capitated contract. Unless the group is very sophisticated in managing their population of patients, this is not an option I would suggest for the average PCP group practice. The rewards can be great for those who know how to manage comprehensive, and a tremendous failure for those who do not fully understand capitated risk.

There are other iterations of risk contracts. Some are upside risks, whereby if the group practice performs well on various metrics, they will receive additional payments or a bonus. When the bonus payment is tied to the income they receive on an FFS basis; the group practice can receive amounts above 110% of Medicare FFS. Some risk payments are tied to a Medical Loss Ratio (MLR). The MLR is calculated by dividing the dollar amount of claims in a given period (monthly, quarterly, annual) to the revenue amount for the same reporting period. It is often expressed in a single number such as 85% MLR. If the group practice achieves an amount better than a target MLR, then savings are split with the MCO. The aggregate income to the practice is then further divided to the individual physicians on some performance/productivity basis.

Medicare is now looking at outcome-based performance for their members. The payment that CMS pays to the MCO is risk-based, meaning each patient has a different risk score and each risk score is correlated to a monthly payment for such patient. The Medicare

Advantage private patients are reimbursed in this manner. The results have been positive for CMS, and they are now looking at ways to introduce such value-based payments on traditional patients. The value-based reimbursement often involves “Population Health Management” (PHM) to accomplish a lower MLR. Physician’s manage one patient at a time. Over the course of a year, however, if we added up all the patients seen by a primary care physician, the entirety of that population may have some common characteristics that may need to be tracked and managed. And to the extent a primary care physician averaged 20 patients visits a day for 210 days out of the year, they would encounter approximately 4,200 patient visits. Some of the visits are repeat follow-up visits and probably account for over 50 percent of the patient “population.” Thus, a primary care physician may have a panel of patients for a year of approximately 2,500 to 3,000 patients or more.

Of that “population” of patients, there are some characteristics of patients that have similar disease classifications. Take Type II diabetes for example; The prevalence rate of Type II is approximately 9.3 percent (i.e., 29 million people) according to the CDC. However, over 86 million have “pre-diabetes.” And of the 29 million people who have Type II, approximately 8.1 million people don’t know they have it and are undiagnosed!

This is a good example where population health management can play an important role for both the patient and the doctor. Imagine if a physician’s practice ran a report that looked at many of the risk factors for type II diabetes. Some of the risk factors would be: Age, weight, ethnicity, and gender, to name a few. That list could be cross-referenced with known lab data to determine whether the “population of interest” had their Hba1c or blood sugars tested and resulted. If not, scheduling the patient for a visit to perform such a test in the population of interest might reveal undiagnosed patients and pre-diabetic patients. Treating the undiagnosed patient and the pre-diabetic patient is the benefit of population health management.

And the Centers for Medicare and Medicaid Services (CMS) is very interested in physicians that understand how to perform population health management functions. CMS understands that physicians that embrace the benefit of population health management should be paid for their patient's improved healthcare outcomes.

Population health management involves many aspects of managing a patient. The goal is to assure that for a given disease; the patient is contacted, treated, followed-up, and the outcome improved.

There have been some early elementary attempts at trying to get physicians to adopt components of population health management. continued on page 16

visit us at www.bcms.org

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continued from page 15

The Healthcare Effectiveness Data and Information (HEDIS) is one such attempt and helps physicians focus on certain metrics that affect payment.

HEDIS is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service.

Many health plans use the HEDIS measurements to highlight their scores to prospective employers.

HEDIS measures address a broad range of important health issues.

Among them are the following: • Asthma Medication Use • Persistence of Beta-Blocker Treatment after a Heart Attack • Controlling High Blood Pressure • Comprehensive Diabetes Care • Breast Cancer Screening • Antidepressant Medication Management • Childhood and Adolescent Immunization Status • Childhood and Adult Weight/BMI Assessment For the Medicare Advantage population, CMS has used another tracking program called STAR. One of the differences between HEDIS and STAR is that HEDIS is responsible for making sure that providers at least perform the activities of measurement as required by HEDIS, whereas STAR requires both the performance of the measurement activity with the additional requirement of demonstrating improved outcomes. Thus, it is not good enough that the doctor saw the patient, they also need to make sure that the prescribed treatment is heading in the right directions regarding outcomes.

Star Ratings are driving improvements in Medicare quality. The Star Rating measures span five broad categories: • • • • •

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Outcomes Intermediate Outcomes Patient Experience Access Process

San Antonio Medicine • December 2017

Not every domain is weighted equally, however. For 2017 Star Ratings, outcomes and intermediate outcomes continue to be weighted three times as much as process measures, and patient experience and access measures are weighted 1.5 times as much as process measures. CMS assigns a weight of 1 to all new measures.

Of the 364 health plan contracts that participate in Medicare Advantage, there were only 81 with a STAR rating of 4.5 or higher.

The lesson in reimbursement for physicians is that that world is getting more complex and there are real opportunities to receive additional pay for performance. It is not an easy objective to achieve and requires a lot of expertise in this area. Even though the physician may achieve a higher level of income, there will be costs associated with achieving the higher reimbursements. Nevertheless, this appears to be the direction the government is heading. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is an example where outcome-based performance payment is heading.

Alan Preston, MHA, Sc.D., is an independent consultant that helps physicians navigate through the difficult regulatory framework and helps them achieve higher reimbursements from insurance companies; skilled with a tremendous background in managed care and Population Health Management, epidemiology, team building, and biostatistics; strong healthcare professional with a Doctor of Science (Sc.D.) focused in Public Health, Health Services Research from Tulane University School of Public Health and Tropical Medicine. Dr. Preston is involved in risk-sharing contracts, ACOs, Medicare Advantage including RAP scores, HEDIS, and STAR ratings which helps physicians and health plans alike in reducing MLR.

visit us at www.bcms.org

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A Brief History of Charitable Hospitals in San Antonio

By J.J. Waller, MD he provision of medical care to the indigent and homeless has been the responsibility of various medical systems to various degrees for ages. Historically, the ancient Egyptians and Greeks had temples dedicated to the treatment of both the successful levels of society as well as the poor. The Romans had scattered hospitals throughout the Empire to treat the military, freeman, and slaves. The declaration of Christianity as an accepted religion in the empire drove an expansion of the provision of care. After 325 CE, construction of a hospital in every cathedral town was begun with frequent separate buildings for various classes of patients.

Throughout the Middle Ages, primarily because of the numerous Crusades, various religious and lay orders were established to provide nursing care. Most of these initially arose as military orders to combat the Muslims in the Holy land; however, the orders, in addition, founded nursing groups to care for the wounded and the many pilgrims who became ill and destitute en route to the holy Christian shrines. One of the most famous was the Knights Hospitallers, also known as Order of Knights of the Hospital of Saint John of Jerusalem, and later the Knights of Rhodes and Malta or the Sovereign Military Order of Malta. Wherever they established a military fortress, they also included a hospital to care for the sick and wounded. One of these orders was the Order of St. Camillus. It started the first ambulance service and initiated the sign of the Red Cross, still in use today.

In the 18th century, in the Age of Enlightenment, the modern hospital began to appear, having separate departments set up for different categories of patients. The voluntary hospital movement began in the early 18th century, forming early in England and being financed by private enterprises such as banks or wealthy merchants.

The concept of voluntary hospitals also spread to colonial America.

Under British control in New York, a prominent almshouse was constructed in 1736. It was a two-story wooden and brick structure costing 80 pounds for building materials and 50 gallons of rum for

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San Antonio Medicine • December 2017

construction. The almshouse contained a room for the sick and insane and a prison in the cellar for the unruly and obstinate. This was subsidized by public funds. The one room infirmary was the seed from which grew the mighty medical complex of Bellevue.

The Franciscan mission of San Antonio de Valero was established on the San Antonio River at San Antonio de Béxar in 1718 along with a military presidio and a small civilian settlement. The mission increased over the decades building a chapel and houses for the local Indians to live and work. The mission was not very successful, and it was secularized by the king of Spain in 1793. In 1803, the mission was occupied by a Spanish military unit from “Alamo de Parras, Coahuila” from whence the “Alamo” name appears to have come into general use.

The first hospital in San Antonio was established on Oct. 19, 1805, in the Alamo by decree of the Spanish government. The Alamo was partially repaired from its deteriorated condition to provide a clean room housing six beds made of reeds (bamboo or cane stalks). The area’s only physician, a civil servant of the Spanish government, was commissioned to treat all the residents of the county, including the military, Native Americans residing in the various missions, and the civilian settlers. In addition to the physician, who was paid 30 pesos a month, there was one nurse, a male, who was paid 12 pesos a month, and a woman to do the cooking for the patients, who was paid 8 pesos a month. The population of San Antonio at that time was approximately 300.

Due to the increasing number of patients, the governor had two additional rooms in the Alamo repaired to house more patients and to provide one as a pharmacy. He ordered the purchase of lumbar to construct “30 beds fully equipped.” This was completed in 1807.

In 1809, the hospital instituted the smallpox vaccination for all military and civilian members of the community. It continued as a military infirmary until 1821 when Mexico became a republic and funds were no longer available to maintain the Alamo as a hospital.

Of historical interest only, after the battle of the Alamo, and during the years of the Republic, the Alamo remained deserted. In

PUBLIC FINANCING 1846, when the United States joined the Republic of Texas to form the State of Texas, the United States Army moved in to San Antonio

as a force to protect the border. They leased the Alamo from the Catholic Church as a military depot and quartermaster center until

1872 when it was returned to the church. The Army had restored considerable portions of the Alamo. The Catholic Church sold it to the State of Texas for $20,000, who in turn turned it over to the Daughters of the Republic of Texas in 1905. Restoration was completed in 1935. Thus, the Alamo, the first hospital in Texas, has had a long and varied history.

During the interval of the Republic of Texas, eventual statehood, and up until the civil war, there was no hospital in San Antonio. In 1869, in response to a second cholera epidemic in San Antonio, the Bishop in Galveston, who’s Diocese covered all of Texas, sent three nuns from the Galveston House of the Sisters of Charity of the Incarnate Word to San Antonio. This order ran the St. Mary’s Infirmary in Galveston. On arriving in San Antonio, the three sisters were notified that a building that had been erected for their use had burned down. With eight months of hard work, they completed a small hospital, which was named Santa Rosa Infirmary, which opened Sept. 3, 1869. This was the first private hospital in San Antonio. It was devoted to the medical care of the poor. Every physician was encouraged to send his patients for care to the hospital, whether paying or charity. At this time, the population of San Antonito was 12,000. Upon opening, nine beds were available. On the first day, eight became occupied. Admissions rapidly increased and the hospital became inadequate. The sisters then occupied a building on West Houston Street, which eventually became the permanent location. This structure had 500 beds and was served by 12 sisters and 6 novices as staff.

In 1900, Santa Rosa became the primary medical facility in the area.

It admitted all the ill in need, especially the children. In 1903, they opened a school of nursing. In, 1915, they opened the first free clinic in San Antonio outside the hospital. In 1922, 3,383 cases were admitted to the infirmary. Of that number, 10 percent were classed as charity cases and 12 percent were partial pay. In 1935, it became the first hospital in Texas to install air conditioning. By 1940, 6,000 patients were admitted annually with no regard to religion or ability to pay.

Now known as Christus Santa Rosa Children’s Hospital, many changes have occurred. With the rising pediatric population, it is now joined with Texas Children’s Hospital and Baylor University College of Medicine to form a completely devoted children’s hospital.

Of special interest is the opening of the Robert B. Green Memorial Hospital in 1917. There is an excellent article about this hos-

pital presented in San Antonio Medicine in the July 2017 issue written by Don Finley. For several years prior to the establishment of

the Green Hospital, indigent care had bene provided by a small San Antonio City Hospital. Endless financial and structural problems

were encountered and by 1915, the community leaders decided to tear down that hospital at North Leona and Morales and build a new facility on the same site. It was financed by a bond issue by the county and city totaling $250,000. Completed in February 2017, partly financed by the Joske family (owners of Joske’s department store in downtown San Antonio). Due to the generally high morbidity and mortality among members in the Hispanic area of San Antonio and high infant mortality rate, a new highly functional hospital to care for the indigent patients was badly needed.

The first patient admitted (Feb. 2, 1917) was a woman suffering from salpingitis. The second admitted was a woman with third degree burns.

In 1918, during the influenza pandemic, Green treated 600 inpatient cases of flu and pneumonia with a low mortality rate (for that era) of 21 percent. The hospital rapidly became the provider of medical care for the indigent patients, immigrants, and victims of trauma. It should be noted that the first hospital contained 200 beds.

The institution struggled for lack of funds and partially shut down in 1947, reopening in 1948. In 1955, the community formed the Bexar County Hospital District and with the access to property taxes, the conditions stabilized. In 1965, a $5 million expansion of Robert B. Green Hospital occurred followed in 1977 by the addition of the Brady Clinic to the Green forming the Brady/Green Community Health Center. It still stands as part of the Robert B. Green Campus, a Multispecialty Comprehensive Outpatient Center seeing 130,000 patients a year.

In December 1965, construction commenced on the $15 million Bexar County Hospital which was to assume the role of inpatient care previously provided by the Green. Construction of the University of Texas Medical School of San Antonio soon followed (now called UT Health San Antonio). Both opened in 1968. The University Health System today includes more than two dozen locations being a primary teaching facility of the health center, a level 1 trauma center, many highly rated inpatient services, and a separate center dedicated to diabetes research and treatment.

San Antonito can be extremely proud of its long history of institutions dedicated to the treatment of the indigent of our great city and county.

J.J. Waller Jr., MD, is a member of the BCMS Communications/Publications Committee. visit us at www.bcms.org

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PATIENT PROTECTION AND AFFORDABLE CARE ACT: Find What’s Missing. Keep What Works.

Fix What’s Broken.

Find What’s Missing in the PPACA Sustainable Growth Rate: Flawed Physician Payment Formula

The Sustainable Growth Rate (SGR) is a flawed funding formula the Centers for Medicare & Medicaid Services uses to pay physicians for the care they provide to Medicare patients.For the past decade, physicians have faced double-digit pay cuts because of the flawed SGR. Only emergency congressional intervention stopped cuts each year. The uncertainty surrounding the Medicare program, especially in this time of change, makes it extremely difficult for physicians to plan for the future. As a result, fewer physicians are taking new Medicare patients. The new health care law did not address this problem.

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TMA Ask: Repeal the broken SGR. Enact a rational Medicare physician payment system that works and is backed by a fair, stable funding formula. Fix the broken Medicare payment system before giving additional increases to any other providers.

Medical Liability Reform

Texas has gained more than 21,000 new physicians to take care of Texas patients since 2003. Of these, around 5,000 can be attributed to Texas’ medical liability reforms. Many of these new physicians practice high-risk specialties such as emergency medicine, neurosurgery, pediatric intensive care, and pediatric infectious disease. Texas patients now can get more timely and convenient care when needed. Twenty-one rural Texas counties have added at least one obstetrician since the passage of Texas’ medical liability reform,

PUBLIC FINANCING including 12 counties that previously had none. The emergency care provisions have saved lives by helping ensure Texas patients have access to critical and timely care. The 2003 liability reforms have worked. They’ve lived up to their promise. Sick and injured Texans now have more physicians who are more willing and able to give them the medical care they need.

The rest of the nation will benefit from Texas-style reforms TMA Ask: New medical liability reforms must measure up to the “Texas-size” reforms. New national medical liability reforms must NOT modify or change reforms now in Texas law.

Antitrust Relief for Physicians

The Federal Trade Commission prohibits a physician’s ability to clinically integrate as imagined by the new health law. The new health law asks physicians to collaborate in ways government has discouraged through antitrust laws. For physicians to clinically integrate so they provide efficient care as imagined by the PPACA, a broad, bright-line rule needs to be established so physicians can work together without fear of government discipline.

TMA Ask: Congress needs to provide antitrust relief for physicians so that they can organize to provide cost-effective care and be protected from unscrupulous corporations putting profits before patients.

Direct Contracting

As baby boomers come of Medicare age, increased flexibility in Medicare will be necessary to ensure patients have access to a physician. One way to accomplish this is to allow Medicare patients to see any physician of their choice. Physicians should be allowed to enter into direct contracts with Medicare patients, even when they opt out of the Medicare.

TMA Ask: Pass the Medicare Patient Empowerment Act. Give physicians the ability to directly contract for any and all Medicare services.

Keep What Works in the PPACA Insurance for People With Preexisting Conditions

From July to October 2009, TMA conducted 16 town hall-style meetings (aka House Call meetings) on health reform across Texas with more than 3,000 patients and physicians participating. At every meeting, both patients and physicians called on Texas legislators and

Congress to prohibit health insurance companies from excluding coverage for patients with preexisting conditions. Patients need access to health care coverage, especially when they suffer from an ongoing medical condition. The PPACA now helps patients who have a preexisting condition obtain and maintain coverage when they are sick.

TMA Ask: Maintain the PPACA provision prohibiting insurance companies from excluding coverage to patients with preexisting conditions.

Prohibition on Rescissions

Patients should not lose their health insurance, especially when they need it most, because of an honest mistake when filling out health insurance paperwork or applications. Prior to the PPACA, health insurers could rescind a patient’s insurance policy if they discovered an alleged misrepresentation in the patient’s initial application for insurance, even an honest mistake or omission.

When coverage is rescinded by an insurer based on a misrepresentation on the application, all coverage is rescinded, leaving the patient responsible for paying for all of his or her health care services past and present. Health insurance applications are confusing, and sometimes people make honest mistakes in completing the forms.

TMA Ask: Insurers should not be allowed to cancel a patient’s health coverage over technicalities in completing forms.

Medical Loss Ratios

Health insurer profits are expressed as part of the industry’s term “medical loss ratio.” The medical loss ratio is the percentage of premium dollars spent on payments to physicians, hospitals, and other health care providers for health care services rendered. The premium dollars left include health plan salaries and overhead, as well as profits. Simply stated, insurers can maximize their profits by spending less on a patient’s health care.

Employers and employees are spending more money on health insurance coverage each year. Yet they have no idea if their hardearned premium dollars are going toward health care or elsewhere. Prior to the adoption of the PPACA, there was not a single definition of a medical loss ratio. This made it impossible for employers and patients to compare health plans. TMA believes a consistent reporting formula for medical loss ratio works.

Now employers and patients can compare health plans with others when shopping for insurance. continued on page 22

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continued from page 21

TMA Ask: Maintain the PPACA provision requiring health insurers to use a consistent reporting formula for medical loss ratio.

Consumer Label for Insurance and Plain Language Explanations

Purchasing health insurance coverage today is increasingly complex. Health insurance companies offer a wide range of plans with different benefits, exclusions, and costs. It is nearly impossible to decipher a health insurer’s sales literature, then make a direct, product-to-product comparison.

Employers and patients need accurate, current, and honest information on copayments and deductibles to make decisions in today’s health care market. The real need for this information is not when patients are sick or injured but rather when Texas businesses and their employees are shopping for health insurance coverage.

Standardized and reliable nutritional labeling has made it much easier for consumers to make better food choices. Consumers can examine 20 different boxes of cereal and easily compare the product benefits, such as number of calories and percentage of fat, sodium, sugar, or protein. TMA believes the same standardized system could aid employers and consumers when shopping for health insurance. The PPACA contains an insurance label requirement, and TMA agrees that plain-language information (like the label) will aid our patients.

TMA Ask: Maintain the PPACA provision requiring health insurance labeling in plain language so patients can better understand their insurance coverage.

Fix What’s Broken in the PPACA Independent Payment Advisory Board

The law creates a 15-member Independent Payment Advisory Board (IPAB) that has the authority to control Medicare spending, starting in 2015. IPAB can make recommendations that lead to decreases in Medicare spending ONLY through lower payment rates to physicians. IPAB recommendations would become law automatically unless Congress passes a law to reach the same budgetary savings.

The issue of Medicare spending is too important to be left in the hands of an unaccountable board with decisions based solely on cost.

TMA Ask: Repeal the Independent Payment Advisory Board. Keep Congress accountable for the Medicare system. If decisions are made to limit funding for health care services, priorities will have to be set. It should not be left, however, to an unelected and unaccountable IPAB. 22

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Workforce/Graduate Medical Education

Texas medical schools are doing their part to expand medical student enrollments. However, graduate medical education (GME) programs are not growing in the same fashion. As a result, many of our newest physicians end up moving to other states for their residency training. GME is a necessary part of a physician’s preparation for medical practice. Physicians who complete both medical school and GME in Texas are three times more likely to remain in the state to practice.

Texas’ medical schools and teaching hospitals have limited funding available to expand GME. The shortage of GME slots guarantees some medical students will be forced to leave the state upon graduation. Those leaving likely will not return to Texas. They will take with them more than $200,000 of state investment in their medical school education. The current model for funding GME in the United States has not changed in more than 15 years. This significantly hurts the ability of states like Texas to offer GME programs to medical students.

TMA Ask: Maintain GME funding through Medicare and consider adjustments for future support based on population growth.

Overbearing "Fraud and Abuse" Enforcement Healthcare Fraud Criminal Statute

Texas physicians recognize the need to rid the health care system of fraud. We want to work hand in hand with Congress to ensure our health care system operates effectively and efficiently. The PPACA includes provisions that increase funding and the government’s authority to combat fraud and abuse. Language was changed in the Healthcare Fraud Criminal Statute that might have unforeseen consequences. The law removed the government’s burden to show that an accused had “actual knowledge of the law or specific intent to commit fraud.” It added this new language: ‘‘(b) With respect to violations of this section, a person need not have actual knowledge of this section or specific intent to commit a violation of this section.” As a result, many physicians may be charged as criminals for honest mistakes. Honest mistakes or errors should not result in a government crackdown.

TMA Ask: Revisit and/or remove language relating to the Healthcare Fraud Criminal Statue

Imaging Referrals

There also are additional written requirements regarding MRIs,

PUBLIC FINANCING CTs, and PET scans. Physicians now must inform patients in writing at the time of the referral that they may obtain services elsewhere and provide a list of others who provide such services in the area.

Physicians already are required to seek preauthorization for most imaging services. They should not also be required to compile and maintain a list of other imaging providers. If the federal government mandates a list, the government should provide it. More paper, more processes, but where is the health care?

TMA Ask: Revisit the imaging referral provision and remove the arduous paperwork requirement, so physicians can spend more time taking care of patients versus pushing paper.

Antidiscrimination Provisions for Health Plans

The PPACA includes a provision stating health plans may not discriminate against any health care providers — acting within their state scope-of-practice laws — who want to participate in the plan.

TMA Ask: Ensure this provision is not misinterpreted to permit providers who have not been trained as physicians to misrepresent themselves as possessing the education, knowledge and training of physicians.

Restrictions on Hospital Ownership

Throughout the health care debate, the Mayo Clinic, Cleveland Clinics, and Texas‘ Scott & White Hospitals were held up as the gold standard of how to deliver efficient and high-quality care.

All these institutions have one thing in common — they are physician-owned and physician-led. In the future, these types of institutions are banned. A provision in the PPACA (under the guise of “fraud and abuse”) actually prevents physicians from establishing hospitals that participate in Medicare. The PPACA makes future hospital ownership illegal for physicians who go to medical school, obtain a license to practice medicine, care for Medicare patients, and then want to refer their Medicare patients to a hospital in which they may have ownership. If a physician had already owned a hospital, the PPACA severely limits how that hospital can expand and operate moving forward.

Accountable Care Organizations: Fairness

The accountable care organization (ACO) is a new concept in the PPACA. It asks for physicians to invest in a new model of health care delivery that increases efficiencies and delivers the right care at the right time. However, the incentives in the program are left to the whim of federal administrators. A participating ACO can’t challenge many government decisions about the performance of an ACO, including: 1. Whether the ACO is eligible to share in any savings it creates,

2. The amount of shared savings to be paid to the ACO, 3. Which patients the government assigns to the ACO, 4. What measurements the government plans to use to determine the quality of care the ACO provides, 5. The government’s assessment of the quality of care the ACO provides to patients, and 6. A determination to terminate the ACO from the program.

TMA Ask: ACO rules must be fair and equitable, and must recognize physician leadership on issues related to patient care, quality assurance, and clinical integration. Physicians should not be viewed simply as another source of labor.

Funding for Health Information Technology

The Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the American Recovery and Reinvestment Act, provided funding and incentives for physicians to adopt electronic health record technology. As a result, many physician practices have made significant investments in these technologies. They are working to integrate these systems into their practices and meet the “meaningful use” criteria established to receive the financial incentives. However, just as these investments are being made, Congress is considering bills that would repeal or significantly reduce its support for HIT. TMA Ask: Protect the HITECH Act from repeal. Continue with the current incentive program to help physicians acquire electronic health record systems. This will improve health care in America in so many ways.

TMA Ask: Repeal legislation that limits physician ownership of hospitals. Promote responsible ownership of all health care facilities, whether owned by a physician, hospital, or other provider.

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MEDICARE FOR ALL

MIGHT MEAN MISERY FOR MOST As the Affordable Care Act (ACA) continues to implode and the replacement or fix is becoming increasingly unlikely, Bernie Sanders and a few of his Senate constituents have suggested that “Medicare For All” may be the solution. Is there any substance to the Bernie Sanders single payer model?

I decided to review Sanders’ website to determine the salient features, positions, and claims he makes about the benefits of a single-payer system and analyze the merits of such. His first claim is: “That Healthcare must be recognized as a right and not a privilege.”

I have previously written about the differences between a right and a privilege, and it bears repeating here.

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By Alan M. Preston, MHA, Sc.D.

What are the “Rights” we have in the Constitution? The Bill of Rights has quite a list of rights. The second amendment provides the right of the people to keep and bear arms, and that right shall not be infringed upon by the federal government. Now, whether or not you support gun ownership is not the primary issue here. The issue is about rights in our constitution. The Bill of Rights exists to protect the “people” from the government, trying to take away such rights. This popular quote says it best: “When governments fear the people, there is liberty. When the people fear the government, there is tyranny.”

Nowhere in the constitution does it suggest that the Federal

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Government must PAY for you to enjoy such a right. Imagine that I wanted to purchase a beautiful revolver that cost $1,200.00. I reached into my pockets, and I am shy by an amount of $1,100.00.

Should I go to Congress and DEMAND that they pay for the revolver of my interest? I could say it is my right and the fact I cannot afford it, suggest I am being denied my right to bear arms as protected by the 2nd amendment of our Constitution.

Whether you are a Democrat or Republican, I suspect both would tell me that it is not the obligation of the federal government to pay for one to enjoy their right to the extent they want to exercise such.

And I would agree with them. However, when it comes to healthcare, and even assuming healthcare was a protected right under the Constitution, it does not suggest that the government has an affirmative obligation to pay for you to enjoy such a right. And like gun ownership, affordability is a different concept than the right itself.

Bernie Sanders has confused the word “RIGHT” with “ENTITLEMENT” of payment to enjoy such a “Right.”

Bernie Sanders then suggests that “the only long-term solution to America's health care crisis is a single-payer national health care program.” Really? I am sure there are many solutions! The challenge is the definition of the word or concept of “solution.” One person’s solution is another’s problem. And suggesting that the government is the only solution via single payer is the definition of socialism.

True believers in socialism have a view that ONLY the government can solve problems of the citizens (and in Bernie’s case, even noncitizens) they govern. Thus, if you like the efficiency of the U.S. Postal system, with the compassion of the IRS at Pentagon prices; you’re going to love government controlled healthcare! Furthermore, single payer can achieve lower cost; however, at the expense of the physicians and hospitals by cutting their reimbursements substantially, which would create a smaller supply of physicians and hospitals, and then waiting lines.

Consider the impact of a single-payer system. If we were to award only one private insurance company to control all insurance in the USA, wouldn’t that create a monopoly or at least a monopsony?

The difference between a monopoly or monopsony is the former is a single seller, and the latter is a single purchaser. Regardless, concentration is funneled into one private company. I suspect that most Americans would be quite vocal against granting such colossal market power to one private company. So why is it different when the single source of power is the Federal Government? Whether we consolidate power to a single private firm or a single government

agency, it is still a consolidation of power, and thus zero competition is involved. Granted, having an iron-fisted monopoly can certainly command lower prices from the doctors, hospitals and pharmaceutical companies; however, how many of the doctors, hospitals, and pharmaceutical companies will agree to see such patients? And those providers that do agree; how long can they offer a plethora of services before they go broke with such a reduction of price controls and mandates? (and I use the word agree loosely given that a mandate or a take it or leave it stance, is hardly the concept of agreeing; it is coercion).

Consider Medicaid and the current ACA dilemma? There is a reason why so many insurance companies are not offering services under the ACA. They are tired of losing money. Likewise, with physicians accepting Medicaid; they have a difficult time making money given the low reimbursement rates, and thus many doctors do not accept Medicaid.

Another element of the Bernie Sanders plan is to “eliminate waste.” This claim is very difficult to take seriously given that Medicare currently wastes through fraud and abuse EVERY YEAR, $60 BILLION! Expanding a program that cannot control fraud and abuse is likely to increase waste; not eliminate it, as Bernie Sanders suggests. If Bernie is so interested in reducing waste, why doesn’t he propose a plan to accomplish this now; or for that matter, 10 years ago? He has no plan or a clue how to accomplish such.

Bernie suggests that a typical family would save $5,000 per year in premium costs under his plan. That is an astonishing claim given that President Obama made a similar claim about the ACA. Obama suggested a savings of $2,500 per family. How well did that claim work out? It didn’t! Healthcare premiums increased, and they continue to increase which is why more and more Americans are opting to pay the penalty to the tune of $31 billion in the aggregate in 2016. Paying the penalty is evidence that millions of Americans do not have insurance under Obamacare yet for some odd reason, we never hear about the millions of Americans that have been effectively shut out from buying health insurance due to the high cost and low availability of health plans and doctors. Welcome to government-run healthcare.

The inherent challenge with socialized healthcare, or any product for that matter, is that it creates major disruptions in the private sector, reduces innovation, reduces access, creates waiting lines and seldom if ever accomplishes the stated objective. The evidence is all around us. Venezuela is an excellent example of socialism gone amuck. The one choice of a loaf of bread may be cheap, but just not available; not continued on page 26

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continued from page 25

a problem though, just get in line tomorrow a tad earlier!

Let’s take a look at cancer survival rates in the USA vs. England.

The USA usually ranks first in the survival rate of cancer. Prostate cancer as an example has a 97 percent chance of the five-year survival rate in the USA compared to England which is about 83 percent. Part of the difference is due to the inherent waiting lines that socialistic healthcare inevitability creates. What is the advantage of having free care if you can’t access it when you need it? The costs of healthcare are one issue; however, quick access to quality providers is more important, particularly if you desire early detection, treatment, and exceptional outcomes. And as I stated in previous articles, one of the impacts of socialism is that it always creates scarcity, reduces competition, stifles innovation, and creates waiting lines! I certainly understand, that when people think their healthcare will be cheaper if it is government run, can be an appealing proposition; however, the reality throughout the world tells a very different story in those single-payer systems.

Seldom do we consider WHY healthcare is expensive here in the USA. And unfortunately, in today’s world, too many people cannot reason and simply blame one aspect of a healthcare delivery system as to the woes of the entire system. Take insurance companies as an example; many blame the increasing healthcare cost solely on the alleged greedy insurance companies. And those that lack an understanding of the healthcare delivery system feel that if we eliminate the private insurance companies and embrace a single government payer system, then the cost to consumers would be dramatically decreased. This line of

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thinking is close to delusional thinking (it is more akin to reactional panic than it is reason and logic).

First of all, for the last 15 to 20 years, most publicly traded insurance companies earned in net profit around 3 to 5 percent!

Hardly what I would characterize as greedy. And the administrative costs are relatively low as well when compared to other industries.

The administrative costs including profit are highly dependent upon the size and thus if they are large, it is usually less than 15 percent, and if they are small, it is 20 to 25 percent as a percentage of revenue. And the administrative cost for the insurance companies would be less if they did not have to comply with the plethora of government regulatory mandates. Shifting the administrative cost functions, such as adjudicating claims on behalf of the doctors and hospitals will not go away if it is consolidated in one monopolistic source. And the Federal Government is notorious for adding layers and layers of administrative cost to any agency. Can you name an agency that has had a reduction in administrative costs? Probably not; which is one reason why the USA is about $20 trillion in debt!

One reason that healthcare costs continue to increase is directly due to government mandates! The government mandates that insurance companies offer “minimum essential benefits.”

These benefits are neither minimum nor essential. They are however costly.

And every time

the government mandates that the insurance company offer some benefit, you the consumer pays for the mandate in the form of higher premiums or deductibles. Even when healthcare is not government-run, they insert themselves into the picture, and the result is higher costs to everyone.

We live in a wonderful country here in the USA. Despite those millionaire athletes who have contempt for this country by disrespecting the very symbol of freedom and liberty; our national flag and anthem, opportunities are everywhere due to our capitalistic approach.

The fact that there is so much freedom of choice is, however, costly.

Duplication of services adds to the costs. The benefit of free choice and individual liberty to make such choices are immensely important as mentioned supra.

The other good news here in the USA is that as we continue to get older, we live longer. And the baby boomer generation has boomed. And all of the innovations have kept us living longer. That comes at a price as well. Innovation follows capital, and if one looks at countries that are more socialistic or communistic, there is little innovation because there is little desire by the citizens to innovate when the government takes the fruits of their intellectual property away from them. Also, since innovation and excess capital go hand and hand, it seems rather obvious to me that if 20 percent of our economy (Healthcare represents about 20 percent of GDP) and one takes away the private capital market and substitutes it for a government-run market, innovation will disappear as well. Is that what you want with single-payer healthcare?

There are many other cost drivers not mentioned here. My point is that the private industry is NOT the sole source of cost drivers to our expensive healthcare system. I mentioned that only 20 percent of the insurance costs are administrative. What does the other 80 to 90 percent represent? Those are claim costs. The money paid out to the doctors, hospitals, and pharmaceutical companies. If the government was the single payer, they could simply pay that group 50 percent of what they receive now and reduce the costs of healthcare. And that is exactly what happens in the single payer countries; the providers make a whole lot less. And when they make a whole lot less, few and fewer decide to go into medicine-related fields, and that creates shortages. Thus, increased waiting lines. Is that a tradeoff you are willing to accept?

Be careful when a politician dangles the word FREE! Not much in life is free, and ultimately someone must pay for all the free stuff.

And the payment for the free stuff comes in all shapes and sizes.

Longer waiting lines, fewer substitutes in services, higher deductible,

higher taxes, payment cuts, less innovation, and the politicization of our healthcare system. If you are a politician and have some illness (let’s assume AIDS or depression) and are in public office, the record of your illness will get leaked to the media to stop you from running again. Or it will be leveraged against you to vote a particular way, contrary to your constituents’ desires. Or maybe your employer would have the information leaked to them and all of a sudden, your position gets eliminated. I would rather have our healthcare system decentralized by private individuals where we can hold them accountable.

Do you still want Medicare for all?

Dr. Alan Preston is an experienced Chief Executive Officer with a demonstrated history of working in the managed care and in a broader context many aspects of the healthcare industry. Skilled in both For-profit and Nonprofit Organizations, with a tremendous background in managed care and Population Health Management Epidemiology, Team Building, and Biotechnology. Strong entrepreneurship professional with a Doctor of Science (Sc.D.) focused in Public Health, Health Services Research from Tulane University School of Public Health and Tropical Medicine. Very involved in risk-sharing contracts, ACOs, Medicare Advantage including RAP scores, HEDIS, and STAR ratings which helps physicians and health plans alike in reducing MLR!

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FEATURE

EDITOR’S NOTE: Earlier this year Dr. Donald Hilton was invited by the Vatican to give an address at Gregorian Pontifical University in Rome, Italy on the deleterious effects of pornography on the developing minds of children. Following is the full text of that speech.

Pornography and the Developing Brain: Protecting the Children Gregorian Pontifical University Rome, Italy October 4, 2017 Donald L. Hilton Jr. MD, FAANS Adjunct Associate Professor of Neurosurgery University of Texas Health Sciences Center, San Antonio The brain’s reward system balances rational thinking and wanting, what Thomas Aquinas called the rational and the animal appetites.

Addictive behaviors can include substances like cocaine or behaviors like viewing pornography, and youth are particularly vulnerable to the harms of pornography. Five considerations are discussed: the immaturity of the frontal judgment areas, the sensitivity of the developing reward center, cultural conditioning of youth, imprinting of the mirror neuron system in forming sexual scripts and templates, and the exposure of vulnerable and impressionable minds to the powerful supranormal stimulus of pornography. It is imperative that we effect a cultural and legal change to protect children from pornography and secure their future.

I would like to thank all who have done so much to organize and administer this marvelous event, and I am grateful for the opportunity to share a few thoughts with you. I have had the privilege of performing and teaching neurosurgery for almost 3 decades, yet I still feel a sense of wonder and awe each time I see and touch the human brain.

We have, simplistically speaking, two brains. Our cortex, or ‘thinking brain,’ allows us to think and to feel, to plan and to plot, and most importantly, to love. Our brainstem, or ‘wanting brain’ simply wants, and powers the brain with dopaminergic desire. Both of these areas sent projections to the reward center of the brain.

The brainstem stays, “Just do it if it feels good,” while the cortex says, “Think about the consequences of just doing it, no matter how good it feels.” The cortex also colors and flavors our pleasure with meaning and context. It knows the difference between fast food and a candlelight dinner.

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The nucleus accumbens, or reward center, is interposed physically and functionally between these two areas. Our current understanding of how the brain balances these forces was remarkably described almost a millennium ago by Thomas Aquinas in his writings about natural or animal appetite and rational appetite, or will. It is the balance of will and appetite that allows pleasure to become a rewarding garnish which motivates, as opposed to addiction, where pleasure becomes a master which overrides the will.

In the last 20 years we have found that learning changes the brain physically. Like a muscle enlarging with exercise, the brain enlarges physically with learning. Music, sports, and studying have all been shown to enlarge different parts of the brain; one scientist said, “The brain is the source of behavior, but in turn it is modified by the behaviors it produces…learning sculpts brain structure.”

The reward system of the brain can be highjacked and diverted from its purpose of helping us survive. If we take in powerful rewards indiscriminately, the reward center can reset the pleasure thermostat of the brain, and a new normal occurs. This can become addiction. Two scientists studying how brain cells change with addiction said, “Addiction represents a pathological, yet powerful, form of learning and memory.” Indeed, addictive learning “sculpts” the brain in a very damaging way.

In addiction, whether to a substance like cocaine or a behavior like sex, physical changes happen at the macro and microscopic level, and we can see these on brain scans. These structural changes are associated with the behavioral changes seen in addiction. The American Society of Addiction Medicine, comprised of medical doctors, defined addiction in 2011 as including sex and food addic-

FEATURE

tion along with substance addiction, because the same changes in these varied addictions are found in brain studies and the behaviors are almost identical.

For instance, a study published in the Journal of the American Medical Association (JAMA) from of the Max Planck Institute in Germany showed alterations in the reward area of the brain in compulsive pornography use, and the more hours of pornography viewed per week, the more the alteration. A study done at Cambridge University examining compulsive pornography users also demonstrated a different alteration in a region associated with the reward center, and both the British and German studies demonstrated impaired connectivity with the frontal executive control centers of the thinking brain.

Children and emerging adults are particularly vulnerable to these brain changes. Let us consider five reasons for this. First, the frontal executive centers in the thinking brain are not fully developed until the mid-twenties. This is because the connections have not matured and the brain wires are not yet insulated, processes which are respectively called pruning and myelination. Yet this age represents a large percentage of those who view pornography and those used as performers in pornography without real informed consent.

Wealthy companies like MindGeek are profiting from the exploitation of vulnerable emerging adults. Their profits are built on the broken minds and bodies of these young people.

Second, brain chemicals such as DeltaFosB which are important in pleasure reward processing and in addiction are expressed more potently in immature brains. Children and emerging adults are more responsive and vulnerable to rewards than adults. Drugs like cocaine and behaviors like sex can reset the hedonic set point, or pleasure thermostat, of their brains more easily and create a new normal. Thus, the evidence supports greater vulnerability in forming novel attachments to powerful rewards such as pornography. An immature braking system is in effect paired with an accelerated reward system drive.

Third, pornography has effectively become the primary mode of sexual education of youth. Because pornography is often the first exposure to sexuality it influences sexual arousal templates and programs sexual scripts. Consider that 93% of boys and 62% of girls under the age of 18 have been exposed to internet pornography.

What are these minors seeing? Ninety four percent reported watching mixed sexual intercourse, 69% watched same sex intercourse, and 83% watched sexual intercourse between more than two people.

A review of the 250 most popular pornographic films found that

Donald L. Hilton Jr., MD meeting the Pope.

88% of the scenes contain physical aggression and 49% contain verbal aggression toward women. Therefore, many girls are thus scripted to be ‘porn-ready’ for ‘porn-conditioned’ boys. For instance, the push for teen girls to allow porn-programmed boys to perform painful anal sex on them was described as “coercion” in a recent study in the British Medical Journal , yet Teen Vogue then contributed to this coercion by encouraging minor teenage females to allow porn-scripted boys to perform anal sex on them. Their sexual scripts are thus programed to cater to males and to suppress their own feelings and desires.

Fourth, the brain’s mirror neuron systems are also an important consideration in understanding the impact of pornography on young brains. Mirror neurons cause us to project ourselves into what we are seeing. A study out of France used functional MRI to examine the effect of pornography on the brains of those watching it. The authors found that “…the mirror-neuron system prompts the observers to resonate with the motivational state ….” of those they are watching. What is the motivational state these youth are emotionally ‘resonating’ with?

Bill Margold, a famous male pornography performer, said, “I’d like to really show what I believe the men want to see: violence against women. I firmly believe that we serve a purpose by showing that. We want to inundate the world…” He and his fellow performers are infusing the next generation of males and females with a violent “motivational state.” They are programming the sexual templates of millions of youth with toxic sexual scripts through a powerful neuroplastic process of pathological learning. Porn is also destroying the ability to feel emotion. As one woman said of the change that came over her husband because of pornography, “A layer of empathy had been ground away.” continued on page 30

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FEATURE continued from page 29

Fifth, pornography is a supranormal stimulus. Nicholas Tinbergen, a Nobel Prize winning behavioral biologist coined the term in the 1970s. He found that when he presented male butterflies with a choice between enhanced, but artificial cardboard females and real female butterflies, the males chose the artificial females over the real females. Internet pornography is a supranormal stimulus as well, and young and old males are increasingly choosing artificial electronic females over real females for a substitute, masturbatory, counterfeit form of mating. Virtual reality pornography with robotic, haptically filmed female performers using telodildonics is making porn increasingly interactive and even more supranormal. No wonder girls and women of all ages are finding it is difficult to compete with porn; as Naomi Wolfe said, “Today real…women are just bad porn.”

And porn is not just targeting males, as females are increasingly exposed. Thousands of teenage girls follow male performers such as James Deen on social media sites, modeling him as the male sexual ideal. When asked about youth viewing his porn movies, he said, "If there was a 15-year-old … that is viewing a scene that I'm in or any sort of porn…it's not necessarily a bad thing." Yet many female performers have accused him of violence on and off set, with one female performer saying, “James Deen ruthlessly attacked and degraded me, leaving me with mental wounds that took years to heal.” Countless youth are thus being programmed with this toxic “motivational state.” Deen and Margold continue the legacy of the late Hugh Hefner: when asked about Playboy’s objectification of women he famously said, “They are objects!” Sadly, some women actually believe this lie that objectification in a world of toxic masculinity is empowering to them. They exemplify Huxley’s “…population of slaves who do not have to be coerced, because they love their servitude. To make them love it is the task assigned…”

Some academic apologists seem to have no concern about youth and emerging adults allowing these teachers of sexual violence and eroticized rage to infuse our children with toxic sexuality, and destroying their ability to feel empathy. They voice no concern about young female performers who are exposed to drug abuse, sexual disease, and emotional, physical, and sexual violence on set.

One academic paper even suggests that society should encourage the use of “…[pornography] at younger ages [to] broaden…” their perspective.

We must not allow pornographers and porn proponents to control the sexual education of our children, as they are now doing. It is time for a public health approach. All now seem to agree we must keep tobacco out of the lungs of our children; we must become as serious about keeping pornography out of their minds. Let us begin 30

San Antonio Medicine • December 2017

by following Britain’s example in protecting children and youth online by blocking underage access to pornography.

Our marvelous brains are designed to allow sexuality to be an apex emotional and physical experience. Pornography is not only hijacking human sexuality, it is destroying our empathetic core, our very humanity. It was a Roman, Cicero, who said, “Yet more, if emotion be eliminated, what difference is there, I say not between a man and a brute, but between a man and a rock, or the trunk of a tree, or any inanimate object?”

We call upon responsible citizens from all nations and cultures, from all perspectives, both secular and religious, and upon health care professionals to defend and protect the physical and emotional health of our children. We invite them to educate themselves on the harmful effects of pornography on the young minds of our children. We call upon lawmakers to refuse to protect the pornography industry and to pass laws that will instead protect our children.

We call upon parents to act responsibly in teaching their children the harmful effects of pornography. Children mirror what they see and feel. Therefore parents must set an example and be cautious and thoughtful regarding their own media choices. Children are our best and brightest hope for the future. They are our only hope.

What kind of world will we leave them with? What will be our cultural and emotional endowment to them? Tolkien made this profound statement, ““It is not our part to master all the tides of the world, but to do what is in us for the succor of those years wherein we are set, uprooting the evil in the fields that we know, so that those who live after may have clean earth to till. What weather they shall have is not ours to rule.” Global culture is presently delivering toxic sexuality to the fertile soil of the minds of our youth. We must change that. May we do all we can to give children and emerging adults clean earth to till, so they can better weather their storms, and have a chance to experience the full measure of human emotion and love. Thank you.

LEGAL EASE

Driving While Intoxicated during a “No Refusal” Weekend

What do I do?

By George F. “Rick” Evans, Jr., General Counsel, BCMS

ow many times have you attended some social event when, after somebody learns you’re a doctor, you get questions about some physical malady or the other?

Same thing happens with lawyers. So, I’m going to start a series of articles discussing some of the more common questions we get. My guess is that it’ll directly relate to a lot of legal questions you have.

Let’s begin with one you might be embarrassed to ask an attorney, but is nonetheless something you’ve wanted to know about. Here it is. What happens when the blue and red lights suddenly start flashing behind your car after you’ve left the restaurant having put down two glasses of Chardonnay with your salmon? And, what if it’s during the holidays when the county has announced it’s a “no refusal” weekend? What does that mean? Do you have to do the field sobriety tests? Do you have to blow into the breathalyzer. Do you have to give a blood sample?

Captain Obvious will tell you not to get in that position in the first place. If you don’t drink and drive, you’ve got nothing to worry about. Pretty simple, right? Even if there’s no designated driver handy, you can always call an Uber or Lyft or taxi. There’s absolutely no excuse for putting yourself in the position of sweating bullets when the red and blue lights flash.

But, maybe you’ve slipped up and it’s too late now. You’re driving

H

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and you’ve had something to drink during dinner. What to do?

Here’s what. Note: the following comments are for a first offense in which nobody was seriously injured or killed. If you’ve been pulled over before or there’s been a serious injury/death, or you have prior DWI convictions, then you’re in a different category altogether and this article doesn’t apply to you. But, for now, let’s assume this is the first time you’ve been pulled over and nobody has been hurt.

First, pull over as soon as you reasonably can. Turn on your fourway flashers if you’re moving so the officer knows you’re aware of the situation. The minute you stop, roll down all your windows, turn on the interior lights and keep your hands on the steering wheel.

Officers are understandably on high alert when approaching darkened cars at night. You can relax their anxiety if they can see you and see your hands on the wheel. That might make the officer just a little more friendly and less suspicious. And open windows may dispel any smell of alcohol inside which, if sniffed by the officer, is not a good thing for you.

Next, remember that you’re on camera the entire time. The police car dashboard cam has you, the officer’s body camera has you, and if you’re put in the back seat of the police car, you’re on camera there, too. The judge and jury will see those videos so you need to act professionally, calmly and very politely. This is not the time to

LEGAL EASE

make jokes, try to chat up the officer, and clearly not the time to be sarcastic, snippy or argumentative.

Don’t jump to the conclusion you’ve been stopped for DWI. Maybe you were speeding or have a broken tail light. Wait for the officer to come to your car and wait for him/her to talk. If you get comments like “you know that’s a 45 mph zone back there?” maybe it’s just a ticket. But if you start to get questions like, “where were you coming from” or “are you coming back from a restaurant or party,” the officer likely has something else on his/her mind. That’s where the rest of this article comes in.

If you’ve been drinking more than prudence dictates, and believe you’ve been stopped because of a suspicion of intoxication, many defense attorneys advise clients not to enter any discussions with the officer. If asked questions like “have you had anything to drink tonight,” or “where have you been tonight,” your answer probably should be “If you’re going to be asking me questions, Officer, I’m going to exercise my right not to answer at this time until I can consult with my attorney.” You may be told that there’s no need for an attorney or that people who won’t talk have something to hide, but stick to your guns and don’t enter into a discussion. You have the right to remain silent. The only things you must do are provide the officer with identification, registration and insurance and to step out of the car if asked. You also must obey any direct commands the officer gives, but confirm that it is, in fact, a direct order and not a suggestion or request. Ask the officer to state if it’s an order. If he/she says it’s a request, you don’t have to do it. Remember, be polite.

You may be asked to perform field sobriety tests (do the horizontal gaze nystagmus test, count backwards, stand on one leg, walk heel to toe on a line, touch your nose with your eyes closed, etc.)

You don’t have to. If you really have been drinking, many attorneys advise against taking any field sobriety tests. After all, even when totally sober, who among us can walk a straight line on the berm of a road (slanted at 5 degrees or more for drainage) when cars are flying by at high speed less than 10 feet from you with headlights on creating a strobe effect? When you’re dumping catecholamines left and right, will your hands really be steady and will your mind function as normal when asked to do some mental arithmetic?

That’s why many defense attorneys suggest you very politely refuse.

You may then be asked to take a breathalyzer test. You don’t have to “blow” and, if you’ve been drinking, many attorneys say you shouldn’t. These attorneys contend breathalyzers are notoriously unreliable and there’s a body of evidence to support their position.

You don’t have to take the test. Note, however, that refusing a breath test likely will result in suspension of your license for at least a few

months (although you may qualify for a limited license during that time so you can go to work). However, many attorneys think it’s much better to have a suspended license than a DWI conviction.

Plus, if you protest the suspension within 15 days, the suspension may be rescinded if you can show the officer didn’t have reasonable grounds to stop you.

You may also be asked to give a blood sample. Again, you don’t have to do that either. The only way you can be forced to give a specimen is if a judge orders it and that takes a formal warrant which can be hard to get late at night. By the time the officer wakes up a judge to get a warrant, the driver’s metabolism may have eliminated or reduced the blood alcohol content so that the lab results are within legal limits. That’s why some defense attorneys argue that the longer the delay, the better.

Conversely, some prosecutors will argue that if you’ve really only had one glass of wine well over an hour ago, you should fully cooperate. They make a valid point that the more uncooperative you are, the more suspicious the officer will be. If you really are clean, prosecutors advise you not to stand on your rights as a matter of principle, but to cooperate and agree to take the tests the officer suggests. That said, if you know your blood alcohol level is high, you can understand why many defense attorneys will tell you to remain silent, refuse to take the field sobriety tests and breathalyzer test, and to submit to a blood sample only when the officer can provide you with a warrant from a judge.

But, it’s a “no refusal” weekend, right? Doesn’t matter. You always have the right to refuse to talk, to do the field tests and to blow. But, as stated above, a judge can issue a warrant to force you to give a specimen, like it or not. During a “no refusal” weekend, it just means the local district attorney has arranged to have a staff of attorneys and judges on hand 24/7 ready to immediately process those warrants. As a result, if you refuse (which is your right), there may not be much of a delay before they can get a warrant and you’re taken to a hospital and forced to give a specimen. The only real difference between a “no refusal” weekend, and any other time, is that arrangements have been made to speed things up to force a sample if a motorist refuses.

So, long story short, what should you do? Answer: don’t get in this position in the first place. You probably won’t remember this article if you’re stopped. But what you may remember is this piece of advice because you can do it right now. Download the ride apps and use them if you’re going to drink. That’s the smartest legal move you can do. More importantly, it’s the right thing to do. For you, your family, and everybody else. visit us at www.bcms.org

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BCMS NEWS

WOMEN IN MEDICINE CELEBRATES 25 YEARS

WITH LEADERSHIP AWARDS

The Bexar County Medical Society Women in Medicine Committee celebrated 25 years this past November and they celebrated this anniversary by honoring 25 very deserving physician in Bexar County who represented all of the major healthcare systems and education institutions in our area.

The event was held on Thursday November 2, 2017 at the UIW Rosenberg Skyroom and was attended by over 400 guests. Dr. Robyn MadsonPhillips Founding Dean of the UIW Ostheopathic Medicine School welcomed the more than 400 guests at the event. Dr. Coleen Bridger , Director of the San Antonio Metropolitan Health District was the evening’s master of ceremonies.

The winners of the Women in Medicine Leadership Awards were selected by the Women in Medicine Committee based on their commitment, service and dedication to the honored practice of medicine (names and pictures are attached on the power point presentation).

Pictured above (L-R): Brissa G. Vela, BCMS Membership Director and Women in Medicine Committee Liaison, Dr. Lubna Naeem, Dr. Carol Dornbluth, Dr. Wendy Kang, Dr. Leah Jacobson, BCMS President, Dr. Melissa Deuter, Dr. Lan-Anh Ngo, Dr. Maggie Beato, Women in Medicine Committee Chair.

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San Antonio Medicine • December 2017

THANK YOU WOMEN IN MEDICINE EVENT SPONSORS PRESENTING SPONSORS

FRIENDS OF MEDICINE SPONSORS

BCMS NEWS

Winners of the Women in Medicine LEADERSHIP AWARDS ILDIKO AGOSTON, MD UT HEALTH SAN ANTONIO CARDIOLOGY

ANNA GONZABA, MD GONZABA MEDICAL GROUP

LORI POUNDS, MD UT HEALTH SAN ANTONIO VASCULAR SURGERY

BRIGITTE BAILEY, MD UT HEALTH SAN ANTONIO VASCULAR SURGERY

DINA GOYTIA-LEOS, MD NIX HEALTH

JAYASREE N. RAO, MD ONCOLOGY SAN ANTONIO

PRABHDEEP K. GREWAL, MD THE SAN ANTONIO ORTHOPEDIC GROUP

JENNIFER RUSHTON, MD CLINICAL PATHOLOGY ASSOCIATES

MARIA BALLESTEROS, MD CHRISTUS SANTA ROSA HEALTH SYSTEM

EMILY BECKER, MD TEXAS DERMATOLOGY AND LASER SPECIALISTS

CORINNE JEDYNAK-BELL, DO, MBA, FACOOG UIW SCHOOL OF OSTHEOPATHIC MEDICINE

DIANA HENDERSON, MD METROPOLITAN METHODIST HOSPITAL

MONIKA KAPUR, MD, MBA UNIVERSITY MEDICINE ASSOCIATES

KRISTI CLARK, MD HEALTH TEXAS MEDICAL GROUP

STEPHANIE M. LEVINE, MD UT HEALTH SAN ANTONIO INTERNAL MEDICINE

NIDA EMKO, MD UT HEALTH SAN ANTONIO FAMILY & COMMUNITY MEDICINE

LUCI K. LEYKUM, MD UT HEALTH SAN ANTONIO GENERAL & HOSPITAL MEDICINE

LOIS A. FIALA, MD PERIPHERAL VASCULAR ASSOCIATES

CLAIRE MCKAY, DO BAPTIST M&S IMAGING

CHRISTINE L. GEAR, MD SOUTH TEXAS RENAL CARE GROUP

TERESA RUIZ, MD COMMUNITY FIRST HEALTH PLANS

JENNIFER SWART, MD SOUTH TEXAS RADIOLOGY GROUP, PA (STRIC)

NICHOLE VAN DE PUTTE, MD COMMUNICARE HEALTH CENTERS

MELISSA ANN WALKER, DO (“DR. MISSIE RAYFORD”) UIW SCHOOL OF OSTHEOPATHIC MEDICINE

LARGE PRACTICE GROUP 100% BCMS MEMBERSHIP HONOREES DONNA MCMYLER, MD GASTROENTEROLOGY CONSULTANTS OF SAN ANTONIO

visit us at www.bcms.org

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San Antonio Medicine • December 2017

visit us at www.bcms.org

37

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

ACCOUNTING FIRMS 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.”

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 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”

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/manijohn-

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San Antonio Medicine • December 2017

ston "UBS is honored to be named Best Bank for Wealth Management 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 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 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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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

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!”

Beyond (HHH Gold Sponsor) Beyond strives to simplify operations, reduce costs and streamline payments for small and mid-size businesses. We provides reliable, flexible, and secure business solutions in a clear, transparent manner.

San Antonio and Austin DSD-San Antonio/Austin Jeromé Vidlock Jerome.vidlock@getbeyond.com 972-839-2423 www.getbeyond.com “The business of Medicine is our specialty”

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than

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."

GRADUATE PROGRAMS

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”

ensure your finances are ready for 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

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

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and

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, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911

continued on page 40

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

HEALTHCARE TECHNOLOGY 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."

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.”

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San Antonio Medicine • December 2017

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”

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 company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage Kristie Arocha 210-255-0013

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

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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 BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Owner Lettie Cantu 210-363-1735 Lettie@progressivebilling.com Administrator Richard Hernandez 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Owner Lettie Cantu

210-363-1735 Lettie@progressivebilling.com Administrator Richard Hernandez 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

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.”

PAYMENT SYSTEMS/ CARD PROCESSING

Beyond (HHH Gold Sponsor) Beyond strives to simplify operations, reduce costs and streamline payments for small and mid-size businesses. We provides reliable, flexible, and secure business solutions in a clear, transparent manner.

DSD-San Antonio/Austin Jeromé Vidlock Jerome.vidlock@getbeyond.com 972-839-2423 www.getbeyond.com “The business of Medicine is our specialty”

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 “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”

PROFESSIONAL ORGANIZATIONS

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

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”

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. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Cary Wright 210-558-1500

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

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

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

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

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 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

Pete DeNeergard 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

Gary Holdgraf 210-862-9769

Wayne Alderman 210-525-9800

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Sean Fortier 210-681-3399

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

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

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300

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

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

William Taylor 210-366-9600

James Godkin 830-981-6000

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

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

North Park Lincoln 9207 San Pedro San Antonio, TX

Scott Brothers 210-253-3300

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

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Sandy Small 210-341-8841

James Cole 800-611-0176

13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

15423 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Dale Haines 210-341-2800

Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

visit us at www.bcms.org

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AUTO REVIEW

2018 NISSAN ARMADA

By Steve Schutz, MD Elsewhere in the world, which mostly means Japan, the Middle East, Africa, New Zealand/Australia, and South America, the Toyota Land Cruiser vs Nissan Patrol battle is a thing. They’ve been competing head-tohead for for decades, but most American consumers, even enthusiasts, have been unaware because only the Land Cruiser has been sold in this country. Nissan has never offered the Patrol for sale here until now.

Sort of...

Regular readers may recall that in 2010, Nissan introduced a new Infiniti QX56 SUV that was based on the Nissan Patrol and built in Japan. That vehicle is still for sale today, badged as the QX80. Last year, Nissan decided to sell a Nissan version of the Patrol as well, but they chose to name it the 44

San Antonio Medicine • December 2017

Armada because their previous full-size SUV had that name. Come on guys, it’s the Patrol everywhere else, why not here? Whatever, they didn’t ask me, so Armada it is.

As you might imagine for a vehicle that’s now almost eight years old, the Patrol, whoops...Armada, doesn’t look particularly fresh or modern. Ordinarily that would be a problem, but since the current Land Cruiser launched three years earlier in 2007, the big Nissan can’t be accused of looking more dated than the competition. Let’s just say the Armada looks like a fairly generic full-size SUV with lots of Nissan-esque styling cues and leave it at that.

Naturally, the interior the Armada is also Nissan-esque, but with beefier knobs and switchgear than its less off-road capable

stable mates. Like the Land Cruiser, the Armada was created for customers who legitimately use it off-road—think ranchers doing chores deep in the Australian Outback or Saudi Bedouins searching the desert for a lost camel—so a more robust cabin is expected.

By the way, the Armada’s significant off road credibility means that it can handle anything South Texas weather can throw at it and that it will age well.

It’s still comfortable though. Presumably because it was conceived with an Infiniti version in mind, the Armada is more luxurious than, say, a Pathfinder. While the materials aren’t quite up to QX80 standards everywhere, in many places such as the polished wood console and the main

AUTO REVIEW function controls on the dash they appear to be identical.

The driving experience is very similar to the Infiniti as well. This is a big heavy (5910 lbs) SUV, so floating and wafting is what you’re going to experience on the road as opposed to bobbing and weaving, but as long as you’re not pushing things it’s all very comfortable.

Twisty back roads and tight urban spaces are not in the Armada’s wheelhouse by any means, but if you take the big Nissan onto the interstate or relatively straight suburban streets, you’re going to be happy. And as I like to remind readers, after a long day operating, cardiac cathing, or getting through a seemingly endless patient list in clinic, we’re tired, and a quiet luxurious oasis is probably just where we want to be.

Naturally, quiet and comfortable generally means big, and big means poor fuel economy. That’s the case with the Armada, which only manages 13 MPG city and 18 MPG highway. (OMG I just fat shamed a motor vehicle, didn’t I?) Most Patrols sold abroad are equipped with diesel engines, but Nissan decided not to offer than powerplant in the US. If they had, the fuel economy figures would be significantly better.

As the Nissan flagship, all Armadas come well equipped, such that even the base SV includes satnav, a 13-speaker Bose stereo, a fold-away third row of seats (that I’d reserve for children only), and dual power front seats. The nicer SL adds leather seats, power up/down for the third-row seats, a power rear hatch, and 20-inch wheels. The loaded Platinum version adds a sunroof, heated and cooled front seats, seat heaters for the second row, and dual rear-seat entertainment screens, among other luxury touches. The Platinum also gets you a number of driverassist technologies such as lane departure warning and blind spot protection, which

are optional on the SL. In case you hadn’t heard, backup cameras are required on all 2018 passenger vehicles for sale in the U.S. While I’d prefer that the Armada be called the Patrol as it is elsewhere in the world, I’m glad it’s being sold here as it’s a worthy competitor to the venerable Toyota Land Cruiser. Like that capable and popular SUV, the Armada is due for a restyling, but that doesn’t really detract from its essential goodness.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-3014367.

Steve Schutz, MD, is a boardcertified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

THANK YOU

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

Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of November 24, 2017.

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San Antonio Medicine • December 2017