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Pediatrics
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JUNE 2018
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VOLUME 71 NO. 6
MEDICINE SAN ANTONIO
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Ambulatory Surgery for the Pediatric Patient By Michael Kim, MD.....................................14 By Mark Boston, MD, FAAP, FACS.................................16
A Conversation with Peter Houghton II, MD Interviewed by Michelle Vasquez ....................................20
Our Health Care Financing System Child Health Coalition Forming in Bexar County to Optimize Health and Reduce Toxic Stress By Anais Biera Miracle .......................23
SUBSCRIPTION RATES: $30 per year or $4 per individual issue
Medical-Legal Aid Program Helps Indigent Youth Seeking Medical Care By Darren Donohue, JD .....................................................24 BCMS President’s Message ...............................................................................................................8 BCMS News .............................................................................................................................................10 BCMS Delegation News............................................................................................................................12 Business in Medicine: The Role of Documentation in Diagnosis-Related Malpractice Allegations By Laura M. Cascella, MD ....................................................................................................26 Legal Ease: Changes are a’comin to Transparency in Medical Billing By George F. “Rick” Evans ................28 The Good Samaritans By Robert Lemke, DDS, MD ..................................................................................30 Maybe it’s Time to Try Something New By Adam V. Ratner, MD, FACR .....................................................32 BCMS Circle of Friends Directory ..............................................................................................................34 In the Driver’s Seat ....................................................................................................................................38 Auto Review: 2018 BMW 230i coupe By Steve Schutz, MD ...................................................................40
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San Antonio Medicine • June 2018
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Pediatrics
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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, MD, Immediate Past President Kristi G. Clark, MD, Secretary John Robert Holcomb, MD, Treasurer
DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Charles Mahakian, MD, Military Representative Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member
BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Community Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member
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San Antonio Medicine • June 2018
PRESIDENT’S MESSAGE
IT’S HARD TO QUANTIFY THE JOY OF WORKING WITH
CHILDREN By Sheldon Gross, MD, 2018 BCMS President Dear Colleagues, This month’s issue of San Antonio Medicine is about pediatrics. Since I have been practicing child neurology for the past 34 years, I assumed it would be very easy to write a one-page column about my feelings working with children. Instead, I have found it to be quite the opposite. I find it impossible to distill the experiences of 34 years into one page. I will however, endeavor to point out a few fundamental philosophies I have developed as a result of my experience with families and with children. 1) Children are more adept at expressing pure unbridled joy and happiness than any others. I have seen this in the eyes of strong and healthy 5-year-olds that have had nothing more serious than minor bumps to the head. I have seen the same joy and happiness emanating from the eyes of a 3-year-old with the most severe form of cerebral palsy. It is almost as though no one ever told them they had neurological problems. I have come to the conclusion that most people who are attracted to pediatrics or pediatric subspecialties do so because they value the exposure to this type of complete and thorough happiness of soul. My life is enriched as much by this exposure now at age 65 as it was when I was 35. I have three colleagues in child neurology who are older than 75 and still practicing. I am convinced that what drives them to maintain their practice is not the thought of making more money. It is the desire to continue the interaction with children and to continue to see the joy in their eyes. 2) I find it fascinating to work with individuals that are growing, developing, and changing. I have many patients with chronic disease such as epilepsy, migraine, or attention deficit disorder. I often start working with them at age 5 or 6 years or even younger. I often continue working with them up until age 21. I see them as they finish elementary school and eventually graduate from high school. I have seen many of them go off to college and choose a career path. When I first tell a mother that her child has epilepsy and I see the shock and fear in her eyes, I never hesitate to tell them that many of my patients with epilepsy are smarter than I am and infinitely better looking than I am. It is difficult to quantify or express the satisfaction one gets from seeing a child struggling in school and wondering what is wrong with them to eventually treating an underlying problem with attention span and watching them graduate with honors and have outstanding academic careers. Watching a child go from being a poorly-controlled epileptic to 8
San Antonio Medicine • June 2018
being completely seizure-free is watching a child’s life change 180 degrees. I have come to realize that most parents view their children as the most valuable thing in their life. It is both humbling and an honor to know that parents are trusting their most valuable and cherished children to you. 3) Lastly, there has been such dramatic progress made in almost every aspect of pediatrics and in my case, child neurology. In one of my earlier columns I mentioned a neurological condition, Werdnig-Hoffman syndrome, which had been uniformly fatal up until the past two or three years. There are now genetic treatments available that offer these children an entirely different future. I have seen hypothermia introduced into the neonatal ICU for term babies that have perinatal asphyxia. I have watched babies that I was convinced would suffer terrible brain damage, only to see them leave the nursery looking like normal children. I have tremendously enjoyed working with colleagues in the various fields of pediatrics. They share my appreciation for the uplifting nature of medicine geared towards children. I realize that this discussion likely seems superficial to many. However, to go more deeply into the various experiences and philosophies I have learned from children over the years would require writing a three or four hundred page book. At times one likes to think back and ask what could I have done differently to have more fulfillment in my career? In my case, the answer is a resounding “I would do nothing differently.” Being a child neurologist and working with children is one of the best decisions I have made in my entire life. I know that most physicians in other fields could write very similar columns about the uniqueness of what they do and why they love it. I would welcome such submissions to San Antonio Medicine and hope to see some of these published in the future. I would also like to take this time to congratulate Dr. Jayesh Shah for being elected to the Board of Trustees of the Texas Medical Association. He is an outstanding individual and will do a superb job for the state. Bexar County Medical Society is very proud to have such outstanding individuals in our membership. Enjoy the summer. Sincerely, SHELDON GROSS, MD, Bexar County Medical Society
BCMS NEWS On May 12, the Bexar County Medical Society and UT Health San Antonio sponsored a symposium to celebrate San Antonio’s Tricentennial called “300 years of History and Advances in Health at San Antonio” at the UT Health Holly Auditorium. Dr. Alfonso Chiscano served as the moderator and master of ceremony as the audience heard more than a dozen presentations on the history of medicine in San Antonio from the earliest records of Native American healers to the modern innovations of medical science driving San Antonio’s economy today.
Dr. Alfonso Chiscano welcomes attendees and introduces the speakers.
Medical artifacts from the Bexar County Medical Society collection.
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San Antonio Medicine • June 2018
Dr. William Henrich, president of UT Health San Antonio, with Dr. Sheldon Gross, president of BCMS.
Former San Antonio Mayor Henry Cisneros gives the keynote address on “Health Institutions as the Key the Future of San Antonio”
Jaime Wesolowski, CEO of Methodist Healthcare System (right), with BCMS CEO and Executive Director Stephen Fitzer.
BCMS DELEGATION NEWS
TexMed 2018 Now in the History Books BCMS Delegation to TMA wraps up House of Delegates Business Jayesh Shah, MD elected to TMA Board of Trustees San Antonio was host to TexMed 2018, TMA’s annual meeting, which took place May 18-19 at the beautiful JW Marriott Hotel. In addition, BCMS hosted a kickoff reception to TexMed on May 16 at Rebecca’s Creek Distillery. TexMed offers numerous committee, board and council meetings, a variety of events and receptions, including the annual TMA Foundation Gala, superb speakers, an outstanding Expo and an endless list of CME offerings for attendees. A special thanks to the following members of the BCMS Delegation to TMA, who were on hand throughout the weekend to conduct business in the House of Delegates meetings, reference committees and Caucus Breakfast: Co-chairs – Michael Battista, MD; Jennifer Rushton, MD and Jayesh Shah, MD; Brian Boies, MD; Chelsea Clinton, MD; Edward Dick, MD; John Edwards, MD; Stephen Gelfond, MD; Alice Gong, MD; Donald Gordon, MD, PhD; Anupama Gotimukula, MD; Gerald Greenfield, MD; BCMS President Sheldon Gross, MD; David Henkes, MD; John Hinchey, MD; William Hinchey, MD; David Hnatow, MD; John Holcomb, MD; James Humphreys, MD; Leah Jacobson, MD; Wendy Kang, MD, JD; Margaret Kelley, MD; Alex Kenton, MD; Michael Kim, MD; David Lam, MD; Monica Lee, MD; William Lewis, MD; Juan Martinez, MD; Milagros Martinez, MD; John Menchaca, MD; Jesse Moss, Jr., MD; Erika Munch, MD; Lubna Naeem, MD; John Nava, MD; Gerardo Ortega, MD; Rajam Ramamurthy, MD; Adam Ratner, MD; Roberto San Martin, MD; John Shepherd, MD; David Shulman, MD; J. Marvin Smith, III, MD; Rajeev Suri, MD; Bernard Swift, Jr., DO; Marc Taylor, MD; Roberto Trevino, Jr., MD; Ryan Van Ramshorst, MD; Miguel Vazquez, MD; David Webster, MD; Alexis Wiesenthal, MD and medical students, Donald Egan and Manojna Kintada. Also, heartfelt congratulations to Jayesh Shah, MD on his election to the TMA Board of Trustees!
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San Antonio Medicine • June 2018
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Clockwise from top left: 1. Dr. Sheldon Gross, current BCMS President, meets with past BCMS President Dr. James Humphreys at the TMA Convention. 2. Leaders of the BCMS Delegation to TMA (from foreground and to the left) Jayesh Shah, MD; Jennifer Rushton, MD; and Michael Battista, MD, listen as delegation member John Holcomb, MD provides comments on resolutions during the TexMed 2018 Caucus Breakfast held on May 19 at San Antonio’s JW Marriott Hotel. 3. Members of the BCMS Delegation to TMA meet during the Caucus Breakfast on May 19 to review final details of the House of Delegates business and elections. 4. Dr. Zubin Damania, who goes by the name ZDoggMD, was the featured speaker at the TMA Convention. 5. John Nava, MD, chair of the 2018 TexMed Planning Committee, welcomes TexMed attendees to San Antonio during the opening session of the TMA House of Delegates on May 18 at the JW Marriott Hotel. 6. Dr. Donald Gordon, BCMS Delegate to TMA and member of the TMA Board of Councilors. 7. Dr. Adam Rather, president-elect of BCMS, at the TMA Convention.
BCMS LEGISLATIVE NEWS
2018 Legislative Mixer Kickoff to TEXMED 2018 On Wednesday, May 16, 2018 the Bexar County Medical Society hosted a mixer to kick off the 2018 TEXMED Conference that took place in San Antonio, Texas from Thursday May 17 thru Saturday May 19. The event was very well attended by several physicians, Circle of Friends members, elected officials and partner sponsors.
Special Thanks to our Event Sponsors:
Dr. Alexander Kenton
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Clockwise from top left: 1. BCMS President,
Sheldon Gross, MD welcomes guests to the
Kickoff Reception to TexMed 2018 hosted by
BCMS on May 16 at Rebecca’s Creek Distillery. On stage with Dr. Gross are Drs. Joe and Alexandra
McColley who provided the musical entertainment.
2. State Representative Roland Gutierrez (District
119) listens to physician concerns during the Kickoff Reception to TexMed 2018 held on May 16 at Rebecca’s Creek Distillery.
Standing (l-r) are:
Gutierrez; BCMS Alliance member Louise Chum-
3
ley; Delbert Chumley, MD and Jayesh
Shah, MD. 3. BCMS immediate past
president, Leah Jacobson, MD and
her husband, Trey Jacobson, chief of
staff in the office of Mayor Ron
Nirenberg, visit with Mark Rosenberg (right), 4th year medical student from the
Universidad
Autonoma
de
Guadalajara (San Antonio branch)
during the May 16 Kickoff Reception
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to TexMed 2018 at Rebecca’s Creek
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Distillery. 4. BCMS Legislative and So-
cioeconomics Committee chairman,
Alex Kenton, MD visits with Justice Rebeca Martinez of the 4th Court of
Appeals during the May 16 TexMed
2018 Kickoff Reception. 5. BCMS
CEO and executive director, Steve
Fitzer (right) visits with John Shep-
herd, MD and BCMS Alliance mem-
ber, Louise Chumley at Rebecca’s Creek Distillery on May 16.
visit us at www.bcms.org
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Photo by Piron Guillaume on Unsplash
PEDIATRICS
Ambulatory Surgery for the Pediatric Patient By Michael Kim, MD
the early 1980’s an estimated 10 percent of surgeries took place in an ambulatory setting. With the increase in number of ambulatory surgical centers, the advent of less invasive and less morbid surgical techniques, and lower costs, more recent data suggest that over 70 percent of surgeries performed in the United States are performed in an ambulatory setting (1). It is thus, not surprising that a similar rate of utilization of ambulatory surgical centers exists in the pediatric population. A recent study suggested that there has been a 50 percent increase in pediatric visits from 1996-2006 from 1.6 million to 2.3 million/year (2). As a result, more and more parents are faced with the reality that their child will have an operation outside of a hospital setting. My hope is to shed some light on the pros and cons, address the issue of safety and discuss how to prepare your child for surgery.
In
Is it safe?
We have all seen the news headlines of a healthy child undergoing an elective procedure suffering catastrophic complications. This situation is what all anesthesiologists spend 4 years of medical school, 4 years of specialized anesthesia training and countless hours inside and outside the operating room studying and preparing for. The vast majority of surgeries and anesthetic exposures proceed without incident and with innovations in monitoring, anesthesia equipment, 14
San Antonio Medicine • June 2018
and pharmaceuticals surgery has never been safer than it is today. However, if you do enough cases and anesthetize enough patients, the less than 1 percent complication or crisis will arise and it is in these moments all those years of training come into play. Not long ago I had a healthy pediatric patient under my care for an elective dental procedure. Despite a thorough history and physical, it turns out the patient contracted an upper respiratory infection that had not yet manifested any significant symptoms. In the recovery room after completion of the surgery, this child suddenly developed severe/life threatening airway edema. Fortunately, early recognition and treatment led to early intervention that saved the childâ&#x20AC;&#x2122;s life and prevented any long-term sequelae, but the fact that despite all the appropriate screening, physical exam, history and physical a situation like this can arise, speaks to the seriousness of placing any child under general anesthesia. Fortunately, this situation is the exception and not the rule. A recent Canadian study showed that the incidence of unanticipated hospital admissions follow ambulatory surgery at a pediatric hospital was slightly less than 1 percent (3). The incident of unanticipated hospital admission is likely less due to stricter patient selection criteria in the ambulatory surgical setting. Risk factors for hospital admission included Age < 1year, prematurity, Surgery Duration >1hr, Type of surgery (orthopedic, dental, ear nose throat), intraoperative event, obstructive sleep apnea
PEDIATRICS ease of scheduling, ability to tailor a staff to meet the unique needs of each type of surgery, tailor facilities/equipment to cater to the needs of the surgical staff. In addition, 90% of ASCs are at least partially owned by physicians. The hope is that with the benefit of cost and convenience, quality of care is not being compromised. On this front, the ASC community has developed a quality initiative voluntarily to promote quality and safety in ASCs. In addition, federal requirements govern ASCs in order to participate in Medicare program (table 1). Based on these interventions and the available data, there does not appear to be a gap in the quality of care between hospital-based surgeries versus ASCs in appropriately matched patient and operation (5).
Cons
While financial consideration makes ASCs very attractive, there are limitations to consider.
Case Selection and ASA 3 or greater (representing significant comorbidity), recent upper respiratory illness. The surgical center is tasked with screening children to deem whether or not he/she is an appropriate candidate for surgery in the ambulatory setting.
Pros
Why even consider sending your child to an Ambulatory Surgical Center (ASC)? From the perspective of the taxpayer and government entities concerned with rising healthcare costs, ASCâ&#x20AC;&#x2122;s serve to decrease health care expenditures. Based on a 2013 analysis between 2008-2011 ASCs saved Medicare $7.5 billion dollars (4). This cost benefit is translated to the patient in the form of lower costs/copays. From the physician perspective, the benefits of operating at an ASC include more control over surgical practices,
As these centers are often not equipped with the facilities necessary for on campus admissions and overnight observations, the scope of surgeries that are feasible are limited. Any operation that would require monitoring/observation for more than a few hours after surgery are not appropriate for this setting.
Patient Selection
Appropriate patient selection is equally as important as case selection. Patients that fall into the category of ASA Physical Status Classification III or higher should be cleared by an anesthesiologist
continued on page 16
visit us at www.bcms.org
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PEDIATRICS
continued on page 16
and/or medical director for their appropriateness for treatment at an ASC (table 2) as they have a higher rate of need for admission to a hospital/overnight observation (6).
Hospital Transfers
As with any surgical procedure or anesthetic exposure, there are risks that range from minor injuries to critical illness. Case appropriateness and patient selection minimize the exposure of the patient and the ASC to the latter, however, if enough cases are performed there will inevitably be the need to transfer a patient to a hospital. ASCs have in place protocols and hospital affiliations that would facilitate a safe transfer of care, but such an occurrence can be a significant burden to the patient and family in many ways, including financial.
Preparation
Anecdotally, in my practice the most common reasons for cancellation are NPO status and failure to report or identify a change in health status. NPO refers to fasting practices prior to surgery. Based on the American Society of Anesthesiology, fasting recommendations (NPO guidelines) are as follows: Clear liquids no sooner than 2 hours prior to surgery • Breast milk 4 hours • Infant formula 6 hours • Nonhuman milk 6 hours • Light meal 6 hours • Fried foods, fatty foods, or meat - additional fasting time (e.g., 8 or more hours) may be needed (7). In terms of recent health changes, upper respiratory infections tend to be the most common reason for cancellation. It would be prudent for parents to report to the surgeon or the ASC any recent upper respiratory infection type symptoms including: cough, runny nose, yellow/green/brown sputum or drainage, change in energy level, fevers, chills, sweats. Keep in mind that if your child is cancelled on the day of surgery, it is for the health and safety of your child first and foremost. Financially speaking, cancellations on the day of surgery are a tremendous cost to hospitals and ASCs alike so it is in their financial interest to minimize cancellations. A study out of Tulane estimated that at their institution, case cancellations for pediatric cases cost the hospital an estimated $5,697 per case cancelled. This figure is likely to be significantly less in the Ambulatory Surgical Center, but still significant (8). That is to say that if your child is scheduled for surgery at an ASC, you can expect that there will be layers of forms, documents and phone calls to ensure that he/she is a good candidate and is adequately prepared for a safe and efficient experience.
Summary
With surgical advancements decreasing the morbidity of surgical
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San Antonio Medicine • June 2018
procedures and the growing emphasis on decreasing the cost of healthcare in the United States, ambulatory surgical centers are here to stay. In the pediatric population, the last decade has seen a 40 percent increase in ambulatory cases. As this trend is sure to continue, more data and analysis with regards to quality and cost at ambulatory surgical centers will certainly emerge. From the parent’s perspective, the question of whether or not their child is safe is paramount. Based on the information available today, the answer is ‘it depends.’ For the appropriate surgery in the appropriate patient, ambulatory surgical centers are an excellent alternative to hospital-based surgeries that can cut health care costs, facilitate earlier scheduling, and provide an ideal environment for surgeons to operate. As the success of ambulatory surgical centers depend on efficiency and quality of care, parents can be assured that there will be measures in place to keep their child safe and avoid delays/cancellations. As the parent of a child scheduled for surgery at a surgical center it is important to always ask questions, communicate changes to a child’s health, accurately report health history and follow the guidelines set forth by the surgery center to ensure a safe and smooth surgical experience.
About the Author:
Dr. Michael Kim is an anesthesiologist working in private practice with a San Antonio-based anesthesia group, Tejas Anesthesia PA. He obtained his medical degree from Boston University and completed his training at Boston Medical Center. He is board certified in Anesthesiology.
Works Cited:
1. Pregler, J. L., & Kapur, P. A. (2003). The development of ambulatory anesthesia and future challenges. Anesthesiology Clinics of North America,21(2), 207-228. doi:10.1016/s0889-8537(02)00073-1 2. Rabbitts, J. A., Groenewald, C. B., Moriarty, J. P., & Flick, R. (2010). Epidemiology of Ambulatory Anesthesia for Children in the United States: 2006 and 1996. Anesthesia & Analgesia,1. doi:10.1213/ane.0b013e3181ee8479 3. Whippey, A., Kostandoff, G., Ma, H.K., Cheng, J., Thabane,, L., & Paul, J. (2016). Predictors of unanticipated admission following ambulatory surgery in the pediatric population: A retrospective case-control study. Pediatric Anesthesia, 26(8),8310837.doi:10.1111/pan.12937 4. Study: Medicare Cost Savings Tied to ASCs. (n.d.). Retrieved from http://www.ascassociation.org/advancingsurgicalcare/reducinghealthcarecosts/c ostsavings/medicarecostsavingstiedtoascs 5. Federal Requirements Governing ASCs. (n.d.). Retrieved from https://www.ascassociation.org/advancingsurgicalcare/safetyquality/federalrequirementsgoverningascs 6. ASA Physical Status Classification System - American Society of Anesthesiologists (ASA). (n.d.). Retrieved from https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system 7. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures:An Updated Report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. (2011, March 01). Retrieved from http://anesthesiology.pubs.asahq.org/ Article.aspx?articleid=1933410 8. Campbell, C, Mora, A, Perniciaro, S, Abdur-Rahman, N, Pierre, N, Rosinia, F, Bent, S. 2011/01/01 The Financial Burden of Cancelled Surgeries: Implications for Performance Improvement.
PEDIATRICS
CHILDHOOD
HEARING LOSS
IN SAN ANTONIO By Mark Boston, MD, FAAP, FACS
earing loss affects an estimated 2-3 of every 1,000 infants born in the United States and approximately 1 of every 1,000 newborns has severe to profound hearing impairment (deaf). More than 90 percent of deaf infants are born to hearing parents and the vast majority of these parents choose to raise their children in a hearing world. Prior to the advent of early hearing screening and advanced technology, these children experienced significant delays and limitations in language development, educational success and vocational opportunities. Today, however, a linked system of early identification, technology, and specialized education provides deaf and hearing-impaired children an opportunity to live, learn, work and succeed in a hearing world. No technologic advancement has improved the opportunity for deaf children to develop spoken language and educational success than has the cochlear implant. Cochlear implants do not “cure” deafness but they can provide access to spoken language at a level unobtainable with hearing aids. And when cochlear implants are a component of a comprehensive program including strategies to maximize the benefits of the cochlear implant in supportive home and educational environments, prelingually deaf children can attain educational and professional milestones on par with their normalhearing peers. But the fullest benefits of cochlear implants can only be realized with early identification of deaf and hearing impaired infants and children. Prior to mandated hearing screening programs, most deaf children were not identified until they were two or three years of age or older. Recognizing the lifelong impact this delay had on children, childhood hearing specialists worked with elected officials to establish laws to ensure that hearing impaired infants were identified
H
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San Antonio Medicine • June 2018
shortly after birth. Legislation passed in 1999 (HB 714) established standards and criteria for newborn hearing screening (NBHS) in birthing centers throughout Texas. The current “opt-out” NBHS program screens approximately 97 percent of births in Texas. Data from the 2015 Texas Early Hearing Detection and Intervention (TEHDI) Program shows that of 397,465 infants who were screened 5,697 (1.4 percent) were referred based on the screening.1 Of those 5,697 who did not pass the NBHS, 491 were ultimately diagnosed with hearing loss. In addition to NBHS, Texas law also requires that children receive hearing screening within 120 days of school enrollment as well as during the 1st, 3rd, 5th and 7th grades in all public, private, parochial, or denominational schools. The continued surveillance of children’s hearing is important because many hearing impaired children are born with normal hearing but develop hearing loss over the first few years of life. Similar to NBHS, most children who fail a school hearing screen will ultimately be found to have normal hearing. But the screening process is designed to ensure that no hearing-impaired child is denied access to appropriate services because of a failure to detect their hearing loss. At The Children’s Hospital of San Antonio, our audiologists (and otolaryngologists) see a large number of infants and children referred for a failed NBHS or school screening. With the 90 percent of infants and children who have normal hearing the office visit becomes an opportunity to discuss healthy hearing habits and how to spot the signs of potential hearing loss, as well as a chance to share good news with a family. For those who are diagnosed with hearing loss, the discussion is typically much longer and focused on answering caregiver questions and discussing the next steps of language
PEDIATRICS
choice, habilitation, early intervention, school services, etiology of hearing loss and other topics. It’s a lot for parents and caregivers to absorb and process and the day of diagnosis is just the beginning. A large team of childhood hearing professionals is needed to provide optimal support and care for newly diagnosed deaf and hearing impaired infants and children and their families. Fortunately, San Antonio has dedicated organizations with experienced individuals ready to take up the challenge of caring for the needs of deaf and hearing-impaired children. One of the most unique and important of these organizations is the Sunshine Cottage School for Deaf Children. For 71 years San Antonio has been home to Sunshine Cottage School for Deaf Children. More than just a school, Sunshine Cottage provides the full-spectrum of audiology, speech pathology, early childhood intervention, classroom instruction, parent resources and, short of surgery, all that might be needed for the child with hearing loss. Their audiologists, therapists, teachers and support staff are invaluable to the care of deaf and hearing-impaired children and their families. For those of us who work with these children we recognize the tremendous value that Sunshine Cottage plays in helping these children to listen, speak, read and learn. In addition, their parent-infant program empowers caregivers to fully participate in the habilitation and education of their child. And this is critical because research has shown that much of the hearing-impaired child’s educational and social success is based on active and
informed parental involvement. Research has also consistently shown that deaf children perform better on speech, language and comprehension testing when they are identified early and receive early intervention with a focus on auditory-oral skills. The resources available to us in San Antonio allow us to link mandatory hearing screening, audiologic and medical assessments, hearing aids and/or cochlear implants, and appropriate educational paradigms into one comprehensive continuum of care. We can’t cure deafness, but in San Antonio we can make successfully raising a deaf child in a hearing world a reality. Note: American Sign Language (ASL) is a beautiful and vibrant language and the language of the Deaf community. ASL is not a topic of this article but it is always a topic I discuss with the parents of deaf children. For some of my patients and families, ASL is the best option; for most it is not. I don’t see this as an indictment of ASL or the Deaf community but rather an affirmation of parents wishing to raise their children in their own way. 1. 2015 Annual Data Early Hearing Detection and Intervention (EHDI)
Program, https://www.cdc.gov/ncbddd/hearingloss/ehdi-data2015. html, Accessed 4 May 2018
Dr. Mark Boston is Surgeon-in-Chief at The Children’s Hospital of San Antonio.
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PEDIATRICS
A Conversation with Peter Houghton II, MD Interviewed by Michelle Vasquez
What drove you or inspired you to go into scientific research?
I was aiming to go into the arts when at boarding school in the United Kingdom, but when I was 15, I participated in a biology course with a truly inspirational teacher named Mr. Tribe. I did well in my national exams that year and specialized in sciences for the remainder of my school career (10-12th grade).
What is your area of expertise? What drove you into this specific area?
I am a molecular pharmacologist focused on pediatric cancer. I think there were two critical events that directed my area of research. The first was the death of a fellow student from a rare form of lung cancer when I was an undergraduate in pharmacy school (hence the pediatric focus), and the second was reading a book chapter called “Evaluation of Drug Activities: Pharmacometrics,” written by Thomas Connors at the Chester Beatty Laboratories in Chelsea/Institute of Cancer Research (ICR) in London. I found his approach to understanding the molecular mechanisms of anticancer drug action to be both honest and inspiring. I was fortunate to be awarded a Medical Research Council graduate fellowship, and studied at ICR with Dr. Connors as my mentor.
What professional accomplishment are you proudest of?
I suppose, from the professional perspective, becoming the chair of molecular pharmacology at St. Jude Children’s Research Hospital was particularly rewarding. From a scientific perspective, we developed the camptothecin class of anticancer drugs that are now part of the standard of care for many pediatric cancers, developed the molecular rationale for a combination therapy that became the standard of care for patients with colon cancer, and our studies rekindled the interest in using rapamycin derivatives as cancer therapeutics.
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What do you want the community to know about you?
I am the director of the Greehey Children’s Cancer Research Institute and have held a number of senior positions. I guess you just have to find something that really inspires you in life. For me, that is improving outcomes for kids with cancer.
What makes UT Health San Antonio a special place to do research?
Collegiality, the work environment and a can-do attitude make UT Health San Antonio a special place to do research. The research institute is an amazing facility in which to conduct cuttingedge research. San Antonio also is a great city.
What unique challenges or opportunities do you have as a scientist in San Antonio?
I think one real opportunity is to impact the childhood cancer problems in South Texas. In this region, the incidence of cancer is 16 percent above the state level, and 19 percent greater than that in the nation. Further, outcomes for Hispanic children with leukemia are worse. So, we have a duty to focus on health issues that are important to our community. In terms of challenges, obviously, federal funding has to increase to support research both at a basic level and for clinical research. That is not unique to UT Health San Antonio, and we have been fortunate to have the Cancer Prevention & Research Institute of Texas (CPRIT) to support our studies. In terms of challenges and opportunities for the Greehey Children’s Cancer Research Institute, I think we have a great opportunity to expand our research focus on childhood, adolescent and young adult cancers. The last three years have been amazing as we have recruited outstanding faculty, and have truly built a powerhouse of researchers focused on childhood cancer. I think we have to maintain this trajectory, which will require extending the research institute, possibly through an additional research building. The challenge will be raising the funds to achieve this goal.
PEDIATRICS
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PEDIATRICS
OUR HEALTH CARE FINANCING SYSTEM: We get what we pay for and complain that we are not getting what we do not pay for. By Juan Ferreris, MD, MHA, FAAP ur current and proposed future health care financing systems create real obstacles to providing patientcentered, value-based care for our pediatric patients. Our current financing system is a fee-for-service model of payment. More procedures and tests and less time spent in direct patient care results in greater payments to providers that provide high-cost procedures and spend little time face to face with patients on prevention and wellness. The planned and desired move towards a system of financing that rewards improved outcomes while increasing access and quality cannot logically occur if our payment structures continue to reward procedural and specialty care. Since our primary care pediatricians spend most of their time in non-procedural activities such as counseling, wellness and disease prevention, and coordinating care, the current system of payments based on Medicare RBRVS, which “values” only high-cost time and procedures, undervalues primary care work. Ironically, the only hope of cost controls and improvement in quality and access rests for a large part on the time spent by the primary care physician doing exactly these undervalued activities. As we look towards the near future, the Affordable Care Act seeks to encourage the development of patient-centered medical homes (PCMH) as a means to increase access and quality. However, PCMH implementation and certification is difficult, time consuming and rife with bureaucratic processes. The additional staff resources required to implement PCMH is not offset by any increase in proposed payments from insurers. In fact, most compensation plans have at most a 5-10 percent patient satisfaction or “quality” component. Given that patients measure
O
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quality and satisfaction based on a perception of a practice’s access and patient centeredness, a PCMH model makes absolute sense as a model to address these two factors. Unfortunately, primary care pediatricians are at the lowest end of the pay scale because payment models of current continue to focus on the procedure and specialty focused RBRVS system. Even the payment models in transition still do not provide any more than a 5-10 percent incentive at the most. With this current reality, the progress towards improved access and outcomes in our health care system cannot occur. Hence, while the “language spoken” by government and private payers rings true with pediatricians, the actions taken thus far lack the support in the form of increased compensation for the time-consuming work of direct patient care. Until we actually change the way we value direct patient contact time, a change in the metrics of access, quality and therefore improved overall population health will never be a reality. How can our current and future financing systems expect primary care pediatricians to spend more time in already undervalued activities such as PCMH if pediatricians and their patients are already some of the lowest cost centers in medicine? Therefore, we should not be surprised when our current health care financing system continues to pay for expensive procedure-oriented care while lamenting the fact that we are not getting improved health outcomes and coordination of care simply because we do not pay for it. Dr. Juan Ferreris is the Medical Director of The Children’s Hospital of SA Pediatric Group and is a physician educator with Baylor College of Medicine and UT Health as clinical adjunct faculty.
PEDIATRICS
Child Health Coalition Forming in Bexar County to Optimize Health and Reduce Toxic Stress By Anais Biera Miracle
dverse Childhood Experiences (ACEs) have long been understood to markedly increase the risk of chronic diseases such as myocardial infarction and behavioral health problems such as substance use disorders and suicide independent of and often beyond other traditional medical risk factors. Persons with an ACE score of 6 or higher have a life expectancy that is 20 years less than their low ACE counterparts. The Children’s Shelter’s inaugural South Texas Trauma-Informed Care Conference was held on May 10th and 11th to build a multidisciplinary network of Trauma-Informed Care in South Texas. Featuring internationally-renowned trauma expert Dr. Bruce Perry and other distinguished trauma experts, the conference provided an opportunity for the establishment of the South Texas Trauma-Informed Care Consortium. The Children’s Shelter in partnership with VOICES for Children hosted the initial framework meeting on Friday, May 11, to develop the South Texas Trauma-Informed Care Consortium. Participants were asked to identify a common working definition of trauma-informed care, to answer four priorities in addressing it, and to identify which parties need to participate to ensure a successful coalition.
A
The first priority of the consortium will be identifying community partners who would be instrumental in the development and implementation of the trauma consortium. The second priority will be building community awareness on the importance of Trauma-Informed Care by moving from trauma awareness to trauma active. The third priority is to provide a robust training calendar and opportunities centered on best practices for Trauma-Informed Care across a diverse array of community partners which would include but would not be limited to education, healthcare, law enforcement, and health and human service organizations. The final priority is the development of sound legislative priorities to inform policymakers on the nature of Trauma-Informed Care and to implement effective advocacy initiatives. Advocacy work will include publication of white papers to explain and document the work of the South Texas Trauma-Informed Care Consortium. Interested parties who would like to connect and actively participate in the consortium please contact Anais Biera Miracle, Chief Public Relations Officer at The Children’s Shelter at abiera@chshel.org or 210-212-2598. visit us at www.bcms.org
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PEDIATRICS
MEDICAL-LEGAL AID PROGRAM Helps Indigent Youth Seeking Medical Care By Darren Donahue, JD
has been well established that a child’s health depends on more than can be addressed by their pediatrician alone. According to the American Academy of Pediatrics, poverty is a strong risk factor for poor health and has been linked to higher rates of asthma, obesity, poor language development, increased infant mortality, and increased risk of injuries. And while pediatricians frequently identify the social and environmental problems that harm their patients, they often lack the time, training, or professional license to adequately address these issues. In an alcove off the waiting room for the Children’s Hospital of San Antonio’s primary care pediatric clinic lies a small team of legal professionals working diligently to ameliorate some of these social determinants. Titled Medical-Legal Assistance for Families (“MLAF”), this team makes up Texas RioGrande Legal Aid’s component of San Antonio’s Medical-Legal Partnership. Formed in 2008, Texas’ first medical-legal partnership has created a referral pipeline for indigent families in San Antonio to obtain legal services for their children. In so doing, MLAF addresses the challenges – education, housing, guardianship, and accessing public benefits – that accompany
It
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San Antonio Medicine • June 2018
poverty and that can be a factor in poor health. Currently, MLAF accepts referrals from the Baylor College of Medicine Department of Pediatrics at The Children’s Hospital of San Antonio and the Department of Pediatrics at UT Health San Antonio. One of MLAF’s most active areas of advocacy is in helping pediatric patients obtain coverage and assistance from their public benefits as guaranteed by law. For children, under the Federal Medicaid statute, Medicaid is required to provide “necessary healthcare, diagnostic services, and other measures…to correct or ameliorate defects and physical and mental illnesses and conditions.” 42. U.S.C. § 1396d(r)(5). However, in many cases, families find themselves being denied Medicaid coverage for exactly the test or procedure ordered by their pediatrician. Following such a denial, the patient has a right to a fair hearing to determine whether the denial was proper. And in these hearings, patients and their families can greatly benefit from the assistance of a lawyer. In one recent example, MLAF was instrumental in obtaining Medicaid coverage for diagnostic services for a girl born with intellectual disability, short stature, dysmorphic facial features, and a
PEDIATRICS
heart murmur. She had initially been diagnosed with Down Syndrome, but her karyotype did not show a trisomy. A geneticist suggested that a chromosomal microarray could help him to make the diagnosis but the child’s Medicaid health plan denied coverage for the test. The child’s mother filed a request for a fair hearing and MLAF assisted by helping her and the geneticist prepare their testimony. Ultimately, the health plan covered the test and the child received the care that she needed. While MLAF provides services to one client at a time, the results of their work can be wide reaching. Due to assistance from MLAF, as well as ongoing advocacy by the geneticist referenced above, Medicaid health plans in San Antonio now cover chromosomal microarrays for children when medically necessary. While that girl had to fight to get care, similar children in the future will benefit from her efforts. Additionally, MLAF has filed suit in the federal court in San Antonio to obtain Medicaid coverage for applied behavioral analysis (“ABA”) for Texas children with autism spectrum disorder. ABA is the most recommended and sole evidence-based treatment for
autism spectrum disorder, and under federal law, Medicaid is required to cover necessary medical treatment. Yet in Texas, and in only a handful of other states, Medicaid does not cover ABA for children with the disorder. Children in these states have had to sue to get coverage that should be guaranteed by federal law. While many physicians can have a complicated relationship with attorneys, this is one area where practitioners from both disciplines can work together for the same patient/client. As a strong ally to pediatricians, a partnership with Medical-Legal Assistance for Families provides a multidisciplinary team that can address a child’s direct and social determinants of health. For more information please contact Susan Zinn from Medical-Legal Assistance for Families at 210-704-8730. Darren Donahue, JD is a former practicing attorney and third year medical student at UT Health San Antonio.
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25
BUSINESS OF MEDICINE
The Role of Documentation
In Diagnosis-Related Malpractice Allegations By Laura M. Cascella, MA
Allegations associated with diagnostic errors — i.e., wrong diagnoses, delayed diagnoses, and missed diagnoses — are a top cause of malpractice lawsuits. A number of risk factors can lead to diagnostic errors, including issues related to documentation of clinical care. MedPro Group’s closed claims data from 2007 to 2016 show that documentation issues occur in almost 1 in 5 diagnosis-related claims. These issues generally fall into three categories: (1) insufficient/lack of documentation, (2) content, and (3) mechanics. Documentation as a Contributing Factor in Diagnosis-Related Claims
Source: MedPro Group closed claims, 2007-2016 When it comes to defending malpractice claims, accurate and thorough documentation of the provision of clinical care is crucial. Thus, understanding the types of documentation missteps that contribute to diagnostic errors can help healthcare providers assess their current processes and adjust as necessary to reduce liability.
Insufficient/lack of documentation
Among the categories represented in the previous graph, insufficient documentation dominates. Examples of situations that can 26
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lead to documentation deficits include: • Failure to document attempts to follow up with a patient about care or test results. • Failure of the healthcare provider to document that he/she has been involved in a patient’s care. • Missing documentation in the patient’s record (e.g., patient problem list, test results, consultations, referrals, signatures indicating review, or medication lists). • Failure to document adequate details about the patient en-
BUSINESS OF MEDICINE counter, which might be particularly problematic in an electronic health record (EHR) system because of reliance on form fields and check boxes.
Content
Content-related concerns include problems such as altered documentation (which might suggest an attempt to cover up mistakes), opinions stated as medical facts, inappropriate comments or speculation (e.g., subjective vs. objective information), the proliferation of inaccurate information as a result of the copy/paste function in EHRs, or general inconsistencies in documentation patterns across records.
Mechanics.
The mechanics category refers to inaccurate documentation within a factual setting. Examples include inaccuracies in transcribing or writing orders, illegibility (including the use of nonstandard abbreviations, shorthand, or “text talk”), delays in documenting, and failure to use an appropriate method for correcting documentation errors and making amendments.
Documentation Risk Tips
Because of documentation's essential role in healthcare, following best practices and standards is crucial. The following key risk management strategies can help ensure adequate and appropriate documentation. Ensure your organization’s documentation policies require providers to document: • Sufficient details related to the patient’s history and physical exam. This documentation will help support continuity of care and comparison of findings from previous visits. • Patient compliance, including missed and cancelled appointments and attempts to follow up with the patient. Providers should be careful to remain objective in their documentation and avoid editorializing. • Treatment plan changes, such as receipt of diagnostic results,
• • • • •
• •
follow-up with the patient, patient response, and phone conversations (including after-hours calls). Consultations and referrals, including conversations with the consulting provider, agreed-upon consulting arrangements, and receipt and review of consultation reports. Patient education, including written and verbal advice, recommendations, and educational materials — as well as patient understanding of the information. Establish appropriate timeframes for completion of documentation following patient encounters. Consider whether documentation in the record supports clinical judgment and decision-making, and whether it clearly identifies how a particular diagnosis was determined. Do not include incident reports or criticism of other providers in patient records. Root cause analysis of errors and near-misses should be documented as part of the practice’s risk management and quality improvement efforts. Understand and educate staff about the appropriate methods for correcting or amending documentation. Ensure that documentation policies address issues unique to electronic documentation, such as the use of copy/paste, form fields, check boxes, etc.
For more helpful documentation strategies, see MedPro’s Documentation Essentials and Electronic Documentation checklists at its website – www.medpro.com. visit us at www.bcms.org
27
LEGAL EASE
CHANGES ARE A’COMIN TO
TRANSPARENCY IN MEDICAL BILLING By George F. “Rick” Evans, Jr., Evans, Rowe & Holbrook Ever wonder what the internist across the hallway charges for a routine office EKG compared to what you charge for the same service? Or what he/she may charge for routine lab work? Or whatever? Read on. June 9, 2015 started off as any other day for Crystal Roberts. Unfortunately, it went downhill rapidly when she was involved in a serious car accident resulting in her transport to North Cypress Medical Center in northwest Houston. She was only in the Emergency Department for three hours before being discharged. During that time, she was provided a series of X-rays, scans and other services. For those services, the hospital billed her $11,037.35. The hospital’s bill was for their full “chargemaster” prices. Noteworthy is the fact Crystal was uninsured. Crystal filed a lawsuit against the car at fault which caused the accident. A nominal settlement was offered of slightly more than $17,000 of which $9,404 was attributed to her medical expenses. The hospital exercised its right to file a lien and sought to recover the full amount of their $11,037 bill. Although Crystal’s attorney tried to negotiate a reduction in the hospital’s claim, no agreement could be reached. Texas law allows a hospital to recover only “reasonable” charges. Makes sense, right? Who would argue a healthcare provider should be allowed recovery for unreasonable charges. The question then becomes what is a reasonable charge? Crystal questioned where the full “chargemaster” charges really were reasonable because she was suspicious the hospital charged lesser rates to insured patients for the identical services. The Texas Supreme Court candidly recognized that, in reality, the healthcare system actually has a two-tiered system of charges. There’s a price list for uninsured patients and a separate and different price list of patients with private or government-based insurance. Big surprise, right? The Court went on to recognize the point that “chargemaster” or “full” prices have lost any direct connection 28
San Antonio Medicine • June 2018
to costs or the amount the hospital actually expects to receive in exchange for its services. The hospital argued that uninsured patients like Crystal shouldn’t be allowed to benefit from contract rates negotiated by insurers for their insured patients. But the Court held that the issue wasn’t whether Crystal could take advantage of rates negotiated by insurers with whom she had no relationship, but whether the rates charged to her by the hospital were reasonable. After all, the hospital is only allowed to recover for reasonable charges; not whatever charge they happen to claim. So, how did Crystal attempt to find out what are reasonable charges? Well, her attorney demanded the hospital provide the rates the hospital charged for patients insured by both private and government sources. As everybody knows, this information is not public and is a closely guarded secret. Predictably, the hospital objected and refused to produce that data. The dispute went up the ladder all the way to the Texas Supreme Court. The Court ruled that a hospital’s reimbursement from private and government insurers represent the vast majority of payments for their services. As such, the Court recognized that the payments the hospital accepts in full satisfaction of its bill are obviously some evidence of what actually is a reasonable charge. The Court recognized that, while these negotiated reimbursement rates may not be dis-
LEGAL EASE positive of what a reasonable charge is, at the very least they are relevant to the ultimate determination of what is a fair charge. Bottom line: The Court required the hospital to disclose to Crystal’s attorney their pricing structure for discounted, negotiated rates with insurers of all types. What’s this mean? For starters, it means that the glass ceiling of secret, allegedly proprietary fee schedules is cracking. More transparency in medical billing has now been legally mandated. The implications of this decision go well beyond hospitals and the liens they may file in personal injury lawsuits by which they seek to recover their bills. The Court’s holding is much broader than that. It strongly implies that any healthcare provider seeking recovery for any service under any circumstance will have to provide full information on its billing practices if there is any difference whatsoever in how the provider bills patients. It can now be argued that doing a routine EKG or lab work in your private medical office should be billed at the comparable rates whether the patient is uninsured or fully insured. Providers can only recover for “reasonable” charges and, to determine what is reasonable, the law now requires the provider identify any differences in
billing practices among the patient base. It’s important to realize that a discounted rate doesn’t necessarily mean that’s the highest rate a provider can reasonably charge. The Court recognized there may be legitimate reasons to justify a discounted rate which don’t apply to an uninsured patient. But, at the very least, the patient (and, ultimately a jury if the provider and patient can’t agree) is entitled to know of any difference in rates charged by the provider to different classes of patients. Perhaps the most significant aspect of this decision is that the shroud of secrecy surrounding tiered-billing practices appears to have come to an end. Not only may this benefit uninsured patients who arguably were being overcharged, but it may benefit other providers, like yourself, who may discover their contract rates aren’t as favorable as a competitor’s contract rate. This may portend a move towards a day when rates are more standardized. Like buying a loaf of bread at the grocery store where the price doesn’t change depending on whether the purchaser is hungry, wealthy, or reimbursed for the cost. Maybe the same will be said of that routine office EKG. The day may not be far off when everybody will know what everybody charges and pays for medical services. Hard to say. The full implications of this decision are just now rolling out.
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Renal Associates of San Antonio, PA San Antonio Eye Center, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.
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29
FEATURE
The Good Samaritans By Robert Lemke, DDS, MD All I wanted to do was leave the office and go to a church event as it was Good Friday. I was to meet my family at noon for Stations but as we know, there are detours in life. This was a detour to remember and learn from: a near death accident. It all went down heading down Blanco. I was in the right of two lanes heading North just before 1604. There was a car in front of me and a motorcyclist in front of them. In the left Northbound lane were a few cars with me in the right. The car in front of me moved to the left lane as the motorcyclist was slowing down. After this car changed lanes, the car in front of them, now in the left lane, decided to take advantage of the “opening” in the right lane and zoomed in – not seeing the motorcyclist who was but a few feet ahead. We all know what will happen next. I saw it all in the proverbial slow motion sequence and was hoping to not see a body pummeled by the tires of a car. The car hit the motorcyclist and then attempted to swerve out of the way back into the left lane. The cyclist lost control and went down to the pavement. All I could do was to slam on my brakes so as to not hit either of them who were about 100 feet in front. The car that hit the motorcyclist finished swerving into the left lane and stopped. I pushed on the emergency lights and got out, phone in hand. The body lay in the street. I saw the cyclist move and reach into his pocket and attempt to grab a phone. Whew, it was not his day to die as the tires must have been only an inch away from his head when the driver swerved away. As I approached, another man ran to the cyclist. He saw me with my phone and said “YOU, call 911.” ‘Shoot’, I thought to myself, ‘that was going to be MY line.’ About two minutes later I got off the phone after answering the multitude of questions including “was he wearing a helmet” which was asked three times. Performing a quick scan, both lanes were stopped, the area was safe and the cyclist appeared to be stable other than the bleeding out of his right leg. 30
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The blood was pooling on the asphalt. His lower leg and foot was at ninety degrees to his pant’s leg. Even an oral surgeon, such as myself, could diagnose a fracture. I looked up and a wall of people began to approach the scene. I had to blink several times as one person approached in scrubs with latex purple gloves on, hands in the air as if walking to an operating room table. “Wow, Darn you are ready!” I said. She was a dental assistant and offered me gloves. I said to the group that we needed to check and make sure that he was not going to bleed to death from his leg and did anyone have a knife? I was immediately handed... a wine bottle opening kit! Really? Well, it does have a ½” blade which proved to be worthless. “Isn’t there a better knife?” I asked. Amazingly a lady walked up and opened what must have been a two-foot-by-two-foot surgical emergency kit all in white with labels everywhere. I was handed the sharpest scissors I have ever seen
FEATURE and they easily cut through his jeans. Good news! He did not have a significant bleed. “Do you have some gauzes in that kit?” I further asked, “ 4x4’s?” Immediately I was handed gauzes. Asking for a kerlex roll I was then given that too quicker than in any OR. At that point another lady came rushing up and said “I’m a doctor.” I’ve learned to always ask “What kind of doctor are you?” Once before I had been in an emergency situation when a person came up and offered their doctoring services... they were a psychiatrist. ‘Really?!?’ Nothing against psychiatrists, of course but .... In this case, however, they said “I’m an ER doc.” Spectacular. Within seconds she looked, assessed and said “Compound fracture. Let’s reduce it.” Being a little hesitant I said “Here? Now?” “How’s his pulses” she responded. “Shoot” I said, “I knew I forgot something!” We smiled. The assistant with gloves provided more gloves and we removed his bloodied sock to reveal good pulses. I looked at him and said” You are one lucky guy! Here you have a nurse, dental assistant, an ER nurse, an ER doctor and an Oral & Maxillofacial Surgeon.” He smiled.
I went on to say “Oh no, we forgot one thing!” Everyone looked at each other around this poor man on a hot asphalt and wondered what? “Did anyone check his insurance?” I said. I smiled and we all laughed (though our new patient less). I looked back at his foot and the ER doc had already reduced it. By the time the EMT’s came, a lot had been done: comforted, evaluated, bandaged and reduced. The miracle on this day was that it was a group effort. Each one of us could have done little or nothing without the others. This was truly a Good Friday or beginning of Passover to always recall. It shows the kindness in so many people. It is a kindness and giving from people who asked for nothing in return and will never be recognized. I left a few hours later after giving the police report. Although I never made it to church I knew I had attended a religious experience spectacular unto itself. Robert Lemke, DDS, MD is a Board Certified Oral and Maxillofacial Surgeon who has practiced in San Antonio for over 24 years and sometimes makes detours.
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31
FEATURE
Maybe It’s Time to Try Something New By Adam V. Ratner, MD, FACR I’m sitting around a long table in a room with nine excited and energetic first-year medical students or “learners” as we now call them. They are having an animated, wide-ranging conversation about a young patient with celiac disease. Each of the learners is bringing to the table the results of their research and study over the past two days. They discuss clinical presentation, pathophysiology, relevant basic sciences, socioeconomics, mental health and so much more at a level I could not have imagined when I was a first-year medical student way back in the last millennium. I’m having a blast. I’ve had the privilege of “teaching” at both UT Health San Antonio Long School of Medicine and now at the University of the Incarnate Word School of Osteopathic Medicine for several years after a 20-year career in private practice. Over the past several decades, I’ve seen many excellent physicians become cynical, get burned out and often leave our profession because they no longer derived joy from their daily work. An overwhelming clinical work load, frustrating administrative burdens and regulations, antagonistic third-party payors are a few of the many reasons we lose sight of what is important, meaningful and fun. While most of the same challenges exist in the world of academic medicine, we in academia benefit from the energy and passion of our learners, whether as students, interns, residents, fellows or faculty colleagues. While they are always challenging us, most are also grateful for helping them obtain the wisdom and knowledge and to learn the skills we have acquired over the years. Many learners seem to be particularly hungry for pearls from the worlds of private practice and appreciate the different perspectives that those of us who have practiced in non-academic environments bring. There are too many potential opportunities for experienced private practitioners interested in the academic world to describe here. If you’re not feeling the joy of practice but also think there still is a burning ember that could reignite a passion for medicine, think about returning to academia. There are volunteer, part-time and fulltime opportunities, but you will have to seek them out. 32
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While searching local academic institutional web sites and job postings are great first steps, academic departments have changing needs and direct conversations with departmental leaders are critical in finding a potential academic niche which may not be advertised or even yet imagined. No matter what the practice setting, the BCMS wants our member physicians to be as happy and productive as possible. If you’re thinking about returning to academia and want to know more, please don’t hesitate to contact me (adam.ratner@bcms.org) or Dr. Rajeev Suri (suri@uthscsa.edu) , the chair of the new BCMS Joint Academic Collaboration Committee. Dr. Adam Ratner is Chair and a co-founder of the Patient Institute and currently serves as the Stewart and Marianne Reuter Endowed Professor of Medical Humanities as well as Clinical Professor and Deputy Chair for Strategic Development and Socioeconomics in the Department of Radiology at The University of Texas Health Science Center at San Antonio. He is also a professor of radiology, health policy and medical humanities at the University of Incarnate Word School of Osteopathic Medicine.
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33
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ACCOUNTING SOFTWARE
cated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
ATTORNEYS 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”
ASSET MANAGEMENT
Avid Wealth Partners (HHH Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and well-served by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedi-
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San Antonio Medicine • June 2018
Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence. Mark R. Flora Partner and Office Head 512-382-8800 mflora@constangy.com William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
ASSETS ADVISORS/ PRIVATE BANKING
U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, businesses, communities and future generations. SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”
BANKING
Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett
210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”
BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com
BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees. Mary Mahlie Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”
Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans. Sam Fisher Vice President/Commercial Lender 210-319-3503 samf@ozonabank.com www.ozonabank.com
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com
RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more. Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org
Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals. Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”
BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants. Michal Waechter, Owner (210) 913-4871 MichalWaechter@gmail.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”
BUSINESS SERVICES
ation, Adaptability and Attainability Doug Elley Financial Consultant 210-961-9991 dougelley@financialguide.com www.newyorklife.com
CONTRACTORS/BUILDERS /COMMERCIAL
Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction. Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com
EMPLOYEE MANAGEMENT
Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"
FINANCIAL ADVISOR
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"
FINANCIAL SERVICES New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreci-
Avid Wealth Partners
( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”
Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”
Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference. Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"
Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com
www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning). Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org
The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank. Carol Mani Johnston Senior Vice President – Wealth Management Senior Portfolio Manager 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."
GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A parttime, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time. Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration
HEALTHCARE TECHNOLOGY RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang
continued on page 36
visit us at www.bcms.org
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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 35
Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."
HOSPITALS/ HEALTHCARE SERVICES
Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research. Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges. Miranda Peck 210-482-3000 mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”
INFORMATION AND TECHNOLOGIES
Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”
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San Antonio Medicine • June 2018
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
INSURANCE
SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships. Deborah Gray Marino VP Community Relations 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® Financial Advisor 210-321-7258 Gcastillo@swbc.com Leslie Barnett, Senior Loan Advisor 830-928-9080 LBarnett@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”
Humana (HHH Gold Sponsor) Humana is a leading health and
well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com
INTERNET TELECOMMUNICATIONS
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
The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance. Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.
Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”
LUXURY REAL ESTATE
Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"
MEDICAL BUSINESS CONSULTING
Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735
BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."
MEDICAL BILLING AND COLLECTIONS SERVICES
all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits. Kristine Edge, Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.
210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”
Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
MEDICAL SUPPLIES AND EQUIPMENT
Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”
PAYROLL SERVICES
SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in
New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only). Doug Elley 210-961-9991 dougelley@financialguide.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”
PRIVATE EQUITY
Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com
PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator
STAFFING SERVICES
REAL ESTATE SERVICES COMMERCIAL
PRACTICE CONSULTANTS Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations. Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."
www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”
Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation. Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com
RESIDENTIAL REAL ESTATE
Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients. Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"
SENIOR SERVICES Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment. Shane Brown, Executive Director 210-305-5713 hello@legacyatforestridge.com
Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.” United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"
TOXICOLOGY LABORATORY TESTING
Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification. Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com For questions regarding services, Circle of Friends sponsors or Joining our program. Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html
visit www.bcms.org 37 37 visit usus atatwww.bcms.org
RECOMMENDED AUTO DEALERS AUTO PROGRAM
• • • •
We will locate the vehicle at the best price, right down to the color and equipment. We will put you in touch with exactly the right person at the dealership to handle your transaction. We will arrange for a test drive at your home or office. We make the buying process easy! When you go to the dealership, speak only with the representative indicated by BCMS. GUNN AUTO GROUP
Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Cary Wright 210-558-1500
Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900
Ancira Chevrolet 6111 Bandera Road San Antonio, TX
Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX
GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154
Jude Fowler 210-681-4900
Esther Luna 210-690-0700
Bill Boyd 210-859-2719
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN AUTO GROUP
GUNN Honda 14610 IH 10 W San Antonio, TX
GUNN Acura 11911 IH 10 W San Antonio, TX
GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209
Pete DeNeergard 210-680-3371
Coby Allen 210-625-4988
Abe Novy 210-496-0806
Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216
Cavender Audi 15447 IH 10 W San Antonio, TX 78249
David Espinoza 210-912-5087
Sean Fortier 210-681-3399 KAHLIG AUTO GROUP
Cavender Toyota 5730 NW Loop 410 San Antonio, TX
Northside Ford 12300 San Pedro San Antonio, TX
Mercedes Benz of San Antonio 9600 San Pedro San Antonio, TX
Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX
North Park Subaru 9807 San Pedro San Antonio, TX 78216
Gary Holdgraf 210-862-9769
Wayne Alderman 210-525-9800
William Taylor 210-366-9600
James Godkin 830-981-6000
Mark Castello 210-308-0200
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Mazda 9333 San Pedro San Antonio, TX 78216
North Park Lexus 611 Lockhill Selma San Antonio, TX
North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX
North Park Toyota 10703 SW Loop 410 San Antonio, TX 78211
Scott Brothers 210-253-3300
North Park Subaru at Dominion 21415 IH 10 W San Antonio, TX 78257
Jose Contreras 210-308-8900
Justin Blake 888-341-2182
Stephen Markham 877-356-0476
Justin Boone 210-635-5000
KAHLIG AUTO GROUP
KAHLIG AUTO GROUP
North Park Lincoln 9207 San Pedro San Antonio, TX
North Park VW at Dominion 21315 IH 10 W San Antonio, TX 78257
13660 IH-10 West (@UTSA Blvd.) San Antonio, TX
Porsche Center 9455 IH-10 West San Antonio, TX
Barrett Jaguar 15423 IH-10 West San Antonio, TX
Sandy Small 210-341-8841
James Cole 800-611-0176
Ed Noriega 210-561-4900
Matt Hokenson 210-764-6945
Dale Haines 210-341-2800
15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800
Land Rover of San Antonio
AUTO PROGRAM
Call Phil Hornbeak 210-301-4367 or email phil.hornbeak@bcms.org
visit us at www.bcms.org
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AUTO REVIEW
2018 Lexus LS 500 By Stephen Schutz, MD
Almost 30 years ago, Lexus was born, and, to quote the great Chris Harris of Top Gear, they “kaboomed the entire U.S. prestige car industry” when their first cars launched in 1989. As many readers will recall, before Lexus was born in 1989 luxury car customers in this country could choose between low-quality and under-engineered American luxury cars or their wonderfully-engineered but persnickety (and seriously over-priced) German rivals. Gee, wondered Toyota, would people buy luxury cars that were much cheaper than the Germans to buy and maintain, as reliable as Camrys, and supported by pampering dealerships that treated customers with respect? We all know the answer to that question. While Lexus actually offered two cars in 1989, the ES 250, a small sedan based on the Camry, and the larger LS 400 sedan, it was the LS that became a sensation. Essentially a better built and more reliable Mercedes S-class that sold for about $20,000 less than its iconic German competitor, the LS 400 changed everything. Who doesn’t remember the famous TV commercial featuring a tower of full champagne glasses sitting unmoving on the hood of an LS 400 as its engine revved? All these years and many kept promises later, Lexus is a well-established brand with a broad portfolio of vehicles. In fact, the U.S. luxury market has changed so much since 1989 that the LS 500 is much less important sales-wise than any of their SUVs. Neverthe40
San Antonio Medicine • June 2018
less, the LS still matters as I was reminded during a recent visit to Manhattan when I saw many LS sedans with chauffeurs driving around with important passengers in back. The all-new 2018 LS 500 sports an exterior design that is best described as different — different from its predecessor, the LS 460, and different from its German and American competitors. The I’mgetting-used-to-it huge grille is there, of course, but gone is the expected low front/high rear profile, replaced by a more coupe-ish form, almost as if the previous car had mated with a Porsche Panamera. I have criticized recent Lexuses for having highly stylized front ends and boring sterns, but if anything, the rear of the new LS has more visual action than the front. In fact, the only quibble I have with the attractive new LS shape is that from the rear ¾ angle it is a little too much like the Nissan Maxima. I have no quibbles with the interior, which is very well done. It’s a Lexus, so everything you see and touch exudes quality, but clearly Lexus has decided to be non-German as well. Instead of focusing on a central controller knob, Lexus decided to go with a small finger-activated control surface on the center console that lets you work various functions as you drive. It’s not ergonomically perfect by any means, but Lexus presumably knew that and left many redundant buttons so that drivers could avoid the controller if they preferred. My favorite button is a two-level knob that allows for easy adjustment of the audio
AUTO REVIEW
volume and radio tuning in one place. Very elegant. My test car included the — Say Wut?!! — $23,000 Executive Package, a collection of many deluxe add-ons designed for chauffeur driven customers, which features two unique elements that are worth a mention. The insides of the doors are lined by handfolded cloth, which looks and feels both unique and special. And the inside door handles are surrounded by etched glass surfaces that are spectacularly beautiful. The 2018 LS 500 is available in either standard or hybrid forms, both of which come with a V6 engine (that’s right, for the first time in 29 years the Lexus LS doesn’t offer a V8.) The LS 500’s V6 is a 416HP twin-turbo 3.4L motor coupled with a 10-speed transmission, while the hybrid integrates a non-turbo 3.5L V6, continuously variable transmission, electric motor, and sophisticated software to maximize efficiency. My two cents: unless you really appreciate hightech mobility and want to help move hybrid powertrains into the mainstream, go with the LS 500 over the LS 500h. My experience with the hybrid involved throttle/transmission/motor hesitation and surging that were annoying. I have no doubt that plug-in hybrids will populate most of our garages soon, but the no doubt fuel efficient LS 500h — it boasts amazing 23MPG city/31MPG highway fuel economy figures – isn’t fully baked yet. Otherwise, driving the new LS is a wonderfully cosseting experi-
ence with a hushed quiet that’s guaranteed to slow anybody’s heart rate. Having said that, I would recommend the smaller diameter wheels rather than the (admittedly gorgeous) 20-inchers. While the big wheels look good, they detract from the LS’ otherwise comfortable ride. As Lexus approaches its 30th anniversary, they’ve introduced an advanced new LS sedan that is clearly designed to be different from the competition, especially the German competition. I love that. The Germans have gained the upper hand in the luxury car market, but kudos to Lexus for offering an alternative that’s actually different. If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 41 41 visit usus atatwww.bcms.org
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San Antonio Medicine â&#x20AC;¢ June 2018