San Antonio Medicine February 2017

SAN ANTONIO

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FEBRUARY 2017

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VOLUME 70 NO. 2

MEDICINE SAN ANTONIO

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POPULATION HEALTH

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FEBRUARY 2017

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VOLUME 70 NO. 2

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.

Are you feeling well? Say thank you...

By Fred H. Olin, DVM, MD ...................................14

Caring for San Antonio’s Refugees

By Eden Bernstein and Fadi Al-Asadi ..................16

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

An anesthesiologist in Ecuador — A Doctor on a Mission By Paul Barton, MD ............................18

Population Health Management

By Alan M. Preston, MHA, ScD .............................22

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

BCMS President’s Message ..............................................8

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Executive Director’s Message .......................................................................................................10

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BCMS Legislative News ..........................................................................................................................12 BCMS News.............................................................................................................................................24 Feature: Dancing with Deva By David Schulz, CHP................................................................................26 New technology paves way for HIPAA-compliant data exchange

By Wayne Parker ..................................................................................................................................28 Business: Fudiciary Duty and what it means to you By Stephanie Dick .................................................30 BCMS Circle of Friends Services Directory .............................................................................................32 In the Driver’s Seat...................................................................................................................................39 Auto Review: 2017 Ford Explorer By Steve Schutz, MD ........................................................................40

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Leah Jacobson, MD, President Adam V. Ratner, MD, Vice President Sheldon Gross, MD, President-elect Jayesh B. Shah, MD, Immediate Past President Gerald Q. Greenfield Jr., MD, PA, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Lori Boies, PhD, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member Arthur D. Cortez, MD, Board of Censors Chair George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Bradley A. Lloyd, MD, Military Rep. Rodolfo Molina, MD, Board of Mediations Chair John Joseph Nava, MD, Member Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

CHIEF OPERATING OFFICER Melody Newsom Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Brissa Vela, Membership Director

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Rajam S. Ramamurthy, MD, Chair Kenneth C.Y. Yu, MD, Vice Chair Carmen Garza, MD, Community Member Kristi Kosub, MD, Member Lauren Michael, Medical Student Sara Noble, Medical Student Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Adam Ratner, MD, Member David Schultz, Community Member J.J. Waller Jr., MD, Member Jane Yoon, Medical Student

6 San Antonio Medicine • February 2017

PRESIDENT’S MESSAGE

The Family of Medicine Needs YOU!

By Leah Jacobson, MD, 2017 BCMS President The 85th Texas legislative session is well underway, and it is now critical that you get involved! There have been more than 1,300 bills filed already, and over 400 of them involve health care in some way. It is important for physicians to continue to fight for our patients and the practice of medicine. We have been very successful in the past with tort reform and scope of practice issues. We must continue our efforts and build upon them.

Physician advocacy is one of the main reasons that doctors join Bexar County Medical Society and the Texas Medical Association. Why be politically active? Here is what physicians are saying: “If we do not work to manage medical legislation, it will be managed for us. Help save our profession.”

“Policy-making is not a spectator sport. You cannot sit on the sidelines and say somebody else will do it. It doesn’t work that way. You’ve got to be involved and you’ve got to be interested.”

“You either help govern or you’re governed.”

“A physician’s responsibility is to seek changes in those requirements which are contrary to the best interest of the patient.”

“Physicians can join TEXPAC and make their voices heard.” ** There are several ways to get involved either directly or indirectly. These include 1. Joining the BCMS Legislative/Socioeconomics Committee The BCMS Legislative/Socioeconomics Committee is chaired by Drs. Alex Kenton and Ashok Kumar and staffed very capably by Mary Nava, BCMS Chief Government Affairs Officer. It meets the fourth Wednesday of each month. Please contact Mary Nava at 210301-4395 or Mary.Nava@bcms.org.

2. Running for a position as delegate or alternate delegate to the TMA House of Delegates Every year in October, you, the members of BCMS, elect a number of delegates and alternate delegates to represent BCMS at the TMA House of Delegates meetings. Throwing your name in the ring, so to speak, is a great way to get involved and learn more about organized medicine at the state level. There are many opportunities to get involved there as well.

3. Joining/Giving to TEXPAC TEXPAC is a non-partisan State and Federal Political Action Committee advocating on behalf of Texas physicians, residents, and medical students. This organization does tremendous work on behalf of the Texas Physicians. Ironically, only a very small percentage of BCMS members actively support TEXPAC. Please go to their website, www.texpac.org, to learn more and donate.

4. Attending First Tuesdays The “White Coat Invasion” has been the key to physicians’ successes in the Texas Legislature since the inception of First Tuesdays at the Capitol in 2003. Our senators and representatives listen when their hometown doctors appear in their offices. Our influence is so much greater when physicians and alliance members arrive en masse in 8 San Antonio Medicine • February 2017

the House and Senate galleries.

It’s time again to bring out Texas medicine’s strongest weapon.

Mark your calendar now to join us during the 85th Texas Legislature on Feb. 7, March 7, April 4 and May 2, 2017.

As part of First Tuesdays, you will: • make a difference now and for medicine’s future.

• become well-versed on the issues facing medicine in the 2017 session.

• inform your senator and representative and their aides about these issues.

• attend committee hearings and House and Senate sessions.

Physicians, Alliance members, and medical students who attend First Tuesdays at the Capitol will focus on: • Preserving physicians’ right to bill for services; • Improving Medicaid payment rates and reducing red tape and hassles; • Protecting the patient-physician relationship while taking advantage of new technologies such as telemedicine; • Physician licensing and disciplinary issues as part of the Sunset review of the Texas Medical Board; • Stop the “scope creep” of lesser trained medical professionals; • Winning funding for public health surveillance and prevention; • Maintaining Texas’ strong medical liability reforms. *** 5. Contacting your legislators Contacting your legislators can be as simple as forwarding information sent from BCMS or TMA to a representative or senator, or as involved as setting up a meeting or call on your own with one of your legislators. Everything helps — calls, emails, letters, meetings.

They all make a difference! Please look on the BCMS website under advocacy for the information on the legislators, or use this link www.fyi.legis.state.tx.us.

6. Talking to your patients Talking to your patients is always important, but not just about their medical conditions. Patients have lots of questions with regards to healthcare, insurance issues, etc. It’s important to keep them involved in the legislative process and let them know that their voice and concerns matter.

Challenge and opportunity is what the TMA is saying this legislative session brings. With your help, the Texas Medical Association and Bexar County Medical Soceity can face up to the challenges and seize the opportunities.

I look forward to your involvement in this legislative session. **BCMS website

***TMA website/brochure

FROM THE EXECTIVE DIRECTOR

What would a businessman do to healthcare?

By Stephen C. Fitzer, BCMS CEO/Executive Director

So the presidential election surprised just about everyone. If you were like me, I was up at 2:00 in the morning listening to the results and couldn’t believe the underdog won the election. The new president won the election by campaigning on many issues that will reverse the trends of the past 8 years, including social issues, military, trade, and yes, healthcare. As to how it affects medicine, only time will tell. Repeal and replace was the motto, but we all know it will not be that simple or that quick.

Significant healthcare mega trends over the past four years, at the national level, have been expansion of Medicaid, paying providers for illusive “quality” performance versus fee for service, and getting everyone on health insurance through a wealth distribution model (remember Jonathan Gruber). Every time the government changes the location of the goal post, it takes years for providers to develop and implement strategies that enable them to adapt and stay in business. The cost of adapting to new models of healthcare cause financial and care setbacks. The government healthcare dollar keeps getting stretched to cover more and more with less and less.

The new president, at the time this article is written, has not yet announced any specifics as to what the new healthcare plan will look like. Of course, the two political parties are either totally in support of change or totally opposed to change, depending upon who is recommending the changes. The general populace consistently asks for unity at the national level based upon what makes the most sense and is in the best interest of the majority. But polarization is fashionable in politics, and politicians generally take the position that not giving ground, not negotiating anything, is the only acceptable position. In such a scenario, the only time anything gets done is when the president’s political party also has majority control in the house and senate. President Obama took advantage of that two-year status to ram through the Affordable Care Act, and President Trump now has a similar edge for at least the next two years.

President Trump is a businessman and will look at things very differently than his predecessor who came at things from a 10 San Antonio Medicine • February 2017

legal/academic perspective. Both presidents surrounded themselves with cabinet choices that reflect their background and perspective. That means we will likely see a 180 degree pivot on methodology going forward. Based upon that, it is interesting to speculate on what and how things can change. One serious disadvantage that the new president has is that the money was all used up by his predecessor. The United States is now about $20 trillion in debt. Interest rates are about to go up which will mean even more interest expense to service the debt created under President Obama. It means that unless President Trump can be more efficient or bring in more tax revenues, his ability to invest in his proposed programs will be finanically limited.

President Trump has promised to invest more in infrastructure, military, immigration control and private sector job creation. Based upon his promises, the places he will target to cut will be entitlement programs Supplemental Nutrition Assistance Program (SNAP and welfare), healthcare, and government size. A significant question to the provider community is “how will that impact the delivery of healthcare?” At this point, we all have our divining rods out. We listen to what he has said, who he has chosen to advise him, and what the landscape looks like and we make our best guesses. Here are some that seem logical to me.

President Trump will seek to turn more responsibility over to the states and to private enterprise. Free market economics are what he understands and believes in. That means fewer federal government programs, including cost cuts, substituted by federal government monitoring. In other words, Trump will seek to cut back the federal government actually doing things that private enterprise can do, and he will let states decide what is best for their own citizens based upon their needs and capabilities. For healthcare, this will likely impact Medicaid funding (block grants to states).

President Trump and his advisors will re-evaluate government expenses and challenge prices, terms and deliverables. Like Trump did with military suppliers, it would seem logical that he would turn his ire to pharmaceutical companies and others who have demonstrated high profile price increases in recent years. Trump appointed negotiators will go toe-to-toe with suppliers to try and extract the best deals possible.

The Affordable Care Act will be assessed as to cost, fairness, and

FROM THE EXECTIVE DIRECTOR

results. The “Robinhood” strategy of the ACA will likely be altered.

Insurance companies will likely compete openly across state lines.

The mandate for everyone to have healthcare insurance will likely be altered or completely removed. The components of children staying on their parent’s insurance policies until the age of 26, and insurance companies being required to accept policyholders with pre-existing conditions will remain, as promised, but I suspect that will come with some twists. One of the biggest reasons the ACA struggles financially is the cost of care for those who have catastrophic health conditions who were formerly uninsurable. Coverage of these patients caused everyone’s insurance premiums and deductibles to be increased exponentially to compensate for the costs.

It seems logical that the government would offer some sort of second tier underwriting of chronically and expensively ill patients, which would allow routine healthcare coverage to be offered at reasonable prices to all.

The CMS will change and will march to a different drummer, i.e. the new president. The business approach that should be expected from a free-market president would be to reduce bureaucracy and red tape. The principles of transparency of pricing will be debated and efforts to make healthcare more like a commodity business will

be considered and in some cases adopted. Monopolies will be challenged. Federal control over states’ actions will diminish. The principles of socialism and free market economy will be debated and accommodations negotiated.

The Supreme Court will become more conservative as vacated seats are refilled. Federal courts across the nation will become more conservative as new appointments are made. Roe v. Wade will be revisited. The ACA-type insurance mandates will be revisited. States’ rights will be revisited. Religious rights will be revisited. All of this will impact the delivery of healthcare.

The status quo is a very hard thing to overcome, even when no one likes the system. It is the nature of people to feel secure by knowing what the rules are and how things work. Change creates uncertainly. People hate uncertainty. Yes, even physicians who hate the bureaucracy of the healthcare system and the involvement of the federal government in their lives are afraid to change to something else, because they don’t know what will happen under new rules. Change is coming. Staying involved and participating in the process of change is the only defense we have. Either we help shape the change, or we resign ourselves to live by what other people decide. Medical societies are all about involvement and ownership of change.

visit us at www.bcms.org

11

BCMS LEGISLATIVE NEWS 85TH LEGISLATIVE SESSION UNDERWAY

The sun shines brightly on the Texas State Capitol on opening day of the 85th Texas Legislative Session.

The 85th Texas Legislature was sworn into office on January 10 and we congratulate Texas House Speaker Joe Straus (House District 121), who was elected unanimously once again as Speaker. Additionally, we congratulate the new members of the Bexar delegation: Rep. Diana Arevalo (House District 116), Rep. Philip Cortez (House District 117), Rep. Tomas Uresti (House District 118) and Rep. Barbara Gervin-Hawkins (House District 120). Cortez is a former state representative, having served previously during the 83rd legislative session. Joining them are the rest of the Bexar delegation, including House members: Rep. Roland Gutierrez (District 119); Rep. Lyle Larson (District 122); Rep. Diego Bernal (District 123); Rep. Ina Minjarez (District 124); Rep. Justin Rodriguez (District 125); and Senate members: Sen. Carlos Uresti (District 19); Sen. Judith Zaffirini (District 21); Sen. Donna Campbell (District 25); and Sen. Jose Menendez (District 26).

Mark your calendars now for First Tuesdays, which kick off on February 7. If you haven't already made plans to attend at least one First Tuesdays visit to the Capitol, please consider doing so. Your participation in First Tuesdays brings awareness to medicine's issues and credibility to the issues your patients and your practice face each day. To register for First Tuesdays, visit www.texmed.org/FirstTuesdays.

To learn more about how you can participate in legislative advocacy, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer and lobbyist, at mary.nava@bcms.org.

TMA COMMITTEE HIGHLIGHT

New Chair of TMA Select Committee on Medicaid, CHIP and the Uninsured Named At its recent Medicaid Strategic Planning Meeting, the TMA Select Committee on Medicaid, CHIP and the Uninsured introduced its new chair, Ryan Van Ramshorst, MD, pediatrician from San Antonio. He replaces outgoing chair, John Holcomb, MD. Dr. Van Ramshorst stated, "I am extremely honored to have been 12 San Antonio Medicine • February 2017

selected to Chair the TMA Select Committee on Medicaid, CHIP, and the Uninsured. I hope to follow in the footsteps of Dr. John Holcomb, outgoing Chair, who for nearly two decades so avidly lead TMA's efforts to improve the Medicaid program for patients and physicians. I first joined TMA as a medical student because of my interest in CHIP and Medicaid and am excited at the opportunity to affect positive change in these critical safety net programs."

Dr. Ryan Van Ramshorst provides opening remarks during the TMA Medicaid Strategic Planning Meeting held Jan. 10 at the TMA headquarters.

The Select Committee on Medicaid, CHIP and the Uninsured reports to the TMA Council on Socioeconomics and Council on Legislation and is charged with the following: • Develop TMA policy relating to Medicaid, CHIP, and coverage for the uninsured.

• Research and develop policy recommendations to improve the availability and affordability of health insurance in the private sector.

• Identify and develop TMA regulatory and legislative policy relating to Medicaid, CHIP, and uninsured, including efforts to reduce the administrative complexity or "hassle factor" of participating in public programs.

• Monitor state and federal regulatory and legislative issues pertaining to these programs as well as issues pertaining to safety net providers and systems.

• Coordinate and collaborate with appropriate state agency officials to promote the efficient and sensible implementation of legislation relating to Medicaid, CHIP and the uninsured and develop TMA positions and/or policy as appropriate. The committee also should track the impact of legislative and budget decisions on the Medicaid physician network, patient access to services, and quality of care.

• Collaborate, as appropriate, with provider associations, consumer groups, Medicaid and CHIP health plans, and external research organizations on studies relating to Medicaid and other publicly financed health care programs.

• Assist the Association in its efforts to promote to employers, local governmental officials, state policy makers, and the public the economic value of Medicaid and CHIP to communities and the state generally as well as the interdependence of Medicaid and CHIP and other public and private payers.

• Collaborate with county medical societies to track and assess innovative health coverage options, such as three-share initiatives, Project Access, and others.

Mary E. Nava, MBA, chief government affairs officer and lobbyist.

POPULATION HEALTH

ARE YOU FEELING WELL? SAY THANK YOU...

By Fred H. Olin, DVM, MD …to the U.S. Department of Agriculture, to Louis Pasteur, to physicians Edward Jenner, James Lind, John Snow and Walter Reed, the veterinary profession, as well as to myriads of biologists, bacteriologists, sanitarians, engineers, chemists, politicians, and scientists in a multitude of disciplines. They are directly and indirectly responsible for you and your family’s health, and to the fact that the environment in which you live isn’t a minute-to-minute risk to your survival. Let’s start with the USDA: I’m willing to bet that even the infectious disease specialists among us haven’t seen a case of Mycobacterium bovis infection in a human being. At the current time, there are usually fewer than 230 cases reported in the U.S. each year, in contrast to about 9,500 cases of M. tuberculosis infection. Back in the late 19th century, however, M. bovis was prevalent, particularly in urban populations. While direct contact or respiratory transmission is possible, the major cause was found to be milk from animals (both cows and goats) infected with the organism. In 1917, after scientific breakthroughs allowed for the early detection of bovine tuberculosis, the USDA began a campaign to eradicate the disease. Agents and veterinarians inspected and tuberculin-tested herds at nearly every cattle farm in the country. They condemned roughly 4 million reactors to slaughter without full compensation. This did not endear them to farmers and ranchers. The testing program continues today, but usually only for herds implicated when an infected carcass is found during routine veterinary inspection at a slaughterhouse. The animal’s origin is traced, and can 14 San Antonio Medicine • February 2017

result in an entire herd being killed. Of course, our friend Pasteur also comes into this discussion: “Pasteurization” involves heating milk to a temperature high enough to kill >99 percent of the viable microorganisms, but not high enough to cause precipitation of the milk proteins.

The USDA’s meat inspection program and regulations have almost eliminated Trichinosis as a significant risk. In 1996 (the most recent statistics I could find), they tested over 220,000 Midwestern market hogs and found a zero incidence of Trichinella spiralis infestation. Although occasional human cases turn up (72 during the five-year period 1997-2001) many were caused by hunters eating wild game, specifically bear meat. A few were from commercial pork products and some others were from locally-sourced (uninspected) pork. Research had revealed that feeding hogs raw garbage containing infested meat waste was the main way that the animals obtained the parasite. Legislation and regulations were put in place that outlawed that practice. Nowadays, even though it has been hard to convince consumers, it is said to be acceptable to eat pork that is only cooked to medium instead of well done. Other veterinary contributions of note are related to rabies, Q-fever, Brucellosis and several of the encephalitides caused by arboviruses, such as the St. Louis and West Nile varieties.

We all know who Jenner was. You know, the 18th century physician who developed the smallpox inoculation. Lind was a Scottish physician who carried out the first-ever clinical trial. He proved that

POPULATION HEALTH scurvy was a deficiency disease that could be prevented and cured by ingesting citrus fruit. In 1854 in London, Snow determined that an outbreak of cholera was linked to a specific public well. He also showed that another outbreak was related to a water company that was delivering River Thames water taken downstream from a sewage outlet. His paper on these incidents is considered the founding event of the study of epidemiology. As for Walter Reed, he gets a lot of credit for his work on yellow fever…but it turns out that the real hero of the determination that mosquitos of the genus Aedes were the carriers of “Yellow Jack” should be Dr. Carlos Finlay, a Cuban physician. Reed built on Finlay’s work, gave him credit in his papers, and experimentally eliminated other means of transmission. These studies led to determining that malaria was also mosquito-borne… and now we have Zika.

All of those individuals are important, of course, but they ultimately fade in contrast to the group of professionals I mentioned in the first paragraph. Collectively, they are nameless, but their activities in cleaning up our streets, homes, food, land, water and air have contributed to the health and longevity of those of us privileged to live in the so-called “first world.” Nineteenth century politicians responded to complaints of butchers and slaughterhouses dumping viscera and bones into the streets by outlawing the practice and requiring the offal be hauled off. Sanitary landfills have largely replaced

the old-fashioned garbage dump in our civilization, greatly decreasing the population of rats, flies and other vermin. Engineers working with biologists and bacteriologists devised modern methods of transporting and treating sewage to turn it into water clean enough to release into streams and rivers. Others developed lead-free paint and gasoline and are working on cleaning up the effluent from the smokestacks of industry and energy production. Mass production of food is accomplished in factories using machinery and techniques designed to minimize contamination. The factories are inspected and re-inspected for compliance with sanitary standards set by local, state and federal agencies. Breaches of the applicable standards can result in the shutdown of a facility.

So, the next time you think that we, as modern physicians, are responsible for our patients’ continuing good health, you’ll be right… to a point. But, as Sir Isaac Newton said, you are “…standing on the shoulders of giants” who did more for population health than any modern individual would be likely to accomplish.

Fred H. Olin, D.V.M., M.D. spent his time as a U.S. Army Veterinary Corps officer performing, along with other duties, sanitary inspections of food processing plants with contracts to serve the Department of Defense. If you have time to sit and listen, just ask him about his adventures doing his duty.

visit us at www.bcms.org

15

POPULATION HEALTH

CARING FOR SAN ANTONIO’S

REFUGEES

By Eden Bernstein and Fadi Al-Asadi

Walking into the San Antonio Refugee Health Clinic (SARHC) feels like stepping out of the country. The patients sit in two rows along a hallway that serves as a waiting room. They display an array of foreign garb including the vibrant colors of traditional African wear and elegant jewelry from Nepal. Your ears are inundated with the sounds of languages you may not have known existed, like Rohingya and Karen. In the background, there is a frenzy of medical, nursing, and dental students running round as they tend to their patients’ needs.

Escaping persecution, violence, and natural disasters from every part of the globe, roughly 4,000 refugees have been relocated to Bexar County over the last 5 years. The SARHC is a free clinic dedicated to serving this population with the help of students and fac16 San Antonio Medicine • February 2017

ulty from the Schools of Medicine, Nursing, Dentistry, and Allied Health. St. Francis Episcopal Church graciously houses the clinic on Wednesday evenings every week. This location is vital to the clinic’s success because it is walking distance from many of the resettlement communities, and lack of access to transportation is one of the many barriers to healthcare in this community.

Another barrier is the lack of access to health insurance. The federal government only offers refugees health benefits for 6 to 8 months upon their arrival. For many, this is not enough time to integrate into a foreign culture, learn English, and find a job that offers healthcare coverage. In certain cases, this is further complicated by a lack of education, difficulty in learning a new language (a common challenge for many of the elderly refugees), and mental illness stem-

POPULATION HEALTH ming from the traumatic situations from which the refugees are forced to flee. Even those who do manage to access health insurance or CareLink often have difficulty navigating the complexities of our healthcare system, a task daunting even for many well-educated Americans. The SARHC plays a vital role in offering these patients free outpatient care while working with the Center for Refugee Services to find ways to link them to the local healthcare system. We address a variety of ailments, from back pain, flu-like symptoms, headache, and rash to uncontrolled diabetes, chronic hypertension, and dental disease. Blood work, imaging services, and basic medications are provided at no cost to the patients, thanks to funding from the School of Nursing and the UTHSA Center for Medical Humanities and Ethics (CMHE), among others.

We first experienced the SARHC as volunteers during the initial months of medical school. In a welcomed break from the pre-clinical curriculum, we had the opportunity to make meaningful connections with real patients instead of textbooks. After several patient encounters as SARHC volunteers, we were both driven to become medical student leaders of the clinic, which involved managing the student volunteers and working with our faculty and the nursing and dental leaders to restructure various aspects of the clinic.

Volunteers at the clinic are undoubtedly moved by how their patients’ specific health ailments are related to the more general struggle that San Antonio refugees face. In a focus group study that we conducted to evaluate the impact of the clinic, we learned more about the refugee experience and how vital the clinic is for many of these patients. Many refugees told us stories about how they purposely avoid the Emergency Department in fear of an insurmountable medical bill after their 6-8 months of Medicaid expires. While some refugee groups have strong support within their communities, others described a sense of isolation and depression. As one Iraqi refugee explained, “Especially if you don’t have any English language, how are you going to express your feelings? Even if you have friends here, they are busy working. That reflects on your body. The pain, you cannot feel. Your body cannot feel.” At the SARHC, these social factors permeate into discussions about health in the form of personal narratives, which are often complex and emotional. In trying to empathize and help our patients, volunteers tend to develop a deep admiration with this population, and some feel motivated to dedicate their time to the clinic on a weekly basis, a formidable task for any busy health professions student.

One refugee from Burma articulated his perception of the struggle of refugees in San Antonio: “We left our countries and we became refugees here because we suffered there and we come here and then start suffering here too.” With help from UTHSA and CMHE faculty, St. Francis church, and the generosity of grant donors, volunteers at the SARHC practice medicine in an exceptional setting.

Fadi Al-Asadi’s experience at the SARHC shows how important the clinic is for both the patients we serve and the student volunteers that are empowered by pre-clinical patient interactions that serve as a reminder of why we came to medical school in the first place: “I had just learned a few physical exam skills and how to collect a basic patient history when I first volunteered at the SARHC and met my first patients, a family of three from Iraq. Instead of shying away, I dove headfirst into the experience. Just like that, I became a part of the body of enthusiastic clinic volunteers, and I enjoyed every aspect of it. I was touched by the gratitude that my patients expressed as we spoke. Their marked appreciation is representative of the general refugee population in San Antonio, which serves as motivation for the continued enthusiasm and the dedication of the many clinic volunteers. Given my personal experience as a refugee from Iraq, I sympathized with every patient who walked into the SARHC. I felt that I owed it to the refugee community to serve them however I could.”

They are reminded of their motivation to pursue a career serving patients and easing the lives of others by practicing healthcare that emphasizes the commonality of the human condition across all ages, cultures, and creeds.

Eden Berstein (left, above) and Fadi Al-Asadi (left, below) are currently third year medical students at UT Health San Antonio. Eden and Fadi served as Medical Student Leaders of the San Antonio Refugee Health Clinic in 2015.

To make a donation to the refugee clinic go to https://makelivesbetter.uthscsa.edu/sslpage.aspx?pid=5 02 and choose "Student Faculty Collaborative Practice" and the amount of money you would like to donate. You will be directed to a page where you can mention that the donation is towards the refugee clinic. visit us at www.bcms.org

17

POPULATION HEALTH

An anesthesiologist in Ecuador —

A Doctor on a Mission

By Paul Barton, MD

Recently, a colleague and I were discussing our respective biographies when he learned that part of my career included working as a missionary anesthesiologist in Ecuador. He then asked if I’d share these experiences here and it’s my pleasure to do so.

My journey began as early as middle school when I “happened” to apply to Health Careers High School in San Antonio only because a friend was also applying, rather than pursuing engineering as I thought I would. Through my experience at Health Careers and later at Wheaton College, my understanding of how doctors could impact the world developed. Concurrently, my understanding of the love and work of Jesus Christ for me began to form. How this has gone from news to truth that informs all that I do has developed ever since. I attended UT Southwestern Medical School with the intention of being a medical missionary, believing that this would allow my life to be lived for the good of others and, subtly believing that it might improve my favor with God. The time during my medical education and initial surgery residency unfortunately lacked growth and closeness with God. I didn’t see clearly the connection of my faith and everyday life. Everyday life, it seemed, was truly all 18 San Antonio Medicine • February 2017

consuming through medical school and surgery residency and I didn’t cope well. Ultimately I changed to anesthesia. Recently, a colleague here in San Antonio, told me that he chose anesthesiology partly because he saw the sour soul I’d become as I was consumed by struggling to keep afloat while a surgical resident. I see that God was protecting me and leading me from surgery to anesthesia and then overseas. Again, what I was lacking and only understood dimly was the role of God and how he informed all of life. My understanding of God’s role was one who saves the soul, while my part of the bargain was to do what I saw as the ultimate good — being a medical missionary. That way I knew that everyday, no matter what I was doing specifically, on the whole, I was serving God and making him happy with me.

After considering our options and visiting various mission hospitals, my family and I moved to Ecuador in the fall of 2007. We first lived in Quito for nine months to learn Spanish and then to our ministry site in the town of Shell in the summer of 2008. Dr. Suarez, an Ecuadorian trained anesthesiologist, and I split coverage at Hospital Vozandes del Oriente, the 30-bed mission hospital in Shell. We

POPULATION HEALTH Opposite page: View of Hospital Vozandes from my back porch with Sangay Volcano in back. This page: One of my patients post apendectomy.

shared call coverage and the operating room schedule generated by the two full-time surgeons and many visiting ones over the years.

General surgery, orthopedics, pediatrics, obstetrics, gynecology, ophthalmology, ENT and the occasional epidural hematoma kept us busy. We even assumed the role of intensivist as the need arose in the hospital’s two ICU rooms. Interestingly, what I didn’t see was much heart disease or obesity. A simple diet and prevalence of walking as the primary mode of transportation was striking. Consequently, I found all intubations relatively easy... and I don’t say that lightly. Though ever vigilant for the difficult airway, it never really came. Occasionally, I would use a video laryngoscope to intubate a trauma patient with an uncleared c-spine, not because their anatomy was particularly difficult.

I practiced anesthesia, in general, much the same way I do in America. The frequent use of spinal anesthesia being the biggest exception. If it could possibly be done with a spinal, it almost always was. The culture of medicine was such that, if a pill was good, an injection was sure to cure making it the natural choice by most patients. Complementing this was the overall fear of a general anesthesia that must have been sown liberally throughout the community by frequent real world mishaps. On many occasions, I heard of the unfortunate demise of some patient’s relative or friend after “going to sleep” for their surgery somewhere else

in the country. Consequently, patients gladly “stayed awake” with spinal anesthesia. Also, I’m grateful to God that this misfortune never happened at our hospital.

I was thankful to have most of the same anesthetic pharmaceuticals available to me here. What I occasionally lacked was medicine choice “B” or “C” if what I had wasn’t quite what was needed though this didn’t feel burdensome. Besides wearing the hats as an anesthesiologist and intensivist, I was also the recovery room nurse. I became adept at caring for both a recovering patient in one room and preparing for the next anesthetic in the adjacent OR. Equipment was thankfully very similar to what I had in residency. I quickly learned what brand of anesthesia machine and monitors are the most robust for the harsh 100 percent humidity environment and those that most certainly were built to function only in the most hospitable of Western hospital environments. ICU ventilators were the most temperamental. I used several brands and models while in Ecuador and they all kept me up at night wondering if they might fail, and sometimes they did. Temperamental ventilators, combined with frequent power outages, made things interesting to say the least.

When those “newer” models did fail, however, I always knew I could pull out “old blue faithful.” This ventilator was so old that it probably is only one generation newer than the iron lung! I don’t think it even had any computer chips, only vacuum tubes and metal dials to make adjustments. It’s simplicity and ruggedness made it perfect for that setting, I guess. It never failed to fire up and breath for a patient so I didn’t have to. I was most thankful it was in the closet and available when needed.

Many days were not so rosy and memories of tragic stories come to mind. Those of children of children perishing from burns, snake bites, and drowning are particularly difficult. Just as heartbreaking is an episode of postpartum DIC that failed to respond to our best efforts claiming the life of this new mother. Another is that of a 28week infant stillborn to a mother with ecclampsia. Other days, miracles abounded including a child recovering from a craniotomy for an epidural hematoma, cerebral palsy patients receiving treatment for limb contractures and the countless healthy babies born, and gall bladders and appendixes removed.

My family thrived in Shell and my four boys still consider it home. My youngest was even born there. How can boys not thrive with Amazon jungle to explore in their backyard and friends of all ages living next door in every direction? I truly enjoyed beginning each day with my 30-second walking commute to the hospital each morning. The view frequently was that of a snowcapped, mostly dormant, perfectly conical volcano to one side and uncut Amazon continued on page 20 visit us at www.bcms.org

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POPULATION HEALTH continued from page 19

rain forest in the other. Occasionally a Cessna airplane emerged over the horizon, taking off from the local airstrip bound for one of 300 jungle dirt airstrips ferrying locals, patients and teachers back and forth from civilization. I took “in house call” coverage for the entire hospital from my own bed. At times, if the weather was just right, I could even hear the ICU pulse-ox beep through my bedroom window. Many nights I would fall asleep to a heavy jungle rain drenching the Above left: Starting craniotomy with hand powered drill. Above: Child who suffered large thin, uninsulated roof of our house. My boys burn now healing after many debridments. walked to the local missionary school daily across a thrilling cable suspension bridge spanning a gorge of about 100 feet deep and 200 feet across. Time God’s purpose for my life, regardless of whether I’m an overseas off was spent quietly enjoying the slower pace of life or exploring missionary or not. As a person created by God and placed exactly the local “eco-tourist” type sites. here in human history and, as I do what God has gifted me to do However, even with this acute sense of a higher purpose, I often and seek to be a servant leader to those around me, I am fulfillwondered if God was truly happier with me because of my job. I ing all that God intends for me to do and be. In doing so, I give now realize that, in part, I had been making an idol of the very thing God glory. This, in fact, is what I was created for and by doing that I’d hope would make me better in God’s eyes. I also found mysuch, I derive my greatest joy. self asking at least every week why was I doing this. There must be Further, I’m learning who my neighbor truly is. You may recall more to it than just service. These questions continued to percolate Christ’s example he used to help us identify our neighbor, in the when the hospital closed in 2013 due to lack of funds and medical parable of the Good Samaritan. Several religious, wealthy and influstaff and I once again made an international move with my family. ential people pass by a poor soul who has been robbed and beaten Faced with adjustment back to America, I’ve been forced to exand left by the side of the road. Those who represented religion and amine my motivations and the lessons during my time overseas. I influence and wealth only offered excuses as they kept on going. The have grown in several ways. First, I see my profession as part of one who stopped and helped above and beyond what anyone would 20 San Antonio Medicine • February 2017

POPULATION HEALTH expect was a foreigner, an unlikely candidate indeed. What stands out to me is that my neighbor isn’t only the poor and unhealthy overseas but the one with whom I interact during the natural course of daily life.

Finally, a Christmas carol you may have heard, Joy to the World, describes how Christ has come to ultimately make everything as it was intended by reversing the curse of sin that has damaged all things. This gives insight to another lesson learned. This carol reminds me that all of nature was damaged and not as God intends due to sin entering the pure and perfect creation of God. Various parts of nature rejoice that the curse is broken and all things are new again as they were intended to be because of Gods renewal. As a physician, both here and abroad, I see in human form the curse of sin that I believe breaks human bodies daily. It’s my privilege to have a small part in reversing this curse with the gifts and opportunities that God has granted me in medicine. I’m able to participate in the cure to the brokenness in human bodies and have the privilege to offer God’s blessings in the form of excellent medical care to reverse a part of this curse. This form of service to my neighbor gives me joy and God glory.

I’m blessed to have had the opportunity to serve abroad and thankful for the insights it has given me into God’s daily work in my life and the lives I encounter daily. I hope that I’ve encouraged

The Barton Family relaxing at home in Shell, Ecuador.

you to see your profession as an opportunity to participate in God’s renewal of all things and that every interaction to bring health to our patients serves this purpose.

visit us at www.bcms.org

21

POPULATION HEALTH

POPULATION

HEALTH MANAGEMENT

By Alan M. Preston, MHA, Sc.D.

As a former professor teaching Epidemiology, the phrase “Population Health Management” resonates with me. Epidemiology is the study of the incidence and prevalence rates of diseases within certain populations. Incidence rates describes the sudden onset of a disease and the prevalence describes how long a disease may be present in a given population. However, in the context of a physician’s practice, “Population Health Management” takes on an entirely different perspective.

Physician’s manage one patient at a time. Over the course of a year however, if we added up all the patients seen by a primary care physician, the entirety of that population may have some common characteristics that may need to be tracked and managed. And to the extent a primary care physician averaged 20 patients visits a day for 210 days out of the year, they would encounter approximately 4,200 patient visits. Some of the visits are repeat follow-up visits and probably account for over 50 percent of the patient “population.” Thus, a primary care physician may have a panel of patients for a year of approximately 2,500 to 3,000 patients.

Of that “population” of patients, there are some characteristics of patients that have similar disease classifications. Take Type II diabetes for example; The prevalence rate of Type II is approximately 9.3 percent (i.e. 29 million people) according to the CDC. However, over 86 million have “pre-diabetes.” And of the 29 million people who 22 San Antonio Medicine • February 2017

have Type II, approximately 8.1 million people don’t know they have it and are undiagnosed.

This is a good example where population health management can play an important role for both the patient and the doctor. Imagine if a physician’s practice ran a report that looked at many of the risk factors for Type II diabetes. Some of the risk factors would be: age, weight, ethnicity and gender, to name a few. That list could be crossreferenced with known lab data to determine whether the “population of interest” had their Hba1c or blood sugars tested and resulted.

If not, scheduling the patient for a visit to perform such a test in the population of interest might reveal undiagnosed patients and prediabetic patients. Treating the undiagnosed patient and the pre-diabetic patient is the benefit of population health management.

And the Centers for Medicare and Medicaid Services (CMS) is very interested in physicians that understand how to perform population health management functions. CMS understands that physicians that understand the benefit of population health management should be paid for their patients’ improved healthcare outcomes.

Of course, the private Medicare Advantage insurance companies are already contracting with physician groups and Independent Practice Associations to share in the savings these organizations deliver in helping physicians achieve such outcomes. And for the independent physician, teaming up with an experienced IPA can add value

POPULATION HEALTH to their practice immediately. Some of the Medicare Advantage plans are sharing in the savings to the extent that the IPA and their physicians achieve a medical loss ratio (MLR) less than the contracted target of the health plan’s MLR. And since the physician receives a fee for service (FFS) amount for each office visit of the Medicare Advantage patient on the front-end, there is simply upside income potential for the physicians on the split savings on the back-end, when the doctor is participating in an experienced IPA. Thus, when the front-end payment is added to back-end split in savings, some physicians have collected over 200 percent FFS in reimbursement for their population of interest. Now that is a compelling reason to begin understanding “Population Health Management.”

Of course, for physician’s that have a full booking of patients, adding more patient visits to their busy schedule can seem daunting.

The key is to prioritize the patients from those with the most severe and acute disease, which may need treatment sooner than later and the less severe that can be fit into the doctor’s schedule over time.

Unfortunately, most practices are not that proactive in managing their patient population. Many practices are filled by the patient demand. A patient has a symptom and calls their doctor to be seen.

Seldom does a practice data-mine their own patient population to determine who might be at risk for some particular disease and reach out to these patients in an effort to slow down the progression of the disease or, in some cases, stop it altogether.

Population health management involves many aspects of managing a patient. The goal is to assure that for a given disease, the patient is contacted, treated, followed-up and the outcome is improved.

There have been some early elementary attempts of trying to get physicians to adopt components of population health management.

The Healthcare Effectiveness Data and Information (HEDIS) is one such attempt.

HEDIS is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Many health plans use the HEDIS measurements to highlight their scores to prospective employers. HEDIS measures address a broad range of important health issues. Among them are the following: Asthma Medication Use Persistence of Beta-Blocker Treatment after a Heart Attack Controlling High Blood Pressure Comprehensive Diabetes Care Breast Cancer Screening Antidepressant Medication Management Childhood and Adolescent Immunization Status Childhood and Adult Weight/BMI Assessment For the Medicare Advantage population, CMS has used another tracking program called STAR. One of the differences between

HEDIS and STAR is that HEDIS is responsible for making sure that providers at least perform the activities of measurement as required by HEDIS, whereas STAR requires both the performance of the measurement activity with the additional requirement of demonstrating improved outcomes. Thus, it is not good enough that the doctor saw the patient, they also need to make sure that the prescribed treatment is heading in the right directions in terms of outcomes.

Star Ratings are driving improvements in Medicare quality. The Star Ratings measures span five broad categories: Outcomes Intermediate Outcomes Patient Experience Access Process Not every domain is weighted equally however. For 2017 Star Ratings, outcomes and intermediate outcomes continue to be weighted three times as much as process measures, and patient experience and access measures are weighted 1.5 times as much as process measures.

CMS assigns a weight of 1 to all new measures. Of the 364 health plan contracts that participate in Medicare Advantage, there were only 81 with a STAR rating of 4.5 or higher.

The implications for physicians is that health plans want to contract with physicians, or IPAs that contract with high performing physicians, that can demonstrate high STAR ratings. Those physicians that have lower STAR ratings may find cancelation notices from the managed care companies. The private Medicare Advantage companies will not, in the long run, keep physicians that are doing a poor job managing their population of patients. Thus, if you are a physician that is looking to participate in population health management, you might want to first look at high performing Independent Practice Associations (IPAs) to assist you with your practice before you receive a cancelation notice from a managed care company that is measuring every doctor on their plan.

Alan Preston, MHA, Sc.D., is the Executive Director of IntegraNet Health San Antonio, an IPA that helps physicians navigate through the difficult regulatory framework and helps them achieve higher reimbursements from insurance companies; skilled with a tremendous background in managed care and Population Health Management, epidemiology, team building, and biostatistics; strong healthcare professional with a Doctor of Science (Sc.D.) focused in Public Health, Health Services Research from Tulane University School of Public Health and Tropical Medicine. Dr. Preston is involved in risk sharing contracts, ACOs, Medicare Advantage including RAP scores, HEDIS, and STAR ratings which helps physicians and health plans alike in reducing MLR. visit us at www.bcms.org

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FREE CME

FEATURE

Dancing with Deva

Infusing a powerful medium into the culture of San Antonio

By David Schulz, CHP, is a member of the BCMS Publications Committee.

It’s a great achievement for a school to reach its 35th anniversary. For a school run by volunteers, devoted to an exotic art, spawning three sister schools, it’s an unmitigated accomplishment a rare feat. But to succeed and endure so well in a city with three centuries of its own dense-packed cultural roots? Well, that’s a story.

And it begins in India, when Rajam (Ramamurthy), a young medical student raised in a small mining town, takes the test for Foreign Medical Graduates (ECMFG) to enter a residency program in the U.S. It was the very last exam given in India, thereafter, the government, alarmed at the growing brain-drain following independence, slammed the door in 1967, halting the test.

“But I was successful in passing and began a pediatric residency in Cook County Hospital in 1967,” Ramamurthy said.

“I came to the U.S. with the idea of training in Pediatric surgery. As an intern, I trained under a great pediatric surgeon, Dr. John Raffensperger,” she said. “Realizing that to do pediatric surgery one trained in general surgery and limited practice to children, I was disenchanted.

It was during my first rotation in the newborn intensive care unit that I fell in love with Neonatology.”

Infant patient care was, as always, a critical issue needing attention. Although neonatal intensive care units were established in most teaching institutions, neonatology as a specialty was recognized by the American Board of Medical Specialties when I was in my third year of pediatric training and I was the first Fellow in the program to complete the fellowship.

“Things were changing very quickly then,” she recalls. Change was happening outside the hospital too, as in 1968 when Chicago became notorious for its highlycharged political atmosphere and demonstrations.

26 San Antonio Medicine • February 2017

“What sticks in my mind,” says Dr. Ramamurthy, “was the Vietnam War and the medical students who were in the thick of it.” But as a foreign student, she was counseled to stay away from controversy.

“I couldn’t be quiet. I wanted to support my colleagues, many of whom were recruited into the services. Activism was everywhere… I was the secretary of the house staff organization and we pulled off the very first boycott demanding improved patient care, better salaries for trainees and better supervision. When the leaders of the house staff were arrested, I narrowly missed going to jail as I wasn’t on call the night the police showed up,” recalls Dr. Ramamurthy.

In 1977, Dr. Ramamurthy’s husband, an anesthesiologist, had an offer from the University of Texas Health Science Center in San Antonio in the startup of their pain management program. With two children under 3 years of age, Ramamurthy decided to work part-time. Very quickly the demands of work pressured her to become full-time. The Windy City’s loss became the Alamo City’s gain.

“We loved San Antonio,” Ramamurthy said. “It was the perfect size for us and a great place to raise kids; Great weather and it was easy to get around with no traffic hassle like in Chicago.”

And then, dance struck. “When my daughter was about to turn five, we were in a gathering with a number of families, and as the women were chatting, the conversation turned to Indian dance … how much we loved dance, and loved to dance.”

Dr. Ramamurthy paused the narrative to provide context of this ancient art: “You see, under British influence, traditional Indian dance was denigrated and kind of taboo, parents did not encourage girls to learn dance.” It was a remnant of the days when only the courtesan community learned to perform the Bharatnatyam, a 3,000-years-

old art. Bharatnatyam encompasses the disciplines of music, dance and drama that was a medium for educating the public about spiritual, social and political concepts.

“This is how culturally embedded lessons were transmitted,” she said. “It slowly moved to the Temples as a holy offering, and eventually, daughters were devoted to the Temple by families as Devadasi — similar to novices entering a convent.”

Back in San Antonio, Ramamurthy says “So four physicians and one computer programmer, were talking about making it possible for our daughters to have an opportunity to study this ancient art form that was denied us.”

“We decided to establish a school in San Antonio. Our teacher, Revathi Satyu from Terrel, Texas, had started a school in Dallas.

But she could only come from North Texas once a month. “We agreed that wouldn’t work for five and six year olds. The mothers decided to learn and hold a class every week.”

“So there we were, five of us and six children, formed the Arathi School of Indian Dance in 1981. It was the third school in Texas and one of the earliest ones in the U.S. We would learn with the children, take notes (Camcorders had not arrived),and teach every Friday evening.”

Words don’t have the bandwidth to describe the rich experience of Indian dance; far better to direct you to the Arathi School videos on YouTube … and be prepared to be mesmerized by colorful costumes and amazing young students. Both strenuously athletic and peculiarly precise, the Arathi training demands physical discipline no less than any classical corps-de-ballet.

Celebrating the school’s 35th anniversary this fall offered Dr. Ramamurthy a chance to review the value of dance instruction, to health and development.

“Dancing is in par with any aerobic

FEATURE

sports, fast walking, and similar activities — dancing fast burns up to 175 calories a minute,” adding that, “the postures one takes in dance make you use a different set of muscles and different joint positions than in other activities like running. In that respect dance is closer to swimming.”

Just as important — or perhaps even more in a stressful world — is the mental engagement.

“It is a pleasurable experience and for me, very like meditation,” Ramamurthy says.

“One’s mind is completely emptied of all thoughts except the pure movement being experienced. I know several students who were in college and medical school who made the time to dance when they were stressed. It is a great healer for the mind as well.”

As a professional focused on children’s well-being, “Teaching dance to children at age four or five has given me great insight as to children’s physical development. Also, being a pediatrician with knowledge about development has helped me to teach movement in a more scientific way.”

Above: The students and teachers of The Arathi School of Indian Dance in 2014.

Below: Dr. Malathi Koli, Dr. Rajam Ramamurthy and Mrs. Madhu Mehta are founders of the school.

In the end, though, it is the addition to the cultural firmament of San Antonio that seems most momentous. “So now, as we celebrate the 35th anniversary of our school, there are a total of four schools devoted to Indian dance in San Antonio — all inspired from our initiative back in 1981. In the four schools in San Antonio, close to 300 students are enrolled in studying Indian classical dance at any given time.”

The Arathi School of Indian Dance provides a forum for the people in the Indian diaspora to connect with Indian culture.

The art and artists have been the first in many ways to connect with the mainstream and have enriched the arts in San Antonio in proportions far beyond the population that accounts for less than 0.2 percent in San Antonio.

“A definite achievement for us founders is the transitioning of the school to two outstanding young women, one our own student and the second an accomplished teacher trained in Chicago that Rajam considers her hometown in the U.S. It is time to pass the baton,” says the school’s founder. visit us at www.bcms.org

27

DATA EXCHANGE

NEW TECHNOLOGY PAVES WAY FOR HIPAA-COMPLIANT DATA EXCHANGE New printer functionality enables cost-effective, quality care coordination throughout healthcare ecosystem

By Wayne Parker As we enter 2017, many would assume that most, if not all, hospitals and health systems have adopted secure electronic data transmission and that the days of faxing reams of patient documentation are long gone. In fact, there are still great discrepancies in technology maturation between large, well-funded medical centers and small to mid-sized, community-based providers. These digital inequities play out all around the country, endangering care coordination and continuity of care when paper documents are misinterpreted, misfiled or lost altogether. But the real-world solution is complex. While large healthcare organizations have benefitted from $30 billion in incentives to adopt Electronic Medical Records (EMRs), there is very little left of that pool of dollars for smaller providers to tap.

Smaller healthcare facilities benefit from streamlined records management Meanwhile, thousands of smaller, community-based skilled nursing, long-term care and rehabilitation and behavioral healthcare providers have been left behind. The irony is that these providers

28 San Antonio Medicine • February 2017

are crucial to creating an efficient continuum of care that is focused on improving outcomes and lowering healthcare costs. It is incumbent upon the healthcare IT industry to develop new, lightweight, low-cost solutions that deliver relevant information at the right time, in the right format and at the point of care to assist healthcare providers in making vital medical decisions. Community-based providers need interoperability options that don’t require heavy IT infrastructure or knowledge, and don’t cause disruptions to existing provider workflows. Every healthcare organization, regardless of size, should have the opportunity to reap the benefits of electronic document exchange to strengthen care coordination.

Simple, easy and secure processing of patient records But there is good news on the horizon. New multifunction printers (MFPs) now on the market have been designed with healthcare providers in mind. They can offer not only fulfillment of administrative tasks, but also the brokering of secure transmissions of Pro-

DATA EXCHANGE

tected Health Information. Using the same outbound workflow, providers can perform any of the five functions: print, scan, copy, fax and the new ability to electronically “share” patient information with another provider via secure data transmission. These new MFPs enable providers to instantly access HIPAA-compliant data exchange networks, regardless of their level of adoption of digital exchange and EMRs. There are also new services that provide subscription-based access to secure health information networks that can be used with the new MFPs. Providers using these services gain the ability to receive digital patient documentation using cloud-based technology. This technology enables providers to exchange patient information in a variety of digital transmission modalities that best meet a given provider’s needs — from cloud fax to direct messaging and more. This ability to digitally send patient information from the MFP device, and electronically send and receive data via a secure network, supplies healthcare organizations with the means to optimize care coordination.

The focus on care transitions continues to increase in significance as community hospitals, specialists, referring providers and larger healthcare organizations collaborate to deliver high-quality care to

populations in a geographically agnostic, technologically egalitarian manner.

At approximately the same price as the standard multifunction model, these new MFPs offer scalable, secure digital transmission capabilities that will support healthcare organizations as they move towards electronic patient document exchange today, and will ease the transition to EMRs in the future.

That an MFP should be leading the interoperability charge is somewhat ironic, because for years, paper-based systems like these contributed to delayed adoption of digital data exchange. Now it is delivering exactly what the healthcare industry has been asking for: a quick, easy and affordable way to drive better care coordination, workflow efficiencies and patient outcomes — across the care continuum — while meeting regulatory-driven demands for interoperable document exchange.

Wayne Parker is a major account executive with San Antonio-based Dahill, a leader in the office technology and business consulting area.

He can be reached at 210-805-8200 ext. 10121 or wparker@dahill.com.

visit us at www.bcms.org

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BUSINESS

FIDUCIARY DUTY and What It Means for You

By Stephanie Dick

A common denominator certainly seems to exist between professionals in the medical, legal, accounting and financial planning industries. There appears to be a genuine attempt to preserve and enhance trust and transparency and eliminate conflicts of interest between practitioners and the public they serve. For example, physicians recite The Hippocratic Oath prior to practicing medicine and are held to certain ethical and professional standards of conduct. Attorneys, Certified Public Accountants (CPA) and Certified Financial Planners (CFP) practitioners take an oath and are bound by prescribed ethical and professional standards of conduct.

It is commendable that these professional disciplines and perhaps others not mentioned here continually strive to raise the bar in the areas of integrity, fairness and objectivity. In the case of the financial planning industry, many commit to similar professional standards but to the consumer it is often less clear. The consumer is left to discern and understand the subtle yet important differences among professionals who market themselves as providing financial planning services.

Understanding Differences “Financial planning” is a phrase ubiquitously marketed in the financial services industry today. A simple Internet search for “financial planning” returns a seeming limitless number of organizations, professionals and articles centered on this topic. While presumably serving similar purposes, these organizations and professionals holding themselves out as providing financial planning services are actually quite different in their objectives and the methods they use to accomplish their goals.

In 2007, the CFP Board’s Rules of Conduct were amended to require CFP practitioners to provide their financial planning services as a “fiduciary.” Specifically, CFP professionals today are required to act in the best interest of their financial planning clients and put the client’s interests ahead of their own when providing financial planning services. On the other hand, professionals who do not hold the CFP certification or another professional designation which requires them to place their client’s interest before their own can still market themselves as providing financial planning services.

The potential and natural consequence here, of course, is that the financial planning professional who is not held to a fiduciary standard is likely not required to disclose all of the material factors, such as compensation, which can help to shape the recommendations 30 San Antonio Medicine • February 2017

they are advising their client to consider. While it may not take a fiduciary standard to be imposed before a professional is willing to share material factors such as compensation with a client, the imposition of a fiduciary duty does help to reinforce what should and needs to be shared with a client so that they can make a fully informed decision.

Explaining Benefits So how can a client potentially benefit by engaging a financial planning professional held to a fiduciary standard? A quick example may help to shed some light on the potential benefits. Suppose Mr. and Mrs. Smith, both in their 70s, have a $15 million net worth, have done very little estate planning, and are concerned that federal estate taxes will erode some of the wealth that they hope to transfer to their son and to charity.

Most planning professionals would agree that there are numerous estate planning techniques and strategies that could be considered here to assist the Smith family with their goal of maximizing the transfer of their wealth to the next generation and charity in a taxefficient manner. For illustration purposes, though, let us assume that a financial planning advisor who is not held to a fiduciary standard is only advising them to create and purchase a second-to-die life insurance policy owned by an insurance trust because the advisor is compensated by insurance commissions. On the other hand, a financial planning professional who is held to a fiduciary duty could certainly recommend a similar type of insurance trust strategy but the advisor would also be bound to share other relevant solutions such as charitable gifting strategies which provide no monetary benefit to the advisor.

Stephanie Dick is vice president of commercial banking for BB&T Wealth in San Antonio. She can be reached at 100 NE Loop 410, Suite 806, San Antonio, TX 78216; 210-744-4396 or SDick@BBandT.com.

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Padgett Stratemann & Co., LLP (HH Silver Sponsor) Padgett Stratemann is one of Texas’ largest, locally owned CPA firms, providing sophisticated accounting, audit, tax and business consulting services.

Vicky Martin, CPA 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com “Offering service more than expected — on every engagement.”

Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com “Dedicated to working with physicians and physician groups.”

ACO/IPA

ASSET MANAGEMENT

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management”

ATTORNEYS IntegraNet Health (HHHH 10K Platinum Sponsor) IntegraNet Health is an Independent Physician Association that helps physicians achieve higher reimbursements from insurance companies whereby some of our higher performing physicians are able to achieve up to 200% of Medicare FFS. Executive Director Alan Preston, MHA, Sc.D. 1-832-705-5674 Apreston@IntegrNetHealth.com www.integraNetHealth.com

ARMY HEALTHCARE 5th Medical Recruiting BN (HH Silver Sponsor) We recruit quality men and women who would like to be a part of our team.

SFC Cherie Kirk 210-692-7376 Cherie.k.kirk.mil@mail.mil www.youtube.com/watch?v=kweqi 3TelO8 "Serving to heal, Honored to serve"

32 San Antonio Medicine • February 2017

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”

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability,

Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

Jeanne Bennett 210- 343-4556 jeanne.bennett@amegybank.com Karen Leckie 210-343-4558 karen.leckie@amegybank.com www.amegybank.com “Community banking partnership”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Stephanie Dick Vice President- Commercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755 vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”

Broadway Bank (HHH Gold Sponsor)

Healthcare banking experts with a private banking team committed to supporting the medical community.

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

Frost (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Lewis Thorne 210-220-6513 lthorne@frostbank.com www.frostbank.com “Frost@Work provides your employees with free personalized banking services.”

IBC Bank (HHH Gold Sponsor) IBC Bank is a $12.4 billion multibank financial company, with over 212 facilities and more than 325 ATMs serving 90 communities in Texas and Oklahoma. IBC BankSan Antonio has been serving the Alamo City community since 1986 and has a retail branch network of 30 locations throughout the area.

Markham Benn 210-518-2500, ext. 26921 MarkhamBenn@ibc.com www.ibc.com “Leader in commercial lending.”

Ozona Bank (HHH Gold Sponsor) Ozona National Bank is a full-service commercial bank specializing in commercial real estate, construction (owner and non-owner occupied), business lines of credit and equipment loans.

Lydia Gonzales 210-319-3501 lydiag@ozonabank.com www.ozonabank.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY www.rbfcu.org Regions Bank (HHH Gold Sponsor) VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com

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

SSFCU (HHH Gold Sponsor) Founded in 1956, Security Service provides medical professionals with exceptional service and competitive rates on a line of mortgage products including one-time close construction, unimproved lot/land, jumbo, and specialized adjustable-rate mortgage loans.

Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs.

Competitive rates, favorable terms and local decisions.

Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org RBFCU (HH Silver Sponsor) 210-945-3800 nallen@rbfcu.org

CONTRACTORS/BUILDERS /COMMERCIAL

Huffman Developments (HHH Gold Sponsor) Premier medical and professional office condominium developer.

Our model allows you to own your own office space as opposed to leasing.

Steve Huffman shuffman@huffmandev.com 210-979-2500 Shawn Huffman shhuffman@huffmandev.com 210-979-2500 www.huffmandev.com

RC Page Construction, LLC (HHH Gold Sponsor) Commercial general contractor specializing in ground-up & interior finish out projects. Services include conceptual & final pricing, design-build & construction management. Single-source management from concept to completion ensures continuity through all phases of the project.

Clay Page 210-375-9150 clay@rcpageconstruction.com www.rcpageconstruction.com

ELECTRONIC DOCUMENTATION AND TRANSCRIPTION SERVICES Med MT, Inc. (HH Silver Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

Ray Branson 512-331-4669 branson@medmt.com www.medmt.com “The Med MT solution allows physicians to keep practicing just the way they like.”

EMPLOYEE BENEFITS

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource adminis-

tration/management, workers’ compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

FINANCIAL SERVICES

Northwestern Mutual Wealth Management (HHHH 10K Platinum Sponsor) Our mission is to help you enjoy a lifetime of financial security with greater certainty and clarity. Our outcomebased planning approach involves defining your objectives, creating a plan to maximize potential and inspiring action towards your goals.

Fee-based financial plans offered at discount for BCMS members.

Eric Kala CFP®, AEP®, CLU®, ChFC® Wealth Management Advisor | Estate & Business Planning Advisor 210.446.5755 eric.kala@nm.com www.erickala.com “Inspiring Action, Maximizing Potential”

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!”

e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to individuals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose.

Managing Partner

Joseph Quartucci, ChFC® 512-268-9220 jquartucci@e3wealth.com Senior Partner Terry Taylor 512-268-9220 ttaylor@e3wealth.com Senior Partner Jennifer Taylor 512-268-9220 jtaylor@e3wealth.com www.e3wealth.com

Frost Leasing (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Laura Elrod Eckhardt 210-220-4135 laura.eckhardt@frostbank.com www.frostbank.com “Commercial leasing for a doctor’s business equipment and vehicle.”

Intercontinental Wealth Advisors LLC. (HHH Gold Sponsor) Your money’s worth is in the things it can do for you, things that are as unique and personal as your heart and mind. We craft customized solutions to meet investment challenges and help achieve financial objectives.

Vice President Jaime Chavez, RFC® 210-271-7947 ext. 109 jchavez@intercontl.com Wealth Manager David K. Alvarez, CFP® 210-271-7947 ext. 119 dalvarez@intercontl.com Vice President John Hennessy, ChFC® 210-271-7947 ext. 112 jhennessy@intercontl.com www.intercontl.com “Advice, Planning and Execution that goes beyond portfolio management” First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor)

continued on page 34

visit us at www.bcms.org

33

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 33 The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

Amer Kaissi, Ph.D. Professor and Executive Program Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

HEALTHCARE REAL ESTATE

SAN ANTONIO COMMERCIAL ADVISORS (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

HOME HEALTH SERVICES Abbie Health Care Inc. (HH Silver Sponsor) Our goal at Abbie health care inc. is to promote independence, healing and comfort through quality, competent and compassionate care provided by skilled nurses, therapists, medical social worker and home health aides at home.

Sr. Clinical Account Executive Gloria Duke, RN 210-273-7482 Gloria@abbiehealthcare.com "New Way of Thinking, Caring & Living"

HOSPITALS/ HEALTHCARE SERVICES

Southwest General Hospital (HHH Gold Sponsor) Southwest General is a full-service hospital, accredited by DNV, serving San Antonio for over 30 years.

Quality awards include accredited centers in: Chest Pain, Primary

34 San Antonio Medicine • February 2017

Stroke, Wound Care, and Bariatric Surgery.

Director of Business Development Barbara Urrabazo 210.921.3521 Burrabazo@Iasishealthcare.com Community Relations Liaison Sonia Imperial 210-364-7536 www.swgeneralhospital.com “Quality healthcare with you in mind.”

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

Miranda Peck 210-482-3000 Jana Raschbaum 210-478-6633 JRaschbaum@selectmedical.com mipeck@selectmedical.com http://sanantonio-rehab.com “The highest degree of excellence in medical rehabilitation.”

HUMAN RESOURCES

e-ESI (HHH Gold Sponsor) Locally owned since 1999, we believe it’s all about relationships. We keep our partners compliant assisting with human resource administration/management, workers’ compensation/risk management, benefit administration, and payroll. We help our partners concentrate on what they do best...Service their customers.

Lisa Mochel (210) 495-1171 lmochel@eesipeo.com www.eesipeo.com

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”

INFORMATION AND TECHNOLOGIES

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey@henced.com www.henced.com Henced offers BCMS members custom pricing.

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need.

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

Frost Insurance (HHH Gold Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

Bob Farish 210-220-6412 bob.farish@frostbank.com www.frostbank.com “Business and personal insurance tailored to meet your unique needs.”

INSURANCE

SWBC (HHHH 10K Platinum Sponsor) SWBC is a financial services company offering a wide range of insurance, mortgage, PEO, Ad Valorem and investment services. We focus dedicated attention on our clients to ensure their lasting satisfaction and long-term relationships.

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

The Doctors Company (HH Silver Sponsor) The Doctors Company is fiercely committed to defending, protecting, and rewarding the practice of good medicine. With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer. Learn more at www.thedoctors.com.

Susan Speed Senior Account Executive (512) 275-1874 Susan.speed@thedoctors.com Marcy Nicholson Director, Business Development (512) 275-1845 mnicholson@thedoctors.com “With 78,000 members, we are the nation’s largest physician-owned medical malpractice insurer” MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.

Patrick Flanagan

844-4-NORCAL pflanagan@norcal-group.com www.norcalmutual.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew Market Manager kaskew@proassurance.com Mark Keeney Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET/ TELECOMMUNICATIONS

Spectrum Business Class (HHH Gold Sponsor) When you partner with Spectrum Business Class, you get the advantage of enterprise-class technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Sales Leader Medical Market Rick Garza 210-582-9597 rick.garza@charter.com “Spectrum Cable Business Class offers custom pricing for BCMS Members.”

MARKETING ADVERTISING SEO

Henced (HHH Gold Sponsor) Henced is a customer communications platform that provides businesses with communication solutions. We’ll help you build longlast customer relationships by effectively communicating using our text and email messaging system.

Rainey Threadgill 210-647-6350 Rainey.Threadgill@rainman.com www.henced.com Henced offers BCMS members custom pricing.

MARKETING SERVICES

solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com

MEDICAL BILLING AND COLLECTIONS SERVICES Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHHH 10K Platinum Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 percent to 50 percent.”

MERCHANT CARD/CHECK PROCESSING Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, collaborating to deliver nextgeneration technology and help our clients grow their businesses.

Sandra Torres-Lynum SR. Business Consultant 25 years of dedicated service 210-387-8505 Sandra.TorresLynum@FirstData.com ‘The true leader in the payments processing industry’

MERCHANT PAYMENT SYSTEMS/CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Heartland Payments is a true cost payment processor exclusively endorsed by over 250 business associations.

Tanner Wollard 979-219-9636 tanner.wollard@e-hps.com www.heartlandpaymentsystems.com “Lowered cost for American Express; next day funding.”

OFFICE EQUIPMENT/ TECHNOLOGIES

Dahill (HHH Gold Sponsor) Dahill offers comprehensive document workflow solutions to help healthcare providers apply, manage and use technology that simplifies caregiver workloads. The results: Improved access to patient data, tighter regulatory compliance, operational efficiencies, reduced administrative costs and better health outcomes.

Major Account Executive Wayne Parker 210-326-8054 WParker@dahill.com Major Account Executive Bradley Shill 210-332-4911 BShill@dahill.com Add footer: www.dahill.com “Work Smarter”

PAYROLL SERVICES

SWBC (HHHH 10K Platinum Sponsor) Our clients gain a team of employment experts providing solutions in all areas of human capital – Payroll, HR, Compliance, Performance Management, Workers’ Compensation, Risk Management and Employee Benefits.

Kristine Edge Sales Manager 830-980-1207 Kedge@swbc.com Working together to help our clients achieve their business objectives.

Digital Marketing Sapiens (HHH Gold Sponsor) Healthcare marketing professionals with proven experience and

continued on page 36

visit us at www.bcms.org

35

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 35

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

John Seybold 210-447-6518 jseybold@employerflexible.com www.employerflexible.com “BCMS members get a free HR assessment valued at $2,500.”

staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Brody Whitley Branch Director 210-301-4362 bwhitley@ favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

REAL ESTATE/ COMMERCIAL

CUSHMAN & WAKEFIELD (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com “Call today for a free real estate analysis, valued at $5,000”

SENIOR LIVING Legacy at Forest Ridge (HH Silver Sponsor) Legacy at Forest Ridge provides residents with top-tier care while maintaining their privacy and independence, in a luxurious resortquality environment.

Shane Brown Executive Director 210-305-5713 hello@legacyatforestridge.com www.LegacyAtForestRidge.com “Assisted living like you’ve never seen before.”

STAFFING SERVICES

To join the Circle of Friends program or for more information,

call 210-301-4366 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

36 San Antonio Medicine • February 2017

or email August.Trevino@bcms.org

Visit www.bcms.org

38 San Antonio Medicine • February 2017

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

We will locate the vehicle at the best price, right down to the color and equipment.

We will put you in touch with exactly the right person at the dealership to handle your transaction.

We will arrange for a test drive at your home or office. We make the buying process easy!

When you go to the dealership, speak only with the representative indicated by BCMS.

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Infiniti 12150 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Bill Boyd 210-859-2719

Pete DeNeergard 210-680-3371

Hugo Rodriguez and Rick Tejada 210-824-1272

Coby Allen 210-625-4988

Abe Novy 210-496-0806

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Sean Fortier 210-681-3399

Gary Holdgraf 210-862-9769

Wayne Alderman 210-525-9800

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230

Ancira Nissan 10835 IH 10 West San Antonio, TX 78230

Jarrod Ashley 210-558-1500

Jason Thompson 210-558-5000

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX Alan Henderson 210-681-6300 KAHLIG AUTO GROUP

Ingram Park Auto Center Dodge 7000 NW Loop 410 San Antonio, TX

Ingram Park Auto Center Mazda 7000 NW Loop 410 San Antonio, TX

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

Richard Wood 210-366-9600

John Wang 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

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

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

North Park Lexus at Dominion 21531 IH 10 W San Antonio, TX

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Sandy Small 210-341-8841

James Cole 800-611-0176

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

AUTO REVIEW

2017 Ford Explorer

By Steve Schutz, MD

In 2008 Ford sold Jaguar Land Rover to Tata Group, an Indian conglomerate, for just over $2 Billion. Unbeknownst to industry observers at the time the company was sold, Land Rover was developing three all new products: the Range Rover Evoque (2012), the redesigned Range Rover (2013), and the all-new Range Rover Sport (2014), all of which have been hailed for their gorgeous styling.

It’s worth noting that, while those beautiful Range Rover designs were unknown to industry observers, they were certainly known to Ford, which apparently, Ummm, borrowed numerous styling elements from their former partners for use in their Explorer SUV. While Ford passed on the Range Rover’s formal upright greenhouse, they gladly cribbed its clamshell hood, chinforward front end, block lettered name in all caps just above the grille, and head- and tail40 San Antonio Medicine • February 2017

light shapes. Sure, there’s a lot that’s Ford and not at all Range Rover, but there’s enough of a resemblance that your very own humble automotive observer is reminded of the ‘90s song, “Things that make you go Hmmm.” Given recent public criticism of the new Lincoln Continental’s styling by a Bentley designer, I’d be surprised if Gerry McGovern and other members of the Range Rover design team haven’t made any number of snarky comments over the years about the Explorer to their compatriots at Ford.

Whatever, the Ford Explorer is undeniably attractive and certainly a departure from the previous models, which had changed remarkably little since the original Explorer’s momentous debut in 1991.

Many of the changes that came with a complete redesign in 2011 reflect the twin modern realities of increasing fuel economy and safety standards.

Improving fuel efficiency means, more than anything, cutting weight, while enhancing safety mostly means increasing size.

Doing both is not easy, as you’d expect, but Ford did it successfully in the new Explorer by making a host of changes that are illustrative of how automakers the world over have been able to produce vehicles that are more efficient and yet also safer. Most of those changes are boring and not worth our time here, but a few are worth mentioning: 1) Increase the use of lightweight materials such as aluminum and magnesium, 2) drop body-on-frame construction and substitute a (lighter) unibody structure, 3) make vehicles longer and wider, to maximize crumple zones, and 4) move seats inboard, as far from the doors as possible, to keep intruding vehicles away from passengers.

Anyway, the new Ford Explorer, after moving in a distinctly modern direction in

AUTO REVIEW

every way, is selling very well. In addition to providing the aforementioned safety and fuel efficiency enhancements — 17 city and 24 highway for the base model Explorer with a 290 HP 3.5L V6, by the way — the Explorer gives customers an excellent interior.

While neither Lexus nor Mercedes owners — let alone Range Rover customers — will feel at home behind the wheel of Ford’s popular family conveyance, it can hold its head high in the company of competitors such as the Chevy Traverse, Honda Pilot, and Toyota Highlander. The materials and fit-andfinish are impressive, and all the tech you might want is either included or available as an option at a reasonable price. Most Explorers are sold off the lot with popular options and packages, so many that you’ll find at your dealership will have keyless entry/ignition, Satnav, dual-zone climate control, blind spot protection, and parking sensors, with expected transaction prices in the $4045,000 range.

The Explorer is fine to drive, but it’s hardly a sports car wannabe. Whether you select the above mentioned normally aspirated V6 base engine, the 230 HP 2.3L Ecoboost four-cylinder motor, or the top-dog 365HP 3.5L V6 Ecoboost powerplant — which my test vehicle had — acceleration is adequate but uninspiring. For the record, Ecoboost means turbocharged with direct injection.

Handling is about what you’d expect for a family vehicle with three rows of seats that weighs around 4,500 lbs. I think it’s fair to describe the Explorer’s driving dynamics as sturdy and trustworthy, but unless you drive a tractor trailer everyday, no way will you quiver with excitement when you get in and drive one to work.

As noted earlier, you can find many well equipped Explorers on every Ford dealer’s lot, and since the vehicles dealers order tend to include the options that most buyers prefer, there’s a good chance you’ll find

something there that you like. Naturally, the prudent buyer will call Phil Hornbeak at the BCMS office to discuss options and pricing before he or she even steps foot in a dealership.

The new Ford Explorer is a fine modern family vehicle that’s on par with competitors such as the Chevy Traverse, Honda Pilot, and Toyota Highlander. If you think it looks more stylish than those vehicles, as I do, thank the kind designers at Range Rover.

They probably had something to do with it.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

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

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THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA

ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX

Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of January 23, 2017.

42 San Antonio Medicine • February 2017