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87TH LEGISLATIVE WRAP-UP BCMS Delegation to TMA Wraps Up House of Delegates Business in Virtual Meeting During TexMed 2021 By Mary E. Nava, MBA .........................12 TMA Physician-led Results of the 87th Legislative Session By the Texas Medical Association ..................14 The 87th Texas Legislative Session is Now in the History Books - A Session Like No Other By Mary E. Nava, MBA..................................................22 The Effects of Prior Authorization By Ezequiel “Zeke” Silva III, MD .....................................24 The State of Texas and Cannabis By John J. Seidenfeld, MD ............................................25 Medical Student Issues and Perspectives in the 87th Legislative Session By Ryan Wealther and Swetha Maddipudi ........................................................26 A Deep Dive Into Texas Women’s Health Services By Winona Gbedey, Chelsea Gerlicki and Sarah Miller, MD, MPH .................................................................28 Medicaid Expansion By Cameron Holguin and Ida Vaziri ..........................................................................32
AUGUST 2021
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VOLUME 74 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 Email: editor@bcms.org MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org SUBSCRIPTION RATES: $30 per year or $4 per individual issue ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com
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Conclusions Drawn from the 87th Legislative Session By Leah H. Jacobson, MD, FAAP ....................34 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance President’s Message ......................................................................................................................10 How I was Inspired by June Bratcher By Jenny Shepherd......................................................................................11 Benzene in Sunscreen By Ryan Wealther, Jane Margaret Anderson and Caroline Zhu............................................35 Book Review: The Health Care House of Cards By David Alex Schulz, CHP...........................................................36 Integrative Medicine By Neal S. Mertiz, MD ...........................................................................................................38 Physicians Purchasing Directory.............................................................................................................................40 Auto Review: 2021 Genesis G80 By Stephen Schutz, MD .....................................................................................44 Recommended Auto Dealers .................................................................................................................................46 PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com
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SAN ANTONIO MEDICINE • August 2021
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BCMS BOARD OF DIRECTORS
ELECTED OFFICERS
Rodolfo “Rudy” Molina, MD, President John Joseph Nava, MD, Vice President Brent W. Sanderlin, DO, Treasurer Gerardo Ortega, MD, Secretary Rajeev Suri, MD, President-elect Gerald Q. Greenfield, Jr., MD, Immediate Past President
DIRECTORS
Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member David Anthony Hnatow, MD, Member Lubna Naeem, MD, Member Lyssa N. Ochoa, MD, Member John Shepherd, MD, Member Ezequiel “Zeke” Silva III, MD, Member Amar Sunkari, MD, Member Col. Tim Switaj, MD, Military Representative Manuel M. Quinones Jr., MD, Board of Ethics Chair George F. “Rick” Evans, General Counsel Jayesh B. Shah, MD, TMA Board of Trustees Melody Newsom, CEO/Executive Director Nichole Eckmann, Alliance Representative Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative
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Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Katelyn Jane Franck, Student Alexis Lorio, Student
BCMS SENIOR STAFF
Melody Newsom, CEO/Executive Director Yvonne Nino, Controller August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Betty Fernandez, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer
PUBLICATIONS COMMITTEE John Joseph Seidenfeld, MD, Chair Kristy Yvonne Kosub, MD, Member Louis Doucette, Consultant Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member Antonio J. Webb, MD, Member David Schulz, Community Member Chinwe Anyanwu, Student Member Winona Gbedey, Student Member Teresa Samson, Student Member Taylor Sullivan, DO, Member Faraz Yousefian, DO, Member Neal Meritz, MD, Member Jaime Pankowsky, MD, Member Danielle Moody, Editor
PRESIDENT’S MESSAGE
Texas and Medicaid By Rodolfo “Rudy” Molina, MD, MACR, FACP, 2021 BCMS President
Medicaid was created in tandem with Medicare in 1965, designed to expand access to mainstream health care for low-income families and individuals. The federal government would partially fund this program which gave states considerable latitude designing their programs. Consequently, states varied widely in their approach for providing health care to the poor and their families. Incremental changes in Medicaid occurred over the ensuing decades, and in the 1990s, further changes were enacted with the passing of the Balanced Budget Act of 1997. The states were allowed to expand with the use of the Social Security Act’s Section 1115 research and demonstration waiver authority, which allowed the states to provide care to the uninsured who were previously ineligible for Medicaid. Also created with this Act was the Children’s Health Insurance Program (CHIP), which will be discussed later in this article. First, we will look at some facts about Medicaid: 1. 5.2 million Texans, 18.4% of the population, lacked insurance in 2020. 2. The cost of Medicaid over the last 10 years is 40% of the state general revenue funds at $65.3 billion, with 97% Medicaid and 3% CHIP. 3. Trends in caseload and spending for major Medicaid client categories have all increased. 4. Texas leads the nation in the rate of uninsured children pre-pandemic, so numbers were possibly higher in 2020. 5. Presently, Texas Medicaid is heavily depended on the 1115 waiver. 6. Although Medicaid is called a federal-state partnership, most of the policy-making authority lies within the federal government, whereas the spending initiatives rest with the states. On April 16, 2021, the Biden administration stated it would not renew the 1115 waiver for the state of Texas and will therefore expire on September 30, 2022. Let’s spend some time explaining this waiver. In brief, the waiver is for the Healthcare Transformation and Quality Improvement Program. It is called the 1115 waiver, as Section 1115 of the Social Security Act allows the federal government to approve waivers for experimental, pilot or demonstration projects. It is an important funding source for the state’s hospitals and other health care providers. The waiver, initially approved in December 2011 and renewed in December 2017, is currently a $25 billion program with costs shared between federal and local governments. The waiver augments the state’s Medicaid managed care program and consists of two funding pools: a program that pays hospitals for uncompensated care (UC) delivered to patients without insurance, and a program which provides funding for innovative health care initiatives, Medicaid recipients, uninsured and low-income patients. Rural hospitals depend heavily on the 1115 Medicaid waiver. For the average rural hospital, it provides about $2 million a year in uncompensated care. The UC payments help cover most of these losses. It is estimated that more than one fourth of a rural hospital’s 8
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revenue comes from supplemental programs provided by the 1115 waiver UC funds. The 1115 waiver was never meant to be a permanent solution and we must remember that UC funds do not cover the costs of care for uninsured patients outside of the hospital, nor do they offset physician charity care costs. Texas is one of 12 states that have opted not to expand Medicaid under the provision provided by the Affordable Care Act (ACA). In an attempt to incentivize states to participate in the expansion, the American Rescue Plan Act of 2021 was passed. This will provide a temporary, two-year fiscal incentive for states to newly implement the ACA Medicaid expansion. Under the law, states that expand would be eligible for a 5-percentage-point increase in the state’s regular, or traditional match rate for two years. Simply put, under the 5-percentage-point bump, the new estimated federal funds would be more than two times larger than the new state expansion costs. A comprehensive literature review of Medicaid expansion showed the possibility of improved access to care and reduced uncompensated care costs. Recent studies have shown an association between expansion and gains in employment as well as growth in the labor market. Medicaid expansion could also support mental health and substance abuse treatment for low-income people. Presently, Medicaid and CHIP insure roughly 35% of all U.S. children. As reported by Perrin, Kenney and Rosenbaum (NEJM Dec. 31, 2020), apart from the elderly, no other age group depends more on public benefits. As stated by federal law, Medicaid funding is tied to state spending. Even though children are considered a low-cost population to insure over the last three decades, the number of children who receive insurance from their parents’ jobs has steadily declined. In my opinion, there are some inequities in the Medicaid program. First, eligibility for children is tied to low income or disability, thereby serving the very poor. Second, funding is tied to state spending, targeting children who have greater economic and health care needs which raises the costs to states. And third, the low physician payment rate, on average two thirds the rates paid by Medicare, reduces physician participation and as a consequence, access to care. One could argue that there were some flaws in the creation of Medicare and Medicaid from the beginning. It has placed the cost of medical care for low-income families and their children on the states. This issue could be seen as a national need. I would agree with Perrin et.al., that “making Medicaid universal and federally funded would enable states to focus on initiatives that improve health care quality as well as those that enhance integration of health care, education, and social services for all children.” Medicaid expansion could possibly help treat our most precious commodity, our legacy that is our children. Rodolfo “Rudy” Molina MD, MACR, FACP is the 2021 President of the Bexar County Medical Society.
BCMS ALLIANCE
JENNY SHEPHERD RECEIVES JUNE BRATCHER AWARD By Lori Boies, PhD
As I sat on the Texas Medical Association Alliance’s nominating committee in September 2017, I enthusiastically recommended Jenny Shepherd (2018 BCMSA President) for the position of VP of Legislative Affairs for the TMA Alliance. She would go on to excel in this position, and additionally, she garnered both national and statewide recognition for her efforts in advocating for medicine. In June 2020, Jenny was honored with the American Medical Association Alliance’s award for Legislative Advocacy and Programming for her innovative “Party of Medicine” grassroots fundraising events. More recently though, Jenny was awarded the prestigious TEXPAC June Bratcher Award for Political Action in May 2021. This is a biennial award presented to a physician spouse for significant involvement in legislative endeavors. The “Party of Medicine” events happened not only at her home in San Antonio, but she also took the show on the road to Lubbock. Through these efforts, she was able to increase TEXPAC memberships and successfully raise funds for State Rep. Leo Pacheco (House District 117) and State Sen. Jose Menendez (Senate District 26). More events had been scheduled but postponed due to the pandemic. I had the privilege of hearing June Bratcher (1979-80 BCMSA President), the namesake of Jenny’s award, speak at a BCMSA luncheon in 2017. It was an inspiring speech centered around the many obstacles she faced as she fought to have her voice heard at a time when the political landscape was mostly male-dominated. Her story serves as an inspiration for anyone striving to accomplish what they believe in. It is a privilege to have so many strong, female trailblazers in San Antonio. Overall, it is important for all of us to channel a little of our innerJune and our inner-Jenny to advocate for medicine. When we advocate for medicine, we are advocating for a safer and healthier Texas and United States. We help physicians practice medicine in effective ways and help patients have access to the vital care that they need. Jenny is currently completing her second masters’ degree with a Master of Public Health (MPH). With her passion and knowledge, I know she will be an unstoppable force on whatever she sets her sights on next. One of the best parts of being on the Alliance has been the friendships I’ve made through this organization. As physician spouses, we all bring diverse strengths and viewpoints to the table, as we not only share friendship, but also take steps towards making Texas a healthier place. I have gotten to know Jenny on so many levels over the years:
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Jenny Shepherd and John Shepherd, MD
she followed me as President of the BCMSA, our families have traveled together and we are currently student peers working on our MPH degrees. Through all these avenues of friendship, I remain in awe of her innovative, creative thinking she applies to any task at hand. I cannot think of anyone more deserving of the June Bratcher Award for Political Action. Jenny, the “party of medicine” is lucky to have you! Lori Boies, PhD is a Bexar County Medical Society Alliance (BCMSA) past president (2017) and currently a presidential advisor. She also serves on the TMA Alliance Board as the Bylaws Chair for 2021-2022. Lori is an Instructor of Biological Sciences at St. Mary's University.
HOW I WAS INSPIRED BY JUNE BRATCHER By Jenny Shepherd
Scrawled on a sticky note affixed to my computer are the words “Fight for the things that you care about but do it in a way that will lead others to join you.” While these are the words and mantra of the late Justice Ruth Bader Ginsburg, they typify the actions of San Antonio legend June Bratcher, for whom the Texas Medical Association’s June Bratcher Award for Legislative Involvement honors. Dissatisfied with how her state representative, a trial lawyer, was leading, she concluded that it was time for a change. “I didn’t feel like he was responding to the community that he lived in, which included a large number of physicians, so I decided that maybe it was time that we got a new representative,” Ms. Bratcher said. She launched a grassroots campaign, rallied the medical community and got to work. While her chosen candidate did not get elected in that race, it was just the beginning for June who not only did remarkable work in San Antonio, but also led the way for physician spouses to become leaders in the political arena. It wasn’t always easy, according to Ms. Bratcher. As she began to get involved, there were a contingent of people who thought physician spouses had a place supporting medicine, but it wasn’t in the realm of politics. Asked to stop, she refused, and forever changed the course of how medicine and politics interact. She paved the way for women and physician spouses to be viewed as equally valuable assets in the fight for better medicine, while also battling to elect senators and state representatives who are sensitive to the needs of medicine. Thank you, June. I’m sure you didn’t think you’d be a hero when you set out to change one thing in your world, but that is exactly what you became for me and countless others. You helped to give us a voice. You taught us that caring about your health, your job and your rights is why we must continue to care about politics because they are inextricably entwined. You became a role model and taught us not to take no for an answer, that new ideas can be valuable and not to underestimate our own power to bring about change. We should all be thankful. I know I am. Jenny Shepherd served as the VP of Legislative Affairs for the Texas Medical Association Alliance for the past three years and is currently the VP of Community Health. She was President of the Bexar County Medical Society Alliance in 2018. Visit us at www.bcms.org
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BCMS DELEGATION TO TMA NEWS
BCMS Delegation to TMA Wraps Up House of Delegates Business in Virtual Meeting During TexMed 2021 By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer
Congratulations to Jayesh Shah, MD, who was reelected to another term on the TMA Board of Trustees during the virtual annual meeting of the TMA House of Delegates held May 14-15 in conjunction with TexMed 2021. Dr. Shah was also reelected as a delegate member of the Texas Delegation to the AMA. He joins the following physicians, also representing BCMS on the Texas AMA Delegation, who were reelected to their posts: Drs. David Henkes, delegate – who also continues to serve as chair of the Texas Delegation to the AMA; Jennifer Rushton, MD, alternate delegate; and Ezequiel “Zeke” Silva, III, MD, alternate delegate. Delegate and alternate delegate members in the Texas Delegation to the AMA represent TMA at AMA meetings. Additionally, Swetha Maddipudi, a medical student entering her fourth year at the UT Health Long School of Medicine, was elected to serve a one-year term on the TMA Board of Trustees, representing the TMA Medical Student Section. Representing BCMS in the TMA International Medical Graduate (IMG) Section will be Rajeev Suri, MD, who was elected to the IMG Section Executive Council as a TMA delegate. A special thanks to the following delegate members of the BCMS Delegation to TMA, who participated in virtual reference committee hearings and house of delegates business meetings throughout the weekend meeting: Jesse Moss, Jr., MD, and Leah Jacobson, MD, chair and co-chair, respectively, of the BCMS Delegation to TMA. Dr. Jacobson also served on the TMA Credentials Committee. Other members of the BCMS Delegation to TMA include: Apeksha N. Agarwal, MD, Resident and Fellow Section – served on the Medical Education and Health Care Quality Reference Committee; Brian Boies, MD; Dianna Burns-Banks, MD; Chelsea Clinton, MD; Steven Gelfond, MD; Prabhdeep Grewal, MD; Pam Hall, MD; David Henkes, MD; David Hnatow, MD; James Humphreys, MD; Margaret Kelley, MD; Meagan Khan, Medical Student Section: David Lam, MD; William Cannon Lewis, MD; Shazli Noorali Malik, MD; Sekinat McCormick, MD; Lubna Naeem, MD; John Nava, MD – Chair of the Socioeconomics Reference Committee; Gerardo Ortega, MD; Adam Ratner, MD; Jennifer Rushton, MD – served on the Science and Public Health Reference Committee; Brent Sanderlin, DO; Jayesh Shah, MD; John Shepherd, MD; Ezequiel “Zeke” Silva, III, MD – served on the So-
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cioeconomics Reference Committee; J. Marvin Smith, III, MD; Rajeev Suri, MD; Nora Linda Vasquez, MD; Veronica Vasquez, MD; Aruna Venkatesh, MD; Nikki Verma, Medical Student Section; and Alexis Wiesenthal, MD. The members of the BCMS Delegation to TMA also submitted five resolutions for consideration during the House of Delegates reference committee hearings. The resolutions follow, along with action taken by the House of Delegates. To read the full summary of actions taken by the TMA House of Delegates, go to texmed.org/hod. Resolution 106 – Creation of Ad Hoc Committee to Study and Make Recommendations Concerning Noncompete Agreements in Physician Employment Contracts. The resolution asks that (1) the Texas Medical Association study noncompete agreements in physician employment contracts and evaluate the impact of noncompete agreements on physicians and patients in Texas with report made to the TMA no later than TexMed 2022; and (2) that the Texas Medical Association assess whether means other than noncompete agreements might suffice to protect physician employers’ legitimate interests with report made to the TMA no later than TexMed 2022. Adopted as amended in lieu of Resolution 114 2021. Resolution 107 – Utilization Review, Medical Necessity Determination, Prior Authorization Decisions (Tabled Res 410 2020). The resolution asks that (1) the Texas Medical Association urge physicians to bring their concerns regarding decisions made by physicians working for insurance companies to the attention of the Texas Medical Board and Texas Department of Insurance, as these decisions affect patient outcome, and that TMA create a clearinghouse of all complaints against insurance companies and insurance doctors and aggregate this data; and (2) the Texas Delegation to the American Medical Association take this resolution to the AMA House of Delegates, urge the AMA House of Delegates to adopt similar policy and urge the AMA Council on Ethical and Judicial Affairs to devise ethical opinions similar to the TMA Board of Councilors’ opinions on medical necessity determination and utilization review. Referred for study with report back.
BCMS DELEGATION TO TMA NEWS
Resolution 206 – Develop Guidelines for Proper Oversight of and Collaboration with Midlevel Practitioners by Physicians (Tabled Res 422 2020). The resolution asks that (1) TMA educate physicians and disseminate to them information on basic tenets of proper physician oversight and supervision of midlevel practitioners and encourage physicians to bring to the attention of the Texas Medical Board physicians who are not providing supervision as required per the delegation of duties, and (2) the Texas Delegation to the AMA take this resolution to the AMA House of Delegates, urging it to develop national guidelines for proper oversight and collaboration of midlevel practitioners by a physician. Not adopted. Resolution 420 – Step-Edit Therapy Contributes to Denial of Care and has not Demonstrated Improved Patient Outcomes or Overall Cost Savings (Tabled Res 412 2020). That the Texas Medical Association (TMA) urge our legislators to review and make transparent the “fail-first” policy of step-edit therapy and study how it affects patient outcomes and that TMA ask the AMA to review the ethical implication of step-edit therapy and make further recommendations on its use. Adopted.
Resolution 421 – Augmented Intelligence (AI) in Health Care (Tabled Res 201 2020). That the TMA Council on Socioeconomics, TMA Committee on Health Information Technology and TMA Council on Medical Education collaboratively develop augmented intelligence (AI) policy. Adopted as amended. Mary E. Nava, MBA is the Chief Government Affairs Officer and delegation liaison at BCMS.
For local discussion or to learn how you can become involved with the BCMS Delegation to TMA, submit your request by email to mary.nava@bcms.org.
Visit us at www.bcms.org
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87TH LEGISLATIVE WRAP-UP
The 87th Texas Legislative Session is Now in the History Books – A Session Like No Other By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer
For the first time, the 87th Texas Legislative Session was mostly a virtual one for physicians. There were no in-person visits to the Capitol in Austin for First Tuesdays, except for approximately 90 physicians from around the state, who were called up to testify in person on behalf of Texas Medical Association (TMA) legislation. Overall, the Session was a success for a number of medicine’s issues. Here are highlights of some key TMA-supported priority legislation: • House Bill (HB) 1445 by House Insurance Committee Chairman Rep. Tom Oliverson, MD, (R-Cypress), eliminates a sales tax on outsourced medical billing services. The bill passed and was one of the first pieces of legislation signed by the Governor. HB 1445 takes effect on Jan. 1, 2022. • HB 3459, TMA’s prior authorization “gold card” bill, by Rep. Greg Bonnen, MD (R-Friendswood), passed and was signed into law. It takes effect Sept. 1, 2021. HB 3459 removes administrative prior authorization requirements for routine prescriptions and treatments. The bill will allow physicians to earn a “gold card” exemption from health plans if the physician achieves an 80% approval rating per procedure and per health plan in one plan year, thus earning a “gold card” for the next year. This legislation also requires that peer-to-peer reviews be conducted by a Texas-licensed physician in the same or similar specialty. • Senate Bill (SB) 248 by Sen. Nathan Johnson (D-Dallas) establishes licensure requirements for e-cigarette retailers and calls for vaping products to be regulated the same as other tobacco products. SB 248, which becomes law without the Governor’s signature, takes effect Sept. 1, 2021. • HB 133 by Rep. Toni Rose (D-Dallas), extends Medicaid coverage for eligible women to six months postpartum instead of 60 days after a woman gives birth or miscarries. The legislation takes effect Sept. 1, 2021. • HB 2658 by Rep. James Frank (R-Wichita Falls), improves Medicaid coverage for children under 19 years of age, providing two consecutive six-month periods of coverage, with verification of a child’s continued eligibility. This legislation started out as HB 290 by Rep. Philip Cortez (D-San Antonio) and was amended onto HB 2658. The legislation becomes effective Sept. 1, 2021.
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Many thanks to the following physicians from Bexar County who testified on behalf of medicine’s issues this session: Adam Bruggeman, MD, Sanjiv Kumar, MD, Michael Leonard, MD, James Lukefahr, MD, Jason Morrow, MD, Zeke Silva, MD and Edward Wright, MD. In addition, we thank the following physicians, Alliance members and medical students who participated in the virtual First Tuesdays at the Capitol: Physicians – Michael Battista, MD, Daniel Deane, MD, Carmen Garza, MD, Pam Hall, MD, Leah Jacobson, MD, Alex Kenton, MD, Scott Kercheville, MD, Alisha King, MD, Rudy Molina, MD, Robyn Phillips-Madson, Joel Reyes, MD, Ninza Sanchez, MD, John Shepherd, MD and Zeke Silva, MD. Alliance members – Jennifer Lewis, Jenny Shepherd and Martha Vijjeswarapu. Medical students – Gloimai Cowan, Rose Ann Huynh, Swetha Maddipudi, Amna Naqvi, Shail Vyas and Ryan Wealther. Of the over 6,900 bills filed, the Governor signed into law 1,034 pieces of legislation that passed during the legislative session. He vetoed 20 bills and 105 bills were filed without his signature. At the time of this writing, the first called special session of the 87th Legislature began July 8. Agenda items cover a number of items, including: Bail Reform, Election Integrity, Border Security, Article X Funding, Family Violence Prevention, Youth Sports, Social Media Censorship, Abortion-inducing Drugs, Critical Race Theory, Thirteenth Check and Appropriations pertaining to property tax relief. To read more about the outcome of medicine’s issues, see the TMA legislative wrap-up brochure in this issue of San Antonio Medicine or visit texmed.org for more details. Mary E. Nava, MBA is the Chief Government Affairs Officer and Legislative/Socioeconomics Committee liaison at BCMS.
To learn more about how you can get involved in legislative advocacy, consider joining the BCMS Legislative and Socioeconomics Committee by submitting your request by email to mary.nava@bcms.org.
Visit us at www.bcms.org
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87TH LEGISLATIVE WRAP-UP
The Effects of Prior Authorization By Ezequiel “Zeke” Silva III, MD
Prior authorization (PA) is intended to confirm the medical necessity and appropriateness of health care services that may be emerging, experimental or infrequently performed. The application of PA has been expanded over the past five years to now include common procedures, therapies and medications. Despite this overuse, most services subjected to PA are eventually approved by the health plans. However, approval often requires an extensive effort by physicians and their staff, regularly necessitating a peer-review process. The complaints among patients and physicians are growing and have been heard by the Texas Medical Association (TMA) and Bexar County Medical Society (BCMS). To better understand the effects of PA, in February 2020, the TMA performed a PA physician survey. The results are telling. An astonishing 78% of physicians report that PA had led their patients to abandon their course of treatment, and 38% report that PA led to a serious adverse event, according to a TMA reference. Subsequent AMA survey data from December 2020 found that, on average, physicians and their staff spend 16 hours a week on PA, while 40% of practices employ full-time staff members who work exclusively on PA. 24
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For these reasons and others, addressing PA was a top priority for the TMA and BCMS during Texas’ 87th regular Legislative Session. The TMA and BCMS supported several legislative PA reform bills, including bills requiring increased oversight of the health plans, greater transparency to the process and decreased burdens on physicians. BCMS members provided House and Senate testimony numerous times in support of these bills. These advocacy efforts yielded significant progress in holding the health plans accountable for the consequences of burdensome PA practices. Several of our supported bills were voted favorably out of the House Insurance Committee. Ultimately, our legislative efforts resulted in HB 3459, by Rep. Greg Bonnen, R-Friendswood, Rep. Penny Morales Shaw, D-Houston and Sen. Dawn Buckingham, RLakeway, with considerable support by Sen. Jane Nelson, R-Flower Mound, passing through both the House and Senate. The bill goes into effect on September 1, 2021. HB 3459 requires that certain health plans provide gold carding status for frequently approved services on a physician-by-physician basis. Gold carding status would apply to a physician who performs a service and has preauthorization requests for that service approved no less than 90% of the time during
the relevant six-month evaluation period. This physician would not be subject to PA requirements for that service after receiving gold card status (but the health plan may assess continued qualification for gold card status at certain intervals). HB 3459 also requires that peer-to-peer review calls be conducted by a physician of the same or similar specialty as the treating physician. Further, HB 3459 would require that any physicians conducting the peer-to-peer calls be licensed to practice medicine in the state of Texas. The health plans’ growing use of the PA process has gone too far. Physicians spoke up, and the TMA and BCMS heard our voices loud and clear. HB 3459 will help protect our practices and our patients from the harms of excessive PA practice. Physicians should be proud of the progress we made in the 87th Legislative Session to address PA burdens. Ezequiel "Zeke" Silva III, MD is a member of the South Texas Radiology Group and the TMA Council on Legislation. He is Chair of the AMA RVS Update Committee (the “RUC”) and is an active member of the Bexar County Medical Society.
87TH LEGISLATIVE WRAP-UP
The State of Texas and Cannabis By John J. Seidenfeld, MD
Texas once again finds itself as the Lone Star “island.” Surrounded by the states of Oklahoma, New Mexico, Arkansas, Louisiana and the countries of Canada and Mexico that have all agreed on medicinal use of cannabis products (and adult use for some), we alone limit compassionate medical use to a very few patients in very few circumstances with cannabidiol (CBD) and very small amounts (</=1%) of tetrahydrocannabinol (THC). We have misdemeanor penalties for possession of amounts starting at less than 2 oz. with felony charges starting for possession of over 4 oz. This legislative session, we made minor adjustments to our compassionate use laws but continue to severely restrict medicinal prescribing and harshly penalize adult use.1 Who uses cannabis? Why should we be concerned? People with conditions such as emesis, epilepsy, Post Traumatic Stress (PTS), anorexia, glaucoma, pain with the goal of reducing opioid use, multiple sclerosis, Parkinson’s and Huntington’s disease and cancer pain relief have been treated and studied with promising results.2 Journals such as the Journal of Cannabis Research are now devoted to the study of cannabinoids, cannabinoid agonists and antagonists and metabolic pathways. Despite Federal controlled substance classification, research has never been more active in this field. Likely, the field of therapeutics will be enriched in years to come by this work. According to the CDC (Center for Disease Control), 38% of youths have used cannabis.3 Studies in The Texas Tribune note that 76% of Texans favor medicinal use of marijuana, and support has increased from 2015 to 2017.4 Studies of veterans have shown 11% use and veterans with PTS, up to 28%. 5 While some see no likelihood of improvement in expanding the therapeutic armamentarium, others argue that we could see
expansion. Just a few years ago, tobacco was consumed in Texas hospitals, public buildings and other gathering places. Many of us worked hard to show the advantages of a smoke-free environment, and today we all appreciate the smoke-free air in our workplaces. Someday soon, patients could be able to access pills or edible cannabis products with assurance of dosage and clearly labeled ingredients, as with most regulated therapeutic agents.
more open to legalizing marijuana — and not just for medical use.2/21/2017. R. Ramsey, University of Texas/Texas Tribune Poll. 5. https://www.ptsd.va.gov/professional /treat/cooccurring/marijuana_ptsd_vets.asp John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee.
References 1. https://guides.sll.texas.gov/cannabis 2. http://bcms.org/SAM/2019/SAM Dec2019/mobile/index.html#p=26 3. https://www.cdc.gov/marijuana/factsheets/teens.htm 4. UT/TT Poll: Support for marijuana growing like a weed in Texas. Texans are Visit us at www.bcms.org
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Medical Student Issues and Perspectives in the 87th Legislative Session By Ryan Wealther and Swetha Maddipudi
Now that the dust has settled and the Texas Legislative Session has ended, we can unpack what the session had in store for medical students. At the forefront of many of our medical student minds was funding for residency positions through the state’s Graduate Medical Education (GME) Expansion Grant Program. Many Texas medical students want to stay in Texas for residency, but if there are not enough spots for Texas medical students to complete residency in Texas, students are forced to leave. What is concerning about this is Texas-educated physicians are about 30% less likely to practice in Texas if they complete their residency out of state.2 According to the most recent State Physician Workforce Data Report by the Association of American Medical Colleges (AAMC), Texas is ranked number 41 out of 50 in the country for physicians per capita.1 Fortunately, Texas’ final budget allocated enough money to GME to maintain the 1.1 ratio of first-year residency slots for every medical school graduate, which will help retain medical students in the state of Texas.2 The Texas state budget also allocated $385 million for medical student education; this adds up to about $45,000 per student per year of medical education.2 This generous allocation to medical education keeps Texas public medical schools amongst the most affordable medical schools in the nation, which helps retain talented pre-medical students in Texas and attracts talent from out of state to attend Texas medical schools.3 It also allows Texas medical school graduates to keep their overall debt burden low. Audrey Phan, a fourth-year medical student at the UT Health San Antonio Long School of Medicine (UTHSA LSOM) and Illinois native, was excited to hear the state decided to continue providing generous funding for medical education. “Growing up with a low socioeconomic background and dreams of becoming an obstetrician-gynecologist, the financial barriers to a medical education seemed nearly insurmountable until I found UT Health San Antonio. With high standards of education and exceptionally affordable tuition, there was no question in my mind that I would make the journey across the country to come to medical school in Texas. Being here has allowed me the opportunity to not only become a physician, but also leave medical school with financial security instead of burdening debt. I couldn’t be more grateful for the future 26
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that the state of Texas has generously awarded me, and I’m happy Texas has decided to continue investing in medical education for future students.” Medical students faced some disappointing news in the state budget as well. The budget sustained cuts to loan repayment programs, family practice residency programs and the statewide primary care preceptorship programs. These budget cuts have resulted in decreased opportunities for students interested in primary care, which is troubling because Texas is ranked number 47 out of 50 in primary care physicians per capita. The statewide primary care preceptorship programs, which match medical students to primary care physicians, provide early primary care experiences to students during a formative phase of their training. Similarly, the promises of loan repayment for primary care practitioners can serve as an added motivator for students leaning towards choosing a primary-care-oriented specialty. Having cuts to the training pathway is disappointing for many of our students, as it increases the difficulty of matching into a primary care specialty. The preceptorship program was especially influential to UTHSA LSOM fourth-year medical student, Christi Jackson. "I had never considered a career in primary care upon entering medical school. Towards the end of my first year, I saw a flyer about the Texas Family Medicine Preceptorship Program and applied, thinking it would be a great way to get some early clinical exposure while also earning some money. I didn’t anticipate enjoying my experience so much that I am now applying to family medicine residency programs solely in the state of Texas. Texas needs more medical students interested in pursuing a future in primary care." These were just some of the issues in the legislative session we, as medical students, witnessed. However, medical students were more than just casual bystanders in the legislative session−we actively participated in First Tuesdays. Medical students have long been involved in First Tuesdays with the Texas Medical Association (TMA). For many, this event has served as a foundational experience in understanding how impactful conversations with legislators can lead to better health care for Texans. When we (the authors) first attended a session as first-year medical students, our chapter put together our own internal briefings and talking points to guide
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our conversations with legislators, making sure we represented the medical student community at our school to the best of our ability. This was a part of the inspiration for a new briefs project we helped to create as leaders of the TMA Medical Student Section (MSS) Executive Council. Over the past year, we mobilized MSS members who were interested in writing about topics that were advocacy focused. We specifically called upon some of the authorship teams to pen briefs on topics we knew would come up during First Tuesdays. Two of the six briefs published in the first iteration of this project focused on TMA’s legislative priorities, immunizations and Medicaid expansion, and specifically focused on explaining important advocacy points in a digestible way for medical students. Our medical student members used these briefs to develop their own talking points and anecdotes they could then share with legislators. By providing medical students with data-driven briefs, they were able to identify points for implementing new policies and provided both trainee and clinical perspectives during discussions. Rishi Gonuguntla, a second-year medical student at UTHSA LSOM and President of the school’s TMA Chapter, also participated in First Tuesdays and has reflected on his experience. “As a first-year medical student, I was excited to attend First Tuesdays, although I was unsure what that would entail. Although I’d only intended to watch and learn, I quickly found myself an active participant. During my first meeting, I was encouraged by the other physicians to talk about how expanding GME funding would affect me as a medical student. Being able to advocate for myself and my peers to a legislator who had the ability to enact change was a powerful experience. When I discovered Texas did expand GME funding, I felt I had contributed to a tangible difference in the world during my first year of medical school. Participating in First Tuesdays is one of the best experiences I have had in the field of medicine, and I look forward to participating again in the future!”
at the Texas Medical Association, for providing essential information to this article. References: 1. Association of American Medical Colleges. (2019). 2019 State Physician Workforce Data Report (pp. 8, 13). Association of American Medical Colleges. https://store.aamc.org/downloadable/download/sample/sample_id/305/ 2. Price, S. (2021, June 23). Physician-Led Results: Lawmakers Invest in Texas’ Future Physicians. Texas Medicine Today. https://www.texmed.org/TexasMedicineDetail.aspx?id=57194 3. Satyanarayana, M. (2017, October 30). Med school on the cheap: Why becoming a doctor in Texas is a bargain. The Texas Tribune. https://www.texastribune.org/2017/10/30/medschool-cheap-why-becoming-doctor-texas-bargain/ Ryan Wealther is a fourth-year medical student at the UT Health San Antonio Long School of Medicine. He currently serves as Chair of the Texas Medical Association Medical Student Section. Swetha Maddipudi is a fourth-year MD/MPH student at the UT Health San Antonio Long School of Medicine and serves as the student representative to the TMA Board of Trustees.
Acknowledgements: Thank you to the quoted students from the UT Health San Antonio Long School of Medicine for providing their perspectives and to Marcia Collins, Associate Vice President for Medical Education Visit us at www.bcms.org
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A Deep Dive into Texas Women’s Health Services By Winona Gbedey, Chelsea Gerlicki and Sarah Miller, MD, MPH
With over 14.6 million women living in Texas, almost 30% of which are uninsured, health programs that aim to support and improve women’s health are of the utmost importance.1 However, many Texas women are unaware of the free and lowcost state-wide medical services available to them. Though each of these programs have their own unique set of services, they each contribute to an extensive network that addresses the barriers many women face when trying to find comprehensive and affordable obstetric and gynecological health care. Join us as we explore Texas’ women’s health programs and how the outcomes of the Texas Legislative Session will impact them.
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WOMEN’S HEALTH PROGRAMS Healthy Texas Women and Healthy Texas Women Plus: Healthy Texas Women (HTW) is the most comprehensive women’s health program in Texas, providing a wide array of women’s health services to uninsured, low-income women. By enrolling in the program, eligible women gain access to innumerable services, including gynecological exams, pregnancy and STI testing, breast and cervical cancer screenings and family planning services, such as contraception and permanent sterilization. Healthy Texas Women, the Texas Family Planning Program and Breast and Cervical Cancer Services all offer basic preventive services, such as cholesterol, diabetes and high blood pressure screenings. However, HTW also tends to women's mental, emotional and social wellness by collaborating with substance abuse programs, mental health inpatient care and housing and emergency hotlines. While HTW itself is not available to women who are currently pregnant, HTW Plus provides services up to twelve months
postpartum. This program offers enhanced postpartum care to support more than 375,000 births per year in Texas. Services include coverage for psychotherapy and peer specialists, imaging studies, medications, monitoring for cardiovascular and coronary conditions, and screening, intervention and counseling services for substance use disorders.2 Texas Family Planning Program: As its name would suggest, the Texas Family Planning Program (TFPP) offers affordable and accessible reproductive health care and family planning services to women and men. These services are especially needed in Texas, where, over the past two decades, there has been an increase in unplanned pregnancies along with maternal and infant morbidity and mortality. In fact, Texas has some of the highest rates in the country, with nearly 300,000 unintended pregnancies every year and many maternal deaths.3,4,5 By emphasizing the importance of reproductive life plans, providing preconception counseling and improving ac-
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cess to sexual and reproductive services, TFPP empowers couples to take charge of their reproductive health to ensure better health outcomes for both mother and baby. Adequate preconception care is a critical component of health care for anyone of reproductive age — but despite its benefits, few women have regular or reliable access to it. Thus, TFPP has become an important weapon in the fight against maternal and infant mortality and morbidity. By addressing the major risk factors, such as obesity, diabetes and substance use that may compromise a woman’s health even before she becomes pregnant, they better prepare her physically for the physiologic changes that take place during pregnancy. Breast and Cervical Cancer Services: Cervical cancer is the third most common cause of cancer for Texas women aged 20 to 39 and the fifth most common for women aged 40 to 49.6 Even worse, breast cancer is the second most common cause of cancer death in Texas women.7 Still, upwards of 30% of the state’s women do not get regular pap smears or mammograms.8 Breast and Cervical Cancer Services (BCCS) also helps provide high quality, lowcost preventive care to eligible low-income, uninsured women. Regular breast and cervical cancer screenings are important for both pre- and post-menopausal women, because early detection of suspicious lumps increases the likelihood of treatment success. Once an abnormality is found, BCCS can direct patients toward additional diagnostic testing, cervical dysplasia management, treatment and assistance applying to the Medicaid for Breast and Cervical Cancer Program. This program grants full Medicaid coverage to patients in active treatment for cervical or breast cancer. Other Programs: Title X is the only federal program dedicated to providing family planning services to
low-income families. Through Title X, over four million men and women annually receive wellness exams, cancer screenings, reproductive care and education, STI testing and treatment. Title X caters to populations that are typically underserved in medicine and serves as an important safety net for those who may not be eligible for services through HTW, TFPP or BCCS. Texas Legislative Session Over the past several months, Texas legislators have evaluated hundreds of proposed legislation on dozens of overarching topics, such as transportation, economic development, criminal justice and health and human services. Now that the legislative session has concluded, we can attest that this has been a big session for women’s health. Over the next two years, Healthy Texas Women, the Texas Family Planning Program and Breast and Cervical Cancer Services will benefit from a slight boost in funding for a total budget of $352.6 million. Texas House Bill 133 will expand Medicaid postpartum coverage from two months to six months. Nationwide, maternal mortality has slowly been rising, with more rapid increases occurring in Texas. Most of these deaths, in-
cluding those from preventable causes like substance use and postpartum depression occur more than 60 days postpartum.9 This bill will support the mothers of nearly half the babies born in Texas each year.10 Finally, Texas Senate Bill 1065 will improve insurance coverage for women with dense breast tissue or with a personal history of breast cancer. When this bill goes into effect, high risk patients will be able to receive diagnostic imaging studies, such as mammography, ultrasound and MRI with the same health plans used for regular screening mammograms. A number of women’s health bills were adjourned sine die, many of which hoped to tackle some of the biggest contributors to maternal mortality in Texas. Nonetheless, the work that was accomplished at the 87th Legislative Session will help many people. Many other bills were also proposed by the Texas Senate and House, each with their own unique benefits. Some wished to study and tackle the factors contributing to maternal and infant mortality (Texas House Bill 420), while others hoped to expand the rights pregnant women have to their bodies in life and death (Texas House Bill 102) and who can join them in the pregnancy suite (Texas continued on page 30 Visit us at www.bcms.org
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continued from page 29
House Bill 415). Despite the intentions of these bills, none of them gained as much support or traction as SB1065 or HB133, and they died in committee. Gaps and disparities still exist, but we are cautiously optimistic for the future. In the legislative sessions to come, we hope to see some of these adjourned bills revisited or new bills passed to further the care and well-being of Texas women. In the meantime, physicians can share this information with their patients to help them optimize their health. References: 1. Texas | 2016 Health of Women and Children Report. United Health Foundation. https://www.americashealthrankings.org/ learn/reports/2016-health-of-womenand-children-report/state-summariestexas. Accessed June 14, 2021. 2. Texas | National Center for Health Statistics. Centers for Disease Control and Prevention. https://www.americashealth rankings.org/learn/reports/2016-healthof-women-and-children-report/state-summaries-texas. Updated March 19, 2021. Accessed June 14, 2021. 3. Texas Summary 2018. United Health Foundation. https://www.americashealthrankings.org/explore/health-ofwomen-and-children/measure/overall_mc h/state/TX?edition-year=2018. Accessed June 14, 2021. 4. Texas Women’s Health Statistics. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/data_stats/pdfs/texas.pdf. Accessed June 16, 2021. 5. Maternal Mortality Rate by State 2021. World Population Review. https://worldpopulationreview.com/state-rankings/maternal-mortality-rate-by-state. Accessed June 30, 2021.
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6. Cervical Cancer. Texas Department of State Health Services. https://www.dshs. state.tx.us/tcr/data/cervical-cancer.aspx. Updated May 19, 2021. Accessed June 16, 2021. 7. Breast Cancer. Texas Department of State Health Services. https://www.dshs.state. tx.us/tcr/data/breast-cancer.aspx. Updated May 19, 2021. Accessed June 16, 2021. 8. Texas | State Profiles for Women’s Health. Kaiser Family Foundation. https://www. kff.org/interactive/womens-health-profiles/?activeState=Texas&activeCategoryIndex=2&activeView=data. Published January 15, 2021. Accessed June 16, 2021. 9. Extend Postpartum Medicaid Coverage. The American College of Obstetricians and Gynecologists. https://www.acog.org /advocacy/policy-priorities/extend-postpartum-medicaid-coverage. Accessed June 30, 2021. 10. Najmabadi, S. Texas lawmakers split over how long to extend Medicaid health coverage for new mothers. The Texas Tribune. Updated May 27, 2021. Accessed July 3, 2021.
Winona Gbedey is a medical student at the UT Health San Antonio Long School of Medicine. Chelsea Gerlicki is a medical student at the Texas Tech University Health Sciences Center School of Medicine. Sarah Miller, MD, MPH will begin her residency at the UC Davis Family and Community Medicine Residency Program.
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Medicaid Expansion By Cameron Holguin and Ida Vaziri
When it comes to hot topics in both politics and medicine, nothing turns more heads than the topic of Medicaid. One cannot simply bring up this topic without a debate ensuing. Yet, despite the complexity of this topic and the discourse that comes with it, Medicaid expansion and the large uninsured population in this country are topics that health care providers must address. Let's take a look at the complex and ongoing story of Medicaid expansion here in Texas. The debate regarding Medicaid expansion began over a decade ago with the passage of the Affordable Care Act. As a part of that original legislation, states were mandated to expand Medicaid eligibility to all adults under the age of 65 whose incomes were lower than 133% of the Federal Poverty Level. This provision was eventually made optional in 2012 following the Supreme Court ruling in National Federation of Independent Business (NFIB) v. Sebelius.1 Following this ruling, over a dozen states, Texas included, opted to decline federal funds for Medicaid expansion once the policy went into effect on January 1, 2014. Since then, 13 states have chosen to opt back into Medicaid expansion, with the most recent state being Oklahoma, which will implement its expansion on July 1 of this year.2 Texas remains one of 12 states who have yet to accept funding provided by the ACA. A 2020 report by Bush School Public Health estimated that $5.4 billion dollars are being left on the table by the Texas Government’s decision to not expand Medicaid.3 Bexar County could have received over $430 million if Texas had opted to expand Medicaid this year.3 It is estimated that these funds, along with the matching provided by the state, would allow for nearly 1.3 million Texans (101,000 in Bexar County) to become eligible for Medicaid.3 Texas has the highest uninsured population in the country, with 5.2 million Texans without insurance. This is over 18% of the population, more than double the national rate of uninsured individuals, which is 9%. It is estimated that expanding Med32
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icaid could save Texas $110 million over the course of just two years. Additionally, states that expanded Medicaid were shown to have fewer closures of rural hospitals and higher patient volumes and quality of care in rural hospitals that remained open. Texas has experienced the highest rate of rural hospital closure in the nation, with 15 hospital closures between 2010 and 2018.4 Texas has opted to continue denying Medicaid expansion, although recent polls have shown that approximately 70% of Texans support it. Additionally, 59% of Texans feel that the state isn’t doing enough to help low-income individuals receive the health services and coverage that they need. A few bills to expand Medicaid have been proposed in the legislative sessions since Texas opted not to expand, but they have not received the approval of some lawmakers. In 2019, Texas State Senator Nathan Johnson proposed Senate Joint Resolution 34, proposing an amendment to the state constitution to require the state to expand Medicaid eligibility per the ACA guidelines.5 This bill did not survive to the 2019 Legislative Session. Lawmakers who oppose Medicaid expansion argue that the state could develop its own system to provide health coverage to the uninsured that is both cheaper and more efficient than Medicaid. Attempts to build this system have caused buzz in the legislature along with the direct expansion of Medicaid. The first attempt to develop this system came in 2013. This by far would have been the most opportune time to create an alternative system, as it would have gone live just as the majority of the nation was expanding Medicaid through the ACA. This attempt, however, failed and Texas became one of the 19 states to not expand health coverage. Another attempt to create an alternative system came in the most recent legislative session when lawmakers proposed SB 117 and HB 3871. These bills received bipartisan support and would have provided Texas with a unique way to expand Medicaid while pro-
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viding incentives for adults to work and manage their own health care responsibly. This legislation had sufficient support to pass the House Floor – as well as backing from nearly 200 business groups, health care organizations and local government entities – though it did not have the chance to be heard on the House Floor. In our opinion, Texas needs to do more for its uninsured population to bring them the health coverage they need. Whether that be through Medicaid expansion or through the creation of an alternative system, we believe the legislature should hold a serious discourse on this topic and consider expanding health coverage in the 2023 Legislative Session. Over one million Texans could possibly have their lives improved by such a policy. Texas is one of the leaders in the nation when it comes to innovation and economic opportunity. We believe it is time for Texas to show that it is also a leader in taking care of the health and well-being of its citizens. We think the legislature should act in 2023 to possibly expand health coverage for those who are uninsured.
2. Kaiser Family Foundation. (2021, July 1). Status of State Medicaid Expansion Decisions. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/. 3. Dague, L., & Hughes, C. (2020, September 14). County-Level Projections of Medicaid Expansion’s Impact in Texas. Episcopal Health Foundation. 4. Hoadley, J., Alker, J., Holmes, M., Schneider, A., & Whitener, K. (2018, September 25). Health Insurance Coverage in Small Towns and Rural America: The Role of Medicaid Expansion. https://ccf.georgetown.edu/2018/09/25/health-insurance-coverage-in-small-towns-and-rural-america-the-role-of-medicaid-expansion/. 5. Evans, M. (2019, February 12). Voters in four states have approved Medicaid expansion by ballot. Will Texas do the same? The Texas Tribune. https://www.texastribune.org/2019/02/12/texas-legislators-filed-bills-put-medicaid-expansion-decision-ballot/.
References: 1. Medicaid and CHIP Payment and Access Commission. (2021, June 30). Medicaid expansion to the new adult group. MACPAC. https://www.macpac.gov/subtopic/medicaid-expansion/.
Cameron Holguin and Ida Vaziri are medical students at the UT Health San Antonio Long School of Medicine.
Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of July 26, 2021. Visit us at www.bcms.org
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Conclusions Drawn from the 87th Legislative Session By Leah H. Jacobson, MD, FAAP
In today’s hyper-political environment, summarizing the outcome of an inherently political process can be difficult. Do I focus on how important it is to participate in First Tuesdays and how to get involved at a local or state level? Or what BCMS and the Legislative Committee have been doing to advocate for its members and patients? Or, a wrap-up of what we know so far from the 87th Legislative Session? Many Texans believe the Legislature was disappointing, as evidenced by the most recent University of Texas/Texas Tribune polls regarding the legislative session and what Texans thought of the issues dominating it. I was once again struck by how many topics directly or indirectly relate to health care and public health. Some issues were directly related to health care, such as the coronavirus pandemic and Medicaid issues. Others focused on more indirect issues, such as public education, immigration, electric reliability, public safety and homelessness, to name a few. The majority of Texans voted on an expansion of Medicaid (sixty-seven percent support it (50% Republicans and 90% Democrats)). There was significant bi-partisan support for this issue, but GOP leaders did not share the same perspective. House Bill 3871 and Senate Bill 117 for the expansion of Medicaid did not make it out of the committee. Two related bills that did pass and were signed involve the Healthy Texas Women Program and expanded benefits (HB 133), and HB 290. The latter was incorporated into HB 2658, which makes it easier for children eligible for Medicaid to receive and keep their coverage. Texans were in favor of the legalization (or 34
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at least partial legalization) of marijuana (only 13% of those polled were against any circumstance being made legal). Almost 60 bills related to marijuana were introduced this Session. Ultimately, only two bills regarding marijuana use were adopted. (House Bill 1535 expands the Compassionate Use Program, and HB 567 protects parental rights regarding the administration of low-THC cannabis to their child for approved medical reasons.) With regards to our state infrastructure and electric system, 52 percent of Texans polled were not satisfied with the Legislature’s work on the reliability of the state’s electricity grid, and even more were less confident that the Legislature had passed laws to prevent future issues in utility services like those that had occurred in February. This is just a small look at some of the issues that are being discussed. With the Legislature returning to Austin in July for the first, though likely not the only Special Session, there will be more topics discussed. We will have to wait and see how these issues affect us and our patients. As The Texas Tribune poll shows, the Legislature does not always represent every single view of their constituents. It is up to us as health care providers to help continue to advocate for our patients and the population at large. I urge you to get involved. You can join the BCMS Legislative and Socioeconomics Committee and meet or contact your state Senator or Representative about a topic you are passionate about. You can also learn about TEXPAC (Texas Medicine’s Political Action Committee) and the TMA’s Political Action Committee and learn how you can get in-
volved in advocacy. Lastly, you can talk to your patients about these important issues and find out what is important to them. These things can all make a big impact! “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” - Margaret Mead Reference: https://www.texastribune.org/2021/06/25 /texas-permitless-carry-medicaid-transgenderstudents-poll/ Leah H. Jacobson, MD, FAAP is the Chair of the BCMS Legislative Committee and was the 2017 President of the Bexar County Medical Society.
Benzene in Sunscreen
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By Ryan Wealther, Jane Margaret Anderson and Caroline Zhu
If you feel like you’re having deja vu because sunscreen is in the news again, you’re not alone. In 2019, the United States Food and Drug Administration (FDA) proposed a rule that called for the further study of 12 active sunscreen ingredients before definitively declaring these ingredients GRASE (generally recognized as safe and effective).6 These ingredients were found to be systemically absorbed at much higher concentrations than previously recognized.3 The FDA has placed these ingredients into a separate category, Category III, while research is ongoing. However, they have not called for the discontinuation of Category III ingredients because no harmful effects have been linked to date. Sunscreen is once again receiving attention because a recent study found benzene in sunscreen. Valisure, a company whose core mission is to bring transparency and increased quality to the pharmaceutical industry, released a report in May 2021 indicating that it found benzene in sunscreen products.2 Benzene is an organic solvent and a known human carcinogen—exposures to even low doses of benzene have been linked to hematologic malignancy.5 The Valisure report found that 78 out of 294 batches from 69 brands of sunscreen contained detectable levels of benzene. Valisure is petitioning the FDA Commissioner to initiate a recall of the sunscreen batches containing benzene and also requested the FDA define limits for benzene in drug and cosmetic products. The American Academy of Dermatology (AAD) released a statement regarding the detection of benzene in sunscreen products.4 It explains that the AAD looks forward to the FDA’s review of Valisure’s report and discusses how it plans to address the findings. The statement also acknowledges that unprotected exposure to the sun’s ultraviolet (UV) rays is a risk factor for skin cancer, and sunscreen is one way to protect your skin and reduce your risk of getting skin cancer. It is important to remember that there are other components of a comprehensive sun protection plan besides sunscreen. Dr. Allison Pye, MD, FAAD, a board-certified dermatologist at Audie L. Murphy Memorial Veterans' Hospital and Adjunct Assistant Professor of Dermatology at UT Health San Antonio, has some advice for patients who are uncomfortable wearing sunscreen for the time being. “I still encourage these patients to wear sunscreens that are known to be safe, but I also encourage them to use other forms of sun protection by seeking shade and wearing SPF clothing and wide-brim hats.” However, there are some important details to consider regarding Valisure’s recent report, which only represents one study and still needs to be validated. Only a minority (27%) of sunscreen batches were found to contain benzene. Even among batches of the same product, some batches were found to contain benzene while others did not. Furthermore, benzene is not supposed to be in any sunscreens. While it needs to be definitively determined how benzene got into these sunscreen batches,
Valisure suggests that benzene is most likely a production contaminant. The full list of affected batches can be found in Valisure’s report.2 While we await the FDA’s review of the Valisure report, uncertainty remains regarding sunscreen, and patients must weigh the risks of potential benzene exposure against the benefits of sunscreen. It is important to remind patients that sunscreen has multiple benefits, including protection against sunburns and the prevention of skin cancer. “UV damage also plays a role in accelerated aging, so in addition to keeping you safe and reducing the risk of skin cancer, sunscreen has the added benefit of maintaining more youthful looking skin,” says Dr. Pye. The AAD and dermatologists recommend using sunscreen that is SPF 30 or greater and broad-spectrum, meaning it protects against both UVA and UVB rays.1 Acknowledgements: Thank you for the expertise and guidance provided by Dr. Allison Pye, without whom we could not have written this article, and for the assistance provided by Dr. Robert Gilson. References: 1. American Academy of Dermatology Association. (n.d.). SUNSCREEN: QUESTIONS PATIENTS ASK. aad.org. https://www.aad.org/public/everyday-care/sunprotection/sunscreen-patients 2. Light, D., Kucera, K., & Wu, Q. (2021, May 24). Valisure Citizen Petition on Benzene in Sunscreen and After-sun Care Products. Valisure. https://www.valisure.com/wpcontent/uploads/Valisure-Citizen-Petition-on-Benzene-in-Sunscreen-and-After-sunCare-Products-v9.7.pdf. 3. Matta, M. K., Florian, J., Zusterzeel, R., Pilli, N. R., Patel, V., Volpe, D. A., Yang, Y., Oh, L., Bashaw, E., Zineh, I., Sanabria, C., Kemp, S., Godfrey, A., Adah, S., Coelho, S., Wang, J., Furlong, L. A., Ganley, C., Michele, T., & Strauss, D. G. (2020). Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients: A Randomized Clinical Trial. JAMA, 323(3), 256–267. https://doi.org/10.1001/jama.2019.20747 4. Petronelli, M. (2021, May 27). Detectable Levels of Benzene Noted in Some Sunscreen Batches. DermatologyTimes. https://www.dermatologytimes.com/view/carcinogen-found-in-multiple-sunscreens 5. Smith, M. T. (2010). Advances in understanding benzene health effects and susceptibility. Annual review of public health, 31, 133–148. https://doi.org/10.1146/annurev.publhealth.012809.103646 6. United States Food and Drug Administration. (2019, February 21). FDA Advances New Proposed Regulation to Make Sure That Sunscreens Are Safe and Effective. Fda.gov. https://www.fda.gov/news-events/press-announcements/fda-advances-newproposed-regulation-make-sure-sunscreens-are-safe-and-effective
Ryan Wealther, Jane Margaret Anderson and Caroline Zhu are medical students at the UT Health San Antonio Long School of Medicine. All three have served as leaders for the school’s Dermatology Interest Group.
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BOOK REVIEW
The Health Care House of Cards By David Alex Schulz, CHP
If American health care were its own patient, "code blue" might be a generous call. It has never been closer to flatlining, according to Brian Alexander’s “The Hospital: Life, Death, and Dollars in a Small American Town.” His exam of natural and artificial forces acting on a typical health care facility leaves the reader shaken and disturbed – particularly as the content largely precedes COVID-19. Alexander’s analysis of a system gone awry focuses on the Community Hospitals and Wellness Centers (CHWC) of Bryan, Ohio: a microcosm through which to see the whole. The author is a storyteller. “The Hospital” is a narrative history, not a chronologic recounting. Through the eyes of patients, physicians, staff and governance, we see generosity, greed and the effects of happenstance and planned malfeasance. In Bryan as elsewhere, public service health care only gained momentum after the Spanish Flu, but relations between private and public medicine, both competitive and cooperative, created an immediate, persistent tension. Alexander says that as early as 1929, “The AMA and local medical societies acted like cartels to block experiments in medical payment that sought to make care affordable.” When Los Angeles doctors formed the country’s first group care plan, the Ross-Loos Medical Group, the Los Angeles Medical Association expelled them. Such tension left physicians uncertain and patients confused. Spotlighting the decade between the Great Recession and Pandemic allows Alexander to contrast access to insurance with the availability of services. Many small-town hospitals “went bankrupt, or were absorbed (and sometimes gutted) by bigger regional health systems, or the towns themselves had slowly become more memory than living reality until there was no point in having a hospital there at all.” CHWC was falling prey to the same travails: “CHWC lost money every month of 2018 … dogged by big hospital chains in Toledo and Fort Wayne … Both had been gobbling up small independents like CHWC for over a decade in a crazed rush to consolidate before they could be targeted themselves by even bigger predators.” Phil Ennen, our protagonist and hospital CEO, faces these trials as a Bryan native and community leader. The author reminds us the title is from business, whereas hospitals once had ‘administrators.’ “Performing like a business while simultaneously taking on a mission nobody fully understood meant that one goal would always be in tension with 36
SAN ANTONIO MEDICINE • August 2021
the other,” reflects Ennen. Detailing patients’ struggles displays that the forces acting on American health could correlate closely with social and economic disparities. Although the 36,000 county clients of CHWC were “preternaturally homogenous, there could be as much as eight year’s difference in life expectancy from one part of the county to the next, and even from one part of tiny Bryan to the next.” In Keith* (surnames redacted), we see the relationship between marginal income and mordant diabetes. Keith discovers his blood sugar level was more than twice the 400 mg/dL at which his reader topped. The Medicaid expansion Ohio’s governor accepted provided insulin support. However, when amputation made mobility an issue and only a Dollar Store (accepting SNAP) is reachable, a healthful diet is harder to access. In Marc*, we see a good-hearted person (kidney donor, community volunteer, model family) suffer a cardiac arrest. Hypertension, arrhythmia, arterial blockage; America was a heartsick nation at this time, and performing cardiac catheterizations were a necessary attribute of even
BOOK REVIEW
a small facility like CHWC. In Valerie*, we have an incredibly hard worker – three jobs! — who one day heaved and strained too far, blowing two discs in her lower back. “Workers’ compensation covered her vertebrae-fusion surgery and physical therapy afterward. But then the recession hit.” Her job disappeared. In the book, we see obesity, over-work, hypertension and cardiac issues as plaguing suburbs and cities alike. Alexander then discusses addiction as a public health issue. As Alexander points out, “Sociologists had tried for years to tell politicians that drug abuse was a symptom, not a cause. The kind of drug was irrelevant … alcohol might be more immediately dangerous than obesity, lousy dental care, poverty and low wages, crummy housing, depression, trauma and anxiety. They were all part of the same pathology, though, and arguing about which was worse obscured the underlying causes of the abuse.” Herein we find Alexander’s primary thesis: the isolating of health care as a separate, biologic-only function fouls our approach from the beginning. To distinguish addiction, depression, or suicidal tendencies as separate from obesity, coronary-disease or cancer is to look only at the manifestations of a deeper, underlying and more widespread epidemic.
“Over years — over two generations — they’d become part of a culture of defeat, what doctors liked to call noncompliant … but noncompliant in a bigger sense. They no longer complied with society’s prescriptions. They were either unable or unwilling to obey. Maybe some of them had tried to obey, once, but obeying didn’t lead anywhere better, or obeying was just too difficult because everything cost so much, or was so hard to achieve, and so they said to hell with it.” Such attitudes, whipsawing people with contradictory messages and magnified by a media alarming the public, leads to a suspicious, dogmatic polarization that COVID-19 lay bare. “The Hospital,” while initiated years before the current crisis, deals with the pandemic as its fitting epilogue, a capstone that provides fitting validation for Alexander’s insights. All quotes from “The Hospital: Life, Death, and Dollars in a Small American Town” by Brian Alexander, St. Martin's Publishing Group March 2021, Kindle Edition. David Alex Schulz, CHP is a community member of the BCMS Publications Committee.
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SAN ANTONIO MEDICINE
INTEGRATIVE MEDICINE By Neal S. Mertiz, MD
Alternative medicine describes medical treatments and products that are utilized in place of traditional mainstream therapies. This is also known as complementary medicine, and when used along with accepted Western medicine, it is now called integrative medicine. More than half of adults in the United States use some form of alternative or integrative medicine. Patients report they are more readily able to cope with stress and feel better by concentrating on relaxation. Integrative therapies allow for a more active role in treatment and recovery as well as a partnership with the health care provider. Many people like the idea that these therapies seem natural and nontoxic. The search for a potentially elusive cure for symptoms and attempts to boost the immune system are also motivations, although less well-accepted. Patients may receive a great deal of comfort and satisfaction from the touch, talk and time offered by an integrative medicine therapist. Acupuncture is a traditional Chinese medicine technique that utilizes needles to trigger specific body points, thus allowing for stimulation of the natural healing processes of the body. Homeopathy involves treating disease with minute amounts of natural substances, like plants and animals, with the belief that this will encourage healing. Herbal medicine employs the parts of the plant, such as its roots, leaves, berries
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SAN ANTONIO MEDICINE • August 2021
and flowers to heal the body. Although this is often the basis for traditional medicine, there is limited evidence for the safety and efficacy of most of these products, with dosage and purity standards that are poorly regulated. Magnetic field therapy uses magnets or electrical currents to treat certain musculoskeletal problems. Proponents of Reiki believe the body’s natural energy can be utilized to speed healing. This is similar to Healing Touch in which a therapist employs an approach which identifies and repairs imbalances in the patient’s energy field. Chiropractic medicine focuses on spinal adjustments that create proper alignment, thus easing pain, improving body function and aiding natural healing. Integrative therapies also include behavioral care, nutrition recommendations, breathing and meditation regimens, and all are well-regarded in most areas of medical practice. Integrative medicine involves the use of both conventional and alternative methods to facilitate the innate healing response of the body. It includes a consideration of all factors that influence health, such as mind, spirit and community. This philosophy neither rejects conventional medicine nor accepts alternative medicine absolutely. Integrative medicine is open to new concepts, though there is a preference for the use of natural, less invasive interventions whenever possible. Multiple
SAN ANTONIO MEDICINE
studies are currently in progress to determine the safety and efficacy of many integrative medicine practices. Obtaining adequate funding is invariably difficult, with studies typically attached to a blockbuster drug. Much misinformation exists, especially on the Internet, regarding integrative health approaches. There are many charlatans, and red flags abound. For example, conventional medicine bashers should be avoided, and preference is often given to integrative providers who coordinate care with conventional proponents. Providers whose promises are too good to be true should also be shunned. Some practitioners are product, test and technology happy and some who sell their own supplements are less than trustworthy. Occasionally, the provider will demand a monetary commitment for an extended period of time. Additionally, hazy credentials are often a sign of troublesome intentions. The greatest danger of integrative medicine is that patients who see alternative practitioners will often discontinue receiving mainstream care altogether. When false and unproven health schemes are promoted for profit, it is called quackery. This term is most often used to denote the peddling of “cure-alls,” as well as the merchandising of fraudulent or ignorant medical practices. Integrative medicine often appropriates several science-based medical modalities, such as nutrition and lifestyle changes. These accepted concepts are then described as complementary or holistic, rather than simply good medicine. Advocates of non-evidencebased medicine are masters of marketing, with integrative medicine being promoted as the best of both worlds, that is, science-based and alternative. If alternative claims are fraudulent and promoted for financial profit, then a caring, holistic provider must avoid embracing them. Despite a mostly proven lack of effectiveness, several reasons for patient acceptance of integrative medicine have been suggested. Proponents take advantage of ignorance regarding conventional treatments. Substances and products known to have no pharmacologic effect on a disease can still affect perception, and this belief may often cause a therapeutic response, leading to improvement. This is known as the “placebo effect” and is now recognized to have a proven neurological basis. Many people have a strong distrust of conventional medicine, of regulating organizations such as the FDA and of major drug corporations. Conspiracy theories are prevalent among many who are anti-science, with the established medical care system suspected of attempting to preserve their power and increase their profits. Many people fear side effects from conventional medications and treatments, or are concerned with cost. Desperation is often a strong motivation. Some practitioners, aware of the ineffectiveness of a product, still intentionally produce fraudulent scientific studies and test results, thus further deceiving potential consumers.
Medical universities now struggle with the problem of how to present integrative medicine in their curricula. Some practices have compelling evidence but aren’t science-based. A survey by the Association of American Medical Colleges revealed that 126 of the 132 schools that responded are now offering classes in these disciplines. Integrative medicine must be taught dispassionately on the basis of the existing evidence. This evidence is positive in a few cases, especially when diet, behavioral therapy, meditation and breathing techniques are included, but negative in the overwhelming majority of studies. It is problematic that most medical schools delegate this task to enthusiasts of the respective therapies. Evidence-based medicine applies the scientific method to medical practice, and it advocates the use of current best data. Advocates of integrative medicine acknowledge the placebo effect may provide significant benefit, but that this fact does not diminish its validity. Many people obtain compelling improvement from alternative types of therapies and they should not be discouraged from pursuing nonmainstream modalities as an enhancement to their conventional medical treatment. There exists a reasonable argument that there is no integrative medicine, only scientifically proven, evidence-based medicine. People who choose integrative medicine think that they are utilizing a safe, effective treatment, but they are often deceived. Integrative medicine may be a strategy to make pseudoscience acceptable, but there are also undeniable benefits for many. References 1. Philosophy of Integrative Medicine by David Rakel MD and Andrew Weil MD. 4th Edition Elsevier 4/2017 2. Modern Medicine vs. Alternative Medicine: Different Levels of Evidence. By Thomas Sullivan Policy & Medicine 5/6/2018 3. What Exactly is Alternative Medicine? By Melinda Ratini MD WebMD 3/20/2021 4. Complementary and Alternative Health Care, Is It Evidence-Based? By Sved Amin Tabish Int J Health Sci 1/2008 5. Medical Schools Embrace Alternative Medicine by Meryl Davids Landau. US News and World Report 4/12/2021 6. Most Medical Schools Offer Courses in Alternative Medicine. Here’s How to Avoid Quackery By Julie Belluz Vox 7/8/2015 7. 5 Red Flags Your Non-Conventional Medicine Provider is Doing Harm. By Anna Medaris Miller US News and World Report 5/1/2018 Neal S. Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee.
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PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors. Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed. ACCOUNTING FIRMS
Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being. Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”
ACCOUNTING SOFTWARE
Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”
ATTORNEYS
Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”
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Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector. Mario Barrera Employment & Labor 210 270 7125 mario.barrera@nortonrosefulbright.com Charles Deacon Life Sciences and Healthcare 210 270 7133 charlie.deacon@nortonrosefulbright.com Katherine Tapley Real Estate 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”
ASSETT WEALTH MANAGEMENT
Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning. Mike Bertuzzi First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres
Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”
BUSINESS CONSULTING
Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”
The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com
BANKING
BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services -- BB&T offers solutions to help you reach your financial goals and plan for a sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you"
BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country
Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help
SAN ANTONIO MEDICINE • August 2021
Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”
Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”
FINANCIAL ADVISOR Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"
FINANCIAL SERVICES
Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning. Mike Bertuzzi
First Vice President Senior Financial Advisor 210-278-3828 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres
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!”
Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com
SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318
mleos@swbc.com swbc.com
HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER
www.expressinfo.com “Leaders in Healthcare Software & Consulting”
HEALTHCARE BANKING INSURANCE BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”
First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise” Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”
Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent & treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com
HOSPITALS/ HEALTHCARE FACILITIES
UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229
INFORMATION AND TECHNOLOGIES
Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward. Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com
TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org “We offer BCMS members a free insurance portfolio review.”
Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com
INSURANCE/MEDICAL MALPRACTICE
Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society
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PHYSICIANS PURCHASING DIRECTORY continued from page 41
MEDICAL BILLING AND COLLECTIONS SERVICES The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.” MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas
INTERNET TELECOMMUNICATIONS
Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”
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Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”
PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.” Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”
MEDICAL PHYSICS
Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board
SAN ANTONIO MEDICINE • August 2021
Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.
MEDICAL SUPPLIES AND EQUIPMENT
ing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”
MORTGAGES
CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience. Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”
MOLECULAR DIAGNOSTICS LABORATORY
SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober
PRACTICE SUPPORT SERVICES
Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.
PROFESSIONAL ORGANIZATIONS iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio provid-
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 CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate” Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease” The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center.
Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/
Join our Circle of Friends Program
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. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”
The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366
TELEHEALTH TECHNOLOGY
CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.
Visit us at www.bcms.org
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AUTO REVIEW
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SAN ANTONIO MEDICINE • August 2021
AUTO REVIEW
2021 GENESIS G80 By Stephen Schutz, MD
Genesis, the upmarket sister brand of Hyundai, has been in business in the country since 2016. While they have been gradually ramping up their sales of cars and SUVs since then, they had garnered very little attention in the press until last February when Tiger Woods famously crashed a loaner GV80 SUV at high speed in Southern California during a PGA golf tournament. It’s said that there’s no such thing as bad publicity, and given the fact that Tiger’s crash markedly heightened awareness of the Genesis brand, it would seem that this old saw is true. Genesis is selling every vehicle they can manufacture these days—to be fair, so are most automakers— and they finally seem to be getting attention from customers who, before now, would only consider Lexus and the big three German brands (Mercedes, BMW and Audi). Lexus is a good brand to mention, actually. When Genesis launched, it seemed like every article about it referenced Lexus as though Genesis was to Hyundai as Lexus was to Toyota. I think a better analogy is Audi. While Lexus became a legitimate luxury brand on day one of its existence, Audi struggled for many years before finally breaking through. It was during the 1970s that Volkswagen first tried to position Audi as a car for upscale buyers who liked VW but wanted something more luxurious, but the effort mostly failed. It wasn’t until the early 1980s that Audi became a legitimate luxury automotive contender thanks to Quattro all-wheel drive, many successes in World Rally Racing, and, oh by the way, much better cars. I doubt it will take Genesis as long to make it as it took Audi, but it’s already clear that they're not Lexus. I recently drove a 2021 Genesis G80 in an effort to gauge the company’s progress in what can only be described as a frantic luxury automotive market. I think Genesis is in good shape. A quick aside: what is the current luxury automotive market? It’s a mixture of newbies (imagine a radiologist who has just paid off her student loans), postponers (an older family practice physician who recently sold his building to a real estate investor), regulars (a dermatologist who’s been leasing a new Mercedes every three years since 1998) and enthusiasts (a surgeon who perpetually “needs” the latest special Porsche as soon as it’s been introduced to the media). It’s more complex than that, of course, but this breakdown gives you an idea of how difficult it is to break into this market. Genesis has a shot at the newbies and postponers, but it has an uphill fight to get to the regulars and enthusiasts. Which means that Genesis has to make excellent vehicles to be a player. The G80 is definitely that. First of all, the G80 looks like an expensive luxury sedan. Tightly designed with a large can’t-miss-this grille, Genesis’ best sedan looks
handsome and contemporary. Numerous creases accentuate the flowing sedan-ish profile, and the stance says, “sporty sedan,” but it’s the grille that grabs your eyes. It’s huge. By the way, when Audi started their successful climb up the sales charts about 15 years ago, they began by putting big grilles on their vehicles. Driving the G80 isn’t as great as its sporty looks would make you think. This is a rear-wheel drive platform (AWD is optional), but the engineers went for comfort over athleticism. The default during spirited driving is understeer, and steering effort has been minimized so you feel less involved on a winding road. The interior is as good as anything you’ll find from the above-mentioned competition. Genesis has borrowed Audi’s terrific diamond stitching to accent their seats, and everything you see and touch looks and feels good. The round controller on the console, which takes you through the various menus on the prominent central screen, is different from the user interfaces other manufacturers use, but you get accustomed to it in time. The entry-level G80 comes with a standard turbocharged 2.5-liter inline four-cylinder engine that makes 300 horsepower, but a more potent twin-turbo 3.5-liter V6 with 375 horsepower is available. Both engines connect with an eight-speed automatic transmission and either rear- or all-wheel drive. My test car came with the larger engine, which I think is the way to go. Pricing starts at around $48,000 for a base four-cylinder G80 with rear wheel drive, but I expect most of these models, like any luxury vehicle, will get optioned up and sell for close to $60,000. That’s not cheap, but compared to a similarly equipped E-class Mercedes or 5-series BMW, it represents a $10,000 to $15,000 savings. Genesis is producing some impressive products like the G80 these days, and according to sales figures, customers are buying them. It’s surreal that a celebrity road accident led to increased awareness, but that’s the way it goes sometimes. As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates. Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the US Air Force. He has been writing auto reviews for San Antonio Medicine since 1995.
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