SAN ANTONIO MEDICINE AUGUST 2019 by Traveling Blender

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AUGUST 2019

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VOLUME 72 NO. 8

MEDICINE SAN ANTONIO

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Legislative Wrap-up

Wins on Tobacco, Prior Authorization, and More Make for a Succesful Legislative Session By Joey Berlin and Sean Price, Texas Medicine ......12 Criminalizing of the Physician — Politicians now legislate how we practice medicine. Consequences for lack of adherence is jail. By Alex Kenton, MD ...............................................22 First Tuesdays: A Medical Student Perspective By Ryan Wealther and Swetha Maddipudi..............24 Making the Changes We Want to See in Medicine By Marc Ghosn ......................................................28

BCMS President’s Message ........................................................................................................................8 Lifebridge: Counseling for Physician Stress & Burnout By Stephen C. Fitzer, BCMS Executive Director ......10 UTHSA: San Antonio has a New Designation: Dementia Friendly Day By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ............32 The Case for Using Circle of Friends Donors By August Trevino..................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 Financial Focus: Life Events Can Lead You to See a Financial Advisor By Elizabeth A. Olney ......................41 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Ram 1500 By Steve Schutz, MD ................................................................................44

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San Antonio Medicine • August 2019

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AUGUST 2019

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VOLUME 72 NO. 8

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

EDITORIAL CORRESPONDENCE: Bexar County Medical Society 4334 N Loop 1604 W, Ste. 200 San Antonio, TX 78249 Editor: Mike W. Thomas Email: Mike.Thomas@bcms.org

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

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

Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO,

DIRECTORS

Medical School Representative

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

Alice Kim Gong, MD, Board of Ethics Chair

David Schulz, Community Member

Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

J.J. Waller Jr., MD, Member

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Gerardo Ortega, MD, Member

Alice Sutton, Controller

Manuel M. Quinones Jr., MD, Member

Mike W. Thomas, Director of Communications

David M. Siegel, MD, JD, Member

August Trevino, Development Director

Rajeev Suri, MD, Member

Mary Nava, Chief Government Affairs Officer

Kelly King, Alliance Representative

Phil Hornbeak, Auto Program Director

Michael A. Battista, MD, Member John D. Edwards, MD, Member

George Rick Evans, Legal Counsel

Mary Jo Quinn, BCVI Director

Col. Charles Gregory Mahakian, MD,

Brissa Vela, Membership Director

Military Representative

San Antonio Medicine • August 2019

Al Ortiz, Chief Information Officer

John Seidenfeld, MD, Member

PRESIDENT’S MESSAGE

Don’t Stress Out By Adam Ratner, MD, 2019 BCMS President

Do you need help...

and don’t feel comfortable speaking to someone you know, or someone provided by your employer? By the time you read this, the Bexar County Medical Society is launching a new confidential physician wellness and mental health program which we call LifeBridge. The purpose of the program is to confidentially address the growing issue of physician stress and burnout.

The Basics of the LifeBridge Program:

• The BCMS LifeBridge program is intended to provide one free month of counseling/therapy to BCMS members for virtually all types of personal mental health challenges and stress. • Online counseling means the user can interact personally with a Texas-licensed counselor/therapist via phone, video conference, text or email. It is available 24/7/365. • The program is confidential and your employer, partners, family, staff will not know you are using the program unless you choose to reveal it. • When initially engaging the program, you will be asked several questions in the sign-up process to determine the best counselor/therapist match for you and your needs. Over 300 Texas-licensed counselors/therapists are in the network. • At the end of the one free month, you can choose to continue using the service at the pre-negotiated rate of $45/week with unlimited usage. • This program is not designed to provide acute suicide prevention services. In these situations, the member will be referred to suicide hotlines. You will be receiving more specific information, but you will also be able to access this member benefit via the BCMS web site when it becomes available. If you have any questions about this program and wish to know more, please don’t hesitate to contact me or Steve Fitzer, our Executive Director. Dr. Adam Ratner is President of the Bexar County Medical Society and serves as Professor and Interim Associate Dean of Student Affairs of the University of the Incarnate Word School of Osteopathic Medicine and Chair of The Patient Institute.

San Antonio Medicine • August 2019

LIFEBRIDGE

Counseling for Physician Stress & Burnout is now a Bexar County Medical Society Member Benefit By Stephen C. Fitzer, BCMS Executive Director

A Tale of Two Cities, the novel opens with, “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity …”. That applies as much today as it did in Charles Dickens’ time. It’s a very stressful time to be alive, even with affluence all around us. Demands on our time, the changing nature of families, government and society, constantly evolving technology, as well as maintaining control of our lives and finances are making us dizzy! For physicians, add the unique problems of reimbursement, administration, management, regulations, legal and ever-evolving medicine and it really becomes a serious conundrum.

San Antonio Medicine • August 2019

Organized medicine began as a way for physicians to come together to learn from each other, advocate for medicine and help to manage their environment. New times and an increasingly complex medical scenario have made those tasks increasingly difficult. But even with this escalating pressure, physicians and would-be physicians have traditionally been reluctant to seek counseling or therapy for issues of stress, burnout or trickledown family problems. Bexar County Medical Society (BCMS) is introducing access to a confidential, professional counseling service for its members. The name of this Bexar County Medical Society initiative is the BCMS LifeBridge Physician Wellness Program.

LIFEBRIDGE

IMPORTANT POINTS ABOUT THE LIFEBRIDGE PROGRAM INCLUDE:

• 24/7 access to online counseling/therapy is available from anywhere via phone, computer, tablet, etc.

• LifeBridge is totally confidential. Physician’s partners, employers, staff, nor BCMS leadership or staff will know who is using the program unless you tell them.

• Specialized counselors are matched to each users’ needs by simply answering a few vetting questions There are over 300 Texas-licensed counselors in the network.

week of usage. Note: BCMS receives absolutely no financial benefit from this arrangement and is providing the service as a membership benefit to its members.

HELP FOR THE STRESSED PHYSICIAN BEXAR COUNTY MEDICAL SOCIETY INTRODUCES

• Counseling is free for any BCMS member for 30 days, covered by BCMS. This service can be extended for a very low, pre-negotiated, weekly rate and is cancelable at any time. • BCMS receives absolutely no money from anyone for this service to members; it is a pure member benefit. It originated to deliver a professional service on a physician’s schedule.

There is a lot more that BCMS members can learn about the LifeBridge program before using it. The program information is available on the BCMS website at www.bcms.org/lifebridge.

This is how the LifeBridge sign-up process will work:

BCMS will upload a confidential file with member email addresses ONLY (i.e. no names or any other information about members) to the central database of the online service provider, BetterHelp. BetterHelp will then send an email to BCMS members inviting them to use the service. In this email, members will be invited to click on a link to start the sign-up process. (Note: counselors/therapists will not have access to any names or email addresses of users). When the member chooses to access the service (either upon receipt of the BetterHelp email or at some future date), the system verifies via email address that the user is approved to use the service. All correspondence is channeled through the BetterHelp central database, so the counselor does not know the email address or the name of the person with whom they are interacting. Once a user actually starts counseling/therapy, the clock on the 30 days free to the BCMS member user begins. Near the end of the 30-day period, the user will be contacted by BetterHelp to see if they want to continue the service for a very low, unlimited usage, weekly rate (pre-negotiated by BCMS at $45/week). Counseling may be discontinued at any time, either at the end of the 30-day period or at the end of any

Are you stressed? Burned out? Need someone to talk to? Want confidential counseling? Want unlimited access?

Go to www.BCMS.org/LifeBridge for information on how this program works. Please don’t be shy about seeking advice from a professional counselor. It will likely help you in the office and at home. Perspective realignment is periodically needed for all of us. Don’t be a victim of stress and burnout; this confidential tool may be just what you need to address your frustrations in a helpful, productive and cost-effective way. If all of your questions are not answered by the information provided in this correspondence or on the BCMS website, you may speak with the dedicated BCMS staff person who liaises with the BCMS PH&R committee. You may send her a note at Lifebridge@bcms.org.

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LEGISLATIVE WRAP-UP

Wins on Tobacco, Prior Authorization, and More Make for a Successful Legislative Session By Joey Berlin and Sean Price, Texas Medicine Illustrations by Caitlin Alexander

San Antonio Medicine â&#x20AC;˘ August 2019

Legislation is just one piece of a healthy Texas. But itâ&#x20AC;&#x2122;s a big piece, and when the Texas Medical Association told the lawmakers of 2019 how it should fit, those legislators largely shaped it to what physicians and patients need.

LEGISLATIVE WRAP-UP

TMA scored on a wide range of goals to improve the state’s medical landscape during this year’s session of the Texas Legislature. In public health, the House of Medicine convinced lawmakers that raising the age to purchase tobacco to 21 was the right thing for the state’s present and future. Medicine also successfully persuaded the legislature and Gov. Greg Abbott to improve insurance network adequacy and directories, which will help with surprise medical bills. Insurers’ prior authorization tactics – which infuriate physicians and delay or derail patients’ access to needed services and medications – took several damaging hits in the form of TMA-backed bills that became law. And the 2020-21 budget includes a number of vital funding increases, including a $68 million increase for women’s health programs, an added $60 million to preserve the state’s healthy ratio of graduate medical education (GME) slots to medical school graduates, and $50 million more for community mental health services. Those were just a few of the big wins medicine and its friends delivered, and they helped to offset the disappointments, such as the legislature failing to grant the long-overdue Medicaid physician payment increase that TMA requested. “On the whole, it was a good session for us,” said Fort Wortharea pediatrician Jason Terk, MD, who chaired TMA’s Council on Legislation throughout the session. “We got a lot of good things done, and we can be proud of our advocacy for the progress we wanted to make in public health, mental health, women’s health, and GME funding, just to name a few. I am also very proud of our advocacy defending against bills that would have been harmful to our patients and us, the physicians who care for them.” TMA chief lobbyist Darren Whitehurst emphasized that success at the Capitol starts with medicine’s grassroots efforts, including the work physician advocates do during TMA’s monthly First Tuesdays at the Capitol. But he stressed that the work continues even after the legislature adjourns. “Really, we don’t have a lot of time to look back. We’ve got to continue to look forward. We’re going to have a busy interim building on the relationships and the work that we did this past session, and looking forward to the next legislative session,” Mr. Whitehurst said. “The issues that we face are a lot of the same issues from session to session. We’ve got to be committed to trying to move forward and to making sure that our doctors are engaged and are involved as part of a political process.”

Assault on Prior Auth, Bad Networks

TMA went into this session looking to attack insurer network inadequacy and health plans’ use of care impeding prior author-

ization demands. On both fronts, medicine scored solid legislative wins that will make it easier for patients and physicians to know who’s in network, and provide needed transparency on preauthorization requirements. And on surprise billing, medicine turned what could’ve been a disastrous bill into something more palatable. Senate Bill 1742 (Menéndez), one of medicine’s biggest legislative victories, will require health plans’ directories to clearly identify innetwork physicians, with separate headings required in the directory to categorize physicians in several different types of specialties, including radiologists, anesthesiologists, emergency department physicians, and others. Dallas cardiologist Rick Snyder, MD, says SB 1742 carries four powerful benefits: • Simplifies the process for patients to compare different plans, • Exerts market pressure on insurers to address deficiencies in their networks, • Makes it easy for patients and family members to make sure all members of a care team are in network, and Allows physicians to see whether a specialist needed to co-manage a patient is in network. “Initially, we’re starting just with the specialties that are most commonly associated with a surprise-billing event; those are the hospital-based specialties,” Dr. Snyder said. “So if you’re at Presby [Presbyterian Hospital in Dallas], for example, and you’re looking at Blue Cross Blue Shield and you look under ‘anesthesia’ and there’s no physicians in network for anesthesia at that hospital, you might want to look at a different plan. So it empowers the patients when shopping for plans.” SB 1742 also requires state-regulated health maintenance organizations (HMOs) and insurers offering preferred provider organization (PPO) or exclusive provider organization plans to post any prior authorization requirements on the internet; introduces new requirements for those insurers to post notice of prior authorization changes; creates a joint interim committee to study prior authorization and utilization review during the interim session; and opens the door for utilization reviews to be conducted earlier in the appeal process by a Texas-licensed physician in the same or similar specialty as the physician requesting treatment approval. As for balance billing, Senate Bill 1264 (Hancock) initially threatened to give health plans disproportionate control over what physicians would be paid for certain out-of-network care. But TMA worked with Rep. Tom Oliverson, MD (R-Cypress), to continued on page 14

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LEGISLATIVE WRAP-UP continued from page 13

Medicine scored solid legislative wins that will make it easier for patients and physicians to know who’s in network, and provide needed transparency on preauthorization requirements. craft an imperfect but improved replacement bill, featuring an arbitration process that takes the patient out of surprise-billing battles while giving physicians a fairer shake on payment. On a significant issue contributing to balance billing – network shortfalls – House Bill 3911 (Vo and Campbell) requires the state insurance commissioner to examine PPO plans for network adequacy at least once every three years. Sen. Donna Campbell, MD (R-New Braunfels), said discussions on balance billing during the past few sessions typically have centered on out-of-network practitioners and facilities, without considering the role health plans and network adequacy play. She says with HB 3911, PPOs will be held accountable to the Texas Department of Insurance the same way HMOs have been. “We pay our insurance premiums every month to get the care that [we] need if we need it. Insurance companies are supposed to pay,” she said. “Insurance companies have gotten more onerous for providers trying to get paid. This is just a small thing, but if it helps in any big way, then that’s what we need.”

Several other insurance bills important to medicine also reached the governor’s desk. Among them:

• House Bill 170 (Bernal) requires certain health plans that cover a screening mammogram to provide at least the same level of coverage for a diagnostic mammogram. • Senate bills 747 and 748 (Kolkhorst) collectively provide and set up funding for newborn genetic screening tests. SB 747 requires HMOs to cover newborn genetic screening tests as part of a well-child exam, and also prohibits plans that provide maternity coverage from excluding or limiting coverage for those tests. • House Bill 2041 (Oliverson) will require freestanding emergency centers to post conspicuous notices that let patients know the facility or the physician may be out of network, and to provide a disclosure statement listing possible observation and facility fees. • House Bill 3041 (C. Turner) requires health plans to allow a physician to request renewal of a prior authorization at least 60 days before it expires.

Triumph Over Tobacco

Texas physicians got the kind of huge win on tobacco issues they haven’t seen in decades – a law to keep tobacco products away from young people. The Tobacco 21 measure, or Senate Bill 21, raises the minimum age to purchase tobacco and vape products to 21 years, except for military personnel. “It’s going to be one bite out of the elephant to help eliminate tobacco addiction among some of our youth,” said Rep. John Zerwas, MD (R-Richmond), who carried the legislation with Sen. Joan Huffman (R-Houston). The law takes the critical step of keeping young people away from tobacco products, Representative Zerwas says. Research shows that about 95% of smokers become addicted to tobacco before age 21, and areas that raise the age for tobacco purchases usually see declines in sales to young people. Representative Zerwas says the goal of the law, which takes effect Sept. 1, is to prevent teens 17 and younger from smoking because “kids who become addicted at a very young age have a dismal opportunity for kicking the habit ultimately.” Texas joins 14 other states and more than 475 cities and counties across the country in raising the age for purchasing tobacco products.

“We’re the first major ‘conservative’ state to pass this for sure,” Representative Zerwas said. “That will help blaze the trail for others to follow suit.” continued on page 16

San Antonio Medicine • August 2019

LEGISLATIVE WRAP-UP continued from page 14

Representative Zerwas also authored House Bill 39 and House Joint Resolution 12 to help renew the Cancer Prevention and Research Institute of Texas (CPRIT). Since it was founded in 2008, CPRIT has awarded about $2.2 billion in more than 1,300 grants to promote cancer-fighting efforts. With the legislature’s blessing, Texas voters will decide on Nov. 5 if the state’s cancer-fighting agency will be able to issue another $3 billion in taxpayer-backed bonds for research and prevention. “I’m very happy that will happen,” said Marian Y. WilliamsBrown, MD, chair of TMA’s Committee on Cancer and an assistant professor of obstetrics and gynecology at Dell Medical School at The University of Texas at Austin. 16

San Antonio Medicine • August 2019

She says CPRIT has drastically improved Texas’ ability to do cancer research. For instance, the 2018 Nobel Prize in Physiology or Medicine was co-awarded to a researcher brought to Texas using CPRIT funds. And Dr. Williams-Brown herself is one of many physicians participating in screening initiatives paid for by the agency. “It’s through these types of programs that we’re able to provide health care to so many people throughout Texas – particularly those who are underserved and might not otherwise have access,” she said. David Lakey, MD, vice chancellor for health affairs and chief medical officer for The University of Texas System and a member of TMA’s Council on Science and Public Health, praised new funding allocated to the Texas Department of State Health Services.

LEGISLATIVE WRAP-UP

“This will allow [DSHS] to address a variety of issues, including support of their lab, tuberculosis control, and extra funding to address maternal mortality and morbidity in Texas,” he said.

Maternal Health Roadblock

One setback for TMA’s public health agenda: preventing maternal illness. TMA advocated for extending Medicaid eligibility for new mothers from the current 60 days to 365 days. While the Texas Legislature did not fund this reform, it did approve Senate Bill 750 (Kolkhorst), which directs the Texas Health and Human Services Commission (HHSC) to look for other ways to extend coverage through the Healthy Texas Women program. Also, House Bill 253 (Farrar) directs HHSC to develop a five-year plan to address postpartum screening and depression, and Senate Bill 749 (Kolkhorst) establishes level-of-care designations for hospitals that provide maternal and neonatal care. Similarly, there was little movement on childhood vaccines policy. Neither pro-vaccine groups like TMA nor anti-vaccine groups were able to advance their agendas. However, TMA did enjoy success on adult vaccine measures, garnering support for more vaccine information and tracking for first responders in House bills 1418 and 1256 (Phelan). Texas also built on recent gains in mental health by funding further construction on state mental health facilities in Austin, Rusk, and San Antonio. Also, Senate Bill 11 (Taylor), which is designed to improve school safety, establishes a state Child Psychiatry Access Network, giving pediatricians and other primary care physicians ready access to a greater range of psychiatrists and other licensed behavioral health professionals. The legislature also passed bills designed to fight obesity. Senate Bill 952 (Watson) requires that child care facilities’ physical activity, nutrition, and screen time rules comply with science-based standards. Gov. Greg Abbott vetoed House Bill 455 (Allen), which would have directed school districts to adopt recess policies. The governor said the bill had “good intentions” but was “just bureaucracy for bureaucracy’s sake.” Likewise, the governor vetoed House Bill 448 (C. Turner), which would have required people to transport a child younger than 2 in a rear-facing car seat unless the child met certain height and weight thresholds. The governor said the bill was “an unnecessary invasion of parental rights and an unfortunate example of overcriminalization.”

GME Growth Plan Adopted

Medical education made some gains in the 2019 legislative session, including the statutory approval of two new medical schools – the University of Houston College of Medicine in Houston and

continued on page 18

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LEGISLATIVE WRAP-UP continued from page 17

Sam Houston State University College of Osteopathic Medicine in Conroe, both of which will open in 2020. TMA also achieved an important goal with passage of Senate Bill 1378 (Buckingham), which requires new public medical schools to plan for the GME needs of their target class size. Previously, schools had to plan only for their inaugural class size, which is often considerably smaller. Legislators provided $762 million over two years to support the education of medical students, an increase of $12.8 million, and $98.5 in GME funding, an increase of $8.4 million. They also asked the Texas Higher Education Coordinating Board to study shortages of physicians and other health professionals.

Other education bill highlights: •

•

House Bill 2261 (Walle) increases the Physician Education Loan Repayment Program’s allowable repayment assistance amounts by $5,000 each year. This raises the total repayment assistance available from $160,000 to $180,000. House Bill 1065 (Ashby) creates a grant program to develop residency training tracks to prepare physicians for rural and underserved settings. However, lawmakers did not appropriate any funds for the program.

Much Work Still to Do for Medicaid Pay Hike

Medicine didn’t get everything it needed from lawmakers for Medicaid, including TMA’s biggest and boldest ask of the 2019 session. Still, progress TMA achieved on managed care reform and other facets of Medicaid will advance physicians’ efforts to care for the most vulnerable Texans. Those wins collectively softened the impact of one of the session’s greatest disappointments for medicine: The legislature provided no new funding for Medicaid physician payments. TMA had requested $500 million in general revenue to give physicians their first meaningful Medicaid increase in decades. Nor did lawmakers follow through on medicine’s request to extend comprehensive postpartum coverage Doug Curran, MD, who was TMA president at the beginning of the session, designated improving physician Medicaid payments as his top priority. He called the legislature’s inaction “hurtful to our people” and said medicine must continue advocating for change before the next session. “Just like a physician who is taking care of a patient and the patient is not doing what they’re supposed to be doing … we must tell our legislators that we’ve got to reach out and change some of the stuff that’s going on in Medicaid, and [with] the underinsured

San Antonio Medicine • August 2019

or the uninsured,” Dr. Curran said. “If we don’t do that, we’re going to see the Texas economy begin to suffer. And that’s probably going to happen within the next three or four years, especially if we have an economic downturn. We’ve got to convince our legislators in this interim that they have got to address the issues of lack of access both in Medicaid and [with] the uninsured and the underinsured.” However, following a year in which negative media attention put Texas Medicaid’s managed care companies under intense focus, several important reform bills earned passage. Senate Bill 1207 (Perry) introduces new requirements to hold Medicaid managed care organizations (MCOs) accountable for prior authorization decisions. The bill requires MCOs to: • Provide an explicit clinical reason for a prior authorization denial, • Provide a specific list of the documentation required to complete a request for prior authorization, and • Give the requesting physician the chance to speak to a medical director within the same or similar specialty who has experience treating the same population as the patient. The bill also establishes a process for patients to request an independent review of an MCO’s denial of care or reduction of services, and requires MCOs to maintain an up-to-date catalogue of prior authorization requirements on their websites. Round Rock pediatrician Maria Scranton, MD, chair of TMA’s Select Committee on Medicaid, CHIP, and the Uninsured, says the requirement for MCOs to “make it clear exactly what the problem is” for prior authorization was a major victory. “Part of the problem with Medicaid is that the paperwork and the administrative responsibilities are so high that first of all, you’re not getting that much money in the first place,” she said. “But now, if you’re having to hire people to help you do all of this stuff, then it’s really taking away [from patient care]. So if you could eliminate some of the paperwork burden, in some ways that would be like a small raise.”

Other promising Medicaid wins: •

•

Senate Bill 1096 (Perry) will ensure that children who participate in STAR Kids, an MCO model for medically complex and frail children, will have uninterrupted access to established medications by heavily restricting the use of prior authorization for prescription drugs. House Bill 25 (Gonzalez) will establish a pilot program to transport pregnant and postpartum women to and from medical appointments, with their children in tow.

LEGISLATIVE WRAP-UP

•

Senate Bill 748 (Kolkhorst) directs the state to expand pregnancy medical home pilots to new sites and to test the use of telemedicine, telehealth, and telemonitoring to improve prenatal and postpartum care. In the 2020-21 budget, lawmakers approved more than $100 million to help rural hospitals, a portion of which is dedicated to helping those hospitals retain labor and delivery services.

PMP Extension Granted

When it came to opioids and pharmacy matters, some of the major pieces of medicine’s 2019 agenda came down to something everyone wishes they had more of: time. Physicians need it to get comfortable with a mandate to check the state’s prescription monitoring program (PMP). Patients need it to make sure the pain medications they’re prescribed do what the drugs are supposed to do. The legislature listened, and TMA achieved wins on both counts, as well as on increased transparency from pharmacy benefit managers (PBMs). House Bill 3284 (Sheffield) bought the time physicians needed to comply with lawmakers’ 2017 mandate to check the state’s PMP before issuing any prescription for opioids, benzodiazepines, barbiturates, or carisoprodol. That mandate was scheduled to go into effect in September. But

thanks to HB 3284, it won’t kick in until March 1, 2020. That gives physicians and their electronic health record (EHR) vendors time to properly integrate their systems with the PMP. Plus, lawmakers appropriated an additional $5 million for the Texas State Board of Pharmacy to spend this year to make the PMP easier to integrate, as well as to cover the licensing fees for all state prescribers and pharmacists. “As it stands now, if I want to check the prescription monitoring program, I have to leave my electronic medical record, log in to a different website, type in the patient’s first and last name and birthdate at a bare minimum, check some boxes, and then click search and then get a printout,” said San Antonio orthopedic surgeon Adam Bruggeman, MD, who’s also board certified in addiction medicine. “That all takes time to get in and out of the system. “TMA has worked very hard with the legislators, and they’ve agreed to help pay for physicians to have an integrated prescription monitoring program. We’re not quite there yet, and I think the September date was a little aggressive to get us across the finish line.” With opioids generating bleak national headlines on a regular basis, lawmakers seemed focused on limiting opioid prescriptions for acute pain to a seven-day supply. But House Bill 2174 (Zerwas) establishes a 10-day limit instead. “It is somewhat of an arbitrary thing to put a particular maximum amount of time for opioid prescriptions,” said Dr. Terk. “We felt like 21 days is probably too long and doesn’t respect the concern about how long it takes for an individual to become dependent on these medications. But the [TMA Council on Legislation] reasoned that [a limit of] 10 days was reasonable for most post-operative and post-trauma patients.” HB 2174 also requires electronic prescribing for opioids beginning in 2021 (when a similar requirement from Medicare takes effect) plus two hours of CME for opioid-prescribing, and generally prohibits prior authorization for medication-assisted treatment for opioid use disorder. Increasing drug-pricing transparency from PBMs was another continued on page 20

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LEGISLATIVE WRAP-UP continued from page 19

priority for TMA in this session, and House Bill 2536 (Oliverson) made a big dent in that problem. The bill requires PBMs to submit a detailed disclosure report when a drug costing at least $100 for a 30-day supply increases in price by 15% or more in one year, or by 40% or more over three years.

Telemedicine Opportunities Expanded

In 2017, legislators ended a long-running standoff over telemedicine in Texas by passing a TMA-backed bill that removed the requirement for having an in-person meeting to establish a patient-physician relationship. Instead, it mandates that physicians meet the same standard of care as that required for an in-person visit. New laws passed with TMA’s support this year will make telemedicine even more attractive to physicians. One of the most significant was House Bill 3345 (Price), which allows physicians to choose the platform for providing services to their patients via telemedicine rather than having health plans dictate the platform. “We’re really excited about that, because it allows the [physicians] to say, ‘This is what I want to put my patients on,’” said Ogechika Alozie, MD, an El Paso infectious disease specialist who is vice chair of TMA’s Committee on Health Information Technology.

Other significant telemedicine bills that passed in 2019 with TMA’s support are: • • • • • •

Senate Bill 670 (Buckingham), which requires Medicaid to cover telemedicine services; House Bill 1063 (Price), which requires Medicaid to cover home telemonitoring for specific pediatric patients; House Bill 3285 (Sheffield), which permits telehealth treatment for substance use; Senate Bill 749 (Kolkhorst), which allows on-call physicians to use telemedicine, if needed; House Bill 871 (Price), which allows telemedicine to be used in rural counties and communities to contact an on-call physician who specializes in emergency medicine; and SB 11, which establishes a telemedicine program through the Child Psychiatry Access Network.

Scope Expansion Shot Down

When it comes to shooting down dangerous attempts to expand nonmedical practitioners’ scope of practice, TMA’s advocacy army once again proved to be expert marksmen in 2019. Medicine trained its scope on bills that would have allowed nurse practitioners, chiropractors, and optometrists, among others, to wade into the practice of medicine. Those and other bad bills flut-

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tered to the ground in heaps of feathers, thanks to the House of Medicine reminding lawmakers there are certain practices only a physician is trained to do. Take House Bill 2733 (Stephenson). That measure would have expanded the practice of chiropractic beyond its current scope – defined in the law as the musculoskeletal system – and introduced the possibility of chiropractors treating the “neuromusculoskeletal” system; in other words, giving chiropractors the authority to treat the nervous system as well. Austin neurologist Sara Austin, MD, says keeping nervous system treatment as the practice of medicine is a matter of patient safety. Adding the nervous system to the scope of chiropractic “has the effect of being really confusing to patients,” Dr. Austin said. “There’s chiropractors now who like to call themselves ‘neurochiropractors.’ No one knows what that means, what their training is or anything, and they’re actually not supposed to be practicing neurology. But they do it anyway. … The public just assumes that means they can take care of the nervous system, which is not true.”

Other troublesome scope-of-practice bills TMA helped bring down include: • • • •

House Bill 1792 (Klick), which sought full independent practice and prescribing authority for advanced practice registered nurses (APRNs) without physician delegation and supervision; House Bill 1798 (Goldman), which would have allowed therapeutic optometrists to perform a number of eye surgeries, including LASIK, and independently manage glaucoma; House Bill 1092 (Zedler), which would have granted independent prescribing authority to psychologists; and House Bill 927 (White), which would have granted independent practice and prescribing authority to APRNs in health professional shortage areas.

Medical Board Put Back on Track

Two years ago during the 2017 regular session, the legislature put the practice of medicine in the state in serious danger, failing to renew the Texas Medical Board (TMB) and the state’s Medical Practice Act. Among other potentially catastrophic side effects, having no medical board and no medical practice act would have meant anyone in Texas could call themselves a physician and practice medicine. Doomsday was averted that year when Governor Abbott called a special session and lawmakers renewed TMB – but for only two years instead of 12, as is customary following the Sunset Advisory Commission’s intensive review of an agency.

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Physicians Stop Bad End-of-Life Bill Just as, if not more, important as passing good bills, medicine’s collective “nay” frequently helped prevent the legislature from enacting bad law. One major example: Senate Bill 2089 (Hughes) would have required a hospital to continue providing medical interventions to an end-of-life patient until the patient is transferred to another facility – even if the hospital’s medical ethics committee process determined that further treatment would harm the patient. SB 2089 gained troublesome steam toward the end of session. But TMA called on member physicians to rally in opposition to the bill. This year, fortunately, TMA didn’t have to sound the doomsday alarm, as lawmakers got it done in the regular session. House Bill 1504 (Paddie) put TMB back on the standard 12-year sunset cycle, renewing the board through 2031. The bill also mandates an expedited licensing process for out-ofstate physicians and enforces timely removal of certain negative information from a physician’s TMB profile, such as when physicians defend themselves against board discipline. While not perfect, the legislation is still an improvement to existing law. “There were amendments that we tried to get put on the bill that were unsuccessful, including ones that would require more fairness and transparency,” TMA lobbyist Dan Finch said. “Other changes we supported were met with some success, including how information is kept on the TMB website when a physician successfully defends his or her actions. However, the medical board has been reestablished for 12 years, and that in itself is a huge success – not to have it held hostage and not to have to go to special [session].” TMB procedures were also part of House Bill 1532 (Meyer), which protects employed physicians’ independent medical judgment and clinical autonomy by creating a process for them to file complaints with TMB against nonprofit health organizations – many of which are hospital-owned – and prohibits those organizations from retaliating against a physician who makes a good-faith complaint. The bill requires health organizations to develop anti-retaliation policies by Dec. 31, 2019.

Hundreds of Texas physicians took up the call, using TMA’s Grassroots Action Center to write their lawmakers. “I believe the whole thing is motivated by a lack of faith in physicians and a desire to impose one group’s political will on everyone else without their say so,” Mary Elizabeth Paulk, MD, wrote in an email to her state senator. “This is just wrong.” Dr. Paulk wasn’t alone. These and other personal and passionate physician stories contributed to SB 2089’s demise. “SB 2089 takes decision-making about dying patients out of the hands of ethicists and physicians who have spent their lives dedicated to training and study so that we understand how best to provide care in exactly these kinds of situations. … When I think of the amount of suffering this bill is going to cause for patients, families, hospitals, and our health system as a whole, I am overwhelmed with sadness,”Faith Holmes, MD, wrote to her state senator. The bill passed the Senate 22-8 but stalled in the House.

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LEGISLATIVE WRAP-UP

CRIMINALIZING OF THE

PHYSICIAN POLITICIANS NOW LEGISLATE HOW WE PRACTICE MEDICINE CONSEQUENCES FOR LACK OF ADHERENCE IS JAIL By Alex Kenton, MD

ealthcare is one of the most regulated and legislated economies in the United States today. Texas is a prime example. Texas has thousands of rules and laws in its books already regulating how we practice, how we bill, and even how we counsel patients. The number of laws has become too many to follow. Indeed, it is estimated that every day an average person commits three felonies but a physician inadvertently commits up to twice that rate. As of 2019, the Texas legislature, not to be satisfied with establishing itself as a top tier state for healthcare regulation, is now trying to establish itself as a top state for criminalizing the physician in the practice of medicine. To be clear, the state legislature has decided that physicians can and should go to jail for providing what the physician believes is the best standard of medical care, providing the most accurate counseling and billing that we physicians would consider a fair fee for our services. Basically our right to practice medicine and bill for those services is being curtailed by the whim of the legislature, with the threat of civil or criminal penalty, including jail time. Without a push for our physicians to participate in advocacy activities such as First Tuesdays and TEXPAC, physicians should become familiar with the consequences of being convicted of a crime. Just this session, Senate Bill 23 was proposed in which a physician who failed to provide life-sustaining support to an infant who was born alive despite an attempted abortion would be subject to a third degree felony and a civil penalty of $100,000. A third degree felony could result in imprisonment for 2 to 10 years! One may think that most obstetricians and neonatologists would be spared as most physicians do not perform abortions, but the definition of abortion itself is left unclear. Unfortunately, a fair number of pregnancies are terminated before viability due to the presence of a life threat22

San Antonio Medicine â&#x20AC;˘ August 2019

ening condition in the mother. In other words, more physicians were at risk with this bill than one might suspect. Senate Bill 1033 ensured that a physician who provides an abortion after the second trimester (only later were some medical emergency protections placed for physicians) would be subject to prosecution for a class A misdemeanor. Consequences for such offenses include imprison-

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ment up to a year in a county jail and a fine of $4,000. The Legislature has further decided physicians can be sued by the attorney general for billing what he/she sees as a fair rate for the service, or accept less pay than what the service is worth. This session, Senator Hancock proposed SB 1264 to end balance billing by physicians. In the original draft of the compromise bill, there was agreement amongst legislators in both the House and Senate to insert language as follows, “ Sec. 752.001 INJUNCTION FOR BALANCED BILLING. (a) If the attorney general believes that an individual or entity is violating a law prohibiting the individual or entity from billing an insured participant or enrollee in an amount greater than the insured’s participant’s or enrollee’s responsibility under the insured’s participants’ or enrollee’s managed care plan, the attorney general may bring a civil action in the name of the state to enjoin the individual or entity from the violation.” It should be noted that TMA later worked to get that language changed such that evidence has to be brought from a state regulatory agency. No statute was written for the insurance company for underpaying the physician or for having inadequate networks. Make no mistake that

this was a bill specifically targeting physicians. Had this bill passed, an attorney general could go after one or more physicians simply because it was politically expedient. Physicians are under siege and now the price of not being engaged in advocacy is going to jail. The legislature wishes to dictate how we practice medicine and criminalize those who fall outside of their parameters. There is no better reason to contribute to and engage with TEXPAC. It is important for all of our futures. Contributions to TEXPAC are used to support and build relationships with legislators. It is much harder for a legislator to vote for a bill which sends you to jail if you have an established relationship with that individual. There is no ambiguity about this. Advocacy protects our livelihoods. There are already laws on the books which assure you are committing a crime each day you practice medicine. The only way to reverse the trend is to be engaged in advocacy. Dr. Alex Kenton is the chairman of the BCMS Legislative and Socioeconomics Committee and is also the chair of TEXPAC.

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LEGISLATIVE WRAP-UP

First Tuesdays: A Medical Student Perspective

A Q&A with Second Year Medical Students at UT Health San Antonio Ryan Wealther & Swetha Maddipudi Tell us about what a day at the Capitol looked like as a medical student.

Swetha: We woke up at 4am to drive up to Austin so we were heavily caffeinated and very energized. We attended an advocacy 101 training before we walked within the crowd of white-coated physicians towards the Capitol—it was a very surreal experience. We participated in meetings alongside the BCMS delegation and spent time observing before we began speaking up and sharing our perspective. Dashing between meetings and working with a quickly shifting schedule kept us on our toes and kept the adrenaline levels high. Once the day completed, we realized just how much we had accomplished in one visit to the Capitol and we were already looking forward to our next visit.

Were you nervous before your first First Tuesdays?

Swetha: So incredibly nervous. Entering the TMA building in my white coat and seeing white coats surrounding me was nervewracking. Though I had been active in our school’s leadership for TMA, I hadn’t yet participated in an advocacy day; I felt a slight return of imposter syndrome from my first days of medical school. However, I quickly found the BCMS delegation and we were warmly 24

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welcomed and briefed on what to expect during the day. The physicians who took us under their wing were informative and helpful, explaining every step of the way what to expect. Walking as part of the white coat invasion assuaged the feelings of nervousness and I entered the Capitol feeling like my voice might have some weight and my brain might have some knowledge. Ryan: I was very nervous. I had never met a legislator before, and I didn’t know what to expect. Would they welcome me? Would they dismiss me? I didn’t know. Fortunately, I had a seasoned fourth year medical student with me during my first time and the BCMS physicians. They prepared me for what to expect and helped me along the way. By the end of my first First Tuesday, I was excited and ready to go to the next one.

How did it feel walking into a legislator’s office for the first time?

Swetha: When I walked into a legislator’s office for the first time, I was initially taken aback. I expected a larger presence in the office, though it was still quite ornate and full of memorabilia of the representative’s tenure. Our group was quite large so we crammed ourselves into a small meeting room and made the meet-

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ing happen. As we were leaving the first office we visited, I realized just how much work gets done in such a small space.

What helped you connect most with the legislators? What advice do you have for medical students, specifically, to connect with legislators?

Swetha: Regardless of political alignment, it is possible to connect with legislators. Sharing a story, especially a personal story, is a technique that we saw work with great success. People remember stories. You can give them a policy brief and a slew of facts, but the reality is, they’re going to remember the stories that you shared. If you don’t have a personal story to share regarding the issue you’re advocating on, ask within your circle ahead of time. You can share stories on behalf of others. Additionally, it’s important to own your role as a medical student. Legislators listen to physicians and they listen to medical students — I often felt like my voice may have been heard more compared with physicians because the legislators view us as the future of medicine.

How did you handle if your views did not align with those of the legislators?

Ryan: Some of the issues we were advocating for were politically charged. If a legislator did not view an issue as we did, we required a different approach. Leading up to each First Tuesdays visit, our chapter’s board compiled a spreadsheet of legislators, their views on the issues we were advocating for, and records of their voting history. If a legislator’s history suggested they may oppose our initiatives, we would brainstorm ways to find a common ground, and then work from there to get our point across. It was important for us to go into meetings calm and collected. Going in guns blazing and spewing out what we knew might be met with resistance would be unproductive, so we avoided it. Even with this approach though, we still did meet legislators who thought differently than us. However, almost universally, we could find something else we had in common with them.

What was the best part of the day?

Swetha: The first time I attended First Tuesdays, I was excited and overwhelmed; I felt that I knew nothing about advocacy but was reassured that I would learn a great deal throughout the day. And that was completely true. My favorite part, at the end of the day, was the increase in my knowledge level and how much more

comfortable I felt in the Capitol after just one day. After one day, I felt that I had a role within the advocacy space and that I had power. I left with a stronger understanding of advocacy work as a medical student and a stronger sense of my ability to create change through the legislative process. Ryan: The best part of the day was the self-reflection I had on the way home. I had originally thought my presence at First Tuesday wouldn’t have much of an influence on anything or anyone, but I realized that I have the ability to make a difference. My voice has power and can enact societal change; I never realized that before. Honorable mention of best part of the day goes to the rattlesnakes that were in the rotunda on that first First Tuesday. Those were pretty cool.

What do you wish had gone differently?

Swetha: I wish we had more time with both the aides and the representatives. As subject matter experts, it was quite obvious that we had a wealth of knowledge to share. For the representatives and senators who aligned with us on an issue, discussion was quite easy and very amicable. However, advocacy is a strong tool for change when it changes mindsets, not just when it confirms established mindset. With representatives and senators who had differing opinions, we felt that we didn’t have enough time to truly try to change their mind on an issue. Observing this and reflecting on it later allowed me to realize that our future advocacy efforts should focus on establishing a strong rapport with aides and congress people as that allows for actual mindset change.

An integral part of advocacy work involves forming connections – what connections did you form during this experience?

Ryan: While we did make connections with the legislators, I think the more important connections I made were with fellow medical students, Texas physicians, especially those from the BCMS, and the staff of TMA and BCMS. The BCMS physicians and staff invited us to attend their meetings and were great mentors. We saw many of the same BCMS faces every month and made some good connections. We met some of the University of the Incarnate Word and UT Dell medical students on multiple occasions as well; forming connections at this stage in our training gives me confidence that I will have a strong network of physician advocates when I practice. continued on page 26

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How did this experience impact you as a medical student?

Ryan: Attending First Tuesdays empowered me because it showed me that I actually can make a difference. My expectation was that the legislators wouldn’t really listen to me because I was just a medical student. However, the opposite was true. Legislators wanted to know my perspective as a medical student and listened to what I had to tell them. One even told me that they had never thought about a certain issue in the way I explained it. It also gave me the confidence and experience to attend the Medical Student Advocacy and Region Conference in DC, during which our school’s delegation met with legislators and spoke about prescription drug pricing, graduate medical education funding, and research into gun violence prevention. Because I attended First Tuesdays, I knew exactly what to do when I attended, and I now feel confident enough to walk into a legislator’s office by myself.

How do you think this will impact your practice as a physician?

Swetha: My understanding of a physician’s ability to be a patient advocate at numerous levels has expanded. We’re in a heightened age of political awareness and more physicians and future physicians are starting to work against the different forces that play into their patient’s health. This experience underscored the strong presence that political interests and policy change have on the wellbeing of patients, while demonstrating how we have a strong voice that can create positive changes for patients. Part of our role in providing high-quality care for our patients, to my belief, includes advocating at the macroscopic level for structural change. Patient care isn’t complete without advocacy work. 26

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Do you believe that you made a difference?

Ryan: I truly do feel that I made a difference. There were times when I would see the wheels turn in legislators’ minds after I would explain something to them—one legislator I met with even started to ponder her long-standing belief on a certain issue. On top of this, a lot of the bills we went to the Capitol to advocate for were then signed by the Governor and became laws! Students at our school who attended said that it was strong affirmation to witness real policy change as a result of our efforts. I can’t say for sure whether I or the other medical students were what caused the bills to pass, but I can definitely say that we played a role.

What advice would you give to future medical students who participate in advocacy days like First Tuesdays?

Ryan: It’s okay to feel nervous for your first First Tuesday; going into the Capitol can be a nerve-wracking experience. But you should also keep in mind that you won’t be alone. There will be other medical students and practicing physicians with you who will show you what to do, and you don’t have to speak until you’re comfortable. Lastly, as a medical student you have a unique voice and perspective in the legislative process, and the legislators genuinely do want to hear what you have to say.

Swetha: Show up. Listen. Learn. And then, speak up. Your voice has power and weight to it as a medical student and you are respected for that. Think about your connection to medicine and use that to share your perspective; you will be heard.

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Making the Changes We Want to See in Medicine By Marc Ghosn order to give my student perspective some context, I’d like to start off with a bit of background about myself and my school. Being a part of University of Incarnate Word School of Osteopathic Medicine’s inaugural class has been an amazing and enriching educational experience. For the past two years I have helped build a couple of school organizations from the ground up and have gained experience with writing, editing, and passing constitutions, as well as cultivating leadership skills. As a learner at a new medical school, we had no upperclassmen to “show us the ropes” on how to be involved in organizations outside of UIWSOM and so we, as a class, took it upon ourselves to become more involved in leadership at state and national levels. I currently serve as chair-elect of Texas Association of Family Physician’s medical student section and as a TEXPAC board of director for the medical student section, and through these organizations I heard about Texas Medical Association’s First Tuesdays. After being active in these organizations for the past two years, I realized that the change we want to see in medicine cannot be rushed, and that we must start small and work towards the goal by building on it over time. Through UIWSOM’s preceptorship shadowing program during years one and two, I was able to see firsthand some of the issues that physicians encounter that we could fix with this year’s proposed legislation. I believe the best time to learn about our political atmosphere is as a medical student, since my extracurricular time will only get more and more scarce as I progress in my career. Although I am currently a third year, my experiences in First Tuesdays occurred in the spring semester of second year, allowing me some free time to attend three out of the four First Tuesday events for this legislative session. We as medical students in San Antonio are lucky to be a part of a strong Bexar County delegation, since Bexar County Medical Society has many active physicians in state leadership roles in many medical organizations (TMA, TAFP, and other orgs). Hearing about First Tuesdays through the TMA this past January, I made it a goal to attend as many of the events this legislative session, and so I planned

San Antonio Medicine • August 2019

ahead, registered online, and booked my hotels in advance. The night before my first First Tuesdays, I stayed up for hours reading every document TMA and BCMS had published on their websites about the legislation we were there to support or oppose. I felt like it was my duty to walk in the following morning ready to hit the ground running, since we had a packed schedule for the day and I couldn’t afford to lag behind! The next morning, I walked into the TMA building in Austin at 7:30 a.m. and was amazed to see what looked like over a hundred physicians and students in white coats in the lobby and large conference room. I felt proud to be a medical student after seeing all those physicians being strong role models to me and the other medical students in attendance that day. I watched and listened attentively, taking notes on the legislative agenda, and I prepared to march to the capitol to help advocate for our patients in Texas. At the end of the welcoming session, I met up with the BCMS delegation in the lobby, and we began our walk to the capitol. We followed our busy schedule, and after meeting with our first set of state senators and representatives, there was a very steep learning curve of catching up to the years of legislation that had been passed before my time, which has led to our current political situation. Luckily, though, my research on current legislation made that quick “firehose-style” history lesson a little bit easier to understand. Taking up a supportive role in the group, I made sure to take as many notes as I could in order to understand the details of where medicine stood on each house and senate bill. Listening and learning that first day from the amazing physicians in our BCMS delegation was truly an honor. They worked as a team, with clear cut roles and areas of expertise: truly a “well-oiled machine” in action. What really amazed me was that, throughout the day, there was never a single mention of political sides being taken, Democrat or Republican, liberal or conservative. Every topic was discussed with the objectivity of medicine and the benefit of the patient! We all know that our current political climate is very muddled, with no side wanting to consider or even listen to the other side’s opinions. I was

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(L-R:) Jean Ghosn, MD, Doug Curran, MD, Marc Ghosn, MSIII; David Fleeger, MD, Marc Ghosn, MSIII.

honestly skeptical at first, wondering if medicine would be able to do the impossible and shake hands on both sides of the political aisle. I thought no organization would be able to make friends with politicians in a bipartisan manner, but because of the hard work of our physicians and the BCMS government affairs staff, as well as the guidance of TMA and their printed handouts, we were able to appeal to our state senators’ and representatives’ reason and compassion, and we gained support for our various causes. I was unable to attend the March First Tuesday event since it coincided with an exam day, but I picked right back where I left off for the April and May First Tuesdays. Having that extra month to continue researching and learning more about the issues we are trying to resolve, I gained an understanding of the important role a medical student can have in the BCMS delegation. There was a lot of legislation pertaining to medical students, residents, loan repayment programs, GME, and residency programs as a whole that would be better represented if addressed by a medical student. Who else should advocate for us if not us students? I was given the opportunity to speak on behalf of medical students in support of these legislations, and with the help of the physicians around me, we were able to hold a discussion on these matters with our county’s senators and representatives. We ultimately secured votes that would increase our state funding for loan repayment programs,

increase GME funding, and help hold Texas accountable for a 1.1:1 residency spot to applicant ratio, thereby helping to keep medical students in the state for residency and practice afterwards. BCMS had already done an amazing job last year by leading the effort for Tobacco 21 locally, helping it to be ratified and go into effect on Oct. 1, 2018. This year, we were able to help continue the momentum to have it approved in both the State House and Senate, and by the end of this legislative session, on June 7th, it was one of many bills supported by TMA and BCMS that was signed by the governor into law, taking effect statewide on Sept. 1, 2019. The experience of working with my mentors and physician role models this legislative session was a blessing and an honor. I learned so much about political dynamics and how we can all help our patients as students, residents and physicians by stepping up and being active, as well as by representing medicine and our patients in state and national platforms. This past year, I have learned about teamwork, dedication, hard work, and what it takes to go above and beyond what is required of physicians in order to make sure Texans stay healthy and ensure that the vulnerable are protected from those who wish to make a profit at their expense. Seeing our efforts this session end in so much legislative success, I am even more driven now to continue my path in medicine and learn as much as I can about how to be a great physician, not just an acceptable one. Being continued on page 30

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surrounded by amazing physicians and seeing them as passionate about their vocation today as much as they were when they graduated medical school gives me a strong sense of hope for our future and a firm belief that we are going above and beyond the minimum standards to advocate for our current and future patients. Lastly, I would like to thank the many BCMS physicians who supported and guided me throughout this past year and legislative session (in no specific order): Dr. Adam Ratner, Dr. Alex Kenton, Dr. Jayesh Shah, Dr. John Shepherd, Dr. Leah Jacobson, Dr. John Nava, and Dr. Ryan Van Ramshorst. I would also like to thank two other physicians who reached out and inspired me to become active in TEXPAC and TMA/BCMS: Dr. David Fleeger and Dr. Doug Curran. Most of all, a huge thanks to Mary Nava, chief government affairs officer for BCMS, for inviting and welcoming me and many other students into the First Tuesdays team. Amazing leadership really does go a long way. I look forward to the next legislative session and can’t wait to continue the fight for my future patients. Marc Ghosn is a third-year medical student at University of Incarnate Word School of Osteopathic Medicine.

Cordially invites you to the

86th Legislative Session Wrap-Up Mixer Tuesday, August 13, 2019 • 6-8 pm PVA Main Avenue Medical Plaza 610 North Main Ave. San Antonio, TX 78205 Located across from the San Antonio Public Library RSVP at www.bcms.org by August 5, 2019 Sponsored by:

San Antonio Medicine • August 2019

UT HEALTH

SAN ANTONIO HAS A NEW DESIGNATION: DEMENTIA FRIENDLY DAY By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio If you look at our city’s greatest successes, they have been accomplished by individuals and groups working together toward a common goal. A great example of this is the announcement that San Antonio is now a Dementia Friendly City. This designation, from Dementia City America, was announced June 15 by our School of Nursing, which has been leading this initiative with the help of several partners. They include University Health System, the Bexar County Sheriff ’s Office, the City of San Antonio, the Alzheimer’s Association and many others. This designation recognizes that our city has a grassroots initiative in place to build a welcoming and supportive environment for indi32

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viduals living with Alzheimer’s disease and other forms of dementia, and to provide helpful resources for their caregivers. While the designation is a reason to celebrate, it also is a call to action for San Antonio to wrap its arms around those living with ― and caring for ― individuals with this health challenge. As Alzheimer’s and other dementias are on the rise nationally and in Texas, most of us have been touched by these diseases or know someone who has. Perhaps your grandparent had Alzheimer’s. Maybe you are caring for a parent with dementia while raising your children at the same time. Have you recently received the diagnosis yourself ?

UT HEALTH

I say this because there is an approaching “tsunami” of Alzheimer’s and other forms of dementia as our population ages. Statistics from the Alzheimer’s Association show that: • In 2019, 5.8 million people in the U.S. are living with Alzheimer’s disease. This includes 200,000 people younger than age 65. • Alzheimer’s disease is the sixth-leading cause of death in the U.S. and has an economic burden of $290 billion.

• Texas ranks fourth nationally for the prevalence of Alzheimer’s, with 390,000 individuals living with the disease.

• The state is second in the number of Alzheimer’s-related deaths, with a 180% increase from 2000 to 2015. • Hispanics are about 1.5 times more likely to develop dementia, making San Antonio and South Texas particularly vulnerable to this disease.

• Nationally, more than 16.2 million Americans provide unpaid care for people with Alzheimer’s or other dementias. That includes 1.4 million unpaid caregivers in Texas.

• In the U.S., unpaid caregivers provide an estimated 18.5 billion hours of care each year, valued at nearly $234 billion.

• Texas caregivers provided 1.6 billion hours of unpaid care at approximately $20.6 billion per year.

We at UT Health San Antonio are doing our best to stem this tide through our Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, where we are providing the latest evidence-based care, conducting research and educating the next generation of health professionals to care for this growing segment of the population. Through the Caring for the Caregiver program, led by Carole White, Ph.D., RN, our School of Nursing is providing regularly scheduled training classes for new caregivers, social opportunities for caregivers and their loved ones, and even a choir called Grace Notes. Caring for the Caregiver supports the Dementia Friendly City advisory board and is the community champion for this initiative. Thanks to the Dementia Friendly initiative, there is a strong core of organizations looking for additional ways to embrace those living with dementia and their caregivers, but there is always room for more. Our colleagues at University Hospital System have the distinction of being the first Dementia Friendly hospital system in Texas. They are training their nursing staff to recognize dementia and support families while their loved one is hospitalized. They also are provid-

ing Alzheimer’s and dementia information in their clinics. The Bexar County Sheriff ’s Office is working with our School of Nursing to provide training for deputies on how to recognize dementia in order to provide appropriate support to those community members and their families. They also initiated a vehicle sticker program for families living with Alzheimer’s to help law enforcement officers recognize that a person with dementia may be on board. The San Antonio & South Texas Chapter of the Alzheimer’s Association provides statistics on these diseases, and supports those who are diagnosed, their caregivers and the medical professionals who care for them. The organization raises funds for needed research, provides support groups, education programs and volunteer opportunities. However, some of the most important voices we need to hear are yours and those of families living with Alzheimer’s disease. You can help by thoughtfully listening to the concerns of your patients, learning more about the community resources available for them and investigating ways to refer your patients and their caregivers to research studies. Through collaboration, we can better understand these diseases and help our patients live through these challenging times. I am proud of the work being done by so many members of the UT Health San Antonio family to improve the quality of life for people living with Alzheimer’s disease and other dementias, while always keeping in mind the welfare of their families and caregivers. We will continue to work tirelessly to tackle and eventually annihilate this terrible disease. We invite you to join the Dementia Friendly City initiative, and learn about the many resources available to family caregivers, by visiting utcaregivers.org or calling (210) 450-8862. Information about research and patient care is available through the Biggs Institute at biggsinstitute.org and (210) 450-9960. The University of Texas Health Science Center at San Antonio, now called UT Health San Antonio, is one of the country’s leading health sciences universities. With missions of teaching, research, healing and community engagement, its schools of medicine, nursing, dentistry, health professions and graduate biomedical sciences have produced 36,500 alumni who are leading change, advancing their fields and renewing hope for patients and their families throughout South Texas and the world. To learn about the many ways “We make lives better,” visit www.uthscsa.edu.

visit us at www.bcms.org

CIRCLE OF FRIENDS

The Case for Using Circle of Friends Donors By August Trevino

Companies that donate to the Bexar County Medical Society through Circle of Friends further the mission of the Society through their generosity.

What is BCMS asking physician members and practices to do?

Circle of Friends donors want an opportunity to compete for your business. So, whether it’s banking, insurance, medical supplies, or whatever, we ask that you show appreciation for their support of organized medicine by allowing them the opportunity to offer a competitive bid. If they can make a case to earn your business, great! If not, you can politely decline their offer. Done!

How does the Circle of Friends program work?

It’s simple. Businesses donate to BCMS; in return, the Society advertises their support in our e-newsletter The Weekly Dose, promotes them in the Physicians’ Purchasing Guide both online and in San Antonio Medicine magazine and the Physician & Medical Directory, and gives them the opportunity to interact with physician members at BCMS events.

San Antonio Medicine • August 2019

How do members benefit from Circle of Friends?

Generous donations from these businesses allow the Society to provide outstanding social events and free CME for our members while keeping membership dues as low as possible, all while catering to physician’s needs.

Does BCMS screen businesses before they become Circle of Friends members?

BCMS doesn’t accept just any business into our Circle of Friends. While BCMS cannot guarantee every business product and service, we do check their reputation through the Better Business Bureau and other sources. Also, BCMS declines donations from businesses that are not beneficial to the physician either professionally or personally. They are helping your medical society, please give them an opportunity to show what they can offer. Thank you! August Trevino is the development director for BCMS and manages the Circle of Friends program. He can be contacted at 210301-4366 or August.Trevino@bcms.org.

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us. ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

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

San Antonio Medicine • August 2019

www.constangy.com “A wider lens on workplace law.”

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

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to

navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients. Robert R. Biechlin, Jr., Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

ASSETS ADVISORS/ PRIVATE BANKING

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

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking

210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

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

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future. Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

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

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

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

DIAGNOSTIC IMAGING

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

FINANCIAL ADVISOR 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) 750-8331 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

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"

help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection. Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Rene Farret Wealth Management Advisor 210-278-3806 rene_farret@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Jon M. Tober SWBC Mortgage—Sr. Loan Officer NMLS #212945 (210) 317-7431 jon.tober@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

FINANCIAL SERVICES

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to

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!”

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

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

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visit us at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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 Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference. Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth” Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans. Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

HEALTHCARE BANKING

Amegy Bank of Texas ( Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556

San Antonio Medicine • August 2019

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

HEALTHCARE CONSULTING

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone. Sabina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

Digital Telehealth Solutions (HHH Gold Sponsor)

Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

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

INFORMATION AND TECHNOLOGIES

Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry. David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

INSURANCE

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians. Bill Brooks Senior Vice President (214) 329-4584 BBrooks@abadmin.com www.osmahealth.com/ “People you know Coverage you can trust”

ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair. Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program. Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

LUXURY REAL ESTATE

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

MARKETING ADVERTISING SEO

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

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

MEDICAL PRACTICE

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted. For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with no-cost CME to local physicians since 1969.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment,

vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans. Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

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

RESIDENTIAL REAL ESTATE

San Antonio Medicine • August 2019

ent residential real estate firm in San Antonio and the Hill Country. Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

RETIREMENT PLANNING

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection. Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

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

956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7. Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, bcms.org/COF.html

BUSINESS LIFE

LIFE EVENTS CAN LEAD YOU TO SEE A FINANCIAL ADVISOR By Elizabeth A. Olney Over the years, you’ll experience many personal and professional milestones. Each of these can be satisfying, but they may also bring challenges – especially financial ones. That’s why you may want to seek the guidance of a financial professional. Here are some of the key life events you may encounter, along with the help a financial advisor can provide: • NEW JOB – When you start a new job, especially if it’s your first “career-type” one, you may find that you have several questions about planning for your financial future, including your retirement. You may have questions about how much you should contribute to your employer-sponsored retirement plan. What investments should you choose? When should you increase your contributions or adjust your investment mix? A financial advisor can recommend an investment strategy that’s appropriate for your goals, risk tolerance and time horizon.

• MARRIAGE – Newlyweds often discover they bring different financial habits to a marriage. For example, one spouse may be more of a saver, while the other is more prone to spending. And this holds true for investment styles – one spouse might be more risk-averse, while the other is more aggressive. A financial advisor can help recommend ways for you and your spouse to find some common ground in your saving and investment strategies, enabling you to move forward toward your mutual goals.

• NEW CHILD – When you have a child, you will need to consider a variety of financial issues. Will you be able to help the child someday go to college? And what might happen to your child, or children, if you were no longer around? A financial advisor can present you with some college-savings options, such as an education savings plan, as well as ways to protect your family, such as life insurance.

• CAREER CHANGE – You may change jobs several times, and each time you do, you’ll need to make some choices about your employer-sponsored retirement plan. Should you move it to your new employer’s plan, if transfers are allowed? Or, if permitted, should you keep the assets in your old employer’s plan? Or perhaps you should roll over the money into an IRA? A financial advisor can help you explore these options to determine which one is most appropriate for your needs.

• DEATH OF A SPOUSE – Obviously, the death of a spouse is a huge emotional blow, but it does not have to be a financial one – especially if you’ve prepared by having the correct beneficiary named on retirement accounts and life insurance policies. Your financial advisor can help ensure you have taken these steps.

• RETIREMENT – Even after you retire, you’ll have some important investment decisions to make. For one thing, you’ll need to establish a suitable withdrawal strategy so you don’t deplete your retirement accounts too soon. Also, you still need to balance your investment mix in a way that provides at least enough growth potential to keep you ahead of inflation. Again, a financial advisor can help you in these areas.

No matter where you are on your journey through life, you will need to address important financial and investment questions, but you don’t have to go it alone – a financial professional can help you find the answers you need. Elizabeth Olney is a financial advisor with Edward Jones and a member of the Circle of Friends program. She can be reached at 210-493-0753 or Elizabeth.Olney@edwardjones.com.

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San Antonio Medicine â&#x20AC;˘ August 2019

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AUTO REVIEW

2019 Ram 1500 By Stephen Schutz, MD

San Antonio Medicine â&#x20AC;¢ August 2019

AUTO REVIEW

For as long as I can remember the list of the top 10 selling new

both numbers close to the corresponding Ford or Chevy compet-

2) Chevrolet Silverado, 3 - 10) various other vehicles. The Dodge

The Ram’s exterior design is standard pickup fare without much

vehicles in the U.S. has looked like this: 1) Ford F-series pickup,

Ram pickup, now just called the Ram, hasn’t really registered until

recently. In 2000 the numbers were, 1) Ford F-series 876,716, 2) Chevy Silverado 645,150, 10) Jeep Grand Cherokee 271,723, and

ing trucks.

to distinguish it from the pack except for a big “RAM” spelled

out in the center of the grille. It’s worth noting that, despite the

fact that the 1993 Ram revolutionized pickup styling with its novel

Dodge Ram somewhere out of the top 10.

Kenworth-like grille, the 2019 Rams look positively mainstream.

competitive. In 2018 the top three selling vehicles in this country

way their predecessors did.

Things have changed, as they say, and the Ram is now seriously

were, 1) Ford F-series 909,303, 2) Chevy Silverado 585,581, and

They’re good looking trucks, but they don’t stand out visually the As a non-truck guy who follows the automotive industry closely,

3) Ram 536,980. And according to Automotive News, the Ram

it seems to me that Ram has caught up with Chevy by equaling

will likely be a switch at number two this year.

ing it in interior quality. Then FCA relied on superior advertising

has outsold the Silverado 9 out of the last 10 months, so there Two possible reasons for the Silverado’s sales swoon are its new

the benchmark F-150 on capability and looks, and then (just) best-

(think – the epic 2013 super bowl ad, “So God made a farmer”)

controversial design and base four-cylinder engine, but I think it

and PR (think – sponsoring the PBR and other rodeos) to connect

(Fiat Chrysler Automobiles) have been making to improve their

With that, I’d like to say a few words about Sergio Marchionne,

makes more sense to look at the Ram and the intense effort FCA

full-size pickup in order to sell more of them. That effort has been paying off, and the 2019 version is all new.

Perhaps the biggest improvement in the Ram has been in the

with their customers.

FCA’s great CEO who died about a year ago and who made Ram

and Jeep what they are today. He quarterbacked the renaissance

of those two brands, which together are now keeping FCA afloat,

Ram. The interior is much better than it was even a few years ago

and he did it by making competitive vehicles and backing them

Ram has the latest version of FCA’s UConnect infotainment sys-

“Chrysler Eminem commercial”, “Dodge Paul Harvey commer-

19-speaker Harman Kardon audio system, and standard Apple

ads, and you’ll see what I mean). If GM had done the same with

and despite that I had no trouble connecting my phone, listening

wasn’t perfect — if he were alive he’d currently be fighting alle-

and is now better than the ones in the F-150 and Silverado. The tem with either an 8.4-inch or optional 12.0-inch touchscreen, a

CarPlay or Android Auto. My tester came with the smaller screen,

up with emotional — and very effective — advertising (YouTube

cial”, and “Jeep 75 years commercial” to see Sergio’s three best

the Silverado I doubt Ram would be passing them now. Sergio

to podcasts, or doing anything else. It’s very intuitive.

gations of bribery and emissions cheating, among other challenges

I noticed the most. They’re best in class, and I suspect the Ram’s

so with almost as much flair.

While the Ram’s ergonomics are excellent, it’s the materials that

interior is what will ultimately sell customers who schlep from

— but he saved Chrysler as surely as Lee Iacocca did, and he did The Ram 1500 pickup is an excellent truck that combines Ford

dealer to dealer kicking tires.

F-150-like utility and looks with an outstanding interior. It’s no

eTorque mild hybrid technology) or a 396HP Hemi V8 (eTorque

race. Somewhere up there Sergio Marchionne is smiling.

The Ram offers two engines: a 305HP V6 (with standard

is a $1450 option), and all Ram 1500s come with an 8-speed au-

tomatic transmission. The V6 gets 19 MPG city/24 highway and the Hemi’s numbers are 17 city/23 highway. While not yet on sale,

I’m told a new diesel V6 will return soon with towing and fuel

wonder Ram is overtaking the Chevy Silverado in the U.S. sales To get your best deal on a new Tesla, call Phil Hornbeak at

BCMS at 210-301-4367.

Stephen Schutz, MD, is a board-certified gastroen-

economy numbers in line with the just-released F-150 diesel.

terologist who lived in San Antonio in the 1990s when

three aforementioned pickup trucks. The Ram’s payload is a max-

been writing auto reviews for San Antonio Medicine since

As far as capability goes, there’s not much to differentiate the

imum of 2,300lbs and towing capability is as much as 12,750 lbs,

he was stationed here in the U.S. Air Force. He has 1995.

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