MEDICINE SAN ANTONIO
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VOLUME 67 NO. 5
cancer treatments
What’s new in
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What’s new in cancer treatments
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MAY 2014
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VOLUME 67 NO. 5
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.
START accelerates pace of global war on cancer By Anthony Tolcher, MD...........................12 New therapies change approach to managing advanced prostate cancer
EDITORIAL CORRESPONDENCE: Bexar County Medical Society 6243 West IH-10, Suite 600 San Antonio, TX 78201-2092 Phone: (210) 582-6399 Email: editor@bcms.org
By Daniel R. Salzstein, MD .........................................14
G-202: Potential prodrug chemotherapy for liver cancer By Devalingam Mahalingam, MD, PhD .....................18
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Latest clinical trials focus on studying new therapies for preventing breast cancer recurrence By Sharon T. Wilks, MD, FACP.............20
BCMS Alliance by Cindy Comfort ..............................................................................................10
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Business of Medicine: The cost of cancer treatment by Joseph P. Gonzales, MHA, FACHE, PMP ....22
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Physician as Patient: Getting ready for chemo by Jay Ellis, MD ................................................24
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COVER: Dr. Anthony Tolcher confers with a patient (left photo); Dr. Sharon T. Wilks examines a patient.
President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ........................................................8
Care System Profiles: Forest Park Medical Center ....................................................................26 Nonprofit: American Red Cross ..................................................................................................28 Lifestyle: It’s all here in red, white and blue by Beth Bond..........................................................32 In the News: Bexar County’s health rankings show mixed results by Robert Ferrer, MD ............34 Book Review: “Aftermath: Travels in a Post-war World” by Farley Mowat, “Aftermath: The Remnants of War” by Donovan Webster, reviewed by Jeffrey J. Meffert, MD ........................36 HASA: Ambulatory sensitive conditions by Vince Fonseca, MD, MPH, FACPM ..................................38 UTHSCSA Dean’s Message by Francisco González-Scarano, MD ............................................40 BCMS News ................................................................................................................................44 Auto Review: Nissan Juke by Steve Schutz, MD ..................................................................................48
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Email: louis@smithprint.net San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.
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BOARD OF DIRECTORS
OFFICERS K. Ashok Kumar, MD, President Jayesh B. Shah, MD, Vice President Leah Hanselka Jacobson, MD, Treasurer Maria M. Tiamson-Beato, MD, Secretary James L. Humphreys, MD, President-elect Gabriel Ortiz, MD, Immediate Past President
DIRECTORS Josie Ann Cigarroa, MD, Member Chelsea I. Clinton, MD, Member John Robert Holcomb, MD, Member Luci Katherine Leykum, MD, Member Carmen Perez, MD, Member Oscar Gilberto Ramirez, MD, Member Adam V. Ratner, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Miguel A. Vazquez, MD, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Luke Carroll, Medical Student Representative Cindy Comfort, BCMS Alliance President Nora Olvera Garza, MD, Board of Censors Chair Rajaram Bala, MD, Board of Mediations Chair George F. "Rick" Evans Jr., Legal Counsel
CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer
CHIEF OPERATING OFFICER Melody Newsom
DIRECTOR OF COMMUNICATIONS Susan A. Merkner
COMMUNICATIONS/ PUBLICATIONS COMMITTEE Fred H. Olin, MD, Chair Estrella M.C. deForster, MD, Member Jay S. Ellis Jr., MD, Member Diana H. Henderson, MD, Member Jeffrey J. Meffert, MD, Member Sumeru “Sam” Mehta, MD, Member Rajam S. Ramamurthy, MD, Member John C. Sparks Sr., MD, Member Chittamuru V. Surendranath, MD, Member J.J. Waller Jr., MD, Member Jason Ming Zhao, MD, Member
6 San Antonio Medicine • May 2014
PRESIDENT’S MESSAGE
An opportunity to serve By Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP
Predictably, rather than permanently revoking the Medicare sustainable growth rate (SGR) behemoth that patronizes and infuriates physicians across the nation, Congress passed the 17th patch, or “doc fix,” to the highly flawed SGR formula which delays a 24 percent cut to Medicare payments to physicians for an additional 12 months. As a nominal gesture toward America’s physicians, whose attitude toward Congress continue to decline substantially, Congress has extended the deadline for the implementation of ICD-10 until Oct. 1, 2015. I know many of you are frustrated by the SGR saga that continues to plague physicians. Furthermore, I know many of you are disenchanted with organized medicine’s ability to advocate successfully on behalf of physicians and patients for policies that improve our healthcare system. But I am still hopeful that our perseverance will help us solve this in the near future!
VOLUNTEERISM IS KEY Let me take you away from these frustrations and talk about a more cheerful and most fulfilling topic: VOLUNTEERISM. There is a growing body of research that indicates that individuals who volunteer have improved and better overall health than their non-volunteering peers. The Corporation for National and Community Service recently published a report compiling the latest research into the benefits of volunteerism. According to the report, which synthesized the latest research on volunteerism, volunteers have lower mortality rates, greater functional ability and lower rates of depression over individuals who do not volunteer. Volunteerism provides a unique opportunity that empowers us to contribute the solutions to problems that are plaguing our society. It also is an important way that we as physicians can continue to demonstrate our sustaining commitment to our community and ensure that we have the strong support of the public as we continue advocating for solutions to our healthcare challenges. Furthermore, volunteerism connects us to others and transforms our own lives, helping renew our mind, body and spirit. Ask yourself: What talents do I have to share? How much time 8 San Antonio Medicine • May 2014
can I realistically devote? Are there other resources I can contribute besides my time and abilities? Then identify a cause or issue you feel strongly about and find ways to get involved. There are many traditional ways of serving our community, like serving in the military, the National Health Service Corps, the Indian Health Service, or the U.S. Public Health Service. I am sure several of you have participated in these programs. There are many more ways to give back and serve. Volunteer opportunities abound within our neighborhood groups, within our religious and ethnic communities, disaster relief organizations, inter-generational mentoring groups, international groups, and wildlife or nature preservation groups, at a park, library or school. As physicians, we have greater opportunities because of the unique skills we can offer. Consider joining a global health mission trip with Doctors Without Borders, or the BCMS committee on International Health, your specialty society or similar groups that are providing healthcare services in low-income communities and countries. Maybe you would be interested in volunteering at a homeless shelter such as Haven for Hope. Or you could mentor high school or college students who are interested in careers in medicine. There are also many volunteer opportunities at the medical school where you could teach or serve as a preceptor for medical students. Many physicians enjoy joining the medical teams for sports competitions, races and large community events. If you can’t think of anything, we here at BCMS have some great ideas! The BCMS Alliance in collaboration with UTHSCSA medical students (TMA Students Section and Family Medicine Interest Group members) and high school students recently engaged in a community service project, TMA’s “Hard Hats for Little Heads,” where volunteers educated children about bicycle safety and distributed 1,000 helmets at Síclovía, San Antonio’s newest community-wide initiative encouraging physical activity. BCMS Alliance is also involved with “Be Wise Immunize” and many other volunteer activities. Please don’t hesitate to contact me. I’m sure together we can find service opportunities that are right for you and our community!
Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014 president of the Bexar County Medical Society.
BCMS ALLIANCE
Increasing relevancy, preparing future leaders By Cindy Comfort, Bexar County Medical Society Alliance President
D
uring my presidency, some of my time and thoughts go to the future. Where the alliance is going and who will be carrying the torch in the coming years are two of the things I have been trying to set the groundwork for in my weekly endeavors. How can we continue to be relevant to members and increase our membership and involvement in the community? What activities have been successful? Who do we need to move the BCMSA forward in the future to ensure the success of the alliance? The future doesn’t just happen; it is the result of planning and a positive attitude toward working together cohesively on our mission as a board under strong leadership. Next year’s board legacy will be the results of the actions and choices we make during this year. Working every day with board members and assisting them with their positions helps them to build their futures as leaders in the alliance. Encouraging them to build strong committees and recruit our future leaders will ensure a cohesive transition of leadership each year. It also prepares them to represent the BCMSA while volunteering in the community in other groups. I feel it is my role to effectively help train and prepare board members to carry out the duties of their prospective offices. Having outstanding board mentors with great prior leadership experiences has been invaluable to new board members and myself in accomplishing this goal. I have been blessed with an outstanding board this year that is achieving our goal of organizing more community programs and new group events to engage the membership and foster fellowship among members. Furthermore, encouraging the board to participate in leadership training by the TMAA at their fall leadership conference is a priority and a benefit of our strong state leadership.
10 San Antonio Medicine • May 2014
As we look to extend leadership roles to all of our members, I would like to ask anyone interested in serving on the board or working on a committee to join us at the Past President’s Luncheon on May 9. The luncheon will be a good opportunity for you to talk with current board members and the past presidents, all of whom are great resources for finding out about a position that is a good fit for your experience and time availability. The nominating committee is composed of the immediate past president as chairman, and members elected from the board and general membership at large who will meet at the end of summer and draw up a slate of officers. The officers are then voted on by the general membership at our fall general meeting. Please consider becoming part of the BCMSA team of leaders. Your ideas and interests are a part of making the alliance relevant and are important in shaping the alliance’s future. One member recently suggested the formation of a new committee: a Junior Volunteer Group. It was a great suggestion for helping medical families support their children with community service under the guidance of our members. It will be a great asset for us to have more help with our projects while training high school students for future roles in service and leadership. We will be formally voting on the issue at our next board meeting, and in the meantime we welcome any input you may have. And as always, our organization welcomes new ideas and is eager to hear from each and every one of our members. As I spend more time working with fellow board members and members in our social, membership and community work, I am confident the alliance is rising to the challenge of preparing for the future with new leaders entrusted to uphold our mission. What will your role be?
CANCER TREATMENTS
START accelerates pace of global war on cancer By Anthony Tolcher, MD In the international war on cancer, San Antonio’s START is firmly entrenched on the front lines. San Antonio is the headquarters for South Texas Accelerated Research Therapeutics (START) — an international Phase I medical oncology program that is not only the world’s largest, putting 600 patients on trials each year, but also represents a new model for Phase I research that is changing the paradigm for oncology drug development. In the world of cancer research, San Antonio is “ground zero,” and what many may not realize is that a large proportion of FDAapproved anticancer agents were first used in patients here at START and, as such, patients do not need to travel to distant cancer centers in other cities to be treated with cutting-edge therapies. In other words, some of the most recognizable names in cancer medicines have had their start here.
BEYOND CITY LIMITS But San Antonio’s reach goes well beyond the city limits. START not only serves patients and leads research efforts from its headquarters in the South Texas Medical Center, but also operates four Phase I clinical research centers on three continents, using an integrated team of researchers working around the clock to develop the most effective treatment therapies. This innovative global approach to research has one singular goal: to accelerate the development of new drugs for the treatment and eventual cure of cancer. With Phase I centers strategically situated in Madrid, Spain, 12 San Antonio Medicine • May 2014
Shanghai, China, and the United States, START’s team of physicians and researchers are using all 24 hours of the clock. When one center closes for the day, another one is just starting. All of the international centers are owned and operated by START and led by physicians who have trained with the oncologists at START in San Antonio. Throughout the network, all researchers strictly adhere to the same exceptional standard operating procedures, unified medical record technology, and quality controls. START also has developed proprietary software that allows the communication of clinical trial data real-time which can shorten the time to decision as to the safety and value of a new drug. This nonstop approach to research is resulting in faster completion of Phase I studies, shortening the decision-making process in determining if a drug is effective or not, increasing patients’ access to innovative drugs throughout the world and most importantly, making the newest drugs more readily available to end-stage cancer patients. In addition to its work in clinical research, START operates a large, AALAC-approved preclinical laboratory that assists biotechnology and pharmaceutical companies evaluate the effectiveness of their drugs in different tumor types and increasingly assists with predictive markers of response. Expertise in this particular field of research does not come from an institution, but from skilled doctors, nurses, research associates, pharmacology and laboratory technicians.
CANCER TREATMENTS
FOUNDED IN 2007 Accelerating the pace of drug development is what drove founders to create START in 2007. A small team of local researchers saw a need to expedite new drug studies by improving efficiency and eliminating bureaucracy in developing new treatments to help patients as soon as possible. The average Phase I study takes 18 months, followed by another eight to 10 years for approval. Cancer patients do not have that kind of time to wait for a treatment that works for them. Establishing a fully-integrated, global Phase I clinical research program represents an enormous achievement, not only for START, but for San Antonio, one that will result in bringing continued, worldwide attention to the city’s exceptional cancer research assets. Anthony Tolcher, MD, is a BCMS member and an internationally renowned cancer researcher and co-founder of START. START operates under the leadership of Dr. Tolcher, Dr. Amita Patnaik, Dr. Kyriakos Papadopolous, Dr. Drew Rasco and Gina Mangold.
Dr. Anthony Tolcher (right) discusses treatment with a patient. Courtesy photo
visit us at www.bcms.org
13
CANCER TREATMENTS
NEW THERAPIES CHANGE APPROACH TO MANAGING ADVANCED PROSTATE CANCER Questions remain about sequencing, cost By Daniel R. Salzstein, MD
The paradigm has shifted. Ten years ago, when a man’s PSA began to rise after prostate
face recurrence. When their PSA begins to climb, often a decade
cancer surgery or radiation, his urologist would use hormone ther-
after initial treatment, men don’t show any symptoms. Today their
apy to send the cancer into remission. When the PSA began to
conversation with the urologist sounds much different than 10
creep up again, his urologist would consider secondary hormone
years ago.
therapy to manage the cancer until it stopped responding. At that point, only one therapy option remained: chemotherapy.
I tell these patients: “I’m going to manage your prostate cancer like it’s high blood pressure. I cannot cure you, but I am going to
In 2014, a man facing advanced prostate cancer has six more
adjust and introduce different medicines along the way to slow
therapeutic options than a man who faced recurrence in 2004.
down the progression. We have a lot of good drugs that will allow
While not curative, today’s treatments offer men better and longer
you to carry on with your normal life and will keep you around
lives. The majority of the new FDA-approved treatments have
for a long time.”
minimal side effects and can be given in the urologist’s clinic or taken at home before, or in lieu of, chemotherapy.
WAVE OF INNOVATION
Despite their clinical promise, the new therapies are expensive.
The tidal wave of new therapies for advanced prostate cancer
Managing a man’s castrate-resistant prostate cancer can cost up to
comes after a lull of nearly 30 years. Six of the seven treatments
a half a million dollars. Medicare and commercial insurances cover
used today received FDA approval in the last four years. Five of
advanced prostate cancer treatments, but there is extreme pressure
the treatments have unique mechanisms of action.
from cost-conscious physicians and insurance carriers to deter-
The new treatments are effective, albeit temporary. Overall,
mine the best sequence or combination of therapies to maximize
they extend life by six to 18 months in men with metastatic
benefit and minimize cost.
castrate-resistant prostate cancer. Unlike chemotherapy regimens, however, the quality of life during this additional time
CANCER AS DISEASE MANAGEMENT Thirty percent of men treated for early stage prostate cancer
is high, allowing men to enjoy activities as usual with their family and friends. continued on page 16
14 San Antonio Medicine • May 2014
CANCER TREATMENTS continued from page 14
NEW THERAPIES The new therapies fall into four categories: immunotherapy, secondary hormone therapy, bone health therapy and chemotherapy.
of the testosterone stops the cancer’s progression and improves survival by 4.6 months. Xtandi, another secondary hormone therapy, works differently than Zytiga with equally impressive results. It blocks testosterone
Immunotherapy
from binding to receptors on the cancer cells so the cells cannot
Provenge is the world’s first therapeutic cancer vaccine. It’s ad-
react to the hormone. Casodex (bicalutamide) functions similarly
ministered by removing immune cells from the patient’s blood,
but has been replaced by Xtandi (enzalutamide) because of the
exposing them to a protein found on prostate cancer cells, and
new drug’s 30-fold increase in effectiveness.
infusing them back into the man’s body to attack the cancer.
For men taking Xtandi, a PSA drop from 200 ng/mL to 2
The therapy improves survival by an average of 4.1 months. Since
ng/mL is typical, and tumor growth is halted in 81 percent of
Provenge (sipuleucel T) uses the body’s immune system to attack the
men. Even among men who failed chemotherapy, Xtandi extends
cancer rather than chemotherapy to poison the cancer, its side effects
life by 4.8 months. By June 2014, Xtandi is anticipated to be ap-
are no worse than the flu, and they fade in a few hours.
proved for pre-chemotherapy use.
Secondary hormone therapy Better understanding testosterone’s role in stimulating recurrent prostate cancer has led to two breakthrough hormone therapies, each delivered in pill form.
Bone health The most dangerous consequence of advanced prostate cancer is the cancer spreading to the skeletal system. Ninety percent of
Zytiga (abirarterone) interferes with an enzyme involved in
the time when prostate cancer spreads, it goes to the bones, usually
testosterone production and shuts down testosterone creation in
the pelvis and the spine, near to the prostate. The result is crip-
the testes, adrenal glands and tumor cells. Primary hormone ther-
pling pain and increased risk for fractures.
apies like Lupron (leuprolide) and Degarelix (firmagon) only stop production in the testes. Primary hormone therapies are considered effective when they keep a man’s testosterone at less than 50 ng/dL. With Zytiga, a man’s testosterone is held in check near 3 ng/dL. Better control 16 San Antonio Medicine • May 2014
A new bone health drug Xgeva (denosumab), given through a monthly injection, prevents calcium from being leached from the bone. It decreases skeletal-related events by 20 percent to 30 percent. Xofigo, another new bone-targeted therapy, harnesses the
CANCER TREATMENTS
dangerous effects of radium to kill cancer from inside the bone.
The answers are beginning to be teased out in clinical trials
A glance at the periodic table gives a clue about how Xofigo
now, and a standard will be refined over the next decade. What
(radium 223) works. It’s chemically similar to calcium, and
is clear is that chemotherapy will be pushed further back in the
therefore when infused into the body, it settles in the bones and
treatment plan.
radiates the cancer cells concentrated there with limited damage to surrounding tissue.
COST CONUNDRUM
Xofigo eases bone pain and slows bone weakening with tolera-
If drugs are given sequentially or in combination, the already
ble side effects. It can turn a patient who is in too much pain to
high cost will escalate. Most insurance companies require pre-au-
drive into one who is pain-free and can play a round of golf.
thorization but pay when the therapy is appropriately indicated.
Xofigo is given monthly for six months by a radiation oncologist.
Having a standard treatment plan for advanced prostate cancer
It also has been proven to extend life by an average of 3.6 months.
will allow insurance to predict costs and price plans accordingly. To lessen the financial burden for the new treatments and, let’s
Second-line chemotherapy
not deny it, to increase their market share, manufacturers offer co-pay
assis-
new treatment
tance
and
for
“quick
The
final
advanced
start”
prostate cancer
programs that
is
allow men to
Jevtana
(cabazitaxel), a
start
therapy
chemotherapy
while their in-
that works even
surance author-
after Taxotere
ization
(docetaxel)
finalized.
chemotherapy
Prostate cancer
fails. The safety
foundations
profile is less
also offer finan-
appealing than
cial assistance,
the other new
and clinical tri-
is
therapies, and
als provide free
many men now
therapy to par-
forgo first-line
ticipants.
and second-line chemotherapy. Still, Jevtana can reduce cancer pain and offers an additional 2.4 months of survival.
These programs don’t resolve the central issue, though. Physicians, patients and the American taxpayers have to confront the cost-value equation of medicine. It’s not an easy answer.
SEQUENCING AND SYNERGY The availability of so many new answers for advanced prostate
Urologist and BCMS member Daniel R.
cancer patients has produced many more questions. Should Zytiga
Saltzstein, MD, is a partner at Urology San An-
be given before Xtandi? Would the effects of the two together be
tonio. He leads the practice’s clinical trials de-
more powerful than each separately? Could one of the new agents
partment and its advanced therapeutics clinic,
shrink a tumor before surgery? If a third promising hormone ther-
which focuses on men with advanced prostate
apy with a different mechanism of action gets approved, where
cancer. Urology San Antonio serves 100 to 150
will it fit in the treatment plan?
advanced prostate cancer patients. visit us at www.bcms.org
17
CANCER TREATMENTS
G-202:
Potential prodrug chemotherapy for liver cancer By Devalingam Mahalingam, MD, PhD Hepatocellular carcinoma (HCC) is of special significance to South Texas. It is the most common type of liver cancer, the fifth most common type of cancer, and the third most common cause of cancer deaths, taking about 360,000 lives worldwide each year. HCC is increasing in the United States and particularly in the Latino/Hispanic population, so we are seeing a much higher incidence than normal in South Texas. Currently, the only FDAapproved drug for treating HCC is sorafenib, approved in 2007. The approval for that drug was based on the results of a trial that showed a mere 3-month improvement in overall survival, so clearly there is a great need for better treatments for this disease. Dr. Devalingam Mahalingam (right) shakes hands with Ramon Castañeda of Corpus Christi, who has been travFortunately, clinical trials eling to the Cancer Therapy & Research Center for two years for treatment of advanced liver cancer. Photo courtesy are going on in the South University of Texas Health Science Center at San Antonio Texas Medical Center that show promise for much-improved liver cancer treatment through prodrug therapy. enough that the drug is now in a Phase II study at multiple sites including the CTRC. PRECURSOR DRUG The challenge of chemotherapy has long been that the drugs A prodrug is a precursor drug that is introduced to the body in that kill cancer cells also kill normal cells, in essence making painactive form, combined with a particular enzyme that activates tients sicker in order to make them healthier. Prodrug chemotherthe drug only in the desired area. apy is an approach that can achieve higher concentrations of A Phase I trial originating in the Cancer Therapy & Research cytotoxic or biologically active agents at a tumor site while avoidCenter (CTRC) used prodrug therapy to target a substance called ing the damaging effects they have on normal cells. PSMA that is found in the vasculature of liver tumors. The trial In this case we are referring to a toxin called Thapsigargin. This showed good results – some of the patients on it lived a year, when plant-derived agent can kill a broad spectrum of cancer cells, but generally they have only a few months. This was promising it also has detrimental effects on normal cells. It kills cells through 18 San Antonio Medicine • May 2014
CANCER TREATMENTS a pronounced increase in cytosolic calcium, which happens when Thapsigargin binds to an enzyme known as a calcium pump that is then unable to move excess calcium out of the cell. Due to Thapsigargin’s toxic characteristics, the question was how to deliver it to tumors while causing the least damage to normal tissue. The answer was to develop a relatively non-toxic form of Thapsigargin; i.e., the prodrug that can be converted into the active agent only at the tumor site. G-202 was generated by coupling a prostate-specific membrane antigen (PSMA)-specific peptide to an analog of Thapsigargin. PSMA was chosen because it is found in prostate cancer and the growing blood vessels in tumors, but not in normal cells. PSMA is also found in 90 percent of HCC tumors. G-202’s active drug would be released only within the HCC tumor upon binding to the highly expressed PSMA in HCC tumor blood vessels. G-202 then causes cell death in the HCC cells. Among the 44 patients treated in an early three-site study, San Antonio was the leading site for patient enrollment. Most of the side effects that were reported were mild, with some patients experiencing increased creatinine/acute kidney injury/acute renal failure, nausea and infusion-related reaction. These side effects were eased by prophylactic hydration, anti-emetics and steroids on the day of infusion.
ENCOURAGING RESULTS Five HCC patients were enrolled in the expansion cohort. This group received an average of six cycles per patient for a total of 29 cycles. It was very encouraging to observe stable disease in two patients for more than nine cycles. This has led to the opening of a multi-center Phase II study among patients with advanced HCC as second-line therapy after treatment with currently approved drugs failed. San Antonio-based GenSpera Inc., is the sponsor of this trial. If the early clinical finding holds true in controlling progression of HCC with minimal toxicity to patients, and we complete a successful Phase II or a larger Phase III study down the road, G-202 could one day become a treatment option for advanced HCC patients. Devalingam Mahalingam, MD, PhD, received his training at the National University of Ireland, Galway, and joined the Cancer Therapy & Research Center at the University of Texas Health Science Center in San Antonio in 2009. He started as an advanced fellow of oncology in the CTRC’s Institute for Drug Development and has launched several investigator-initiated trials here. Dr. Mahalingam’s focus is as a physician and translational researcher in pursuit of identifying novel therapeutic targets, particularly for patients with GI and GU malignancies
visit us at www.bcms.org
19
CANCER TREATMENTS
Latest clinical trials focus on studying new therapies for preventing breast cancer recurrence By Sharon T. Wilks, MD, FACP
Clinical trials have been essential in advancing the treatment of breast cancer. Clinical trials illustrate how our approach to treating breast cancer has evolved from traditional chemotherapy to hormone therapy, targeted therapies, angiogenesis inhibitors and immunotherapy. Two of our most current clinical trials go beyond traditional approaches to cancer treatment and may lead to the development of vaccine therapies for the prevention of breast cancer recurrence, and to a better understanding of endocrine resistance in breast cancer.
PREVENTING RECURRENCE WITH IMMUNOTHERAPY The immune system has a critical role in controlling cancer. Cancer immunotherapy — treatments that harness and enhance the innate powers of the immune system to fight cancer — represents one of the most promising new cancer treatment approaches. Much research is now focusing on the Her2 Vaccine (E75), which directs the immune system to target breast cancer cells producing the HER2 protein. Because the HER2 vaccine targets the HER2 protein, researchers initially thought that breast cancers producing large levels of the HER2 protein would be most affected by the vaccine. Results have shown that even HER2-positive cancers with lower HER2 protein levels are affected by the vaccine. One clinical trial currently enrolling patients in San Antonio involves the administration of a HER2 vaccine along with Herceptin. The purpose of this clinical trial is to assess the combination of Herceptin and the HER2 Vaccine which is co-administered along with GM-CSF (granulocyte macrophage colony stimulating factor) in the adjuvant setting. This trial is in20 San Antonio Medicine • May 2014
dicated for women who have early-stage breast cancer involving the regional lymph nodes and low HER2Neu expression, or for women with node-negative, hormone receptor-negative and low HER2Neu expression. Both of these types of patients are in a higher-risk group for the recurrence of breast cancer. Early studies have shown a synergism between the HER2 Vaccine and Herceptin for this patient cohort. This clinical trial, like many others that are being studied, reflects the importance of activating the patient’s own immune system to help prevent a cancer relapse, and if this technology proves to be successful, this intervention may one day lead to the use of vaccines for prevention of cancer. This clinical trial is important because there should be a large number of women in our community who meet the criteria. Estimates suggest that this group encompasses 60 percent to 70 percent of all newly diagnosed patients who have low HER2Neu expressing breast cancers.
REVERSING ENDOCRINE RESISTANCE IN BREAST CANCER RECURRENCE Our improved understanding of why patients experience cancer recurrence after proper hormone therapy in breast cancer has led to the discovery of new research drugs now in clinical trials. It appears that in some patients with estrogen receptor positive (ER+) and progesterone receptor positive (PR+) breast cancer, the sole use of drugs to block the ER signaling pathway is not enough for disease control. Palbociclib is an investigational, oral and selective inhibitor of cyclin dependent kinases (CDK) 4 and 6. CDK 4 and 6 are two closely related kinases that enable tumor cell progression during phase G1 to phase S in the cell cycle, necessary for DNA replication and cell division. In pre-clinical studies, palbociclib was
CANCER TREATMENTS
shown to be an inhibitor of cell growth and a suppressor of DNA replication by preventing cells from progressing from G1 into the S phase. In 2013, palbociclib received Breakthrough Therapy designation from the U.S. Food and Drug Administration for breast cancer treatment. A Phase 3 study is currently under way evaluating palbociclib in combination with letrozole (a non-steroidal aromatase inhibitor) versus letrozole alone as a first-line treatment for post-menopausal patients with ER+, HER2- locally advanced or metastatic breast cancer. Improved understanding of tumor resistance and recurrence is encouraging and helpful in our understanding of why tumors progress on what was believed to be effective therapy in hormone positive breast cancer. The importance of this clinical trial is to confirm the prior report of the ability to reverse resistance in patients with hormone positive breast cancer
Dr. Sharon T. Wilks researches breast cancer treatments. Courtesy photo
Sharon T. Wilks, MD, FACP, is one of the nation’s leading principal investigators in breast cancer clinical trial research. As a medical oncologist, hematologist and a national principal investigator, she has overseen numerous clinical trials leading to FDA drug approvals.
visit us at www.bcms.org
21
BUSINESS OF MEDICINE
The cost of Cancer treatment
IS IT WORTH IT? By Joseph P. Gonzales, MHA, FACHE, PMP
In a 2010 issue of the Journal of the American Medical Association, it was noted that the costs of cancer treatment in the United States jumped from $27 billion in 1990 to more than $90 billion in 2008.
INTRODUCTION Researchers are learning more about what causes cancer and how it grows and progresses, according to the Vanderbilt-Ingram Cancer Center. The nature of cancer and its treatment encourages researchers to look for ways to improve the quality of life for people with cancer, during and after their treatment. The endeavor to find treatments and cures for various forms of cancer and the endeavor to improve the cancer patient’s quality of life are noble causes, but they come at a price. It’s a vexing issue for our society: Are we willing to discuss whether cancer treatment is worth the cost?
CASE IN POINT A story in the June 20, 2004, issue of Bloomberg Business Week related that Dr. Roy S. Herbst, a lung cancer specialist at M.D. Anderson Cancer Center in Houston, put his patient, Gibson, on a combination of Avastin, a new colon cancer drug, and Tarceva, an experimental lung cancer treatment. The two drugs, both from Genentech Inc. (DNA), are part of a new generation of targeted therapies designed to block a tumor’s growth and tame cancer as a chronic but manageable illness. After a few months, Gibson’s tu22 San Antonio Medicine • May 2014
mors had shrunk by an almost unheard-of 90 percent. Although not a cure, it was better than the alternative. One aspect of his treatment could remain a major obstacle: the enormous price. Standard chemotherapy costs a few hundred dollars a month, but Avastin, a drug taken intravenously, lists for $4,400 per month. Tarceva, a pill, costs close to $2,000 a month. These types of prices, typical for the growing array of therapies that target specific cellular mutations, threaten to put an enormous burden on an already strained healthcare system. It is estimated that 174,000 people will be diagnosed with lung cancer in the United States this year. If a small fraction of those patients receive just one of these targeted therapies, the cost would be huge. Like many promising drug therapies, as the acceptance and usage of such drugs spreads, those costs will grow, adding to the nation’s healthcare bill, and so we may want to ask, how do we decide if it is worth it? Study after study demonstrated that both the new generation of targeted therapies and better uses of older chemotherapy drugs were able to extend the median survival for patients with late-stage cancer, which otherwise has usually been a death sentence. Oncologists, pharmaceutical companies and the government will have to focus on the best way to lower prices for these drugs. Meanwhile, is our society willing to face the dilemma: Is treatment, no matter how low the chance of success, always worth the price? Another aspect of this same issue: How will we decide who gets a drug and who will be denied?
BUSINESS OF MEDICINE
TO MEASURE VALUE OR WORTH In the Harvard School of Public Health Journal, 2010 winter issue, several pages were dedicated to this dilemma. It was noted that the World Health Organization (WHO) has a rule of thumb: three times per-person income per quality-adjusted life year gained is a cost-effective intervention. In the United States, per-person income is about $40,000, so an intervention that costs less than $120,000 per quality-adjusted life year would be considered costeffective, according to the WHO rule. So looking at this formula and applying it to some therapies, we find if a doctor prescribes a beta-blocker for a high-risk patient after a heart attack, it costs about $5,000 to buy that person one quality-adjusted life year. Dialysis for end-stage kidney failure costs $50,000 to $60,000 per quality-adjusted life year, which is still a good value in this country. Most countries with national health insurance plans use cost-effectiveness analysis to form policy. In the United States, we don’t have a national insurance plan, but we do have Medicare, national health insurance for people over 65. But Medicare doesn’t look at cost (even under the Affordable Care Act). According to Dr. Milton Weinstein, the Henry J. Kaiser Professor of Health Policy and Management and a professor of medicine at the Harvard Medical School, if we don’t have a national discussion with respect to the costs of medical technology, one can expect costs to keep going up. People will keep demanding costly new procedures, and the disparities as to access to care will likely get worse. Dr. Weinstein also points out that when it comes to our loved ones and “end-of-life medical decisions,” it is not unusual to hear mixed messages: “I want the best available medical care regardless of cost” — 90 percent of people agree with that. “I think that healthcare is too expensive” — 90 percent of people agree with that. “I think healthcare should be available for everyone” — 90 percent of people agree with that. It would appear that when it comes to healthcare, we would like to have it all!
CANCER TREATMENTS Depending on the type of cancer, there are various treatment plans that can include surgery, radiation therapy or chemotherapy. Some can involve hormone therapy or biological therapy. In addition, stem cell transplantation may be used so that a patient can receive very high doses of chemotherapy or radiation therapy. Targeted cancer therapies are drugs designed to interfere with specific molecules necessary for tumor growth and progression.
According to the National Cancer Institute, targeted cancer therapies that have been approved for use in specific cancers include drugs that interfere with cell growth signaling or tumor blood vessel development, promote the specific death of cancer cells, stimulate the immune system to destroy specific cancer cells, and deliver toxic drugs to cancer cells. Targeted cancer therapies also hold the promise of being more selective for cancer cells than normal cells, thus harming fewer normal cells, reducing side effects, and improving quality of life. Another promising treatment or modality is that of molecular profiling, or personalized medicine. The researchers at the Georgia Tech Foundation and the St. Joseph’s Mercy Foundation found that the molecular profile of each individual cancer patient is unique in terms of the most significantly disrupted genes and pathways. The cost of this profiling analysis is coming down and currently is about $2,000, half the cost of this analysis just five years ago. According to Wikipedia, personalized medicine or PM is a medical model that proposes the customization of healthcare, with medical decisions, practices and products being tailored to the individual patient.
CONCLUSIONS In the past several years, there has been a revolution in human genetics that is having an impact on virtually all specialties of medicine. This increased knowledge is expected to help shape personalized medicine. According to the Center for Personalized Genetic Medicine at the Harvard Medical School, this knowledge of the genetic basis of human disease is helping to usher in a new era in drug development. In my opinion, the discussion that our society needs to have surrounds the aspect of developing a process for determining the value of medical treatment, and then as a society accepting that process as it applies to cancer treatment and other treatments that are contributing to the overall healthcare costs in this country. Maybe then we may realize that we can’t have it all, and we can start to control the ever increasing costs of healthcare in the United States. Joseph P. Gonzales, MHA, FACHE, PMP, is a specialist master with Deloitte Consulting LLP. An adjunct faculty member at the University of Texas at San Antonio, he teaches in the MBA program, business of healthcare track. visit us at www.bcms.org
23
PHYSICIAN AS PATIENT
Physician as Patient
EDITOR’S NOTE: This is the second in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the BCMS Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of lifethreatening illness.
Getting ready for chemo By Jay Ellis, MD
After I made the trip to the ER, I called my oncologist, Dr.
by engaging in meaningful activity. It helps distract people from
Greg Guzley. He saw me right away. The bone marrow exam was
their distress. For the first time I had a chance to test my hy-
inconclusive, and he told me that we needed tissue to confirm the
pothesis. In my personal series of one patient, I concluded that
diagnosis and establish the right chemotherapy. He gave me some
it does work. When I went to the operating room or when I was
tasks to accomplish. Get a vascular access port placed. Get an
in the clinic, the need to focus on someone else’s problem dis-
echocardiogram as a baseline, and schedule a percutaneous biopsy
tracted me from my own. In clinic, I would sit each day and dis-
of my retroperitoneal mass.
cuss with patients the necessity of moving past the sadness and
Having specific tasks to accomplish gave me focus. My friends
anger from their illness and focus on the good things in their
and colleagues were wonderful. Dr. Mack Sykes inserted the
life. I found that I felt better after these discussions. I wasn’t
port, and Dr. Bob Saad arranged my echocardiogram. The only
preaching to the choir. I was preaching to the preacher.
delay was getting the biopsy. The procedure schedule at Methodist was booked solid for over a week. My wife, Merrill,
PAIN INCREASES
was not happy about this, and several doctor friends I spoke to
As the days passed leading up to my biopsy, my pain began in-
listened to my story and tried to pull some strings, but some-
creasing at an exponential rate. The irony of the pain doctor deal-
times the schedule is the schedule. I resolved to be patient and
ing with his own cancer pain wasn’t lost on me. The pain wasn’t
bide my time. After all, what difference could a few days make?
so bad during the day, but the nights were misery. After an hour
Greg gave me some tramadol to manage the pain, and it helped.
lying down, my dull, aching left upper quadrant pain would be-
I was able to go to work. For years, I have told my pain patients
come a severe, constant, cramping sensation. I wondered if this is
they need something to focus on besides their pain, best done
what labor pain felt like, and if it is, women have a bad deal. At
24 San Antonio Medicine • May 2014
PHYSICIAN AS PATIENT
first, the tramadol would buy me a few hours of sleep. One night
nant, with two sons – a 3-year-old and an 11-month-old – and
I took it so often that I woke up with tremor and agitation. The
she was packing up her house for a move to Germany. I told her
pain management physician gave himself serotonin syndrome
she just couldn’t afford to come. Just as she did when she was a
from tramadol overdose. I called Greg Guzley, and he gave me
teenager, she ignored me and booked the tickets. My son told me
some oxycodone at my request. It seemed to ease the pain and
he was coming to San Antonio, but I suggested we all meet in
allowed some sleep.
Houston to celebrate his birthday. I hoped that a trip out of town
My biopsy was done at Methodist radiology, and the staff could
might distract me from my condition. My stepson, Brent, called
not have been nicer. I did get the traditional two sticks of the IV,
and “Breaking Bad” fan that he is, told me he hoped that I would
obligatory for every physician requiring healthcare, but after my
not start cooking meth. Humor is always a great relief. Through
counseling for the procedure I received my sedation and remem-
all this, Merrill constantly monitored my health. I don’t think I’d
ber nothing else. The turnaround on the pathology specimen was
ever felt so loved in my entire life.
rapid, and we had our diagnosis, Non-Hodgkin’s B cell lymphoma. I was ready to start treatment right away, but since I have
EATING BECOMES CHALLENGING
private insurance, the next step is, of course, preauthorization.
Merrill noted first, and the scale confirmed, that I was losing
Greg assured me that the turnaround time was three working
weight at a rapid rate. In two weeks I dropped 10 pounds. The
days. Unfortunately, that included a weekend. Being on the other
cancer was consuming me. I could not maintain weight. Eating
end of insurance authorization is no more fun than being on the
was a challenge since I had no appetite. I would be full after just
providing end. My nighttime pain continued its exponential in-
a few bites of food. I made every effort to eat to keep Merrill
crease. The combination of tramadol and oxycodone was no
happy, but there was certainly no enjoyment in it. Horrible night
longer effective. I would sleep for an hour, awake in pain and walk
sweats began, accompanied by fever. I marveled at my own posi-
the floor for 30 minutes until the pain subsided. I would repeat
tive review of systems. Still no word on the start of my treatment.
this process several times each night. I got little sleep, and I suspect
We made the trip to Houston to see my son, his wife, my
my poor spouse got even less. I thought about taking some Am-
daughter and grandsons. My brother and his family came as well.
bien, but I realized, despite my pain-addled state, that if the Am-
The weather was glorious. We spent the day in a park playing
bien, tramadol and oxycodone all peaked at the same time I might
with the boys. My pain was manageable, and I even had a little
fall asleep and never awaken. I pride myself in being an expert on
bit of an appetite. It would be the best day I would have for a
cancer pain and realized that I had the same problem as the pa-
long time. That night the pain reached its zenith. The cramps
tients I see in the office. It is hard to control severe, episodic pain
became daggers and lying down felt as if I were being impaled. I
with oral opioids at doses that don’t impair cognition, or in the
took an extra dose of steroids, which worked well enough to keep
worst case ventilation. I called Greg the next day, and he started
from going to the ER. Merrill insisted that I call Greg and get
me on some steroids, which helped significantly. I was not pain-
some help. We made the trip home to San Antonio, and I called
free, but I was able to sleep for more than one to two hours.
Greg the next day. I told him I couldn’t take it anymore. We ei-
During this time I also had to make the phone calls to family.
ther had to start treatment or he would have to hospitalize me.
I called my mother, my children and my brother and sister. My
My ability to cope was gone. I was 15 pounds lighter. He made
mother found that great balance of being appropriately concerned
some phone calls, increased my steroids and got me through the
and reassuring, a gift that is somehow bestowed on all mothers.
48 hours until I started my first chemo.
My brother and sister argued over who was a better match if I needed a bone marrow transplant. My daughter told me she was
NEXT MONTH: In the chemo room.
flying in to see me. I told her this was a bad idea. She was pregvisit us at www.bcms.org
25
CARE SYSTEM PROFILES
Forest Park Medical Center San Antonio Special to San Antonio Medicine EDITOR’S NOTE: This is the eighth article in a planned series of Care System Profiles, highlighting various healthcare providers in Bexar County in the pages of San Antonio Medicine. The goal of the series is to inform BCMS members about the relationships that exist within and among various local institutions. Articles will focus on what distinguishes one system from another, and what is unique about each organization. Representatives of local healthcare delivery systems are being invited to submit an article describing their institutional initiatives for publication in the series. Organizations are featured in the order in which their articles are submitted and approved. Members of the BCMS Communications/Publications Committee review articles before publication, and content may be edited for format, style and clarity. For guidelines and more information, email editor@bcms.org.
Who are the legal owners of this institution? Forest Park Medical Center is a Dallas-based physician majority-owned and governed hospital system dedicated to providing unsurpassed surgical specialty care. Approximately 70 percent of ownership rests under local physician governance, and Forest Park Medical Center San Antonio currently has approximately 90 local physician partners invested in the project. Who is served by this healthcare delivery system? The Forest Park Medical Center system is pioneering surgical procedures in virtually every discipline of medicine – from bariatric to orthopaedic to implementing the da Vinci Robotic Surgery System into its offerings. Forest Park Medical Center San Antonio will specialize in bariatric surgery, neurosurgery, orthopaedic sur26 San Antonio Medicine • May 2014
gery, reconstructive plastic surgery, general gynecology and urology. The hospital also will host a state-of–the-art cardiac catheterization lab. Upon opening, Forest Park Medical Center expects to create approximately 175 jobs and that this number will rise as operations ramp up and volume increases. How is this institution funded or financed, and how successful is the funding? Forest Park Medical Center is a privately owned company that attributes the extraordinary results achieved systemwide to its unique physician ownership and governance structure. How does this care system operate? As a majority physician-owned and governed hospital, Forest Park Medical Center San Antonio will bring the latest and most
CARE SYSTEM PROFILES Forest Park Medical Center San Antonio, a majority physician-owned and governed hospital, is scheduled to open in the third quarter of this year near the intersection of I-10 and Loop 1604. Courtesy photo
est Park Medical Center San Antonio is targeting gold certification, a definite distinguishing factor from other local institutions. Are there any future plans, goals and/or announcements to be made at this time? Forest Park Medical Center San Antonio is located at 5510 Presidio Parkway, near the intersection of I-10 and Loop 1604. With current operations in Dallas, Southlake and Frisco, Forest Park San Antonio will be the system’s fifth facility. The system also is developing campuses in Fort Worth (slated to open in August 2014) and Austin (slated to open in May 2015).
effective technology in medical care while providing quality, costeffective care to patients. The state-of-the-art facility will be approximately 150,000 square feet containing 12 fully integrated operating suites; 54 private inpatient rooms, including family suites; and six intensive care beds. Forest Park San Antonio has attracted the best and the brightest healthcare professionals to run operations. The relationship the leadership team has with physicians allows for decisions to be made quickly when it comes to patient care, making Forest Park San Antonio the premiere destination for physicians to practice medicine. What types of business relationships exist within this organization, particularly with physicians? Forest Park Medical Center is primarily physician-owned, allowing patients to receive unsurpassed surgical specialty care in state-of-the-art facilities. The ownership model allows for an efficient way of practicing for physicians and cost-effective care for patients in an environment that is truly designed to help the healing process. In addition, Forest Park negotiates in-network contracts with most insurers and is continuously exploring unique pricing models to provide the best enduring solutions. What distinguishes this institution from others locally? Forest Park Medical Center San Antonio, an approximately $98 million project scheduled to open in the third quarter of this year, is committed to elevating the status of its patients and the San Antonio community by providing unmatched care in a vibrant and focused environment while maintaining and enhancing its status as a leader in the healthcare industry. All Forest Park hospitals are certified by the U.S. Green Building Council’s Leadership in Energy and Environmental Design (LEED) program standards. For-
What is the one main thing BCMS members should know or remember about this care system? Founded in 2009, the primary focus of the Forest Park Medical Center system has always been providing patient care of unparalleled quality in a relaxing environment that contributes to the wellbeing of all who walk through the doors. Forest Park’s state-of-the-art facilities are licensed, accredited, contain emergency and intensive care departments, and are staffed by physicians 24/7. These physicians work in an environment that allows them to practice medicine without constraints, thus, resulting in better patient care. At Forest Park, it’s all about the patient receiving the best experience possible from entry all the way through discharge. Additional comments? Julie Seale serves as CEO of Forest Park Medical Center San Antonio. She brings more than 22 years of healthcare management experience to her role at Forest Park, including equipment and facility planning for hospitals and physician practices; systemwide, strategic managed care contracting; and revenue cycle management. Before transitioning to her role with Forest Park Medical Center San Antonio as CEO, Seale served as director of operations. She holds a bachelor’s degree in business administration from the University of Texas at Arlington. “Our team of highly experienced physicians and staff at Forest Park Medical Center look forward to a seamless opening late this summer and becoming a leading pillar for superior patient care and service in the San Antonio community,” Seale said. Dr. Robert Wyatt, founding physician and chief medical officer, Forest Park system, said, “This is an exciting time for Forest Park as we continue to expand our presence throughout Texas and bring the unsurpassed quality care we are known for to the great people of San Antonio. “Forest Park offers unique, unmatched care to the marketplace, and we look forward to continuing to prosper as a hospital system delivering high quality and outstanding care to our patients,” he said. “In addition, we are excited to offer a specialty focus that allows our dedicated physicians a more efficient and cost-effective method of surgical practice to prioritize the quality of our patient care and facilities.” visit us at www.bcms.org
27
NONPROFIT
2013 was record year for Special to San Antonio Medicine
The San Antonio Chapter of the American Red Cross is part of the Southwest Texas Region of the American Red Cross. The region serves 44 counties and stretches east to west from New Braunfels to El Paso, and north to south from Odessa to Laredo. There are Red Cross chapters in El Paso and Midland, and branches in New Braunfels, Del Rio, Laredo and soon Eagle Pass. The organization will celebrate 100 years of serving San Antonio in 2016. Last year alone, Red Cross volunteers went to disasters and emergencies all over the United States, including • Super Storm Sandy • West, Texas, fertilizer explosion • Moore, Okla., tornadoes • San Antonio flooding • Eagle Pass flooding • El Paso flooding and • Carrizo Springs/Cotulla flooding. Add to that the record amount of fires responded to between Feb. 23 and March 23, and 2013 will be remembered as one of, if not the most, active years the chapter and region have experienced – ever! The American Red Cross is dedicated to
helping people in need throughout the United States and throughout the world. It depends on the many generous contributions of time, blood, and money from the American public to support its lifesaving services and programs. Clara Barton and a circle of her acquaintances founded the American Red Cross in Washington, DC, on May 21, 1881. Barton first heard of the Swiss-inspired global Red Cross network while visiting Europe following the Civil War.
BLOOD SERVICES • Approximately 5.6 million blood donations are collected by the Red Cross each year. • Roughly 3.3 million generous volunteer blood donors roll up a sleeve each year. • More than 8 million transfusable blood products are distributed each year thanks to generous donations. • 2,700 hospitals and transfusion centers around the country receive Red Cross blood products. Red Cross blood donors are ordinary
people – high school students, factory and office workers, business executives, parents and grandparents, and people from every walk of life. But they share one thing – a generous spirit, a desire to give back to their community and help others. Blood donors play an integral role in the delivery of modern healthcare. Many lifesaving medical treatments and procedures involve blood transfusions and would not be possible without a safe and reliable blood supply. The Red Cross is also a leader in research and testing to protect the safety of the blood supply. It was among the first to develop and implement testing for many infectious diseases including HIV, hepatitis B and C viruses, West Nile virus, and more recently the agent of Chagas disease.
HEALTH AND SAFETY TRAINING The Red Cross has been the go-to source for more than a century for information, skills and confidence to act in an emergency, at home, in school and in the workplace. Many jobs require up-to-date lifesaving skills because individuals address health continued on page 30
28 San Antonio Medicine • May 2014
NONPROFIT continued from page 28
Did you know?
States, ranging from fires to hurricanes, floods, earthquakes, tornadoes, hazardous materials spills, transportation accidents and explosions. People count on the Red Cross to help them in their darkest hour. In turn, the support of donors makes it possible for the Red Cross to fulfill its humanitarian mission. Red Cross disaster relief focuses on meeting people's immediate emergency needs. When disaster threatens or strikes, the Red Cross provides shelter, food, and health and emotional health service to address basic human needs and assist individuals and families in resuming their normal daily activities independently. The Red Cross also feeds emergency workers such as firefighters and police, handles inquiries from concerned family members outside the disaster area, provides blood and blood products to disaster victims, and helps them access other available resources.
The American Red Cross is simply the Swiss flag with the colors inverted? emergencies every day – people such as healthcare providers, first responders and lifeguards. Others, including teachers and babysitters, are entrusted with precious young lives that could require aid on a moment’s notice. Those who don’t face health emergencies every day can benefit from Red Cross training. With a wide array of Lifeguarding, Caregiving and Babysitting, and Swimming and Water Safety courses, the Red Cross can provide individuals with the training and skills needed to prevent, prepare for and respond to emergencies.
DISASTER RESPONSE Each year, the American Red Cross immediately responds to about 70,000 natural and man-made disasters in the United 30 San Antonio Medicine • May 2014
RED CARPET GALA The public is invited to join dignitaries
from throughout the city and the American Red Cross, San Antonio Area Chapter, at the Red Carpet Gala Sept. 27 at Valero Headquarters. The keynote speaker will be Dr. Ruth Berggren. During Hurricane Katrina, Dr. Berggren was the teaching physician assigned to the infectious disease ward of New Orleans' Charity Hospital. She remained at Charity for six days and nights after Katrina struck, working with medical staff to care for critically ill, abandoned patients. After all patients were evacuated from Charity Hospital, Dr. Berggren and her team were rescued by a private jet from Texas. She has subsequently published two articles in the New England Journal of Medicine about the experience and about the impact of Hurricane Katrina on healthcare infrastructure in New Orleans. Dr. Berggren is board-certified in both internal medicine and infectious diseases with significant experience and particular interest in clinical AIDS and viral hepatitis research, as well as in implementing HIV care in resource poor settings. For more information, visit www.redcross.org/tx/san-antonio.
visit us at www.bcms.org
31
LIFESTYLE
It’s all here in red, white & blue: 32 San Antonio Medicine • May 2014
LIFESTYLE
25
Military River Parade stars In San Antonio’s annual Military River Parade, the floats really do float. The city is gearing up for one of the River Walk’s largest celebrations of the year, a waterway procession of about 25 decorated barges that will glide down the San Antonio River in celebration of National Armed Forces Day. Locals and visitors are invited to the event, at 6 p.m. May 17 on the River Walk, as thousands of flag-waving spectators honor men and women in uniform. San Antonio is widely recognized as Military City USA, so it should come as no surprise that the Military River Parade is one of the River Walk’s biggest events of the year — in fact, it is second only to the holiday parade held the day after Thanksgiving, a 33-year tradition. “It only made sense to honor the military with a parade like this,” said Nancy Hunt, executive director for the Paseo Del Rio Association, which has organized the Military River Parade for three years running. “We are proud to be part of a community that embraces the military community, and it is our privilege to produce this parade to recognize and honor the men and women of our armed forces — active, retired and passed on.” In particular, one man will be honored at the parade as grand marshal: Dr. Granville Coggs, one of the original Tuskegee Airmen and a San Antonio resident. Coggs’ fascinating life story arcs from a World War II stint with the country’s segregated unit of African-American aviators to being an invited guest at President Barack Obama’s 2008 inauguration. Coggs earned a medical degree from Harvard on the GI Bill, pursued a noteworthy career in radiology and embraced competitive running in his mid-70s. “I am grateful,” he said, referring to the invitation to lead the parade. “It didn’t take me more than two seconds to accept that designa-
patriotically themed floats
tion. This is my first time to be a grand marshal, and I’m planning to play my gut bucket on the barge.” That’s right: a gut bucket. The goodhumored 88-year-old is passionate about the instrument he describes as “an economical, one-string bass fiddle” and frequently adds a plucking performance as part of his many public speeches. Parade-goers can watch the barges go by from anywhere along the River Walk, but Hunt recommends the Arneson River Theatre as the best spot for spectating. The amphitheater’s 800 seats are carved out of stone on one side of the river and look out to a stage on the other side. For $15, visitors receive a reserved seat at the Arneson; it’s the center of the action where camera crews set up to broadcast the parade locally. (Need another hint that this parade is a big deal? It’s later syndicated nationally to 55 television markets, where it’s aired on Memorial Day, Fourth of July or Veterans Day.) Ticketholders also will have a close-up view of performances before and during the parade by Tops in Blue, the touring ensemble of activeduty members of the U.S. Air Force. The Military River Parade’s 25 patriotically outfitted floats — stars, stripes, eagles, Mount Rushmore, the Statue of Liberty, it’s all here in red, white and blue — are sponsored by local companies and carry service members, veterans and folks who work to support them. Each is dedicated to saluting a particular segment of the military. This year, Kelly Aviation Center will feature members of the USO on its float, the San Antonio Convention and Visitors Bureau will salute active-duty military families, and Security Service Federal Credit Union will honor
By Beth Bond
Esposas Militares, to name a few. Add about 500 yellow ribbons tied to the trees along the city’s famed River Walk, and it’s an even more moving scene. For $5, you can sponsor a yellow ribbon in honor or in memory of someone who served in the military. In addition to a ribbon tied around a tree, the honoree’s name will be listed in the Military River Parade event program and on the Paseo Del Rio’s website. “It’s a beautiful sight,” Hunt said of the hundreds of ribbons. “It’s a visible way to support the military even if you’re not here on parade day.” To sponsor a yellow ribbon, visit thesanantonioriverwalk.com. Parade tickets are available for $15 at the Arneson, online at thesanantonioriverwalk.com or by calling (210) 227-4262.
visit us at www.bcms.org
33
IN THE NEWS
BEXAR COUNTY’S HEALTH RANKINGS SHOW MIXED RESULTS Environment improves; poverty, uninsured rates remain high By Robert Ferrer, MD
The Robert Wood Johnson Foundation on March 26 released its 2014 County Health Rankings, which it compiles yearly in partnership with the University of Wisconsin Population Health Institute. These rankings have emerged as a high-profile barometer of health in U.S. counties. Bexar County’s 2014 overall rank is 69th of the 232 Texas counties with adequate data, up from 86th in 2013. The rankings are calculated from a set of 29 factors than combine health outcomes and underlying causes. Examples of health outcomes include rates of premature mortality (deaths before age 75) and self-reported physical and mental health status. Health factors measured in the rankings include: • Health behaviors: Tobacco use, diet and exercise, alcohol and drug use, and sexual activity • Clinical care: Access to care and quality of care • Social and economic factors: Education, employment, income, family and social support, and community safety • Physical environment: Air and water quality, housing and transit. The data are drawn from vital statistics, census data, population surveys, environmental health measures, and other databases. The most recent data were collected in 2012, but some measures are averaged across four to six years to increase statistical reliability. The purpose of the health rankings is to allow citizens and policy makers to compare their county’s health with others across the state — being graded is always provocative, after all, and the rank-
34 San Antonio Medicine • May 2014
ings are freely available to everyone. The foundation’s other motivation is to focus attention on the social, economic and environmental determinants of health. These broader factors often get overlooked when health debates focus narrowly on clinical care. By assembling the data on broader determinants, the rankings try to rebalance the discussion. What can we glean from Bexar County’s health rankings? First, we rank in the top quarter of Texas counties for length of life, health behaviors and physical environment. The first two rankings have been relatively stable since 2010, while the environment has sharply moved up the rankings. Years of potential life lost have decreased 6 percent since 2010. But self-rated physical and mental health have not improved and remain low. Rates of excessive drinking are high, as well as alcohol-impaired driving deaths. We continue to have high poverty and uninsurance. The good news is that we in Bexar County have receptive ears for these data. Initiatives such as SA2020 are taking on the social determinants as Metro Health, the Mayor’s Fitness Council and the Health Collaborative, among many others, are engaged in responding to the policy needs in medicine and public health. To view the rankings, visit www.countyhealthrankings.org. Robert Ferrer, MD, is a faculty member at the University of Texas Health Science Center at San Antonio. He is a member of the Mayor’s Fitness Council and the board of the Health Collaborative. The views expressed are his own.
BOOK REVIEW
“Aftermath: Travels in a Post-war World” Written by Farley Mowat
“Aftermath: The Remnants of War” Written by Donovan Webster Reviewed by Jeffrey J. Meffert, MD Wars make for exciting news and some great movies, but when the last shot has been fired and the last soldier has gone home, in some ways the scars, if not the fight itself, continue. Two books with the same main title look at different aspects of the aftermath of major conflicts. “Aftermath: Travels in a Post-war World” by Farley Mowat chronicles the travels of a former Canadian soldier as he drives (and writes) his way across Europe with his wife to visit his past battle sites to see what has become of the land and the people. The trip was made in 1953, and he had to come to grips with roads, villages and fields still ruined by bombs from the decade before and his own attitudes about the newly affluent Germans he encounters who are also re-tracing their battles. Post-traumatic stress disorder (PTSD) was not a diagnostic term in 1953, but it becomes clear that when Mowat is on battlefields he fought through, he has it. In France and Italy, he takes many side roads and shares many a drink with former partisans, former Allied soldiers, and even the occasional former enemy. It is clear the war, and the emotional wounds incurred, are still too fresh for many who are trying to come to grips with vanished villages and the loss of a generation of fathers, sons and brothers — civilians and soldiers alike. The author starts his trip in London during Queen Elizabeth’s coronation, works his way through western and southern France into Italy, where he experiences firsthand a national election in which the Communists, Social Democrats and Neo-fascists are all trying to take control of a still-devastated country. Mowat describes isolated tribes of fishermen and potters who are still practicing the “Old Way” and leads you to wonder what has become of them in the intervening half-century. He finishes back in England with exploration of ruined Roman forts and half-finished, turn-of-the-century mansions while jet fighters from a nearby airbase fly overhead. “Aftermath: The Remnants of War” by Donovan Webster is 36 San Antonio Medicine • May 2014
less philosophical in its prose and less of a travelogue of places you might want to visit than a reminder that some wars seem to never end. Despite efforts of multinational humanitarian organizations, there are still millions of landmines scattered across Africa and Asia. The landmines continue to maim and kill, sometimes as a surprise and sometimes by desperate people in war-torn lands looking for scrap metal. No one knows how many artillery shells the Germans, French, British and Americans hurled at each other in the relatively confined battlefields of World War I but not all of them exploded, and farmers, trying to prepare their French and Belgian fields for crops, still run into unexploded ordinance which includes poison gas shells that, after all this time, still retain much of their potency. Fields on the Russian steppes are described with still-unburied dead from battles decades earlier. Some U.S. locations are still “hot” from nuclear bomb testing in the 1940s and ’50s. Webster’s book was written in 1996, and one wonders if these soldiers have finally been laid to rest, if French farmers are still plowing up mustard gas shells, and if we will ever remove the last landmine from the rice paddies of Vietnam and Laos. The book was the subject of a 2001 Canadian documentary by the same name. Both books are out of print but can be found at book resellers and online sales and auctions. They should be required reading for any politician eager to start another war before we have truly cleaned up the battlefields and healed the warriors from the last dozen or so. Jeffrey J. Meffert, MD, is an associate professor of dermatology and cutaneous surgery at the University of Texas Health Science Center at San Antonio and 2013 chair of the BCMS Communications/Publications Committee.
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37
HASA
Ambulatory sensitive conditions:
Potentially preventable hospitalizations By Vince Fonseca, MD, MPH, FACPM
Over several issues we've seen different perspectives on improving care coordination to improve the health of patients and different types of measurement systems to track that improvement. Last month, we briefly reviewed accountable care organizations (ACOs) and their performance measurements. The underlying concept is that improved care coordination will improve health and help to control costs. Robust HIT support is critical for ACOs as the healthcare providers work together in these high-impact target areas for the U.S. healthcare system: • Prevention and wellness • Chronic disease • Reduced hospitalizations • Care coordination across transitions TABLE 1 • Multi-specialty care coordination of complex patients. The Certification Commission for Health Information Technology (CCHIT), www.cchit.org, developed the ACO HIT framework and described four HIT foundational requirements: • Information sharing: between providers and also with patients • Data collection and integration from these sources: clinical, financial, operational and patient-generated • Patient safety • Privacy and security risk analysis.
care Research and Quality (AHRQ) because high quality, coordinated outpatient care can prevent many of the hospitalizations for these conditions. This set of quality indicators to estimate adult preventable admissions are called the Prevention Quality Indicators (PQIs). One indicator, PQI 92, is the Prevention Quality Chronic Composite. This one calculates the rate per 100,000 population, ages 18 and older, for these conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, or angina without a cardiac procedure.
TABLE 2
These same HIT foundational requirements, which Healthcare Access San Antonio (HASA) supports with its service lines, also can support efforts to prevent certain hospitalizations — those in patients with ambulatory sensitive conditions (ASCs). These ASCs have been defined by the Agency for Healthcontinued on page 42 38 San Antonio Medicine • May 2014
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39
UTHSCSA DEAN’S MESSAGE
Robert Floyd Curl
and more people behind the street names By Francisco González-Scarano, MD Floyd Curl Drive winds its way through the middle of San Antonio's Medical Center, starting at Huebner Road and ending at Louis Pasteur Drive on the southeastern end. These two miles are home to many healthcare facilities, including the UTHSCSA School of Medicine and its practice, UT Medicine, and Methodist and St. Luke’s hospitals, among others. However, few people know that Methodist Hospital was the first facility located in the medical center, preceding the School of Medicine. The street's namesake, Robert Floyd Curl, was a leader in the Methodist ministry and truly was the "grandfather" of the medical center. All the streets in the medical center are named after people who helped shape the area. Robert Floyd Curl, whose legacy is forgotten to most, was arguably one of the most important in establishing San Antonio’s South Texas Medical Center. Born in 1897 in Winfield, Ala., the tenth of 12 children, Curl was 16 when he graduated from high school. Almost immediately he set off to Texas. Even then Texas was known for having a solid economy and being a land of opportunity. With a strong intellect, Curl was fixated on attending college and soon enrolled at Southern Methodist University, where he attained a bachelor’s degree as well as a master's degree in theology. He spent his early career as a preacher in Alabama and later in many different parts of Texas. He also worked as a teacher, and eventually became the principal at a school in Bandera where he met his wife, Lessie Merritt. According to his son, Robert Floyd Curl Jr., 1996 Nobel Laureate in Chemistry, the family moved frequently. The younger Curl attributes his father's intelligence and focus on academics as a foundation for his own love of chemistry. "When I was 9 years 40 San Antonio Medicine • May 2014
old, my parents gave me a chemistry set. Within a week I decided to become a chemist, and never wavered from that path." Curl Jr., is a graduate of San Antonio’s Thomas Jefferson High School and a professor emeritus at Rice University and a co-discoverer of the carbon compounds known as fullerenes (“bucky balls” are one of the fullerenes). The senior Curl loved preaching in the Methodist Church above all else, but when the church discovered his keen ability to manage and coordinate people and programs, he was appointed to administrative positions and rose through the ranks. After several moves throughout his career, including San Antonio, the Lower Rio Grande Valley and Austin, Curl settled in the San Antonio area and focused on building Methodist Hospital and helping to establish the medical center. There were various entities besides the Methodist Church involved in the negotiations, including the San Antonio Medical Foundation, which owned the land and had been working for years on building a medical school and establishing a medical center in San Antonio. Founded in 1947, the foundation’s goal was to build a medical complex similar to Houston’s, with a school as its anchor. The Houston foundation had been started only two years earlier. Originally, the San Antonio Medical Foundation’s effort focused on moving Texas’ first medical school – the UT Medical Branch at Galveston – to San Antonio. But there was too much political resistance, and the effort soon turned to building a new school here. The initiative was delayed for two years by a dispute over whether to build it downtown or in the “Oak Hills” area, so called because of the adjacent Oak Hills Country Club, which opened in the early 1920s and continues today.
UTHSCSA DEAN’S MESSAGE of the foundation’s land use committee. In addition, he was chairUnlike the effort to establish a medical school, the Methodist man of the board for the foundation from 1982 to 1986. Church had few objections to building a hospital. Not surprisMerton Minter, MD, was chairman ingly, their biggest obstacle was fiof the UT Board of Regents and 1953 nancing, with the hospital expected to All the streets in the medical BCMS president. He played an imcost as much as $5 million. The fedcenter are named after people who portant role in passing legislation aleral government would cover half of helped shape the area. lowing for the creation of the “South that (thanks to the Hill-Burton Act of Texas Medical School,” as it was called 1946), but this was still a considerable Robert Floyd Curl, whose legacy in the planning stages. From 1971 amount of money at that time. The is forgotten to most, was arguably through 1977, he was chairman of the foundation, the Bexar County Medone of the most important in board of trustees of the San Antonio ical Society and the Chamber of Comestablishing San Antonio’s Medical Foundation. merce, as well as other groups, South Texas Medical Center. Tom B. Slick was a charter member supported the hospital. The church’s of the foundation’s board of trustees. effort began in 1955, and Curl Sr., He also was instrumental in the formation of the South Texas Biowore many hats as he worked to bring different groups together medical Research Institute and the Southwest Research Institute, and keep the church’s focus on the project. Methodist Hospital which are today both important and thriving research institutions. opened eight years later, in 1963. Just across the street sat the Joe John M. Smith Jr., MD, was a charter member of the foundaJ. Nix dairy farm, which would soon be cleared for construction tion’s board of trustees and one of the most active in securing the of the medical school and University Hospital. A year after the legislation establishing the medical school. Smith, the 1967 hospital opened, the medical school opened. By this time, Curl BCMS president, brought together the society and the Greater Sr., still preaching, had retired from medical activities, and two Chamber’s Task Force to form the foundation, which he also years later he passed away. chaired from 1991 through 1993. OTHER NAMESAKES Edgar Von Scheele was a successful businessman and was one With the help of the San Antonio Medical Foundation, we offer of the “Seven Oaks Group" composed of four individuals who brief biographies of some of the other men and women whose donated the original 171 acres to the foundation. He owned the names we see every day at the medical center, but whose roles reproperty surrounding Von Scheele Drive. main little-known pieces of San Antonio history. Wurzbach Road was named for the Wurzbach family, who had Ewing Halsell was a Texas rancher and philanthropist whose property in what is now the Ingram Mall area, as well as the foundation contributed approximately one-third of the funds Colonnade area around Interstate 10. Wurzbach Road predates needed to purchase an additional 434 acres comprising the South the medical center by many decades. Texas Medical Center. The many individuals who worked to create this medical center The street Hamilton Wolfe existed before the medical center would be surprised to see how it has grown; it is an honor to rewas formed. The Hamilton came from a then-famous horsemember them in this column. Many thanks to Robert “Bob” Curl woman, known as “Miss Hamilton,” who owned the land where Jr., as well as the Methodist Ministry Archives and the San AntoHamilton Wolfe meets Babcock. The second part of the name nio Medical Foundation for their assistance with this article. was for Worthy Wolfe, who owned Wolfe’s Inn, as well as the land where Fredericksburg meets Wurzbach. Dr. Francisco GonzálezMelrose Holmgreen, the namesake for Holmgreen Drive, was Scarano is dean of the School of a charter member of the foundation’s board of trustees and an acMedicine, vice president for tive member of the land acquisition committee in the 1960s. medical affairs, professor of neuSid Katz was a charter member of the foundation’s board of rology, and the John P. Howe III, trustees and a central figure in securing the donation of the origMD, Distinguished Chair in inal 171 acres, which are the site of the Health Science Center Health Policy at the University campus, University Hospital and the Audie L. Murphy VA Hosof Texas Health Science Center pital. Charles Katz was the son of Sid Katz, who, like his father, at San Antonio. His email adtook an active interest in real estate and was a long-standing chair dress is scarano@uthscsa.edu. visit us at www.bcms.org
41
HASA
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42 San Antonio Medicine • May 2014
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continued from page 38
Efforts to decrease preventable hospitalizations for these few conditions (cardiometabolic: diabetes, hypertension, heart failure, angina; and respiratory: COPD and asthma) have been promoted nationwide and also throughout Texas. Medicaid 1115 waiver initiatives target some of these conditions and the BCMS Public Health and Patient Advocacy Committee has prioritized the prevention and management of cardiometabolic diseases through clinical and community coordination. These conditions result in preventable hospitalizations in Bexar County that have high human and financial costs. For the fiveyear period ending in 2011, table 1 on page 40 provides the estimate of preventable hospitalizations and costs in Bexar County produced by DSHS using the hospital discharge database — more than 88,000 admissions and $2.6 billion. We can do better in providing highquality, coordinated outpatient care to patients with these conditions so that they are healthier, and we provide better value for healthcare dollars spent. Using the HIT foundational requirements available in HASA services (e.g., information sharing between providers, data collection and integration in a private and secure system) and applying the appropriate high-touch, human services to deliver the services in the first column of table 2, we can make a large positive impact in the health of our patients and our community. Vince Fonseca, MD, MPH, FACPM, is the director of medical informatics at Intellica Corp., and the medical advisor for Healthcare Access San Antonio (HASA), the local Health Information Exchange (HIE) provider authorized by the state of Texas to create a community-based, regionwide HIE in Bexar County and 22 surrounding counties. Visit www.hasatx.org.
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REACH YOUR TARGET MARKET Are you trying to reach the 4,400 physician-members of BCMS with your business message? Consider joining the BCMS Circle of Friends program, which provides a unique opportunity for business leaders to network and communicate with physicians through a variety of BCMS-sponsored events and services. By helping to underwrite society events, Circle of Friends members help fund BCMS’ mission of enhancing the practice of medicine for healthcare providers and Bexar County residents.
For more information, contact August C. Trevino at 210-301-4366, email him at August.Trevino@bcms.org, or visit www.bcms.org. BCMS does not endorse businesses and involves itself only in services and programs that benefit members and their patients.
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43
BCMS LEGISLATIVE AND POLICY NEWS
CONGRESS HAS VOTED: SGR receives yet another patch; next cliff is April 1, 2015 ICD-10 delayed to Oct. 1, 2015 By Mary E. Nava, MBA, BCMS Chief Governmental and Community Relations Officer The gloves can come off again … for a little while. After months of consternation and a hard fight by physician members of BCMS, TMA and the AMA urging lawmakers to repeal SGR, Congress has placed another patch on SGR, the sustainable growth rate formula, averting for one year the 24 percent physician payment cut that had been scheduled for April 1, 2014. HR 4032, the Protecting Access to Medicare Act of 2014, passed the U.S. House of Representatives on March 27 and the U.S. Senate on March 31. Although the opportunity to fix SGR once and for all is all but lost, something good did come out of HR 4032’s passage – the one-year delay (and second deadline extension) of ICD-10 implementation to Oct. 1, 2015. BCMS members visited with Congressmen Henry Cuellar, Joaquin Castro and Pete Gallego about the SGR issue in February and March, and at the time of this writing, physician members were scheduled to meet with Congressman Lamar Smith on April 22.
BCMS members and staff visit with Congressman Henry Cuellar (Texas District 28) on Feb. 24 during a reception held in his honor.
To cover the costs of the patch, HR 4032: • Establishes targets of 0.5 percent in savings from "misvalued" Medicare physician payment schedule services from 2017 through 2020, for an estimated savings of $4 billion. • Revises the payment system for diagnostic tests and the laboratory fee schedule, based on market-based private sector rates ($2.5 billion). • Reduces payments for using CT equipment that does not meet certain dosage standards and implements appropriate use criteria for advanced imaging services ($200 million). • Revises the Medicare sequester in 2024 to effectively amplify the sequester's impact on all Medicare providers in that year ($4.9 billion).
Congressman Joaquin Castro (Texas District 20) pauses for a photo with BCMS members and staff on March 17.
Also under the bill, the Geographic Practice Cost Index (GPCI) geographic adjustment “floor” of 1.0 for physician work in the Medicare fee schedule is extended for 12 months. From 2003 to March 2014, Congress enacted 16 SGR patches to the tune of $153.7 billion, a total the TMA, AMA, and other organizations say far exceeds what it would cost to reform the Medicare physician payment system once and for all. The 10-year cost of bipartisan, bicameral legislation that would have repealed the SGR is $138 billion. For local discussion on this and other advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava at mary.nava@bcms.org. 44 San Antonio Medicine • May 2014
Congressman Pete Gallego (Texas District 23) visits with members of the BCMS Board of Directors and Legislative and Socioeconomics Committee on March 18.
BCMS NEWS
March’s Unsung Hero honored Rick White of Greater San Antonio Emergency Physicians (GSEP) has been named the BCMS Unsung Hero for March. Mr. White, who has been the administrative leader of GSEP for more than 10 years, has assembled and leads a team of very dedicated staff, who come to work each day with an attitude of “what can I do to make GSEP better,” said the group’s physicians in their nomination. Among Mr. White’s many accomplishments in the past year have been hiring a new accounting manager/controller; renewing a hospital service agreement for three years; realizing significant savings from a renegotiated management services agreement; reviewing and revising the professional courtesy policy; adopting an online compliance training program; updating and adopting the professional fees schedule; adopting a new business office reporting system with more robust features to improve accessibility to patient information, and many others. “Rick reminds us consistently that the success of GSEP is because of the high quality care that we deliver to patients each and every day,” his nominators said. “He has created an administrative team that allows our doctors to be doctors and confidently trust that he will conduct our business affairs with integrity and let us focus on providing quality care.”
Greater San Antonio Emergency Physicians staff include (from left) Maegan Drummonds, Dr. Robert Frolichstein, Dr. Robert Wilson, Maribel Guerrero, Dr. Kathlene Bassett, Rick White, Dr. Sam Mehta, Dr. David Hnatow, Dr. Brian Bates, Jennifer Lincoln, David Zamora and Nick Garza.
The Unsung Hero program allows BCMS members to recognize their office managers/administrators for their dedication and hard work in assisting physicians in delivering the best attention and care to patients. PHYSICIAN MEMBERS: Please remember to recognize your "Unsung Hero." Monthly deadlines and additional information are at www.bcms.org.
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BCMS NEWS
DOCTORS’ DAY District 8 City Councilman Ron Nirenberg (left) reads a city proclamation for Doctors’ Day during a March 28 event at the UT School of Medicine at the Health Science Center San Antonio. Attending were BCMS President Dr. K. Ashok Kumar and BCMS Alliance President Cindy Comfort.
Credentialing service certified by NCQA Bexar Credentials Verification Inc.’s systems and files were reviewed for accuracy and quality control by the National Committee for Quality Assurance (NCQA) and received the highest possible score for the reviews with no adverse findings in any category for which it applied for certification, said BCMS CEO/Executive Director Steve Fitzer. “This level of accomplishment by any organization is unusual and exceptional,” he said. “BCVI is to be commended for this level of success.” Bexar Credentials Verification Inc. (BCVI) is the credentials verification subsidiary of BCMS.
BCVI received certification from the NCQA for the following credentials verification services: Application processing Education and training DEA certification License to practice CVO application and attestation content Malpractice claims history Medicare/Medicaid sanctions Medical board sanctions Work history BCVI's verification services are structured to be consistent with NCQA credentialing standards. BCVI reduces the time, aggravation and expense of verifying the necessary credentials on San Antonio physicians for the area hospitals, am-
bulatory surgical centers and managed-care organizations that require them. NCQA President Margaret E. O’Kane said achieving Credentials Verification Organization (CVO) certification from NCQA “demonstrates that BCVI has the systems, process and personnel in place to thoroughly and accurately verify providers’ credentials and help … clients meet their accreditation goals.” The NCQA certification is a voluntary review process that evaluates a credentials verification organization's management of various aspects of its data collection and verification operation, and the process it uses to continuously improve the services it provides. For more information, call BCVI at 210-3014370 or visit www.bexarcv.com.
Save the date May 6, 6:30-8:30 p.m. Spring General Membership Meeting
Sept. 24, 6:30-8:30 p.m. Fall General Membership Meeting
Embassy Suites Hotel Northwest, 7750 Briaridge ACA Update from TMA Research and Data Director Donna Kenny (1 CME Ethics Credit) Complimentary Mexican buffet, cash bar, update and Q&A (give TMA your input).
Hilton at the Airport, 611 N.W. Loop 410 Talk to the new TMA President for Legislative Updates (1 CME Ethics Credit) Complimentary Polynesian buffet, cash bar, update and Q&A (give the TMA your input).
June 3, 6-8 p.m. New Member Welcome The Argyle Club, 934 Patterson Ave. Mix and Mingle – Complimentary buffet and cocktail party. Jacket but no tie required, no jeans. Come meet your fellow members at our popular annual event.
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Oct. 16, 5-9 p.m. BCMS Auto Show BCMS office parking lot, 6243 IH-10W Mix and Mingle – Complimentary buffet and cocktail party. See the new 2015 models (family and friends welcome).
Oct. 2-3 BCMS Fishing Trip Rockport, Texas For information and pricing, please contact Mark Lachenauer at (210) 301-4391. Have fun with your fellow physicians at the happy hour and dinner, and morning guided fishing trip!
Nov. 1, 11 a.m. to 3 p.m. Women in Medicine Appreciation OMNI Hotel at the Colonnade, 9821 Colonnade Blvd. Luncheon with celebrity speaker Dr. Robin Eickhoff, style show, gifts and prizes. Bexar County Medical Library Association fundraiser showcasing female physician models.
Gunn Acura 11911 IH-10 West
Cavender Audi 15447 IH-10 West
Ancira Chrysler 10807 IH-10 West
Red McCombs Hundai NW 13663 IH-10 West
Ingram Park Auto Center 7000 NW Loop 410
Ingram Park Auto Center 7000 NW Loop 410
Ingram Park Auto Center 7000 NW Loop 410 * Gunn Infiniti 12150 IH-10 West
Ancira Dodge 10807 IH-10 West Ingram Park Auto Center 7000 NW Loop 410
Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Mercedes-Benz of San Antonio 9600 San Pedro Ave.
North Park Subaru 9807 San Pedro Ave.
* Mini Cooper The BMW Center 8434 Airport Blvd.
Cavender Toyota 5730 NW Loop 410
Ancira Jeep 10807 IH-10 West
BMW of San Antonio 8434 Airport Blvd.
Ingram Park Auto Center 7000 NW Loop 410 Ancira Elite Motorcars 10835 IH-10 West
Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604)
North Park Toyota 10703 SW Loop 410 Ancira Kia 6125 Bandera Road
Gillman Mitsubishi 16040 I-35 North Selma, TX 78154
Northside Ford 12300 San Pedro Ave.
Batchelor Cadillac 11001 IH-10 at Huebner
Ancira Ram 10807 IH-10 West
* Ancira Volkswagen 5125 Bandera Rd.
Cavender GMC 17811 San Pedro Ave.
* North Park Lexus 611 Lockhill Selma
* Gunn Honda 14610 IH-10 West (@ Loop 1604)
* North Park Lincoln/ Mercury 9207 San Pedro Ave.
Ingram Park Nissan 7000 NW Loop 410
Cavendar Cadillac 801 Broadway
* The Volvo Center 1326 NE Loop 410 Porsche Center 9455 IH-10 West
Tom Benson Chevrolet 9400 San Pedro Ave.
visit us at www.bcms.org
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AUTO REVIEW
Nissan Juke
offers unconventional styling; fun, interesting drive By Steve Schutz, MD
About three years ago, Audi executives raised many industry eyebrows when they
While the Juke’s proportions are attractive, the actual Juke has a design that’s quite
while the Juke is designed to take you to work and then carry you, your SO, a dog,
bought a few Nissan Jukes and told their designers that the Juke’s proportions were a window into the future. When I read about this interesting turn of events in Automotive News, I raised my eyebrows, too, but I took note and waited for an Audi that matched the Juke’s size and shape. Finally, the Juke-inspired Audi we’ve been waiting for has been announced and will be here soon. It will be called the Q1 – no surprise there as its larger siblings are the Q3, Q5 and Q7 – and will be sold around the world in about a year. Given Audi’s recent track record, it will certainly succeed, and, oh, by the way, the competition is already joining the battle: Lexus recently showed a similarly proportioned small crossover that will hit our market in a year or two, and you can bet Mercedes and BMW will introduce similar vehicles in short order.
polarizing. The windshield and front doors are conventional, but the downward pointing roof, bulging hood, and exaggerated wheel arches are anything but. And the numerous extra design elements like the Leaflike rear end, accent lights on the hood, hidden rear door handles and wacky front end are just ... wow. OK, there’s a lot going on with the Juke’s styling, but that’s presumably what its intended audience wants. At a price point of roughly $25,000, combining great proportions with a not-for-everyone design is probably a smart way to attract 20- and 30-something buyers. Still, older customers are less likely to be enthused. I n t e r e s t i n g l y,
and a bunch of gear out to the trails, it would seem that a better choice to do all that would be the Juke’s showroom sibling, the Nissan Cube. The diminutive Cube has more space than the Juke – it’s called the Cube for a reason – yet still provides roughly the same fuel economy. Apparently, looks trump utility, as the Juke outsold the Cube by more than five to one in 2013. The Juke is certainly fun to drive. Thanks to a low curb weight of around 2,900 pounds, the Juke jukes (sorry, I
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AUTO REVIEW couldn’t resist) happily around town and scampers over the highway remarkably well. Nevertheless, while the Juke is very good in most driving situations, it’s less at home at speed on the interstate. The interior of the Juke is well suited for its useful/fun-for-younger-buyers mission. The gauges and controls in front are well thought-out and solid, though it should be said that Nissan interiors have historically not been as long-lasting as those from Honda and Toyota. The rear seats are tight, as you’d expect in this vehicular class, but they are comfortable. And the space under the rear hatch is easily accessible and pretty big. For any load that’s more than a few grocery bags, you’ll want to fold the rear seats down, and when you do that, you’ll find a lot of usable real estate. I stuck my 29-inch mountain bike (with the front wheel removed) back there when I had my test car, and it fit in nicely. The Juke is offered in four
trim levels: the S, SV, SL, and top-of-theline Nismo (short for Nissan Motorsports). Standard equipment on the entry-level S is fairly basic but still includes 17-inch alloy wheels, AC, keyless entry, cruise control and Bluetooth phone connectivity. The Juke SV comes with a sunroof, automatic climate control, nicer upholstery, keyless entry/ignition, and driver-configurable settings for steering, throttle and the CVT (continuously variable transmission). Just so you know, if you don’t want a manual transmission, you’ll have to live with the CVT, a transmission I don’t favor. The optional Navigation package includes a touchscreen navigation system, powerful Rockford Fosgate audio system and rearview camera. The SL comes with all that plus automatic headlights, leather seating and heated front seats. A Nismo Juke like my tester provides a sport-tuned suspen-
sion, a little more power, upgraded 18-inch alloy wheels, unique exterior and interior styling details, and sportier front seats. Naturally, there are other packages and stand-alone options that we don’t have space to discuss here. Phil Hornbeak will happily help you with any and all information if you call him at the phone number listed below. Fun to drive every day, interesting to look at, and useful, that’s what the Juke is about, and I think explains its popularity. Audi obviously thinks Nissan is onto something here, and the Juke’s sales figures would seem to bear that out. Is it right for you? Call Phil and drive one to find out for yourself. 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. For more information on the BCMS Auto Program, call Phil Hornbeak at 3014367 or visit www.bcms.org.
visit us at www.bcms.org
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