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Legislative Introduction

Vaccinations: Public Health vs Personal Choice By Rodolfo Molina MD ....................................18

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

Restoring Cuts to Medicaid Children’s Disability Services By Robert Luedecke, MD.................................20

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BCMS President’s Message........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 Letter to the Editor ....................................................................................................................................11 Business of Medicine: A Solution for After-Hours Call Processing in Bexar County By Dan Kilday, Circle of Friends member ...............................................................................................22 UTHSCSA: Through Cancer Care and Research, UT Health San Antonio serves South Texas’ most seriously ill children by William L. Henrich, MD, MACP............................................................................24 2019 BCMS Honoree Induction ................................................................................................................28 2019 BCMS Joint Installation of Officers....................................................................................................30 2019 BCMS Alliance Installation Ceremonty..............................................................................................33 Health: Do you know your gluten ID? By Shelly Gunn, MD, PhD................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 BMW M5 By Steve Schutz, MD .................................................................................44

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San Antonio Medicine • February 2019

VOLUME 72 NO. 2

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

Keep our Texas Educated Doctors in Texas By Jayesh B. Shah, MD ...................................16

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San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

On Call at the Capitol: TMA’s 2019 Legislative Agenda By Joey Berlin and Sean Price, Texas Medicine ...............................................12

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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member Michael Joseph Guirl, MD, Member David Anthony Hnatow, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones Jr., MD, Member David M. Siegel, MD, JD, Member Rajeev Suri, MD, Member Kelly King, Alliance Representative George Rick Evans, Legal Counsel Col. Charles Gregory Mahakian, MD, Military Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO, Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member

San Antonio Medicine • February 2019

PRESIDENT’S MESSAGE

IT’S TIME TO DO SOMETHING

DIFFERENT By Adam Ratner, MD, 2019 BCMS President

By the time you read this, the Texas Legislature will be in session. This triggered thoughts of deep disappointment about the influence we as physicians have lost over the last decade and a half. Back then, we celebrated a just and hard-fought victory over the tort system which had gone awry and impaired our ability as physicians to practice medicine. So, what has happened since? The tort reform victory has had very long legs and for that we all should be very grateful. But what else? My political friends have an answer to this: Some relatively obscure but terrifying bills that we fought off or some legislation that protected somebody’s turf for another two years. Agreed, but where are we in the big picture? Despite our major tort reform victory and the subsequent smaller victories/defeat avoidances, I see serious decline. Physicians have less power and influence over how we practice medicine and serve our patients. We seem to be unhappier. More and more of us feel we are forced to accept one-sided contracts that rob us of our ability to use our hard-earned knowledge, skills, experience and devotion to help take care of our patients. Many of us feel we are indentured servants to our non-physician employer masters. Some say we’ve already lost the battle in Washington, too many big players and too much money against us. While there is some truth to this, particularly regarding Medicare, we should remember that health care and insurance are largely regulated at the state level. This means that actions of our state legislators and regulators are still critically important. So, what are we going to do about it? First, we must take stock. Our strengths: The physicians of Bexar County and Texas are very smart, hard-working and honorable professionals. We want to do the right things for our patients and our practices. We are still relatively wealthy. We have some strong physician-led institutions. Our weaknesses: We spend so much time working and thinking about our patients and practices, we are vulnerable to those who can and do spend the time and effort to take advantage of us and our work ethic. We are politically diverse and, on many issues, have conflicting views. Our specialty societies too often fight with each

San Antonio Medicine • February 2019

other while the private and governmental payers and regulators, big Pharma and other large corporate interests look on. Second, we must learn from what has worked in the past. The battle for tort reform was ultimately won because of unity of purpose, persistence, effective organization and marshaling of resources. There were very few physicians who opposed tort reform. We were united and we ultimately won. Third, we must identify a new unifying strategic goal or two upon which almost all of us can agree and focus. It is up to us, the membership of BCMS and TMA, to decide what the goal or goals should be and not be distracted by the smaller issues that divide us. Fourth, we must create and execute a plan to achieve our goal(s). Many of us are offended by the “pay-to-play” environment of Austin and Washington and don’t want to waste our hard-earned financial fuel on the fire of institutional political corruption, particularly if we will always be out-gunned financially. That said, we have other resources we can deploy, if properly engaged and motivated, to win and win big. There are more than 50,000 TMA and 5,700 BCMS members. We have the BCMS and TMA Alliances including all of our spouses/significant others and families. We have our Circle of Friends, business associates and staff/employees. If we wisely choose a goal our patients can support, they can multiply our influence in traditional and social media, in the halls of power, the marketplace, as well as the ballot box. Please let our Legislative/Socioeconomics team leadership, Alex Kenton, MD, Committee Chair (alexander_kenton@pediatrix), Mary Nava, MBA, Chief Government Affairs Officer (mary.nava@bcms.org), and me (adam.ratner@bcms.org) know one or two unifying issues that you think will make your life and your patients’ lives better. It’s time to do something different and do it now! Dr. Adam Ratner is President of the Bexar County Medical Society and serves as Professor and Assistant Dean of the University of the Incarnate Word School of Osteopathic Medicine and Chair of The Patient Institute.

BCMS LEGISLATIVE NEWS

The 86th Legislative Session opened Jan. 8 and Rep. Dennis Bonnen (R-Angleton) was elected unanimously by the House of Representatives as our new Texas House Speaker. On Jan. 15, inauguration festivities for Gov. Greg Abbott and Lt. Gov. Dan Patrick took place on the north steps of the State Capitol. For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

San Antonio Medicine â€˘ February 2019

LETTERS TO THE EDITOR To the Editor, I wish to support the article by Dr. Alexander Kenton entitled â€œA Call to Armsâ€? in the January edition of San Antonio Medicine. After holding leadership positions in both TEXPAC as well as AMPAC, I would often hear two frequent reasons for physicians not participating. The first reason was the reluctance to feel like they were buying votes by supporting a candidate. I would say in response that the very last thing I wanted was a legislator whose vote could be bought. We could never keep up with the finances available to the insurance industry or to the trial bar. Our goal was always to elect people who philosophically had the same viewpoints held by the Texas Medical Association and the American Medical Association. This is going to become increasingly important as we hear an increasing number of people call for a single-payer system in the United States. We have to be able to stand strong and support the concept of pluralism with regards to healthcare. The second reason for lack of participation was the feeling that physicians would support congressmen and state officials in their district. They felt no need to get involved in other races. I would

respond by saying it is a good idea to support the officeholders in your district. However, there are key players at both the state and national level. There are committee chairs and particular voices that have a great deal of influence. These individuals may need support in elections and they may not live in your district. You may not know who they are unless you actively keep up with legislative action. A PAC has the ability to identify these individuals all over the state and country and make sure they have adequate support when running for reelection. Thirdly, the physician community has to be strong politically. This is how we achieved TORT reform in Texas. This is how we established prompt payment legislation regarding insurance companies. Hopefully this will be how we maintain a tradition of pluralism with regards to healthcare financing. If we fail to accept this political challenge to remain active, we will have no one to blame but ourselves if healthcare goes in a direction we do not support. Sincerely, SHELDON GROSS, MD Past President, Bexar County Medical Society

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LEGISLATIVE INTRODUCTION

ON CALL AT THE CAPITOL: TMA’s 2019 Legislative Agenda By Joey Berlin and Sean Price, Texas Medicine

he faces at the Capitol change. The legislative flashpoints and fights come and go. But every two years, the House of Medicine’s commitment remains the same: Persuade legislators to improve Texas laws for physicians and patients. The Texas Medical Association will keep that focus in 2019 as it pursues better Medicaid coverage for postpartum women, insurer accountability for narrow networks, more funding for community mental health, and many other aims. When the 86th Texas Legislature convenes on Jan. 8, TMA will build on its major successes of 2017, renew some of the biggest battles that stalled two years ago, and tackle relatively new ones. Physicians will make their case to a somewhat new makeup of lawmakers. After the Democrats flipped seats in both state chambers in November’s elections — gaining 12 in the House of Representatives and two in the Senate — this year’s session will feature a somewhat more bipartisan legislature. Republicans still control a majority in both chambers, but at press time the new breakdown was 83-67 in the House and 19-11 in the Senate, with a December special election set to fill one Senate seat. And there is a new Speaker of the House — Rep. Dennis Bonnen (R-Angleton) — to replace outgoing Rep. Joe Straus (R-San Antonio). Jason Terk, MD, chair of TMA’s Council on Legislation, says Medicaid will be a top-priority issue for the council. He thinks the new makeup of the Legislature bodes well for medicine’s push to get more money for Medicaid payments, which is part of the perpetually contentious budget process. “It’s always a food fight. But I expect it,” the Keller pediatrician said. “In years past, of course, we have always supported improvement in payment rates. But I think that there’s a little bit different dynamic now, [such] that we potentially have a higher chance of getting some substantive improvement this year.” From budgetary matters and insurance legislation, to public health gains and much more, here’s a look at some of medicine’s biggest goals. 12

San Antonio Medicine • February 2019

A healthy budget?

Funding for Medicaid, behavioral health, and women’s health will be among medicine’s foremost budgetary focuses, though the legislature will be weighing such asks against its priorities for public school finance reform, Hurricane Harvey relief, state infrastructure needs, and lowering property taxes, TMA leaders say. On the plus side, TMA lobbyist Michelle Romero says a betterthan-expected economy has put the state in good position to cover the current budget’s Medicaid shortfall, estimated at $2-3 billion due to caseload growth, without tapping the state’s “Rainy Day” fund. In September, state Comptroller Glenn Hegar announced that the fund was on track to reach nearly $12 billion at the end of 2019. That’s about 10 percent of the overall budget and the most in the fund since 2015. Sales tax and oil and gas revenue also were up. The question is whether that positive economic outlook will continue, Ms. Romero cautions. The comptroller always issues another revenue estimate just before the session begins.

Medicaid, women’s health, GME

TMA President Doug Curran, MD, has made Medicaid the centerpiece of his presidency. TMA hopes lawmakers will take up that mantle with solutions to reduce costly red tape, streamline care coordination for the most complex patients, and improve coverage for the state’s working poor. In addition, Medicaid’s low payment rates have depressed physician participation in the program. In written remarks to the Legislative Budget Board (LBB) in September 2018, TMA said it supports revitalizing Medicaid and Children’s Health Insurance Program (CHIP) physician networks, noting physicians haven’t received a meaningful payment increase in Medicaid in nearly two decades. But improving Medicaid coverage goes well beyond properly compensating physicians, and medicine will throw its weight behind other hoped-for improvements. TMA will urge lawmakers to enact a maternal health platform also supported by the state’s Task Force on Maternal Mortality and

LEGISLATIVE INTRODUCTION Morbidity. David Lakey, MD, chief medical officer at The University of Texas System and previously chair of TMA’s Maternal Health Congress, says Medicaid currently covers low-income women for only two months after the birth of a child. The task force has called for a federal waiver that would extend coverage to one year, which TMA supports. “We know that moms are at risk during that first year afterwards,” Dr. Curran told physicians at one of five tele-town hall meetings on TMA’s legislative agenda in October. “So just increasing availability of services and care is going to make an enormous difference in outcomes.”

Among other budget-related items on TMA’s agenda:

• Revising eligibility and enrollment systems so adolescent females who age out of CHIP or children’s Medicaid can enroll seamlessly in the state’s Healthy Texas Women program; • Ensuring that women who lose their CHIP perinatal coverage can connect to the state’s family planning program to avoid gaps in preventive care; • Improving the availability of long-acting reversible contraceptives (LARCs); • Funding for graduate medical education (GME) to maintain the target ratio of 1.1 entry-level-positions per medical graduate, which Texas achieved during 2018; and • Expanding the availability of behavioral health services to children and adults, including substance use disorder treatment, and using innovative telemedicine initiatives. TMA also will support funding to expand the capacity of state hospitals and community mental health services. The Texas Women’s Healthcare Coalition’s (TWHC’s) aims for this session are similar to much of TMA’s women’s health agenda. Evelyn Delgado, TWHC chair, says LARC availability is a benefit to women who decide they don’t want to be pregnant anytime soon, and a benefit to the state financially. Meanwhile, on GME, the recent boom of new medical schools in Texas makes it continuously important to work for the proper number of slots for graduates, Dr. Terk says. “Otherwise, we’re just educating some other state’s physicians,” he said. “We know that physicians tend to stay where they train. So, we’re going to need to watch that carefully and make sure that with the three or four new medical schools that are coming online now and in the next couple of years, that we don’t end up in the same situation we were in for several years previous, where we didn’t have

enough GME slots.”

Insurance: Time for accountability

TMA’s biggest wins of 2017 came in the insurance realm, laying the foundation for more reforms during this year’s session. Victories on balance billing and step therapy were the headliners two years ago; now, it’s time to tackle medicine’s other top-line insurance goals, including: • Prior authorization: On medicine’s agenda this year: Relieving physicians of the burden to get pre-approval for treatment or medication with legislation to ensure prior authorization requirements have medical relevancy — and aren’t just a way for health plans to deny care or delay payment. • Network adequacy: Medicine will again push for action on two of the biggest causes of surprise bills: insurers’ narrow networks and their often out-of-date network directories. TMA will seek legislation to mandate that the Texas Department of Insurance (TDI) review insurers’ PPO products, which unlike HMOs and EPOs, don’t undergo any proactive review, TMA lobbyist Clayton Stewart says. Also, medicine will again ask to require insurers to update their network directories more frequently than the current mandate to do so every 30 days. “We at least need to know whether or not the physicians are out of network,” Mr. Stewart said. “That really benefits the patient, but also [would help] because TDI a lot of times will use those network directories to do a network exam regarding the adequacy of said insurance company’s network.” • Pharmacy benefit managers (PBMs): Mr. Stewart says PBMs are essentially unregulated. Yet, they’re making health care decisions for patients — such as determining the step therapy protocols insurers use to keep patients off more expensive medications. Last session, Mr. Stewart says, many lawmakers weren’t familiar with PBMs and what they do. That changed with passage of a TMA-backed measure that dramatically slashed the amount of time an insurer generally has to approve a physician’s override of a step therapy plan. After examining and passing that bill, Mr. Stewart says, lawmakers are more versed on PBMs’ role in medication. So, TMA expects to see more scrutiny of PBMs during this session and legislation to introduce more transparency and accountability for them.

Public health momentum

Few of medicine’s public health objectives gained traction in the 2017 legislative session. However, Dr. Lakey says momentum building behind some of medicine’s key campaigns could translate to ac(continued on page 14)

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LEGISLATIVE INTRODUCTION (continued from page 13)

tion in the 2019 session. Improving funding for the Texas Department of State Health Services (DSHS) is at the top of the list, he says. DSHS’ budget will determine the state’s ability to handle public health priorities such as disease control and disaster response. That includes support for bolstering the statewide child immunization program Texas Vaccines for Children, and maintaining the state’s current vaccine exemption requirements in schools and other facilities. On vaccine exemptions, Dr. Lakey said, “It will be controversial, but there will be conversations there. And I think there will be efforts [by anti-vaccine groups] to require child care centers to accept children who are not immunized, and I think there will be pushback.” Aside from the DSHS budget, Dr. Lakey says, four key areas offer openings to improve public health: reducing maternal illness and death; increasing the age for purchasing tobacco to 21; reducing the rate of obesity; and improving mental health services. One measure to watch will be Senate Bill 63 authored by Sen. Jane Nelson (R-Flower Mound), which is designed to expand mental health care by creating a consortium of 12 of the state’s medical schools and health science centers. “It will better utilize the regional academic centers in solving the mental health issues,” Dr. Lakey said. “As the chair of the Senate Finance [Committee], [Senator Nelson will] be in good position to make sure that bill gets the funding it needs to get implemented.” In the TMA-supported drive to rebuild state hospitals, modernization will be important, says Ms. Romero. “When they’re going to rebuild the state hospitals, they need to be built and planned where it’s not just the mental health that patients are being treated for — that it’s also their physical health,” the TMA lobbyist said. For example, “We’ve heard Rusk [State Hospital] is … not meeting the needs of patients today. It was planned 100 years ago, and so we need to look at how do you treat patients in the modern hospital, give them modern care.”

Scope of practice: They’ll be back

This is one fight that never stops. Every two years without fail, nonmedical professionals back bills that would allow them to play doctor — that is, expanding their scope of practice beyond their training and expertise. One reliable source of such legislation: Advance practice registered nurses (APRNs), who have consistently but unsuccessfully pressed for independent prescribing authority in recent sessions. TMA lobbyist Dan Finch expects this year to be no different. “The nurse practitioners will be back,” he said. “We’ve told them 14

San Antonio Medicine • February 2019

that our core principle has remained the same: Independent diagnosis and prescribing is the practice of medicine. Physicians can delegate, but must supervise, because ultimately, they’re accountable.” As always, the House of Medicine will take a stand against any bill that seeks to grant medical practice authority to nonphysicians of any profession.

Sunset and TMB (again)

Political wrangling left renewal of the Texas Medical Board (TMB) and the state’s Medical Practice Act up in the air at the end of the 2017 regular session, prompting Gov. Greg Abbott to call a special session. Fortunately, lawmakers averted medical anarchy in Texas by reauthorizing TMB and the state’s medical law — but for just two years, instead of the customary 12 that would’ve kept TMB on the standard cycle for Sunset Advisory Commission review. That means it’s already time to renew TMB and keep the practice of medicine properly regulated past its current expiration date of Sept. 1, 2019. Medicine is hoping for a 10-year extension this time to get the medical board’s review back on the standard Sunset schedule. As it has in recent years, medicine is asking for this year’s TMB sunset bill to improve transparency and due process for physicians implicated in the board’s disciplinary process, which TMA believes has become less fair over time. TMA supports eliminating the board’s one-per-lifetime limit on remedial plans for physicians, as well as making remedial plans more available for minor administrative violations. Also, TMA will again advocate for a TMB complaint process for physicians employed by 501(a) nonprofit health care organizations who want to fight back against improper corporate interference in the practice of medicine. A 2017 bill to that effect, SB 833, passed the Senate but died in the House.

Making the PMP work

A mandate for physicians to check the state’s prescription drug monitoring program (PMP) looms later this year. TMA’s legislative aim will be to make that mandate as burden-free as possible for physicians. As things stand now, starting on Sept. 1, prescribers will be required to check the PMP before writing any prescription for opioids, benzodiazepines, barbiturates, or carisoprodol. But at TexMed 2018, TMA’s House of Delegates adopted policy to advocate for initially limiting the mandate to Schedule II drugs. TMA will work to convince lawmakers that’s a more sensible approach. Medicine also is stressing the importance of integrating the state’s

LEGISLATIVE INTRODUCTION monitoring program, PMP Aware, into physicians’ electronic health record (EHR) systems. Mr. Finch says that’s the ultimate long-term solution to making a mandatory PMP check work, and EHR integration is already happening in other states. “Texas would be the biggest state to undertake it,” he said. “But it is clearly where we want to go, because it creates an opportunity to use the PMP as a clinical database without an intrusive workflow imposition. It’s a click away, as opposed to stopping a patient care encounter to go do something in [the system and] return. And it’s not because it’s an unreasonable imposition. It just comes on top of every other reasonable imposition that takes away from doctors’ time with a patient.”

MEDICAID PARTICIPATION IN TEXAS: BY THE NUMBERS Increasing physician participation in Medicaid is one of TMA’s top priorities. According to TMA’s 2016 Survey of Texas Physicians: • 45% of physicians treat Medicaid managed care organization (MCO) patients • 60% of physicians who don’t accept those patients avoid doing so because of inadequate payment • 20% say they would accept more Medicaid MCO patients, and 35% say they would consider it if payment rates increased by 5 to 10 percent • 55% say they’re likely to accept more Medicaid patients if the program decreased its administrative burden

TMA’S 2017 SUCCESS: A LOOK BACK Here are several of medicine’s priority bills that became law following the 2017 Texas Legislature: • Senate Bill 507 by Sen. Kelly Hancock (RNorth Richland Hills) greatly expanded the availability of balance billing mediation. • Senate Bill 680 by Senator Hancock and sponsored in the House by Rep. Greg Bonnen, MD (R-Friendswood), allowed a physician to continue prescribing a medication that’s effective for a patient even if an insurer’s step therapy protocols call for the patient to switch medications. • Senate Bill 1107 by Sen. Charles Schwertner, MD (R-Georgetown), established a statutory definition and framework for telemedicine in Texas and clarified that the standard of care for telemedicine services is the same as for a traditional, in-person medical visit. • Senate Bill 1148 by Sen. Dawn Buckingham, MD (R-Lakeway), eliminated many of the burdens associated with onerous maintenance of certification requirements. • Senate Bill 62 by Rep. Tom Craddick (RMidland) banned texting while driving statewide.

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LEGISLATIVE INTRODUCTION

KEEP OUR TEXAS EDUCATED DOCTORS IN TEXAS By Jayesh B. Shah, MD or 2019, one of the key legislative agenda items for the Texas Medical Association is ensuring that Texas has a ratio of 1.1 entry-level residency positions for each Texas medical school graduate.

The United States is facing a serious shortage of physicians mainly due to a growing, aging population. A 2018 study conducted by IHS Markit, Ltd. for the Association of American Medical Colleges (AAMC) predicts that the U.S. will face a shortage of physicians ranging from 42,600 to 121,300 by 2030. Medical schools have increased enrollment by nearly 30 percent since 2002. There are new medical schools in the U.S. In the past three years, Texas added two new allopathic medical schools, The University of Texas at Austin Dell and The University of Texas Rio Grande Valley in Harlingen, along with an osteopathic medical school at the University of the Incarnate Word in San Antonio. In addition, there are plans to build three more medical schools through 2020 and talk of even more. While Texas has a ratio of 1.1 entry-level residency positions per medical school graduate now, it will be a challenge to maintain this ratio with the increasing number of medical school graduates on the horizon. In addition, the 1997 cap on Medicare support for graduate medical education (GME) has served as a disincentive for growing residency training at the same rate as medical schools. In the 2018 National Resident Matching Program, 1,078 U.S. allopathic medical students; 849 previous graduates of U.S. allopathic medical schools; 846 U.S. osteopathic school medical students/graduates; 2,175 U.S. citizen students/graduates of international medical schools; and 3,105 non-U.S. citizen students/graduates of international medical schools did not match on the first day of Match Week. Over 8,000 fourth-year medical students and physicians, with more than 15,000 clinical hours of training each did not match on Match Day while mid-level providers with 700 clinical hours are ask16

San Antonio Medicine â€˘ February 2019

ing for independent practice. Also, there is a lack of standardization in the educational requirements for online programs for advanced practice registered nurses (APRNs). Physician shortages pose a real risk to patients. Some of this shortage is creating an increased demand for mid-level providers but there is a lack of regulation over APRN online education. Also, online education for APRNs has become extremely popular. Texas Medical Association is monitoring the lack of regulation over APRN education. It would be a good idea for standardization in APRN education just like medical school education. Medical school clinical rotations and residency training are intensely organized to provide a clear, definable, and objective set of experiences.

The Solution:

Fixing the physician shortage requires a multi-pronged approach. 1. There should be an innovative and better use of technology to make more effective and efficient team-based care to improve access to care. 2. There should be additional federal support to generate about 3,000 more physicians a year by at least a partial lifting of the cap on federally funded residency training positions. 3. There should be support for physician workforce development programs like Conrad 30 J-1Visa Waiver Program, National Health Service Corps (NHSC), Public Service Loan Forgiveness (PSLF), and Title VII/VIII to recruit a diverse workforce to practice in underserved communities. 4. There should be continued state support for the creation of new residency positions.

The Texas Legislature took a monumental step in 2015 by creating the stateâ€™s first permanent GME fund to expand the physician

LEGISLATIVE INTRODUCTION workforce because of TMA’s several years of advocacy. The state’s initial investment of $300 million in the permanent fund came from excess money at the Texas Medical Liability Insurance Underwriting Association. It is important to find additional funding sources in order to grow the fund to an amount sufficient for supporting the growth of GME at the level needed to keep up with medical school enrollments. In addition, the state provided about $50 million for 2018 and 2019, including monies from the state’s permanent GME fund, to support recently created residency positions. Since 2014, a total of 237 new GME positions have been created and maintained with state funding. An additional $30 million in state funding is needed per year to maintain these positions in 2020-21. 5. There should be renewed support for GME positions in Texas through the Medicaid program.

With frozen federal Medicare funding, this state support is critical for an increase in residency spots and to achieve and maintain the state goal of 1.1:1.

Resources:

1. Amy Lynn Sorrel, Texas Creates a Permanent Fund to Sustain Graduate Medical Education, Texas Medicine, August 2016;112(8):41-45. 2. AMA report – Options for unmatched Medical Students – Informational Report 2016 3. Results and Data 2018 – NRMP Main Residency Match 4. P. Ranasinge, MD, International Medical Graduates in the US Physician Workforce, The journal of the American Osteopathic Association, April 2015, Vol.115, Number

Acknowledgements:

Mrs. Marcia Collins, Director of Medical Education at Texas Medical Association Dr. Jayesh B. Shah is a past president of the Bexar County Medical Society and current member of the TMA Board of Trustees.

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LEGISLATIVE INTRODUCTION

VACCINATIONS: Public Health vs Personal Choice By Rodolfo Molina, MD

recently received an email from my nephew's wife informing all family members of her due date and also requesting that we receive a DTaP vaccine if we plan to visit her and the baby. It reminded me of a question I'm hearing more frequently by my patients who are grandparents: "Is it safe to get this vaccination while taking my arthritis medications?" A newborn is scheduled to get their first three doses of diphtheria, tetanus, and acellular pertussis (DTaP) vaccination (and some other vaccinations) by six months. After 15 months, they receive another booster. Our Primary Care colleagues are doing a great job educating parents about vaccinations. The idea and practice of immunization is hundreds of years old, dating back to Buddhist monks drinking snake venom to confer immunity to snake bites. In the 17th century, the practice in China involved smearing a skin tear with cowpox to protect against smallpox. Edward Jenner is given credit for the development of the

San Antonio Medicine â€˘ February 2019

first vaccine to protect against smallpox in 1798. Since then, there have been numerous effective vaccines against prior known epidemics and illnesses that are potentially lethal. The vaccine my grandparents-patients ask me about is the Tdap, an improved version of the typical tetanus booster that was licensed in 2006. This newer version contains an additional component to protect against pertussis. All adults, especially those who will be around young infants and who can unwittingly pass this potentially fatal disease, should be vaccinated with this newer vaccine. Despite vaccinations having armed our immune systems leading to longer life spans, there is still controversy surrounding their administration. In 1998, Andrew Wakefield and 12 colleagues published an article in the Lancet stating there may be a link between the MMR vaccine and the development of autism putting into question the safety of vaccinations. However, that article has now been completely debunked because of faulty data (reported sampling was

LEGISLATIVE INTRODUCTION consecutive but was in fact selective) and was completely retracted by the Lancet in February 2010. Furthermore, Wakefield's motive was questioned because of possible financial gain working for lawyers representing parents pursuing lawsuits against the pharmaceutical companies making vaccines. Yet there still exists a belief that there is a link between vaccines and autism. New data published in 2018 points to a disruption of heavy metal metabolism that occurs in utero in autistic children. They accomplished this by using tooth-matrix biomarkers to measure temporal profiles from the second trimester up to approximately one year postnatally. Paul Curtin, et al published findings of a disruption of the fetal and postnatal zinc-copper rhythmic metabolism in people with autism spectrum disorder. While metals have been implicated in autism for many years, these authors found abnormal metal rhythmicity rather than concentration was associated with autism in a highly predictive manner. Presently, there are no federal vaccination laws, but all 50 states have laws requiring children attending public school to be vaccinated against DTaP, polio (IPV), measles, mumps and rubella (commonly in an MMR vaccine), and varicella (chickenpox). All 50 states allow for exemptions: 47 allow religious exemptions, and 17 states allow philosophical exemptions. A review of disease emergence and vaccination refusal was published in JAMA March 2016. In 2000, measles was declared eradicated from the United States, but by 2014, the CDC reported 23 measles outbreaks (total 668 cases) since that time. This included the outbreak that originated in Disneyland in Anaheim, CA (111 cases, half of which were unvaccinated). Reviewing CDC data on the epidemic curve of measles, outbreaks correlate with the resurgence of exemptions to vaccinations among children. Moreover, states with less barriers to exemptions have higher incidence rates of pertussis, which is endemic to the United States. Of interest is a similar story that was reported in Italy where the Italian Parliament dropped mandatory vaccinations. As a result, 5,000 cases of measles were reported in 2017, a six-fold increase from previous years. It becomes clear that vaccinations help suppress the emergence of preventable diseases. So, returning back to any patients' question, "Is it safe for me to get this vaccination?" A good rule of thumb on who should avoid a vaccine would be if he or she is moderately or severely ill or has a history of a previous allergic reaction to the vaccine. However, the CDC has clear regulations on who should avoid vaccinations and each vaccination

has its own recommendations for who should and shouldn't receive it. (See reference link for more details: https://www.cdc.gov/vaccines/vpd/should-not-vacc.html.) Now to answer my patients’ question, if a patient is on biologics such as Enbrel, Humira or others, live vaccines are contraindicated. If a patient is on methotrexate they should hold it for two weeks after receiving the flu vaccine in order to get a better immunological response. The latter recommendation concerning methotrexate is based on newer information published in 2018. As research like that of Curtin, et al continues to peel away the conundrum surrounding the etiology of autism, which concerns many of the anti-vaxxers, these issues will be better addressed. We, as healthcare providers should advocate for our patients by understanding that our role is to provide the best possible advice while remembering it is ultimately the patients’ choice and we should also take their concerns into consideration. So, to those who refuse vaccinations for themselves and their families, they must be properly informed of the increased risk of contracting and spreading a preventable disease. Although we learn quickly in our training how each patient is unique, our responsibilities lie in the education of our patients and staying up-to-date on current findings and associations that may impact their or their loved one’s health. Rodolfo Molina, MD, is vice president of the Bexar County Medical Society. visit us at www.bcms.org

LEGISLATIVE INTRODUCTION

Restoring Cuts to Medicaid Children’s Disability Services By Robert Luedecke, MD athan and Ethan are 2½ year-old twins. At 1½ years Nathan began banging his head against walls and not acknowledging the presence of his parents. His pediatrician started Nathan on a very intensive treatment program for moderately severe autism and he is markedly improved. How would you feel if you were Nathan‘s parents and you did not have the extremely good health insurance necessary to help him have a more normal life? Many Texas parents are in exactly that situation. In 2015 the Texas Legislature cut $350 million from the Medicaid program to provide speech, occupational, and physical therapy for children with disabilities. After these cuts, some therapy programs closed and many cut back on the frequency of services. Especially in rural areas, parents said they were not able to find therapists that could work at the greatly reduced pay. In the 2017 Legislative special session, Republican Rep. Sarah Davis said, “We made the wrong decision in the 84th legislative session, and now we have the opportunity to correct that.” Concerning a study that prompted the cuts, she said, “This was simply not a valid or complete study. By restoring the [Medicaid reimbursement] rates today, we’re doing the right thing for Texas children while remaining fiscally conservative.” The Texas House voted unanimously to re- Depriving children of store the cuts to Medi- needed medical care caid children’s disability is not ‘conservative’ services. Several lawmak- and has no place in ers including House Texas politics. Speaker Joe Straus and Republican Rep. Matt Krause of the conservative House Freedom Caucus urged Gov. Gregg Abbott to add the issue to the special session agenda. The legislation died when Lt. Gov. Dan Patrick and Gov. Abbott refused to consider restoring the cuts. For autism and many other disabilities, the younger you start appropriate treatment, the better are the results. To delay treatment or provide less intense treatment than needed can result in more severe disability for the rest of that child’s life. Disability advocates have pointed out that the right treatment at the right time can decrease the likelihood the child will later need expensive special education. Every member of the Texas House voted in favor of restoring cuts made to the Medicaid pay of speech, occupational, and physical

San Antonio Medicine • February 2019

therapists of children with disabilities. While it is true that Joe Straus is no longer Speaker of the House, it is also true that every Tea Party member and every Freedom Caucus member voted in favor of this even in the face of an impending election. They voted in favor of this because they (L to R) Nathan, Robert, Ethan knew it was the right thing to do. They voted in favor of this despite the fact that future opponents might point to this vote as showing they are not conservative enough. With the courage shown by everyone in the Texas House to stand up for restoring the cuts to Medicaid children’s disability services, will we have the courage to remind Gov. Abbott and Lt. Gov. Patrick this is unfinished business that can’t be forgotten? Will we follow the lead of some of the most conservative members of the Texas House in saying that depriving children of needed medical care is not “conservative” and has no place in Texas politics? Will we ask our elected officials to find the money to do the right thing? Would it help us speak up for restoring cuts to Medicaid children’s disability services to think about how we would feel if it was our child?

References:

https://www.texastribune.org/2017/08/03/House-gives-earlyok-reversing-cuts-disabled-children/ https://www.mysanantonio.com/opinion/commentary/article/Medicaid-cuts-devastating-Texas-families-11278498.php https://www.texastribune.org/2018/11/07/texas-house-speakerjoe-straus-midterm-election-results/ Robert Luedecke, MD, is an anesthesiologist in private practice in San Antonio.

BUSINESS OF MEDICINE

A Solution for After-Hours Medical Call Processing in Bexar County By Dan Kilday, Circle of Friends member Many physicians in San Antonio will experience a change regarding after-hours call handling this year. It can be a scary time for a practice to undergo a change with such a trusted part of the connection between the patient and physician. Time is a valuable commodity in the medical profession. For a physician, time is just as precious on the job as it is away from it. Knowing that your patients are in great hands while away from the office is crucial to your peace of mind. Working with a quality medical call center to process your after-hours calls can make a huge difference. But how do you choose the right medical call center for your practice? What attributes are most important? Below, you’ll find important tips on what you’ll need to look for to select the highest quality call processing service for your patients. 1. Longevity. Believe it or not, the call center industry is a rough business! It’s very difficult for a company to survive for long unless they provide service above and beyond the many competitors out there. It’s a 24 hour a day, 365 day a year business with an enormous amount of responsibility when it comes to handling emergency calls. Finding a service that has been around for a long time instantly tells you that it has provided an outstanding service which allowed it to survive and prosper over many years. 2. Security. We live in a time where sensitive information can be hacked and stolen daily. It’s extremely important to protect this information by working with companies that follow HIPAA guidelines, using encrypted coding for SMS messages. It’s also important to ask where your information is stored. Is it in a highly secure, tier-4 data center? Is the data center in compliance with HIPAA? Are calls recorded and stored in case you need to 22

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go back and listen to a call? Never use a call center that cannot follow these requirements. 3. Bilingual Agents. Communicating with our Spanish speaking patients is imperative for a thriving practice in South Texas. It should go without saying that your call center should be able to handle calls from those who are unable to speak English. A bilingual medical call center is of the upmost importance. 4. Texas Based Agents. The “buy local” mantra is used for everything from book stores to beef in our state. It creates a huge boost to the local economy and helps provide more jobs for our community. This can also apply to your medical call center. But there’s more to it than just dollars and cents. When a patient calls, it’s comforting to know that the person on the other end is a local citizen who knows the area. 5. Easy On-Call Scheduling. For larger practices with a complicated on-call schedule, this attribute can be a life saver. It’s important to find a call center with a web portal that allows you to input and adjust the on-call schedule easily. For example, if you have one provider listed as the on-call for Thursday and he or she calls in sick, you can easily go in and replace that person on the schedule. You don’t have to call or email the call center. The change is automatically updated on the other end and the dispatch will contact the replacement instead. This saves time and energy for everybody involved. 6. Time-Based Billing. It’s important to understand how your billing works with your medical call center provider to make sure that you’re getting the best “bang for your buck,” with the service. Time based billing is, by far, the most cost-effective and efficient way to track your usage. Think of it this way… A call comes in and it’s a wrong number. The call center immediately

BUSINESS OF MEDICINE and professionally exits the call in 6 seconds. In “per call” billing, that counted as an entire call. In “time based” billing, you are only credited for those 6 seconds. This works very similarly to cell phone plans. You’ll select a package of minutes that is appropriate for your call volume. If you keep getting overages, you are welcome to increase your time to a higher plan. Likewise, you can “bump down” to a lower plan if you aren’t using your allotted minutes. This system will allow you to effectively utilize your service in the most cost-effective way. 7. Disaster Recovery. Does your office have a plan if your entire system goes down? What happens if your phone lines suddenly go out completely? Your medical call center should have a staff capable of handling a sudden influx of calls if-and-when your telecommunication systems are down. The call center itself should also have a disaster plan in place. Do they have back-up generators in case a storm or nearby construction knocks the power out? Are they able to route calls to another location if the phone lines are cut? It’s imperative that your practice is available to your patients 24 hours a day, even during a crisis. A medical call center with a disaster recovery plan in place is the best way to do this. 8. Customization. From the flavor of ice cream to the temperature of the room, everybody has a different preference. Your group of physicians may have a variety of inclinations for how they want their calls handled and dispatched. It’s important to find a medical call center that isn’t using a “one size fits all” dispatching protocol. You may have one provider who prefers text messages. Another may prefer to be called or emailed. They may

also require different information from the caller. The ability to customize the way calls are handled makes a huge difference and adds to your practice’s value to your patients. My wife recently had sinus surgery. That evening, I found myself dialing her doctor’s number to let him know that she was in much more pain than we were expecting. It was a tremendous relief to hear him say that everything we were experiencing was normal for the first night after surgery. That’s all I needed! I just wanted to hear somebody tell me that this was all part of the process and there was nothing to worry about. It was extremely comforting to have that connection after regular business hours. That call between a patient and a doctor is crucial to healthcare and it’s important to have a medical call center that can provide what your practice needs after-hours or even during the day. These steps will help assure that you have selected a quality service that keeps you connected to your patients. Dan Kilday is an account representative with TAS United, a bilingual medical call center that has answered calls for healthcare professionals in San Antonio for over 30 years. He can be reached at dkilday@tasunited.com.

visit us at www.bcms.org

UTHSCSA

Through cancer care and research, UT Health San Antonio serves South Texas’ most seriously ill children By William L. Henrich, M.D., MACP, President and Professor of Medicine UT Health San Antonio I would like to take this opportunity to share About 15,000 U.S. with you some examples children and adolescents of important and lifeunder age 20 are changing work being undertaken by the expert diagnosed with cancer pediatric cancer physiannually. Five-year cians and researchers of survival for all childhood The University of Texas cancers has increased to Health Science Center at greater than 80 percent, San Antonio, also known as UT Health but for some tumors, such San Antonio. All of as those of the brain and these efforts take place bone, five-year survival in the Joe R. and Teresa remains below 75 percent. Lozano Long School of Medicine, which is led by Robert A. Hromas, M.D., professor and dean. Guided by the goal of improving the lives of One of the medications recently studied by the group was an imchildren with cancer, both for today and tomorrow, we remain communotherapy drug called atezolizumab, which was used to treat formitted to continuously advancing the care that is provided to chilmer President Jimmy Carter’s melanoma. UT Health San Antonio dren battling cancer. Comprehensive clinical care is accomplished is one of 10 consortium partners in the U.S. and Canada providing through the South Texas Pediatric Blood Disorders and Cancer such trials through the Pediatric Oncology Experimental TherapeuCenter, which is offered in partnership with University Health Systic Investigators’ Consortium (POETIC). Anne-Marie Langevin, tem. Our clinical team is led by Gail Tomlinson, M.D., Ph.D., of M.D., of the pediatric hematology-oncology faculty, leads these and the Department of Pediatrics/Division of Hematology-Oncology other clinical trials. and the Greehey Children’s Cancer Research Institute. The team is Care of children with cancer does not stop when treatment ends, refining treatment options based on what we learn from Phase I trias more than 75 percent of survivors will experience at least one als about young patients whose cancers aren’t responding to other chronic health condition related to previous treatments, and up to forms of treatment. Team members are ever mindful of the psyone-third are afflicted with a life-threatening condition. Gregory J. chosocial aspects of a cancer diagnosis, as well. Emphasis also is Aune, M.D., Ph.D., is a 27-year survivor of childhood Hodgkin’s placed on counseling families who may have genetic factors that lymphoma. Dr. Aune, of the Greehey Institute and pediatric hemacould indicate future risk of cancer within the family. continued on page 26

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UTHSCSA continued from page 24

tology-oncology, is studying serious health problems such as heart disease among long-term survivors. His research includes clinical investigations with cancer survivors, as well as laboratory investigations in which he has developed animal models of toxicity. Allison Grimes, M.D., pediatric hematology-oncology and Greehey Institute, is addressing the issue of further protecting cancer survivors from HPV-related second cancers. Cancer survivors are particularly vulnerable to these cancers. This project will be supported by a $1 million grant from the Cancer Prevention and Research Institute of Texas (CPRIT). Leanne Embry, Ph.D., a child psychologist in pediatric hematology-oncology, leads a National Institutes of Health-funded study looking at the cognitive late effects that can result from intensive chemotherapy and radiation therapy. Of course, as you know, it is always basic research discoveries that lead to new and more effective therapies becoming available. Here at the health science center, our Greehey Children’s Cancer Research Institute is the largest freestanding pediatric cancer research facility in Texas and one of the few research institutes worldwide devoted exclusively to childhood cancer. The Greehey Institute, led by Peter Houghton, Ph.D., of the Department of Molecular Medicine, is conducting a National Cancer Institute-funded project grant in childhood sarcomas that grow in bones, muscles, tendons, cartilage and other anatomic features such as nerves. A $5 million grant from CPRIT is enabling the Greehey Institute to develop novel animal models of pediatric cancers. These models, which focus on Hispanic children in Texas, will enhance research in drug development and be made available freely to pediatric cancer researchers statewide and beyond. Furthermore, a 26

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separate $3.6 million CPRIT grant is enhancing computational biology to provide powerful statistical analyses to researchers studying children’s cancers. Myron Ignatius, Ph.D., of the Greehey Institute and Department of Molecular Medicine, has developed a genetic model of a type of soft tissue cancer called embryonal rhabdomyosarcoma that generally occurs in children. Our faculty all join me in congratulating Dr. Ignatius on being recognized this year by The Max and Minnie Tomerlin Voelcker Fund with a Young Investigator Award. Lastly, Manjeet Rao, Ph.D., of the Greehey Institute and Department of Cell Systems and Anatomy, has conducted groundbreaking work demonstrating that a micro RNA, the molecule MiR-584-5p, is able to kill medulloblastoma, the most common childhood brain cancer. His team’s preclinical findings show that MiR-584-5p sensitizes the cancer to chemotherapy and radiation, making it plausible to treat the tumors with one-tenth the dose that is currently required. This work, which points to a way to improve the quality of life of children treated for brain cancer, was published Oct. 31 in Nature Communications. It is truly a privilege to be able to share this small part of the proud body of work being undertaken here at UT Health San Antonio. Our mission is to make lives better through excellence in education, research and patient care, and through engagement with the individuals, families and organizations of this region. Equally important, we remain deeply grateful to all our esteemed partners in medicine who live and practice across our community and share in our commitment to serving patients and their families across South Texas.

BCMS HONOREES

HONOREE INTRODUCTION The Bexar County Medical Society gave out special awards to three of its most distinguished and long-serving members during the 2019 Installation ceremony on Jan. 19. The honorees were Drs. David P. Green and Manuel QuiĂąones, who both received the Golden Aesculapius Lifetime Service Award, and Dr. Marvin Forland, who received the BCMS Distinguished Service Award. In the coming months, San Antonio Medicine will publish feature articles on each of the honorees who are briefly introduced below.

Dr. David P. Green

A native Texan, David Green, MD, grew up in El Paso, but went to New York City for his orthopaedic and hand surgery training. In 1970, he joined the full-time faculty of the Department of Orthopaedics at the Medical School in San Antonio. For eight years he was the Coordinator of Resident Training, serving also as Chief of the Hand Surgery Service. While at the medical school, Dr. Green co-authored, with Dr. Charles A. Rockwood, a twovolume textbook on fractures that is now in its 8th edition and is the standard reference book on this subject. It is used in all orthopaedic residency training programs throughout the country. In 1978, he left the medical school and became the first surgeon in San Antonio to devote his practice entirely to hand and upper extremity surgery. He is the hand surgery consultant for the San Antonio Spurs, and has treated numerous professional athletes, including members of the Dallas Cowboys, world class gymnasts, professional rodeo cowboys, and golfers on the PGA tour. Dr. Green has edited a comprehensive textbook entitled Operative Hand Surgery (now in its 7th edition), which is used not only throughout the entire United States, but by hand surgeons in virtually every country in the world. Because of this book, Dr. Green has an international reputation in hand surgery and has been invited as a guest speaker to many foreign countries. He is also a past president of the American Society for Surgery of the Hand, and in 1997 was named the Distinguished Alumnus of his own residency training program. Dr. Green is an enthusiastic skier, a drop-out bluegrass banjo picker, and has published several non-medical books. 28

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BCMS HONOREES

Dr. Manuel M. Quiñones, Jr.

Manuel M. Quiñones, MD, is a native San Antonian. He is Board Certified in Family Medicine, fluent in both English and Spanish, and continues to practice medicine here in San Antonio. Dr. Quiñones has a special interest in treating adult patients with hypertension, diabetes and high cholesterol, conditions so common to so many residents of San Antonio and South Texas. As a caring physician, Dr. Quiñones makes it a point to spend more time with his geriatric patients during their office visits, and treats them like he would his own family. Dr. Quiñones went to college at St. Mary’s University in San Antonio, did his medical training at the Baylor College of Medicine in Houston, Texas, did his Family Practice Residency at The University of Texas Health Science Center in San Antonio, Texas, and served on the Faculty of the University of the Incarnate Word School of Osteopathic Medicine in San Antonio, Texas. Dr. Quiñones has been an active member of the Bexar County Medical Society having served on the BCMS Board of Directors, various elected officer positions, and as the 2008 President of the Society. Dr. Quiñones enjoys hunting and ranching. He especially enjoys spending time with his wife and their two Jack Russell terriers at their ranch in Medina County. In 2018, Dr. Quiñones received the great honor of being invited to serve as a member of the Texas Medical Board. Dr. Quiñones was voted one of the Best Doctors in San Antonio®, Best Doctors in America®, Top Doctors in America®, Texas Super Doctors® and Bridges to Excellence® award recipient.

Dr. Marvin Forland

Marvin Forland, MD, is a native of northern New Jersey. He received his bachelor's degree Magna cum Laude from Colgate University in 1954 and medical degree from Columbia University College of Physicians and Surgeons where he was the Theodore Vosseler Scholar. He completed his internal medicine and nephrology training at the University of Chicago Affiliated Hospitals. His introduction to San Antonio was two years as assistant chief of the Renal Branch of the Army's Surgical Research Unit at Brooke Army Medical Center. Following military service, he spent four years as an assistant professor in the department of medicine at the University of Chicago School of Medicine. Dr. Forland accepted an invitation to participate in the development of the newly opening University of Texas Medical School at San Antonio in the fall of 1968, influenced by the major medical needs he had observed earlier in San Antonio, and UT's outstanding support of the Medical Branch and Southwestern Medical School. Initially chief of the division of renal diseases in the department of medicine, Dr. Forland helped initiate the new curriculum and the hemodialysis, renal biopsy and renal transplantation programs at the developing school and its affiliated hospitals. He authored or co-authored over 80 papers and book chapters, primarily in the area of renal diseases, and edited the Concise Textbook of Nephrology. In 1975, he became deputy chairman for clinical activities and residency program director in the department of medicine. Dr. Forland was named Professor Emeritus of Medicine upon retirement from UTHSCSA in April, 1999. A medical student scholarship in his honor was established by the UTHSCSA Medical Alumni Association that year, and a "Marvin Forland, M.D., Distinguished Professorship in Medical Humanities and Ethics", endowed by a former patient. The Forland Professorship was filled in July, 2002 by Dr. Abraham Verghese, infectious disease specialist, teacher and writer, who was the founding director of The Center for Medical Humanities & Ethics. visit us at www.bcms.org

BCMS INSTALLATION

2019 BCMS JOINT INSTALLATION OF OFFICERS The 2019 BCMS Joint Installation of Officers was held on Saturday, Jan. 19, in the Mays Family Center at The Witte Museum.

Dr. Adam Ratner was sworn in as the 2019 BCMS President and Kelly King was sworn in as the 2019 BCMS Alliance President. Dr. David P. Green and Dr. Manuel Quiñones were awarded the Golden Aesculapius Lifetime Service Award and Dr. Marvin Forland received the BCMS Distinguished Service Award. About 320 people attended the sold-out event.

Thank you to all of the sponsors including:

2019 INSTALLATION PRESENTING SPONSORS UT Health San Antonio • University Hospital System University of the Incarnate Word • Mednax – Pediatrix Medical Group

2019 FRIENDS OF MEDICINE SPONSORS Dr. Sheldon Gross • Dr. John Holcomb • Dr. Gabriel Ortiz Dr. Rodolfo Molina (Arthritis Associates, PA) • The Patient Institute • Dr. Rajeev Suri 1

San Antonio Medicine • February 2019

2019 CIRCLE OF FRIENDS SPONSORS 2

BCMS INSTALLATION 3

1. New BCMS President Dr. Adam Ratner with his daughter Shayna and wife Varda. 2. Members of the “Manuel Quiñones Fan Club” donned fake mustaches to celebrate Dr. Quiñones’ award.

6 5

3. Dr. Jayesh Shah, TMA Board of Trustee member and past BCMS President, with his wife Neha.

4. BCMS Immediate Past President Dr. Sheldon Gross (right) swears in the 2019 BCMS Executive Committee (L-R) Dr. John Nava, Dr. Gerald Greenfield and Dr. Adam Ratner.

5. Dr. Adam Ratner, 2019 BCMS President

6. Dr. Sheldon Gross with TMA President Dr. Doug Curran and BCMS Executive Director Stephen C. Fitzer. 7. BCMS Honorees Dr. David P. Green, Dr. Marvin Forland and Dr. Manuel Quiñones

8. 2019 BCMS President Dr. Adam Ratner

9. Dr. Francisco Cigarroa (left); Dr. Robert Hromas (back center) and Dr. K. Ashok Kumar (center) and Dr. Ruth Berggren (front right) with UT Health SA students.

visit us at www.bcms.org

BCMS INSTALLATION BCMS Past Presidents (L-R) Dr. Neal Gray; Dr. Garbriel Ortiz, Dr. David Shulman; Dr. Jose Benavides; Dr. K. Ashok Kumar; Dr. Jayesh Shah; Dr. Adam Ratner (in front); Dr. Sheldon Gross; Dr. David Henkes; Dr. Gerardo Ortega; Dr. Donald Gordon; Dr. Leah Jacobson; Dr. Al Sanders; Dr. Delbert Chumley; and Dr. Manuel Quiñones. BCMS Board of Directors for 2019 (L-R) Dr. John Nava; Dr. Jayesh Shah; Dr. David Hnatow; Dr. Robyn Phillips-Madson; Dr. Brent Sanderlin; Dr. Adam Ratner (in front); Dr. Gerald Greenfield; Dr. Michael Battista; Dr. Sheldon Gross; Dr. Gerardo Ortega; Dr. Manuel Quiñones; and Executive Director Stephen C Fitzer. Dr. Adam Ratner (center) with UIW Medical School students and staff.

San Antonio Medicine • February 2019

BCMS ALLIANCE

2019 BCMS ALLIANCE INSTALLATION CEREMONY 2018 BCMS Alliance President Jenny Shepherd swore in Kelly King as the new President for 2019 during a ceremony on Saturday, Jan. 19, in the Mays Family Center at The Witte Museum. All of the 2019 officers for BCMS Alliance were sworn in as well during the ceremony at which new BCMS President Adam Ratner, MD, was sworn in as well.

To learn more about BCMS Alliance and find out how to join go to their web page at www.bcms-alliance.org. visit us at www.bcms.org

HEALTH

Do you know your Gluten ID? If not, here’s why you should By Shelly Gunn, MD, PhD

Chances are you’ve noticed the growing number of gluten free food choices when shopping at your local grocery store or dining at a favorite restaurant. Clearly supply is increasing to meet a certain demand, but what is motivating consumers to adopt a non-grainbased diet? We know that approximately 1 percent of the world population is afflicted with pathology proven celiac disease, but the ubiquity of gluten free options clearly appeals to a broader population. Many U.S. consumers, savvy about health and wellness, proactively reduce gluten consumption based on directives from the wellness ‘self-help’ literature, or as a reaction to peer and family pressure. However, a growing number of individuals, eager to learn their genetic predisposition for developing gluten intolerance disorder, are opting for DNA-based Gluten ID testing. Who can benefit from knowing their unique inherited susceptibility to gluten intolerance? The answer is virtually everyone. In fact, universal screening for gluten sensitivity has been on the table for decades but in this new era of personalized medicine, we finally have the laboratory tools to make it a reality. The Backstory: Gluten, the major storage protein in wheat, was first introduced into the human diet around 10,000 years ago when the Paleolithic period menu of hunted meats and gathered fruits was replaced by farmed, grain-based nutrition. Due to the inherent stability of wheat, it became a valuable nonperishable exchange 34

San Antonio Medicine • February 2019

commodity soon spreading via trade routes around the globe. However, a small percentage of the human population was unable to consume wheat without experiencing gastrointestinal (GI) symptoms. The earliest reports of diarrhea and malabsorption from wheat consumption were reported by the celebrated Greek physician Aretaeus of Cappadocia 2,000 years ago. He described the malady as “koiliakos” meaning “abdominal” from which the term “celiac” was later derived. In the late 19th century, celiac disease (CD) from wheat consumption was documented in the Northern European medical literature. By the 1990’s, CD had come to be recognized as a worldwide disease entity affecting approximately 1 percent of the population in gluten-consuming countries. The Molecule: Comprised of long strands of protein chains, the gluten molecule cannot be completely broken down by human digestive enzymes. Thus, the stable attributes of wheat that made it such a valuable exchange commodity in the ancient world are also a major reason why wheat consumption can trigger symptoms of gluten intolerance. Once gluten enters the human gut it remains there for many hours, long enough for the immune system to mount a response against specific regions of the protein chains. However, this strong immune reaction occurs only in individuals who have inherited the gene’s coding for the specific immune cell receptors capable of recognizing gluten proteins. Gluten does not evoke the

HEALTH same reaction in individuals who lack genes encoding these immune cell receptors. This explains why, even in ancient times, only a subset of the population has been reported to develop GI symptoms from gluten consumption. Gluten Genetics: Using molecular genetic laboratory techniques, we can identify an individual’s inherited susceptibility to gluten intolerance. DNA-based testing will identify the presence or absence of the genes encoding the gluten recognition immune cell receptors, HLA-DQ2 and DQ8. The receptors are comprised of two protein chains, alpha and beta, (encoded by genes DQA1 and DQB1 respectively) that can be inherited from the same or different parents. An estimated 30 percent of the human population carries combinations of the DQ2 and DQ8 gluten intolerance susceptibility genes. Within this population of genetically susceptible individuals there is a spectrum of elevated risk for developing severe celiac disease accompanied by 50 percent or 100 percent chance of transmitting combinations of these genes to future generations. Conversely, individuals lacking DQ2/DQ8 gene combinations have virtually no risk for development of celiac disease and 0 percent transmission risk. Celiac Disease Testing: Prior to the Precision Medicine era, clinical laboratory testing for celiac disease (the most extreme expression of gluten intolerance) has primarily been performed at the protein (not DNA) level. Antibody-based tests including tTG-IgA and IgA Endomysial antibody (EMA) remain the mainstays for laboratory diagnosis because they are quick and accurate in acutely ill patients who have been consuming gluten in their diet. However, in individuals with celiac disease who are on a gluten free diet and asymptomatic family members, antibody testing often gives false results because gluten antibodies are not being produced by the immune system. DNA testing thus provides a stable alternative to antibody testing and only needs to be performed once in a person’s lifetime to provide accurate, unchanging results. DNA test results are often included with findings from antibody testing, clinical presentation, and small bowel biopsy to help make the diagnosis of celiac disease. The high negative predictive value of DNA test results essentially rules out the diagnosis of celiac disease in individuals lacking the DQ2 and DQ8 genes. Non-celiac Gluten Sensitivity (NCGS): For some individuals with symptoms of gluten intolerance, genetic testing results are negative for DQ2 and/or DQ8 genes. The good news for those with NCGS is their chances of developing severe celiac disease requiring small bowel biopsy is less than 1 percent. In addition, these individuals have 0 percent chance of transmitting DQ2 and DQ8 genes to their children. However, these positive factors do not diminish the reality of their gluten-related symptoms or detract from the importance of a gluten free diet as a path to wellness. DQ2 and DQ8 positivity has been well documented in the medical literature as a

reliable biomarker for celiac disease susceptibility, but emerging protein and genetic biomarkers may one day be clinically available for NCGS. Additionally, NCGS individuals may have a wheat allergy (WA) caused by an IgE mediated immune reaction to gluten as opposed to the celiac specific T cell attack on the gut. Gluten is the least digestible, most immunogenic protein in the human diet so it comes as no surprise that the human immune system has multiple ways to recognize and mount a targeted response against the gluten proteins. Human tissues including the gut, thyroid, and musculoskeletal system are often in the line of fire and suffer collateral damage through molecular mimicry when normal tissues are mistaken for gluten proteins. The Path to Wellness: Anyone with unexplained GI symptoms, autoimmune disease, brain fog, chronic fatigue syndrome or known celiac disease in a first degree relative could potentially benefit from knowing their Gluten ID. In the direct to consumer (DTC) era of genetics, DQ2/DQ8 testing can be performed with cheek swab kits purchased online and results reported directly to the individual. However, for purposes of wellness planning, it is desirable that DQ2/DQ8 test results be included in the medical record. Therefore, Gluten ID testing is optimally ordered and performed by physicians such as family practice or functional medicine, rheumatologists, and gastroenterologists so it can be integrated into the patient’s preventive medicine and wellness plan. Gluten intolerance is best viewed on a spectrum of risk, and those with the highest risk have increased incentive to be cautious about how much of a highly immunogenic protein they introduce into their digestive system. Celiac and autoimmune diseases can be silent for many years, just like a glass gradually filling with water. However, as a glass overflows suddenly, so do celiac and autoimmune disease symptoms often present without warning. Therefore, the path to wellness begins with knowledge about each person’s unique genetic predisposition to gluten intolerance and continues through a lifetime of steps taken towards reducing risk and promoting health. In the era of personalized medicine, this pathway empowers each individual to know their susceptibility and transmission risk for celiac disease in order to appropriately minimize gluten consumption and maximize a lifetime of wellness.

References

Chou, et al: Screening for celiac disease: a systematic review for the uS Preventive Services Task Force. March 2017, AHRQ publication NO. 14-05215-EF-1. Lebwohl B, et al: Celiac disease and non-celiac gluten sensitivity. British Medical Journal 2015, 351:h4347 Ludvisson JF, et al: Screening for celiac disease in the general population and high-risk groups. United European Gastroenterology Journal 2015, 3:106-120. visit us at www.bcms.org

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.”

ACCOUNTING SOFTWARE

ASSET MANAGEMENT

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection. John M. Albert |The Farret Team | Financial Advisor 210.278.3816 john.albert@ml.com www.fa.ml.com/farretgroup “Life’s better when we’re connected®”

San Antonio Medicine • February 2019

Avid Wealth Partners (HHH Gold 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 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence. Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

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. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 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”

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients. Robert R. Biechlin, Jr., Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

ASSETS ADVISORS/ PRIVATE BANKING

BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future. Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

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 EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle. Moses D. Luevano

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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. Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions

210-650-1738 nallen@rbfcu.org www.rbfcu.org

"We provide peace of mind, giving compassionate care to our community with integrity"

FINANCIAL ADVISOR Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals. Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!” First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust. Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you. Utilizing marketing and business development tactics, we create a plan tailored to your needs! Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service. Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance. Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com

Jon M. Tober SWBC Mortgage – Sr. Loan Officer NMLS#212945 210-317-7431 Jon.tober@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold 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 ommitted 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 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle. Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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visit us at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for 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 Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to

San Antonio Medicine • February 2019

assist with financing of building acquisitions, construction projects, and machinery and equipment loans. Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

HOSPITALS/ HEALTHCARE SERVICES

Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

INSURANCE

HEALTHCARE BANKING

Amegy Bank of Texas ( 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 EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE CONSULTING

Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry. David Stich Senior VP of Strategic

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

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 Asso-

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY ciation, 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.” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET TELECOMMUNICATIONS

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango, CEO

956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

LUXURY REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage. We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country. Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

MARKETING ADVERTISING SEO

Veerspace (HHH Gold Sponsor) We're a nationwide digital advertising agency that specialize in growing aesthetics practices through videography and social media. Office contact number is 210-969-7850. Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BILLING AND COLLECTIONS SERVICES Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold 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 to 50 percent.”

PHYSICIAN SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For in-

dividuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance. Gil Castillo, SWBC Wealth Management, 210-321-7258 gcastillo@swbc.com Kristine Edge, SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Debbie Marino, SWBC Insurance & Benefits, 210-525-1241 dmarino@swbc.com Jon M. Tober SWBC Mortgage – Sr. Loan Officer NMLS#212945 210-317-7431 Jon.tober@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

PROFESSIONAL ORGANIZATIONS 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, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tina Turnipseed, President Tom Tidwell, President-Elect info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie@kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

San Antonio Medicine • February 2019

RESIDENTIAL REAL ESTATE

ate a more productive workplace. Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

RETIREMENT PLANNING

TELECOMMUNICATIONS ANSWERING SERVICE

New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to cre-

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

RECOMMENDED AUTO DEALERS AUTO PROGRAM

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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 Rudy Solis 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 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

Eric Schwartz 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Marty Martinez 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

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 Toyota 10703 SW Loop 410 San Antonio, TX 78211

Scott Brothers 210-253-3300

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

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

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Victor Zapata 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

AUTO REVIEW

2019 LEXUS LC 500 By Stephen Schutz, MD

The old Brad Paisley song, “He Didn’t Have To Be,” is a touching number about a man who marries a single mother and becomes a great dad to her son even though he didn’t have to. Driving the Lexus LC 500 reminded me of that song because it’s a luxury coupe that drives much better than it needs to. Several months ago I wrote about one of the Lexus LC’s more expensive competitors, the Mercedes S-class coupe, and said that it’s a very impressive car that’s not stimulating to drive. That’s fine because buyers expect big luxury coupes (or sedans for that matter) to be serious. They’re about comfort, safety, and image. So how cool is it that Lexus actually made the LC fun? Let’s start with the engine. It’s a naturally aspirated 5.0 liter V8 that pumps out 471 HP and, critically for me, awesome exhaust notes. Turbochargers are taking over the (pre-electric) automotive world because they add seemingly endless power with little fuel 44

San Antonio Medicine • February 2019

economy penalty, but regrettably turbos are also the enemy of good engine sounds. Listening to this car rev, on the other hand, is highly pleasurable. During my week with it, I frequently found myself pushing the throttle more than I needed to just to hear the LC’s delicious V8. Yum. That engine is also plenty muscular, by the way. Its 0-60MPH time of 4.4 seconds is quicker than the 1979 LeMans-winning Porsche 935, and I always felt as though I had plenty of power despite the LC’s hefty curb weight of, gulp, 4,280 lbs. The standard transmission is a 10-speed automatic, and fuel economy is 16MPG city/26MPH highway. It’s higher if you choose the hybrid LC 500h, but given the additional weight and CVT that version includes I’d stick with the standard LC 500. In addition to providing a powerful engine, Lexus spent extra time making sure the LC handles well. Twisty back roads are no

AUTO REVIEW

trouble for the LC, nor are long interstate on-ramps, quick intown lane changes, or fast trips on B-roads. But what really convinced me that the LC can handle was driving two hot laps on the Weathertech Laguna Seca Raceway. I had that opportunity last year at a (non-Lexus) event and was surprised at how well the LC fared. Not only did it not float or understeer as I expected, but it dove into corners and even let the tail hang out a bit. No, the LC isn’t as good on the track as a Porsche 911 or even its showroom sibling, the wonderful and underrated GSF, but for a car in this class it does remarkably well when pushed. It’s a good looking car, too. A tidy profile and voluptuous hips dominate the visual experience, but attractive creases and other detailing catch your eye in a very positive way. Even the big and controversial Lexus grille is quietly integrated into the design, unlike on some other Lexuses where the grille is like the diva NFL receiver who can’t shut up because it’s always all about him. Tastefully luxurious also describes the interior, which combines a cozy cockpit similar in feel to a sports car but with noticeably upscale materials and modern electronic gauges. On a pampering scale it’s as good as the aforementioned S-class coupe. Visibility is also good despite the generous A- and Cpillars, which of course add structural stiffness. (No convertible option is available.) The biggest downer is the touchpad infotainment interface. When it debuted ten or so years ago, Lexus’ unique Remote Touch infotainment interface was a breath of fresh air. Now it’s just odd and more difficult than its competitors. This is a coupe, so getting in and out of the LC is harder than

a sedan or crossover, but it’s not too bad thanks to relatively high seats and a steering wheel that moves up and away when you turn the car off. Still, the long doors mean you'll need extra room to open them, luggage space is limited, and the two rear seats are very tight. While the LC 500 is expensive with a starting price of just over $90,000, it’s less costly than all of its direct competitors from Germany. There are individual options and packages that raise the price somewhat, but the annoying German habit of charging extra for features that should be standard like keyless stop/start doesn’t apply at Lexus. As always, call Phil Hornbeak for more information and to get your best BCMS deal. If you’re looking for a top-shelf luxury coupe this might be the best one out there. With its looks, fine interior, and wonderful naturally aspirated V8, I’d take it over the Mercedes S-class coupe and, probably – I haven’t driven it yet – the BMW 850i. Thank you Lexus for making it more fun than it had to be. As always, contact Phil Hornbeak at 210-301-4367 to get information about options and your best BCMS deal on a Navigator.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

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San Antonio Medicine â€˘ February 2019