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THE 87TH LEGISLATIVE SESSION The 87th Session of the Texas Legislature By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer.................................................................12 TMAs Legislative Priorities for the 87th Texas Legislature By TMA....................................................14 How to Advocate for Medicine: COVID Style By Jenny Shepherd.......................................................16 The No Surprises Act By Ezequiel Silva, MD....................................................18 “Sin” Taxes on Tobacco Should Match State Expenditure By John J. Seidenfeld, MD ......................20 Prior Authorization Shenanigans By Neal S. Meritz, MD ...................................................22 Prior Authorization Delays and Undermines the Best Patient Care Jayesh Shah, MD..........................................................23 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 TMA Winter Conference .........................................................................................................................................24 The Plight of the Immigrant Physician By Amar Sunkari, MD..................................................................................26 My First Day By Daniel Rosas, MD ........................................................................................................................28 What Do Patients Believe Makes a Good Doctor? By Kalli Davis ............................................................................29 Texas Medical Board Controlled Substance Prescribing Requirements...................................................................30 BCMS & H-E-B Cooperate to Vaccinate 1,700.......................................................................................................32 Circle of Friends Directory ......................................................................................................................................34 Recommended Auto Dealers .................................................................................................................................39 Auto Review: 2021 Ford Expedition King Ranch By Steve Schutz ..........................................................................40

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SAN ANTONIO MEDICINE • March 2021

MARCH 2021

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VOLUME 74 NO. 3

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. EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com 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, its members, 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

Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President

DIRECTORS

Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Charles Mahakian, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Stephen C. Fitzer, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student

BCMS SENIOR STAFF

Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Yvonne Nino, Controller 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 John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Donald Bryan Egan, Student Member Teresa Samson, Student Member Alexis A. Wiesenthal, MD, Member Neal Meritz, MD, Member Stephen C. Fitzer, Editor Jaime Pankowsky, MD, Member 6

SAN ANTONIO MEDICINE • March 2021

PRESIDENT’S MESSAGE

Women in Medicine: Accomplishments and Challenges By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President

March 1st marks the beginning of a month dedicated to the history of women. I thought the center piece of this article should explore and compare the challenges and accomplishments of the first woman to graduate from medical school in America, Elizabeth Blackwell, to our present-day female physicians. Now, more than half of the entering medical school class is female. So, what new challenges are women in medicine facing since Dr. Blackwell received her degree 170 years ago? Full disclosure, my wife is a physician and I also have two daughters in medicine: a second-year internal medicine resident and a fourth-year medical student. Let me begin with a brief narrative of Elizabeth Blackwell’s story. In 1849, British-born Elizabeth Blackwell became the first woman to earn a medical degree in the United States. After being rejected from a multitude of medical schools, she was finally admitted to the Geneva Medical School in New York. Originally, the dean opted to also reject her application, however, he decided her acceptance would be contingent upon the 100% approval of an entirely all-male student body. They unanimously voted yes (reportedly as a joke), but she was soon met with new challenges. From the town women shunning her to the professors not treating her as an equal to her male counterparts, Dr. Blackwell learned to not shy away from adversity. One of the professors even requested she leave the classroom during a “sensitive” male reproductive lecture. She refused and with the support of her male colleagues, she stayed. After graduating, she focused her efforts on establishing her career in New York, but was not allowed to practice in any hospitals. Unfortunately, Blackwell struggled to dispel the negative basis of dealing with a female physician. Being a female physician was thought by some to be code for abortionist. Because she was not allowed to practice in hospitals, she was urged by friends to go to Paris for further training. The French were not any different from the Americans about allowing her to continue training at one of their hospitals, but eventually she was allowed to work at a maternity hospital alongside mid-wives. Eventually, through family influence, she was given a place at St. Bartholomew, a prestigious London hospital. In 1859, Blackwell succeeded in becoming the first woman to be included in the newly formed British Medical Register. She befriended several women along the way who became prominent figures in the history of medicine including Florence Nightingale. Eventually they parted ways and Nightingale later gained notoriety for her service during the Crimean War. Dr. Blackwell returned to America and tried to establish herself in New York City. She struggled finding paying patients. In the face of adversity and with her tenacity, she founded the New York Infirmary 8

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for Indigent Women and Children for the purpose of caring for those in need. At the outbreak of the American Civil War, she hoped the American military would welcome the contributions of female physicians. To her surprise, she was relegated to be under the supervision of a head nurse with the duties of recruiting suitable nurses to help the war effort. In 1869, Blackwell returned to London and later taught at the London School of Medicine for Women, established in 1874. Due to health reasons, she moved to a country side house in 1879 where she continued to write numerous lectures, articles and books until her death in 1910. Her obituary in the London Times stated, “She was in the fullest sense a pioneer who, like all pioneers (when discouraged) heard but did not listen.” What about now? Societal mores, in particular those embedded with gender biases or expectations, are deeply rooted and not easily erased from memory or tradition. While female physicians today are not openly shunned like Elizbeth Blackwell, there is a level of unconscious bias working against female physicians in the workplace that exists today. A large review of the literature covering multiple countries regarding the female nurse-physician relationship was published by the Mayo Clinic Proceedings in May 2020. It concluded that many women physicians perceived gender inequity and did not receive the same level of respect from female nurses as their male counterparts. This dynamic is in evolution and, as more women become medical doctors, will likely (hopefully) change. However, today women physicians still face other challenges. Here is a summary of a 2020 survey published in Medscape 15 July 2020. A panel of women physicians developed the questions used in this survey which included over 3000 participants. The Women Physicians responded to the issue of what was the most challenging problem: • 64% - work-life balance • 19% - gender equity • 6% - age discrimination • 43% - compensation • 16% - career development • 1% - sexual harassment • 30% - combining parenthood with work • 16% - relationship with colleagues and staff

PRESIDENT’S MESSAGE

Women aged 45 years or less found combining parenthood and work more of a challenge compared to those older than 45 years. Compensation, gender equity and age discrimination were more challenging for the older group. 94% of those surveyed said they made a personal life trade-off because of work obligations. Society’s view of women as caretakers is powerful and many surveyed felt they needed to choose a specialty that allowed for flexible hours in order to be the primary caretaker at home. Although 71% of the women surveyed felt very confident about taking a leadership role, more than half were not in a leadership role. Only one quarter of healthcare organizations provide classes, seminars, mentorship programs or other activities aimed to support and encourage women physicians as leaders. Addressing these barriers is essential and is the first step for system-wide reforms for the betterment of our communities. Just an FYI, our Bexar County Medical Society does provide a course on leadership open to all members. Being a physician is challenging enough, but being a female physician comes with distinct challenges that are unique and perhaps all too often overlooked. Despite these challenges, women physicians have been contributing to medicine since the first woman received her medical degree. I’ve compiled a list of women physicians who have made important contributions to medicine. • Ann Preston MD (1813-1872) – First female dean of a US-based medical school, who also trained the first black and Native American female doctors and created social programs meant to educate poor women about hygiene and physiology.

ated the Blalock-Taussig-Thomas shunt to prolong the lives of children born with tetralogy of Fallot. • Helen Flanders Dunbar MD, PhD (1902-1959) – considered the “mother of holistic medicine” and founded the American Psychosomatic Society and its journal Psychosomatic Medicine. • Virginia Apgar MD (1909-1974) – Created the Apgar score, the first standardized tool to evaluate the newborn; a pioneer in the new field of anesthesiology. • Elizabeth Kubler-Ross MD (1926-2004) – A pioneer in the study of death, dying, and grief. Her book, On Death and Dying, published in 1969, became a standard text for those caring for the terminally ill and to help improve end of life care. • Audrey Evans MD (1925-) - a pioneer in the treatment of childhood cancer, instrumental in the creation of the Ronald McDonald house (1974), a place for families of sick children with cancer to stay while receiving their treatment. • Patricia Bath MD (1942-) – Founded the discipline of community ophthalmology, was the first female chair of an ophthalmology residency program in the US in 1977, and co-founded the American institute for the Prevention of Blindness.

• Rebecca Lee Crumpler MD (1831-1895) – First black woman to earn an MD; tireless activist that practiced alongside other black doctors to treat freed slaves.

• Antonia Novello MD (1944-) – First woman and the first person of Hispanic origin to become the Surgeon General of the United States; played an important part influencing policy aiding children and later became a special representative to the United Nations Children’s Fund.

• Mary Edwards Walker MD (1832-1919) – First female surgeon and first female surgeon in the US Army; active during the Civil War and was captured and imprisoned. She later won the congressional Medal of Honor in 1865.

• Nancy Dickey MD (1950-) – The first female president of the American Medical Association and, as president, proposed the patient’s bill of rights. She is an active member of the American and Texas Academy of Family Physicians.

• Susan L. Flesche Picotte MD (1865-1915) – first Native American woman to receive a medical degree, pursued medicine after she witnessed an Indian patient die because a white doctor refused to provide care; cared for >1300 patients on her 450-square mile territory; before her death, a hospital was built in her honor.

I would keep listing more women physicians who have notably contributed to the field of medicine if I had more space; however, I wish to end by recognizing and congratulating all our female colleagues, both present and future, who are contributing to healthcare in a very positive manner and on multiple levels. Thank you for continuing to inspire and save lives every day.

• Gerty Cori (1896-1957) – The first women to earn a Nobel Prize in Physiology and Medicine for her work identifying the enzyme that converts glycogen into glucose. • Helen Brooke Taussig MD (1898-1986) – first female president of the American Heart Association; helped establish the specialty of pediatric cardiology. Together with Drs. Blalock and Thomas, cre-

Rodolfo (Rudy) Molina, MD, MACR, FACP is a Practicing Rheumatologist and 2021 President of the Bexar County Medical Society.

BCMS ALLIANCE

Why First Tuesdays? By Martha Vijjeswarapu Texas Medical Association Alliance President

First Tuesdays at the Capitol began when Susan Todd, an Alliance member, advocated for a law requiring that all motorcycle riders wear helmets. While it was passed into law, the following session, the people opposing stood strong and it was reversed. This was proof that a conversation was needed at every session to remind legislators of the importance of issues. Following the success of First Tuesdays at the Capitol, First Tuesdays in the District was created to foster strong relationships and promote effective communication with legislators throughout the year. These programs offer an avenue to advocate for issues affecting the Family of Medicine and to gain support for our communities and patients. This year, First Tuesdays will be held virtually. There will be a noon briefing and an action plan given on the issues at hand to communicate with our legislators. Please plan to be a part of the action calls for your legislators. First Tuesdays have long been known as the time for white coats to show at the Capitol. This year, those coats may not be seen in person, but our voices will still be heard through Zoom calls, emails, and text messages to our legislators. When a medicine-related bill comes up on the House or Senate floor, they pull the file to see how local physicians and Alliance members stand. Did they weigh in with their support or opposition by phone, email, or with an office visit? If they don’t hear from YOU — their local constituents — then they assume we don’t care about the bill. Our voices do matter and they do make a difference. TMA will provide all the information regarding the issues. Please pass this information on to the legislative offices. The avenue we have with TMA/TMAA for advocacy is not to be taken lightly. Let's use this opportunity for the Family of Medicine. Martha Vijjeswarapu is the Texas Medical Association Alliance President.

SAN ANTONIO MEDICINE • March 2021

87TH LEGISLATIVE SESSION

The 87th Session of the Texas Legislature: How the COVID-19 Pandemic Has Affected The 2021 Legislative Session By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer

Never before experienced in the Texas Legislature’s 175-year history, the 87th Legislative Session is the first ever to require social distancing protocols, the wearing of masks and in some cases, a negative test result for COVID-19. This Session kicked off at noon on Tuesday, January 12 with the Texas House and Senate chambers conducting the swearing-in of the elected members of both chambers. During previous sessions of the Legislature, both Chamber floors and galleries were packed with family and visitors to mark the occasion, but for this session, only a limited number of guests joined in the ceremonies. In addition, as is customary, members of the House of Representatives elected a new speaker, Rep. Dade Phelan from Beaumont, currently serving his fourth term

SAN ANTONIO MEDICINE • March 2021

as state representative for House District 21. Congratulations to Speaker Phelan, who becomes the 76th Speaker of the Texas House. We also congratulate a new State Representative from San Antonio, Rep. Elizabeth “Liz” Campos, representing Bexar County’s House District 119, the seat formerly held by now Senator Roland Gutierrez. On the Senate-side, senate members elected Senator Brian Birdwell of Granbury as Senate president pro tempore. The president pro tempore will act as acting governor when Governor Greg Abbott and Lt. Governor Dan Patrick are out of the state at the same time. Congratulations to Senator Birdwell as well as to a new member of the Senate from San Antonio, former Rep. Roland Gutierrez, now Senator Gutierrez, who represents the sprawling area of Senate District 19, the

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seat formerly held by Senator Pete Flores. Rules adopted by the Senate introduced COVID-19 protocols to be implemented for everyone during the first 60 days of the session. As stated, any person, including members of the Senate, entering the Senate Chamber, the Senate gallery or attending a Senate committee hearing, must first test negative for COVID-19. Members of the public are not required to take a COVID-19 test prior to entering the Capitol. Free testing is available, however, and individuals who test negative are given a wristband in order to enter the Senate gallery or Senate committee hearing. Additionally, wristbands will be given to individuals showing proof of vaccination. Adjustments to these rules could be considered in March. The adopted rules of the House of Representatives do not call for strict testing protocols as outlined in the Senate. Basically, discretion on testing is left to the individual House members and to the public. All visitors to the Capitol may get tested, if they wish, at no expense to them. The state representatives have the right to require testing of anyone that comes into their personal office. As with every legislative session, the only bill that must pass is the state budget. At the time of this writing, both the Senate and House have filed budget bills and committee hearings are underway. A number of issues are being tackled this session. One committee that started working right out of the gate is the Committee on Redistricting. Normally, the work of this committee is conducted during the interim, but due to the COVID-19 pandemic, earlier in-person hearings around the state had to be postponed. The Committee on Redistricting has been holding regional, public hearings virtually via videoconference. In addition, members of this Committee await the data from the 2020 Census, also delayed by the COVID-19 pandemic, which is critical to the work of the Redistricting Committee. The Census data will show how the population of Texas has changed over the last decade. This information identifies changes in the number of congressional seats for the state, thereby providing key data for lawmakers to assess as they work to redraw house, senate and congressional district lines. Among the issues prioritized as emergency items by Governor Abbott for the 87th Legislative Session, as presented during his State of the State address last month, are: 1) the expansion of broadband access; 2) funding police; 3) fixing our flawed bail system; 4) election integrity; and 5) civil liability protections for businesses, individuals and healthcare providers during a pandemic. Emergency items are fast-tracked during the first 60 days of the Session. At the time of this writing, the February 2 First Tuesdays visits with our legislators are behind us and what has been different this session is that there are no trips planned to Austin for in-person First Tuesdays

visits at the Capitol. Since the start of the pandemic over a year ago, Zoom meetings became the norm and replaced all in-person meetings. During the interim, TMA and BCMS joined forces with the TMA Alliance to participate in First Tuesdays in the District. These were visits with our state representatives from Bexar County, in their district offices. We were fortunate to visit with a couple of our legislators in person just before the pandemic hit. After that, BCMS and TMA held several visits with our legislators last Fall in preparation for the start of the 87th Legislative Session. Presently, we are actively participating in virtual meetings with our legislators and their staffs to advise them of medicine’s issues. Another change this Session is that the First Tuesdays visits are scheduled anytime and not held strictly on the actual First Tuesday of each month between February and May. As with each legislative session, TMA prepares a legislative agenda which highlights key items of importance to medicine (the full agenda is available in this issue of San Antonio Medicine). Among the key items on TMA’s radar are: coverage expansion for the uninsured and underinsured; improve access to telemedicine services for patients; support of telemedicine payment parity; reduce health insurance prior authorization red tape; strengthen the state’s public health infrastructure; preserve health care funding in the state budget; ensure patient safety through team-based care (scope of practice); prevent taxation of medical billing services; preserve funding for medical residency and rural loan repayment programs; increase the Texas tobacco tax and create a tax for vape products; and retain Texas’ landmark medical liability reforms. As your lobbyist and representative with our elected officials, I also work with the TMA lobby team, led by Dan Finch, VP of Advocacy, along with associate directors of advocacy, Troy Alexander, Michelle Romero and Clayton Stewart to keep our physicians informed on the status of medicine’s issues as key legislation on these items moves through the legislative process. In addition, as staff liaison to the BCMS Legislative and Socioeconomics Committee, I assist the physician members of the committee to track and monitor important legislation, coordinate visits with legislators and provide key details and alerts as information becomes available. Members of this committee are active participants in visits with our legislators. Mary Nava is the Chief Government Affairs Officer at BCMS. To learn more about how you can participate in the First Tuesdays visits with our legislators, register at www.texmed.org/firsttuesdays and consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at mary.nava@bcms.org.

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87TH LEGISLATIVE SESSION

SAN ANTONIO MEDICINE • March 2021

87TH LEGISLATIVE SESSION

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87TH LEGISLATIVE SESSION

How to Advocate for Medicine: COVID Style By Jenny Shepherd

For the last year, our world has been turned upside down and COVID has changed virtually everything, including how we advocate for medicine. What hasn’t changed is our need to do so…to stand up for science, to stand up for public health, to stand up for medicine. Never before has it been more important for the voice of medicine to be heard as the experts over the voices of influencers. How do we make that happen in our socially-distanced world? First Tuesdays: Learn about the pressing issues from Texas Medical Association lobby staff every first Tuesday February through May. It’s never been easier. Register on their website https://www.texmed.org/FirstTuesdays/, get a zoom link and sign in at noon to hear a short presentation on the legislation affecting medicine today along with a question-andanswer session. Virtual Legislative Visits: Visit with our Bexar County legislators virtually to discuss with them their priorities for medicine as well as talk about what is important to medicine. Pre-authorization hassles? Meaningful changes to Medicaid? You have a story to support the facts. Join the conversation and tell it. Educate yourself: Curious about what Texas Medical Association’s legislative priorities are? Their website has downloadable one-page summaries of almost every priority issue for the 87th Legislative session from vaping, scope of practice, maternal health and graduate medical education. Get Involved: The legislative committee for the Bexar County Medical Society meets the last Wednesday of every month to discuss legislative issues and works to strengthen bonds with our local legislators. Meetings are currently on-line so it has never been easier to volunteer your time to serve medicine.

SAN ANTONIO MEDICINE • March 2021

Use Social Media to Form Legislative Relationships: Follow your legislator on Facebook and Twitter. It’s a great way to get to know about your elected official. Not only do you get a chance to find out what is important to them and what they are doing in their district, but they know you are interested in them. Retweet, like, share and comment showing your support for what they are doing especially when it relates to medicine; these are all excellent ways of letting them know the family of medicine is paying attention. And don’t forget to say “thank you” publicly for their time and support for medicine’s agenda. Spread the word about the TMA and medicine’s legislative and health priorities: Use your public platform to be the voice of what is important for public health, for patient care and for Texas physicians. In a time where there are many opinions to be heard, let the family of medicine be at the forefront. Join TexPac: Learn more about medicine’s political action committee and consider becoming a member. Your membership in TexPac helps to elect the right candidates for medicine; not Republican or Democrat, but medicine friendly. When you start with legislators who have an open mind to the needs of medicine, it is easier to enact legislation that meets the needs of medicine. Finally, make 2021 the year you commit to becoming an advocate for medicine. If you’ve never ventured into realm of medical advocacy, try something new. If you are already active, consider doing more. The voice of medicine, your story, your needs have to be shared. If you aren’t willing to talk, legislators will be listening to someone else. Jenny Shepherd, past president of the Bexar County Medical Society Alliance, now serves as Vice President of Legislative Affairs for the Texas Medical Association Alliance. Additionally, she is a member of Texas Medical Society’s Council for Legislation and the TexPac Board.

87TH LEGISLATIVE SESSION

The No Surprises Act By Ezequiel Silva, MD

Surprise billing occurs when a patient receives a bill for the difference between an out-of-network provider charge and the amount covered by the patient’s health insurance. Forty percent of adults report having received an unexpected medical bill during the preceding 12 months, and 13% of these bills exceeded $2,000. (Reference: KFF Health Tracking Poll (conducted August 2328, 2018). Available at: https://img.datawrapper.de/A5lJn/full.png. Accessed January 25, 2021). Policymakers have long been aware of the stress unexpected bills cause patients and have been eager to craft a solution. Several states, including Texas, have laws to curb surprise billing. But state laws apply only to health insurance plans that are fully regulated by the state. This means that most health plans in Texas are not impacted by state law. For example, plans that are covered by the Employee Retirement Income Security Act of 1974, so-called ERISA plans, are regulated by the federal government. To address surprise billing in federally regulated plans, Congress passed the No Surprises Act (henceforth, referred to as the ACT), which was signed into law at the end of December 2020 and goes into effect on Jan. 1, 2022. Enforcement of federal plans to which the law applies shall be the responsibility of the Department of Labor. The law allows the federal government to impose penalties of up to $10,000 per violation. As with most new laws, the statutory language provides a framework for implementation, but the specifics of implementation will be defined by regulations to be published over the next year and beyond. Usually, proposed regulations are subject to public comment, which heightens the need for physicians and their practices to

SAN ANTONIO MEDICINE • March 2021

understand the requirements and details of the law. The law seeks to take patients out of the middle of payment disputes between insurance carriers and physicians. In general, insurers and employers have favored the use of benchmark payment standards to determine payment amounts, whereas providers have favored an independent dispute resolution (arbitration) process to settle disputes. In the end, the Act does not use a benchmark standard. Instead, the law requires voluntary negotiations between providers and insurers with arbitration as a backup, should those negotiations fail. An important goal of the new law is patient protection from surprise bills. The law seeks to achieve this goal by limiting patient cost-sharing and providing greater transparency on costs. The law mandates that patients who receive services from an out-of-network provider may be held responsible only for the cost-sharing they would have incurred from an in-network provider. The requirement for greater transparency to patients comes in the form of an advanced explanation of benefits prior to a health-care service. In addition to a good faith estimate of costs and cost sharing, patients must be informed whether their provider is in network or out of network. When the provider is outof-network, patients must be instructed on how to find an in-network provider for their service. Insurers must maintain up-to-date provider directories, enable price-comparison information and a web price-comparison tool. In instances where charges are substantially higher than the good faith estimate, patients may directly invoke the independent dispute resolution (IDR) process. These consumer protections apply to care

in both emergency and non-emergency settings. Emergency care protections apply regardless of whether the facility is in-network or out-of-network. They also include protection on all emergency services from initial evaluation and treatment until the patient is stabilized and able to consent to transfer to an in-network hospital. These emergency-related protections also apply to out-of-network air ambulances, but they do not apply to ground ambulances. Consumers are also protected from surprise billing for non-emergency services provided by an out-of-network provider during care at an in-network facility. This includes ancillary services, such as those provided by an anesthesiologist, radiologist or pathologist. It also includes unexpected specialty care such as care from a neonatologist or other specialist. The ACT allows patients to voluntarily accept exemptions to the surprise billing limitations, but this requires that the patient knowingly and willfully agree to use an out-of-network provider. We have established that patients are removed from payment disputes between providers and insurance carriers, but how are these disputes resolved? The details on the independent dispute resolution (arbitration) process have important, practical implications for physician practices. Before entering arbitration, 30 days must pass in order to allow for private negotiations between providers and insurers. Should those negotiations fail, either party then has four days to request arbitration. If no arbitration is requested during those four days and the parties fail to reach an agreed amount, then the provider must accept the amount paid by the insurer for the claim. Conflict-of-interest rules apply to the arbitrator.

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Forthcoming regulations may define more specifically how the independent dispute resolution process occurs, but for now, the law establishes that arbitration shall be “baseball style.” Under this style of arbitration, each party proposes a single payment amount and the arbitrator must select one or the other. In other words, the arbitrator may not choose an amount in between the two proposed amounts. Once the arbitrator reaches a decision, that decision is binding. However, continued negotiation is allowable. Providers may batch together multiple cases into a single arbitration proceeding.

This is allowable only if the cases involve the same insurer, provider and medical condition. In addition, these cases must have occurred within the same 30-day period. The Act includes provisions to prevent overuse of the arbitration process. For example, the losing party must pay the administrative costs of the arbitration proceedings. Moreover, the party that initiates the arbitration process may not take the same party to arbitration for the same service for 90 days after a decision has been reached. Arbitrators must consider several factors in reaching their decision. These factors in-

clude the following, as they relate to the provider: level of training or experience; quality and outcomes; market share, prior contracted rates, and good faith efforts (or lack thereof ) to join the insurer’s network. Regarding the insurance provider, the arbitrator may consider market share and median in-network rate paid. Other considerations include patient acuity and complexity, teaching status, case mix and scope of services performed. The arbitrator may not use government payor rates, such as Medicare. The effects of the new law remain to be seen, and continued study is required. For example, the Act requires regular reports to Congress regarding the outcomes from arbitration cases, as well as the general impact of the law. Further, the law requires reporting on impacts on health costs, provider consolidation and access in rural areas. The Government Accountability Office is required to prepare reports on (1) the law’s impact on network adequacy, (2) impact on provider payment rates, and (3) reports on the independent dispute resolution process, including relationships between providers and private equity firms. The impact of the Act on local practices remains to be seen. What effects, if any, will the law have on contracted rates, network adequacy and patient out-of-pocket costs? It will be important for practices to understand the Act and its specific requirements to inform questions of this sort. Along the way, BCMS, TMA, and AMA will be important conduits to influence the evolving regulations around this law. Ezequiel "Zeke" Silva III, MD is a member of the South Texas Radiology Group and Co-Chair of the AMA Digital Medicine Payment Advisory Group, Chair of the AMA RVS Update Committee (the “RUC”), and Dr. Silva is on the Board of Directors of the Bexar County Medical Society. Visit us at www.bcms.org

87TH LEGISLATIVE SESSION

“Sin” Taxes on Tobacco Should Match State Expenditure By John J. Seidenfeld, MD

We are aware of the terrible toll of disease, disability, and death from the use, combustion, and inhalation of tobacco and byproducts such as nicotine and countless hydrocarbons. Illnesses caused include atherosclerosis affecting all organs, not the least of which the heart and brain; chronic obstructive pulmonary diseases; and cancers of many organs in addition to the lungs and oral cavity.1 Recently, vaping of tobacco products has added to the disease burden which many predict will be equal or worse than that caused by cigarettes. In Texas there are some three million cigarette and vape users. The societal and budgetary costs attributable to smoking are high. The costs show a significant state shortfall in terms of work missed, healthcare costs and opportunity costs. The individual costs over a lifetime and per year for Texas smokers are shown in Table One.2 It will be a few decades before we have data for vaping, but many pulmonologists predict similar adverse effects over time. Table One. Societal Costs Related to Smoking in Texas and State Rank

*Data from Wallethub.com 2020, US dollars, from CDC and US Bureau of Statistics ** Lowest numeric rank means lower income, lower opportunity cost, and lower health care spending by Medicare and Medicaid

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How do we determine taxes for the significant expenditures that smokers incur? Texas taxes cigarettes, according to the comptroller, $1.41/package as excise tax and $0.34 as sales tax. Vape products have no current excise tax and only sales tax. In addition, the Federal government adds $1-2 depending on the size of the cigarettes. On average, a package of cigarettes costs $5.78 in Texas.3 In Australia, the cost of a pack of cigarettes is $27 USD and in Mexico $3 USD. Texas legislators voted down an attempt to add an excise tax for vaping in 2019, and as of today these products still are not assessed an excise tax. Overall, tobacco use costs over 90 times the amount that we tax on smoking in Texas (Table 2), adding to the yearly subsidy we get from big tobacco after the lawsuit at the end of the last decade, and we still have a huge shortfall.3a

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Table Two. 2019 Cigarette and Tobacco Taxes vs Costs in Texas

The Texas Public Health Coalition (TPHC), made up of thirtyone health care organizations in the state including the Texas Medical Association and BCMS, is in favor of 1) banning all characterizing flavors including menthol in E-cigarettes, which younger users favor, 2) increasing taxes on conventional cigarettes as well as imposing an excise tax on E-cigarettes, and 3) strengthening enforcement measures on retailers.4 What is the broader purpose of raising funds through excise, Pigouvian,5 and sales taxes on tobacco and related products? Our duty as health care professionals is to help prioritize recommendations to policy proponents such as the TPHC, lobbyists, and legislators.

The major areas to support are: • Prevention of tobacco product use disorders, helping youth make sound healthy judgements, and immunizing to prevent further infections of the lungs and affected organs • Education of health care students and workers, counselors, and youth • Enforcement of tobacco use, vaping, age limitations, and tax regulations • Research into use disorders and tobacco related health consequences • Treatment of tobacco and vaping related disorders Prudent citizens and health care professionals advise and advocate for a) additional taxes as compensation for the state’s expenditures on the costs of tobacco and vape use and abuse, b) protection of youth from marketing directed actions that lead to a lifetime of tobacco or nicotine use disorder, and c) leaders who are guided by fiscal and scientific guidelines in future taxation legislation. John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee.

References and links 1) https://www.cdc.gov/tobacco/data_statistics/fact_sheets/ 2) https://wallethub.com/edu/the-financial-cost-of-smoking-bystate/9520 3) https://comptroller.texas.gov/about/media-center/news/2019/ 190904-sales-tax.php 3a) https://www.dshs.texas.gov/tobaccosettlement/pay2020.aspx 4) https://static1.squarespace.com/static/ 5) https://www.taxfoundation.org

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87TH LEGISLATIVE SESSION

Prior Authorization Shenanigans By Neal S. Meritz MD

Doctors continue to shoulder the burdens of the Prior Authorization process, but that might all change if proposed bipartisan legislation becomes law this year. Medical Economics,, reports that at least 30 to 45 minutes are required to complete each individual Prior Authorization, which totals 20 plus hours per week per practice. This time is unreimbursed and it is now estimated to cost over $68,000 a year for every practice. It is a labor-intensive procedure for physicians, as denied requests necessitate manual intervention resulting in subsequent practice cost increases. Denials sit unworked as they often require multiple letters of documentation and many telephone conversations. Hold times are staggering, often lasting up to an hour. An authorization denial means no payment for the physician and a refusal of coverage by the insurer for the medication or the procedure for the patient. Prior Authorization is a system invented by health insurers that requires physicians to obtain advance approval for prescription medications and medical procedures from a health care plan before delivery to the patient. A refusal by the insurance company does not deny or reject the medication or service; it simply states that the insurer will not pay. Health Care Plans contend that Prior Authorization programs are important for controlling costs and avoiding unnecessary or non-standard care. Cost Control began in the 1950s with concerns about increasing hospitalizations. Medicare and Medicaid legislation in the 1960s necessitated the creation of Utilization Review committees. These usually evaluated the appropriateness of hospitalizations as well as problematic physician behaviors. Gradually, this evolved into a program called Prior Authorization, a process designed to provide patient protection and cost savings. In theory, these concepts were seen as a benefit to consumers because the result would be the prevention of unnecessary procedures and the avoidance of expensive brand name medications when cheaper generic alternatives exist. 22

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Continuing, some diagnostic studies and some medications deemed inappropriate by the insurance company would also be subject to Prior Authorization requirements. Insurer related shenanigans significantly impact patients, with interruptions and delays in treatment being very common. The patient must figure out whether the process is stalled because of the doctor, the pharmacy or the insurance company. Patients are forced to forego necessary treatments in order to avoid the Prior Authorization unpleasantness, meaning treatments must often be abandoned. A survey conducted by the AMA in 2018, reported that 92% of doctors agreed that Prior Authorization harms patient access to care by 92%! Physicians are united in their insistence that the Prior Authorization system must be reformed. The AMA has developed a concerted program to encourage changes. Minimizing care delay is crucial, as these frequently result in potentially unnecessary adverse patient events. In addition, the volume of Prior Authorization demands for prescriptions and medical services has steadily increased. Utilization management requirements must be applied by insurers more rationally and judiciously. Regular reviews should eliminate services and medications which are unnecessarily subjected to Prior Authorization. Time required might be shortened considerably by using online tools and algorithms for rapid turnaround. Transparency in communication between insurers and providers must be improved, possibly by creating an NIH panel not affiliated with insurers in order to avoid a conflict of interest. Continuity of patient care should be deemed critical, with special attention regarding the avoidance of interruptions and delays. Finally, the adoption of electronic Prior Authorization transactions based on existing national standards could significantly improve the process for everyone involved. U.S. Representatives Suzan DelBene (DWA), Mike Kelly (R-PA), Roger Marshall MD (R-KS), and Ami Bera MD (D-CA) introduced HR 3107 in June, 2019. This bill would require Medicare Advantage Plans to streamline and standardize Prior Authorizations and improve transparency in health insurer programs. The bill is called the Improving Seniors’ Access to Timely Care Act, and it now rightfully has the bipartisan support of 219 members of the House of Representatives. In December, 2020, this legislation was introduced into the Senate by John Thune (R-SD)

and Sherrod Brown (D-OH). The bill also seeks to establish an electronic Prior Authorization (ePA) system in order to approve medical services and prescriptions in a more timely manner. Reviews by qualified medical personnel would be required, and beneficiaries would be protected from disruptions in their care. Here in Texas, the Texas Medical Association (TMA) has been active in the encouragement of Prior Authorization legislation. Governor Greg Abbott signed SB 1742 in June, 2018, sponsored by Senator Jose Menendez (D-San Antonio). This bill requires greater transparency involving Prior Authorization procedures, and it mandates that utilization reviews be conducted by a Texas-licensed physician in the same specialty as the requesting physician. Two physicians in the Texas State Legislature, Greg Bonnen MD (R-Friendswood) and Dawn Buckingham MD (D-Lakeway) have proposed a bill mandating that insurers post the health services that require Prior Authorization and that explain how it works. This includes a list of documentation the physician must provide. Senator Menendez and Representative Julie Johnson (D-Carrollton) are proposing the elimination of Prior Authorization requirements for benefits already demanded by the State of Texas such as mammography, prostate cancer screenings and diabetes supplies. These legislators, both Federal and State, are to be commended. Their efforts are a good start though they not nearly enough. Reforming the Prior Authorization process is a formidable task; insurers have absolutely no incentive to change their current practices. Obfuscation, confusion, and bureaucratic inefficiency have always been insurance company tactics when dealing with physicians. It seems that the object of the insurance company is to collect premiums and to not pay claims. The Prior Authorization system is onerous, time consuming and very expensive to physicians. It is potentially devastating to patients. It does make more money for insurers. The efforts of the AMA and the TMA and the work of the involved legislators are supported by all independent physicians, and there must be continued aggressive activity to reform the Prior Authorization system. Neal S. Meritz MD is a retired Family Medicine physician and a member of the Bexar County Medical Society Publications Committee.

87TH LEGISLATIVE SESSION

Prior Authorization Delays and Undermines the Best Patient Care By Jayesh Shah, MD

As if COVID-19 was not enough to stress the health care system, the Prior Authorization (PA) burden is growing and making it difficult for physicians to take care of their patients. During this pandemic, many private practices were not able to survive and had to close; others had to furlough or lay off support staff. Prior authorization was a nightmare even before COVID-19 and its impact during the pandemic is intolerable for patients and physicians. Physicians continue to describe the prior authorization process as an extremely frustrating process that hurts their patients. For example, in my wound care practice, a delay in prior authorization could potentially delay healing. There is evidence that once a diabetic patient has an amputation, they have a mortality of 68% within five years. It is higher than the mortality of breast cancer, prostate cancer, and lymphoma combined. Over the last five years, the vast majority of Texas physicians (87%) and AMA physicians (88%) say that they have seen an increased burden as a result of the PA process, and 69% of Texas physicians describe it as very burdensome. The number of prior authorizations required for prescription medications (85%) and medical services (80%) continues to increase, inversely impacting the access to care for patients. With decreasing reimbursement and increasing overhead to obtain prior authoriza-

tion, it becomes a perfect scenario for the closure of many solo private practices. If solo private practices close, again, the access to care decreases. The physician's private practice office is the lowest cost center in the complex health care system. It is critical to advocate and educate our legislators on these prior authorization issues. We have a chance to make a difference. Due to COVID-19, the Texas Medical Association has arranged all first Tuesdays at the Capitol as virtual events (https://www.texmed.org/ FirstTuesdays/). Please use this opportunity to connect to our legislators, so you can advocate on behalf of our patients from the comfort of your home or office. There was already a shortage of physicians, but now, due to the global pandemic, the shortage is getting worse. In this already stressed environment of COVID-19, physicians had to spend hours on the phone to get proper care for their patients. On average, practices complete 33 prior authorizations per physician per week. Physicians and their staff spend an average of almost two days (14.4 hours) each week completing prior authorizations. 36% of physicians nationally and 48% of physicians in Texas report that they have to hire staff just to work on prior authorizations. Most patients do not realize how much work their physicians put in behind the scenes to authorize care with insurance companies. Most physicians get multiple denials before finally getting approval. 85% of Texas physicians report delayed access to care and 81% report interrupted continuity of care as an outcome associated with these prior authorizations. 78% of physicians report that patients abandon treatment due to prior authorization problems. Even worse, 35% report delayed care leading to serious adverse events. The AMA survey shows that 16% of physicians report that a prior authorization led to a patient’s hospitalization, which unnecessarily increases the cost to the health care system. Another problem with the prior authorization process is that there is a wait time for any

response from the insurance company. 64% of physicians reported the wait time of at least one business day, while 29% reported waiting at least three business days. I recently testified at an AMA interim meeting that, if insurance companies require prior authorizations, they should make staff available 24 X 7 to process approvals. This 24-hour availability will at least improve the timing for the decisions and hopefully decrease serious adverse events for the patients. Delays in obtaining prior authorization also cause problems with discharge planning for patients. During COVID-19, it becomes a problem when most hospitals do not have extra beds, and patients who have to be transferred to another facility require a quick turnaround. In summary, prior authorizations are problems for both patients and physicians. Delayed care is unnecessary and should not be allowed. Most of the time, the decisions involved with the prior authorization process are made by someone who is not familiar with the patient or by someone who is not in the same specialty. Unfortunately, apart from patient care delays, prior authorizations also increase the cost for the patients and the health care system. Jayesh Shah, MD, a wound care specialist certified in Internal Medicine and Undersea and Hyperbaric Medicine, is a member of the Board of Trustees of the Texas Medical Association. Resources Doctors say that delays are hurting patient outcomes https://www.medicaleconomics.com/ view/prior-authorizations-negatively-affect-care https://www.ama-assn.org/system/files/202006/prior-authorization-survey-2019.pdf 2020 TMA Survey on Prior Authorization 309767 Prior Auth Data Sheet Onepager.pdf Shah JB, Sheffield P, Fife, Textbook of Chronic Wound Care, Best Publishing 2018.

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Texas Medical Association Winter Conference As one of the most unique eras of both living and lawmaking continues, attendees at TMA’s Winter Conference heard about medicine’s legislative agenda in both Austin and Washington, D.C., and how COVID-19 has helped shape this year’s legislative focus.

TMA President Diana Fite, MD, led a panel Saturday of three other physicians and one legislator in the state and federal crucibles: Austin oncologist Debra Patt, MD, chair of TMA’s Council on Legislation; Fort Worth allergist Susan R. Bailey, MD, president of the American Medical Association (AMA); Houston plastic surgeon Russ Kridel, MD, chair of the AMA Board of Trustees; and state Sen. Lois Kolkhorst (RBrenham), chair of the Texas Senate Committee on Health & Human Services. The Winter Conference also included a discussion by two top state health officials on Texas’ COVID-19 vaccination efforts. State legislative priorities Drs. Fite and Patt outlined TMA’s priorities at the state level, which include expanding health coverage to address the problem of the state’s uninsured and underinsured; reducing the impact and red tape of prior authorization; improving patient access to care through further advancement of telemedicine; and avoiding a now-delayed tax on medical billing companies, which would inevitably result in costs passed onto physicians. While telemedicine made “leaps and bounds” during COVID, and has been found to be very advantageous for many disabled

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and elderly patients, it’s “hard to arrange in some rural areas where they don’t have access,” Dr. Fite noted. “We did get approval in some places for telephonic-only (telemedicine visits), because some people are not set up to be able to do visual as well. But we need to have telemedicine to remain at parity for full clinic visits as well for payment purposes, and including after the pandemic is over.” Stressing the burdens of prior authorization – and the fact a lot of those hassles increased during the pandemic – Dr. Patt listed several • Reducing red tape, such as by requiring state-regulated health plans to “gold-card” certain physicians out of the prior-auth process; • Requiring insurers to make staff available around the clock and on weekends to process pre-approval requests ; and • Reforming peer-to-peer calls so physicians who must make them are talking to an actual “peer” who knows something about their specialty. Senator Kolkhorst ran through some of what’s in the Senate’s base budget proposal, Senate Bill 1, and also discussed the importance of giving physicians full, lawful practice autonomy while stopping scopeof-practice infringements by nonmedical

professionals. “There’s some really good news in health care. But … our focus has to be on post-pandemic recovery, lessons learned making sure that we have protection for you doctors who have given us so much over the last 11 months, and making sure, too, that you get to practice at the top of your credentials, while making sure that others don’t try to creep into that and we see a dip in what we think is quality health care,” she said. Dr. Patt emphasized to attendees that during the current session of the Texas Legislature, “what we need is you [physicians] to be active in your constituency and make sure that you’re reaching out to important leaders like Senator Kolkhorst and others.” The National Picture Laying out some of the landscape at the national level, Dr. Bailey said AMA’s federal priorities include the recent surprise-billing restrictions passed by Congress that will take effect in 2022, and pushing back against scope-of-practice reaches by nonmedical professionals. Dr. Bailey said AMA will be deeply engaged in the regulatory process on the new surprise-billing law. In several states, she said, legislators “have adopted the health insurers’

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messaging” and used surprise billing legislation as a way to “broadly reduce” physician payments. “The AMA will continue to fight these efforts, and we will look to Texas for help as that comes about,” she said. And now that vaccinations for COVID19 are available, Dr. Kridel said medicine can press ahead on other issues that are plaguing physicians, including eliminating caps on Medicare payments. “Through our arcane payment system – and it’s nothing else but that – physicians are singled out and paid differently than hospitals, nursing homes among other facilities, and the pharmaceutical industry, which all get cost-of-living … increases yearly,” he said. “It just has to stop, and we need to demand change.”

Easy Ways to Get Involved in TMA Advocacy The 2021 legislative session brings new opportunities to get involved in TMA’s grassroots advocacy efforts at the Capitol. Your participation is a vital component of our legislative success. Please help strengthen the voice of medicine by joining our advocacy efforts. • Participate in First Tuesdays at the Capitol, which are virtual this year. The first one is tomorrow, Feb. 2. Register today. • Learn more about our top legislative priorities. You can find more detail in January’s issue of Texas Medicine. • Respond to time-sensitive Action Alerts by contacting legislators through our Grassroots Action Center. You’ll receive Action Alerts via email and can respond right from your phone. • Read TMA’s Legislative Hotline in your daily Texas Medicine Today. If you miss it in your inbox, you can also find it online. • Follow us on social media via Facebook, Instagram, Twitter, and YouTube. • Learn more about TEXPAC to help elect medicine-friendly candidates to office. Stay up to date on TMA’s progress in the legislature. And take advantage of other opportunities to get involved with our advocacy efforts.

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The Plight of the Immigrant Physician By Amar Sunkari, MD

I have been a practicing physician in hospitals for more than 10 years now and in the United States for more than 15 years. During this time, I have abided by the law, contributed to communities in professional and nonprofessional capacities, paid my share of taxes and followed every rule US immigration has set forth. My children were born here and are US citizens. Every asset I own is in the US. I have experienced and shared the same adversities, joys and problems as everyone else in the communities in which I have lived, from surviving hurricanes to local fundraisers for good causes.

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Yet, I am years away from getting a green card, let alone US citizenship. I am an alien national and will be for at least the next 10 years. It means that every time I cross the border, I have to visit a consulate to get a visa and go through an immigration check. I am expected to always carry all of my immigration papers with me. Each time I leave this country, whether I can return or not hangs by a thread. This is not just my story, but is the story of thousands of Indian doctors who have migrated to the US. The reason is many of us have entered the US under a J1 waiver to serve in national interest areas

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(medically underserved areas) for 3 to 5 years. That commitment has resulted in us often being separated from our wife, husband and/or children. This is the rule book. During this last year with COVID-19, we worked just like the rest of the healthcare workers, risking our lives in fulfilling our professional duty to care for the sick. However, it also meant that if we lost our jobs, we would have to exit the country within 15 days, leaving everything we earned and own behind. Alternatively, if we got sick and passed away, our spouses and kids would be kicked out of the US because they are on dependent visas. Our closest kin wouldn't even get to see us or say goodbyes in our last moments. We are capable professionals and have the resources to start our own practices and businesses that can create and employ others; but because we are on visas, we aren't allowed to do that. Instead, we end up working as an “employee” for other employers. Imagine trying to explain this to patients who ask us “Do you have a clinic where I can come and see you?”. They often are incredulous when we try to explain it to them. We get requests from staffing professionals requesting us to fill an urgent need, but we cannot take advantage of those opportunities because our visas are tied to the place of practice and we are not allowed to work anywhere else. Often employers know this, and some use it to their advantage. The situation exists for two main reasons. First, physicians are included in the same category as any other master’s degree job professionals, called EB2. This wasn't the case until a law was passed moving physicians from immigration category EB1 to EB2. Now other professionals such as multinational company managers and scientists have priority over physicians. Second, there is a green card cap (limit) on immigration based on country of origin. There are 65,000 H1B visas issued every year, most of which are taken up by Indian or Chinese nationals, often software professionals. Yet only 7,500 green cards can be

issued per country. The result is that physicians on EB2 visas are stuck in the EB2 queue that gets longer every year. It is estimated there are roughly a quarter million physicians in the USA who are Indian immigrants. The green card backlog is about 300,000 for Indian immigrants which is manyfold higher than all other nations combined. About a quarter of the entire US healthcare workforce are immigrants. There have been attempts to address these issues, but little headway has been made because these attempts are often attached to far more popular, widely-debated and controversial issues such as DACA. Hence, Indian physicians are trying to raise awareness and gather support to address our plight. We are asking US lawmakers to be fair, meaning recognizing our efforts, contributions and the sacrifices we have made and will continue to make. If you believe there is merit to what we are requesting, please help us in making these points to legislators and policy makers. Amar Sunkari, MD is a member of the Bexar County Medical Society.

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My First Day By Daniel Rosas, MD

Finally, July 1st: I’m starting my internal medicine residency in the medical ICU service, on night shifts. Imagine starting a new dream job in a brand-new place, in the middle of a global pandemic, and with a new electronic health records system. This was going to be fun. The local surge of COVID-19 cases in the city, as well as in the hospital where I was going to start, made me nervous about this great learning opportunity; but finally, the opportunity to help! Until now, I had only experienced the pandemic on a television screen. Now, at 10:00 pm, there I was, fueled with coffee, stethoscope and pens ready, pager on, looking professional with scrubs and badge, ready for anything … or so it appeared. Upon arriving at the ICU and introducing myself to the resident, he asked me why I was there so early. The answer came with a nervous and shaky voice tone; it was my first day so “early meant on time”. The resident was very kind and took me to the workroom to review the patients to be assigned. They assigned me a total of six patients; four of them were diagnosed with respiratory failure due to COVID-19. That is scary. Immediately the images of healthcare workers seen on the news for the past months were a reality. From that moment on, I was one of the healthcare workers, and although scared, eager to help and learn. The resident instructed me to chart-check my patients; so, the attempt at navigating the new electronic health record system began. Tutorials used during orientation had not prepared me for this. With no idea what I was doing, after some struggle I found out how to read previous notes; they were filled with more abbreviations than everyday text conversations with friends. Not being sure about what details to pay attention to, almost everything was written down. I googled most of the unknown abbreviations, wrote the word “medicine” after the abbreviation, and Google almost always had the answer. The computer next to me showed that someone had searched “what does I/O mean?” Good to know I wasn’t the only one feeling lost. Six hours later (that’s right, one hour per patient), it became clear why during orientation they had told us so many times “do not worry, you will get efficient reviewing charts with time”. This made so much sense now. When reading patients' charts, most of the patients with COVID-19 were in their 40s and 50s and were very sick. It was while checking the chart of my 4th patient with COVID-19 that I saw something that I will never forget. The patient was only 18 years old! This shook me to my core. Although the scientific data shows that older patients and those with comorbidities are at a higher risk of a severe infection, there isn’t an age range that is immune to the virus. It has also been shown that in the current surge, the higher number of cases have been in a younger population than it was during the first wave of infection. One reason is the reopening phase, which puts the younger 28

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population at risk of infection when going outdoors more-so than with the older population. Continuing to evaluate the patients, I wrote down my findings and started getting ready for rounds. When the attending entered the room, we all introduced ourselves and then we went on to start rounding. Three pages of notes per patient contained random facts and lab values written all over the pieces of paper; there weren’t enough pockets on my scrubs to fit all those paper sheets. Each time upon presentation, the resident and fellow corrected me on lab values, medication doses and 24-hour events, among many other details I either had not found or presented the wrong number. After reporting the wrong “I/Os” on my first four patients, on the 5th one I told the attending I was sorry but now knew where to look for that information the next time. The attending said it was alright and, since it was July, everybody understood that we were just starting and getting used to everything. This was so encouraging to hear, and it was said with such a positive attitude that I wanted to show up the next day and be ready and more efficient than the day before. What an example she was being for everybody there. It’s hoped that the fellows, residents and interns from that moment on will follow this approach with their future interns on their first day. If it hadn’t been for this amazing group of co-interns, sensational residents, a mind-blowing fellow, and a one-in-a-million type of attending, I don’t know what would have happened to me. Maybe it was just luck having those types of people around me the first day, but I could not help but think about other interns on their first day who had a superior that was demeaning and treated their interns/residents/fellows with aggressiveness and shame. That kind of behavior and medical education philosophy makes people feel bad about themselves when they do not know the answer to a question. I believe this type of educational philosophy must change. Every physician should remember their first day as an intern when they read this and, regardless of how that day was, be willing to help people on their first day on the job. This not only gives an example to follow but encourages us to do better every day. I hope that every healthcare worker remembers and sees how far they have come and how strong they have become along the way to face challenges like the one we have been facing for months, and probably will face for months to come. Thank you to the teachers that gave us good examples to follow but thank you also to the teachers that show us how we are not supposed to behave. Inevitably, the student becomes the teacher. Daniel Rosas, MD is a PGY-1 in the Internal Medicine Residency Program at UT Health San Antonio.

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What do Patients Believe Makes a Good Doctor? By Kalli Davis, Ryan Carbone, Justin Fredericks, Alex Basdeo and Joshua Lujan

This question was posted as a short, single-question survey on social media and encouraged people to respond and share. The results were submitted to the 2021 Texas Osteopathic Medical Association Midwinter Conference Student/Resident poster competition in the category of “Original Research”. The poster presentation by Kalli Davis, a second-year medical student at the University of the Incarnate Word School of Osteopathic Medicine, was awarded first place. The project was developed as part of the School of Medicine Community Engagement Partnership, which is built into the curriculum requirements for second year medical students. This scholarly project provides students the opportunity to develop research under the guidance of experienced faculty.

“What Makes a Good Doctor: A Qualitative Study of Patient Perspectives”, was developed by five learners: Kalli Davis, Ryan Carbone, Justin Fredericks, Alex Basdeo and Joshua Lujan; and was overseen by two faculty members, Adam Ratner, MD and Arunabh Bhattacharya, PhD.

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Controlled Substance Electronic Prescribing Requirement Effective January 1, 2021, Texas Health and Safety Code, §§481.0755 requires that prescriptions for controlled substances to be issued electronically, except in limited circumstances, or unless a waiver has been granted by the appropriate agency. A prescription for a controlled substance is not required to be issued electronically and may be issued in writing if the prescription is issued: • by a veterinarian; • in circumstances in which electronic prescribing is not available due to temporary technological or electronic failure, as prescribed by board rule; • by a practitioner to be dispensed by a pharmacy located outside this state, as prescribed by board rule; • when the prescriber and dispenser are in the same location or under the same license; • in circumstances in which necessary elements are not supported by the most recently implemented national data standard that facilitates electronic prescribing; • for a drug for which the United States Food and Drug Administration requires additional information in the prescription that is not possible with electronic prescribing; • for a non-patient-specific prescription pursuant to a standing order, approved protocol for drug therapy, collaborative drug management, or comprehensive medication management, in response to a public health emergency or in other circumstances in which the practitioner may issue a non-patient-specific prescription; • for a drug under a research protocol; • by a practitioner who has received a waiver from the requirement to use electronic prescribing; • under circumstances in which the practitioner has the present ability to submit an electronic prescription but reasonably determines that it would be impractical for the patient to obtain the drugs prescribed under the electronic prescription in a timely manner and that a delay would adversely impact the patient's medical condition; or before January 1, 2021. 30

SAN ANTONIO MEDICINE • March 2021

A physician may apply for a waiver from the electronic prescribing requirement by: • submitting a waiver request to the TMB and providing required information, and • demonstrating circumstances necessitating a waiver from the requirement, including Economic Hardship, including: ▪ any special situational factors affecting either the cost of compliance or ability to comply; ▪ the likely impact of compliance on profitability or viability; and ▪ the availability of measures that would mitigate the economic impact of compliance; o technological limitations not reasonably within the control of the physician; or o other exceptional circumstances. Request a waiver The Electronic Prescribing Waiver form is available for submission through your MyTMB account. • Verification of an approved waiver will be displayed on the physician profile once granted. • Once approved, waivers will be issued for a period of one year. • Physicians may apply for a subsequent waiver no more than 30 days before an active waiver expires. Please contact Registrations@tmb.state.tx.us if you have any questions or need assistance.

BEXAR COUNTY MEDICAL SOCIETY

BCMS & H-E-B Cooperate to Vaccinate 1,700 The Bexar County Medical Society (BCMS) had the privilege of hosting the COVID-19 second dose event at the BCMS building on Saturday, February 6, 2021, as the follow-up to the January 10 first dose event. The weather cooperated for the most part this time; a slight mist in the morning turning to bright and sunny skies! With a little head start on planning, and learning from other events, everything was very well organized. Appointment times were adhered to and people were in and out without a hitch. Thank you to H-E-B Pharmacy and the UIW Feik School of Pharmacy for providing the staff, vaccine, and supplies! BCMS is very proud to have successfully hosted an amazing event! BCMS continues to work with local pharmacies, hospitals and community practices to arrange vaccinations for our physicians and their staff. Please keep an eye out for communication from BCMS about future vaccination opportunities. For updates on vaccine availability and vaccination opportunities, please visit the BCMS website at www.bcms.org and click on the BCMS Vaccine for Physicians banner. Information is updated as information is available. Also, please complete the very short questionnaire “Do you or your staff still need the FIRST dose of COVID-19 vaccine?”. This will put you on the list to be contacted when vaccination opportunities arise. The vaccine situation changes rapidly; stick with us because we want you to be the first to know when vaccination events are coming!

SAN ANTONIO MEDICINE • March 2021

BEXAR COUNTY MEDICAL SOCIETY

Visit us at www.bcms.org

PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

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”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. 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”

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

BANKING

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a

SAN ANTONIO MEDICINE • March 2021

private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank 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 BBVA Compass (HH Silver Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities" BB&T (HH Silver 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 https://www.bbt.com/wealth/star t.page "All we see is you" Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking serv-

ices they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

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 (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity. Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR Elizabeth Olney with Edward Jones (HH Silver 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 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO (210) 525-1241 DMarino@swbc.com

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!”

Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® CEO | Wealth Advisor 210.864.3350 eric@avidwp.com avidwp.com “Plan it. Do it. Avid Wealth”

HEALTHCARE BANKING Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (512)226-0208 www.Regions.com

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable” Amegy Bank of Texas (HH Silver 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 TECHNOLOGY SOLUTIONS SUPPLIER GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors. Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”

INFORMATION AND TECHNOLOGIES

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps

physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org 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 OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

continued on page 34 Visit us at www.bcms.org 35

PHYSICIANS PURCHASING DIRECTORY continued from page 33

MEDICAL BILLING AND COLLECTIONS SERVICES 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) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” 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 PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL PHYSICS

SAN ANTONIO MEDICINE • March 2021

shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-434-2713 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience. Henry Schein Medical (HH Silver 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.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society. Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945

(210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group, Insurance Services, SWBC Wealth Management and PEO Relations (210) 525-1241 DMarino@swbc.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” 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. Tom Tidwell, President info4@samgma.org www.samgma.org

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

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. Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

Enhance the Patient Experience.

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

TELEHEALTH TECHNOLOGY

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

Visit us at www.bcms.org

SAN ANTONIO MEDICINE • March 2021

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

Northside Ford 12300 San Pedro San Antonio, TX Marty Martinez 210-525-9800

Rick Cavender 210-681-3399

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216 David Espinoza 210-912-5087

Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX William Taylor 210-366-9600

KAHLIG AUTO GROUP

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 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

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

KAHLIG AUTO GROUP

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

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

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

AUTO PROGRAM

Chuck Nash Chevrolet Buick GMC 3209 North Interstate 35 San Marcos, TX William Boyd 210-859-2719

AUTO PROGRAM

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.) San Antonio, TX Ed Noriega 210-561-4900

AUTO PROGRAM

AUTO REVIEW

SAN ANTONIO MEDICINE • March 2021

AUTO REVIEW

2021 Ford Expedition King Ranch By Stephen Schutz, MD

General Motors announced recently that they intend to stop producing vehicles with internal combustion engines by 2035. Since electric cars are “The Future”, it wouldn’t surprise me if other manufacturers including Ford made similar announcements soon. I’m no Luddite, but I still don’t get it. Battery electric vehicles (BEVs) are less than 2% of the US market, about the same as five years ago, and sleek new offerings from Audi and Porsche have yet to move the needle. So far the dogs aren’t eating the dog food. What are the dogs eating? Full size pickups and SUVs for one thing, all with internal combustion engines, and many built, ironically, by GM. I drove one non-GM example recently, the Ford Expedition, and was reminded of why these big brutes are much more popular than any BEV. Consider who buys an Expedition. It’s usually a 40-ish mom or dad with 2-3 kids who uses their big Ford to ferry their progeny hither and yon along with sports gear, friends/teammates, and a dog or two, doing all they can to raise what they hope will one day be productive and happy adults. Reaching that (laudable) goal generally involves driving a spacious vehicle thousands of miles around home, in addition to many road trips to soccer (or whatever) tournaments and family vacations. And doing all that is exactly where the Expedition excels. It handles all of the transportation needs you and your family might have, not just some. It is undeniably big. Measuring around 16ft long x 6ft wide and 6.5ft tall, the Expedition can carry pretty much anything a family of five might need to haul. Neither driving pleasure nor parking ease is happening in an Expedition (please don’t act surprised), but the ability to see above traffic and cruise serenely on the highway definitely are. And let’s be honest for a sec here: when you’re a stressed parent who has to go from school to ballet to baseball to (OMG where is it, I’m already late?!!) some pizza place in Boerne, having a Ford Expedition to drive there is a good thing. An Expedition is safe too. As noted above, it’s a large vehicle and heavy too, weighing in at roughly 5400lbs. That means that the likelihood that you and your children survive a serious crash is high, which matters to any parent (or grandparent). A quick aside. Years ago, a friend and I were driving on I-10 just outside of San Antonio when we spotted an Expedition going the other way weaving erratically. As we watched horrified, it suddenly drove into the median and rolled over and over many times. Since we’re both physicians, we immediately turned around and ran over to help. Inside the crushed cabin was a wide-eyed young woman who

was scared but completely unharmed. Thank you “big metal vehicle” and thank you Ford. Nevertheless, the exterior design of the Expedition is uninspiring. While the F150 upon which the Expedition is based looks unequivocally cool, no matter the version the Expedition seems to have been styled tentatively. It’s not ugly, to be sure, but it isn’t cool either. Given its raison d’etre—carry kids, dogs, and parents/grandparents to the soccer/lacrosse/ballet event comfortably and safely—that’s not surprising, but I wish it looked as good as GM’s new full size SUVs do. The interior of the Expedition, predictably, looks a lot like the F-150’s. The plastics and other materials are well considered, and, in the better optioned models like my King Ranch press car, very nice. No, the interior of an Expedition will not make you think you’re in a Mercedes or Range Rover, but it’s inviting and comfortable nevertheless. All Expeditions come with a turbocharged EcoBoost 3.5L V6 mated with a smooth 10-sp automatic transmission. Fuel economy is 17MPG city/24 highway, and horsepower is 375 for most versions and 400 for the King Ranch and Platinum. While Expeditions start at just over $50,000, my loaded King Ranch tester came in at around $75,000, and I would guess that the average transaction price for all models is in the $60-65,000 range (Ford considers both the King Ranch and Platinum editions to be equivalent, with the former aimed at rural buyers while the latter is intended for urban customers). I accept that the future belongs to BEVs, but I also know that the present belongs to internal combustion engined vehicles like the Expedition. It may be big and thirsty, but the Expedition fits into and helps the lives of many Americans. I don’t expect it to go away any time soon. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.

Visit us at www.bcms.org

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of February 18, 2021. 42

SAN ANTONIO MEDICINE • March 2021

San Antonio Medicine March 2021

Articles inside

Recommended Auto Dealers

Auto Review: 2021 Ford Expedition King Ranch By Steve Schutz

Circle of Friends Directory

Texas Medical Board Controlled Substance Prescribing Requirements

BCMS Alliance

The Plight of the Immigrant Physician By Amar Sunkari, MD

My First Day By Daniel Rosas, MD

TMA Winter Conference

What Do Patients Believe Makes a Good Doctor? By Kalli Davis

BCMS & H-E-B Cooperate to Vaccinate 1,700

BCMS President’s Message