San Antonio Medicine magazine July 2014

MEDICINE SAN ANTONIO

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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JULY 2014

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VOLUME 67 NO. 7

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.

Prognostications

Physician reimbursements predicting the future

By Bernard T. Swift Jr., DO, MPH...............................10

How very special(ized)?

By Jeffrey J. Meffert, MD............................................12

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

President’s Message

by K. Ashok Kumar, MD, FRCS, FAAP ..............................8 Physician as Patient: Complications of treatment

by Jay Ellis, MD ..............................................................14

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History of Medicine: A visit with Hippocrates

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San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS or its staff.

San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

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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., General 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 • July 2014

PRESIDENT’S MESSAGE

Patient-centered care: An effective marketing strategy

By K. Ashok Kumar, MD, FRCS, FAAFP 2014 BCMS President

First of all, congratulations to the residents and fellows who are graduating from their training programs in San Antonio later this month! I wish each of you great success in your professional career and much happiness in your personal lives. I encourage you to join and actively participate in your local county medical society and your specialty society. For those of you who will practice in Bexar County, I invite you to become active members of the Bexar County Medical Society (BCMS) and Texas Medical Association (TMA). We need your new ideas, enthusiasm and energy!

Second, I want you to consider using patient-centered care as a marketing strategy for your practice. Although patient-centered care is now a trendy phrase in healthcare, we all know that it has existed since our profession began. I suggest we analyze our practices and identify specific ways we can make our care more patient-centered. Such a transformation can produce practices in which patients become your marketing partners and share their positive experiences in your practice with their family, friends and co-workers.

WHAT IS PATIENT-CENTERED CARE? In 2001, the Institute of Medicine’s Crossing the Quality Chasm report described patient-centered care as one of the six main elements of high-quality care. Patient-centered care was defined in that report as “respecting and responding to patients’ wants, needs, and preferences, so that they can make choices in their care that best fit their individual circumstances.”1 There are many benefits to practicing patient-centered care. Patients love patient-centered care because it makes them feel like they are treated like people instead of a case of abdominal pain or a stroke.

Patient-centered care also produces many important patient outcomes like increased patient knowledge, increased adherence to treatment and improved self-management.2

8 San Antonio Medicine • July 2014

Physicians in all specialties can adopt this patient-centered care strategy. As physicians, we have the obligation to effectively communicate with our patients so they understand their diseases, the treatment options available to them, and their responsibilities as patients.

Patient-centered care can be used to address obesity and tobacco use, the two most common causes of chronic disease, disability and death in our country. For example, we can talk to (not scold) patients about what they eat, drink and smoke. In addition, we can learn about the context in which patients live so we can talk to them about their family, culture, educational background and social circumstances. This kind of patient-physician interaction tells patients that we are genuinely interested in them as people and not merely as disease entities. In my experience, patients then listen to our recommendations about medications, diet, exercise and habits. This trusting relationship results in patients’ changing their lifestyles and embracing better health practices. They then attribute the positive outcomes in their health to their visit with us and praise our bedside manners and caring attitudes. They now become our marketing allies and tell their friends and relatives about us and how we helped them achieve better health. I believe this “word of mouth” marketing is better than any other advertisement to promote our practices.

1.

2.

Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press, 2001.

Levinson W, Lesser CS, Epstein RM. Developing physician communication skills for patient-centered care. Health Affairs 2010;29:7, 1310-1318.

Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014 president of the Bexar County Medical Society.

PROGNOSTICATIONS

Physician reimbursements predicting the future

By Bernard T. Swift Jr., DO, MPH Diplomat, ABPM in Occupational Medicine “The times, they are a-changin’…” – Bob Dylan In business, change is the only constant. If a business doesn’t change with the times and adapt to new market dynamics, it will soon be out of business. Of course, this applies directly to the private practice of medicine as well since we are, after all, in the “business” of providing medical care.

The private practice business model has enjoyed relative stability over the years. Yes, reimbursements have gradually come down relative to various inflation indexes, and new models of private practice have come and gone (HMOs, IPAs and roll-ups come to mind).

But the model of private practice physicians being paid by managed care companies or the government on a fee-for-service (FFS) basis has remained relatively constant. But there’s a new “Center for Medicare and Medicaid innovation” prescribed in the Affordable Care Act, which is charged with coming up with new payment systems. The old FFS model could be on its way out.

PRACTICE INCOME FALLS The federal government (via CMS) has slowly, but surely, ratcheted reimbursements down over the last 10 to 15 years. In fact, while the Medicare Economic Index – a measure of practice costs – has increased 18 percent over the past 10 years, physicians’ overall Medicare reimbursements have gone up a paltry 5 percent.

Even more damning, the Medical Group Management Association has reported a 49 percent increase in per-physician operating costs over the same 10-year period (Donna Kinney, Texas Medical Association). Since most managed care contracts into which we enter are based on the CMS conversion factor, those reimbursement increases have also been minimal. It isn’t hard to understand why physician practice income is down as these office expenses continue to rise.

As a direct result of reduced reimbursements, private practice physicians are entering what can be described as the early phase of consolidation. Payers will increasingly attempt to decrease provider payments even further as the easiest way to control their costs. Just like the old adage, “All bleeding eventually stops,” so too, all practices cease to exist when they’ve bled too many expenses over an extended period of time with not enough new blood (revenue). Eventually, many physicians (certainly not all – I’m not all gloom and doom) will be faced with stark choices: close, merge, or sell their practice – i.e., “consolidate.”

But who are the buyers? They’re the business guys: the hospi10 San Antonio Medicine • July 2014

tals, venture capitalists, other physician groups. They’re people who can improve the ineffiencies of small practices, achieve economies of scale, and bring expertise to creating and managing new forms of payments.

If a physician makes a decision to sell or merge, what does that do to their psyche and the way they care for patients? For some, it will be a big relief from having to worry about the struggles and uncertainties of running a business. For others, it will result in seemingly overbearing control, an expectation of “processing” more patients, and possibly unbearable intrusions into the freedoms once enjoyed in private practice. It certainly can be a helpless feeling, knowing control has been lost. Many of us either have or will experience this.

The practice of medicine is really at a very strange place in history. In a “normal” free market economy the supply/demand curve plays out. Thus, with an impending shortage of physicians, rates should rise. And that will likely be true for some providers in a few specialties.

BARGAINING POWER But healthcare is not a “free” market today, as too few payers (Medicare, Medicaid, a few major carriers) control reimbursements for the demand side of the curve, and confer rigid fee schedules that come in the form of “take it or leave it” propositions. Physicians have taken those low rates all too often, for a variety of reasons. The net effect is that the bargaining power between the two sides is significantly in favor of the payers. For many physicians, unless we start saying “no,” it won’t change anytime soon. But that’s hard to do when a substantial part of a practice’s income may go away.

At some point, however, physicians can only look forward to the payers running out of physician supply at the low rates they’re currently willing to pay, and will have to agree to some relief. Just maybe the supply will then begin to balance the actual demand.

Whether that truly ever comes … and when, is an open question. I do not have a crystal ball and unfortunately, cannot predict the future.

Bernard T. Swift Jr., DO, MPH, has been the owner of Texas MedClinic for 32 years. He is the current chair of the TMA Council on Socioeconomics and is on the BCMS Board of Directors.

PROGNOSTICATIONS

How very special(ized)!

By Jeffrey J. Meffert, MD There was a time when one could go to a medical school of unexamined quality, serve as apprentice to an experienced physician of unverified sobriety for a few months and then head out to start your private practice. Doctors of old did everything from general surgery to obstetrics to all manners of inpatient medicine.

Although they are now much better trained, some Texan family physicians, especially those serving in small towns, have a practice the “horse and buggy doctor” would recognize. Even in the 18th century there were physicians known to be especially good or especially interested in a particular medical niche who began to confine their practice to that field of study.

The American Board of Medical Specialties (ABMS) was formed in 1933 to start to recognize “specialists” and also to try to ensure the quality of their training. The first members of the board predated the board itself with the establishment of the boards of Ophthalmology (1917), Otolaryngology (1924), Obstetrics and Gynecology (Ob/Gyn)(1930) and Dermatology (1932). There are now 24 host boards and 145 specialties and subspecialties recognized.

TECHNOLOGY MARCHES FORWARD This has not been a static process nor one confined merely to the addition of new boards as technology has marched forward.

Subspecialties have merged with host specialty boards or with other subspecialties. Sometimes this is an agreeable arrangement with the intent to merge two groups into a single stronger one.

The American Board of Allergy and Immunology formed in 1971 with allergists from both Internal Medicine and Pediatrics. In 1982, the American Board of Preventive Medicine began issuing certificates in “Public Health and General Preventive Medicine” rather than each of those as a separate board certification.

Sometimes it appears that changing names is more for marketing purposes than building combined political strength. “Pain Management” changed its certification name to “Pain Medicine” in 2002. Evolving subspecialty techniques have led others to seek recognition and certification within their larger host specialty board.

Some of the newest subspecialties are Pediatric Anesthesiology, Sleep Medicine (both under Anesthesiology), and Female Pelvic Medicine and Reconstructive Surgery (under Ob/Gyn) which were all approved by the ABMS in 2011 and are now issuing their first certificates.

Practicing medicine means job security, although that security does not necessarily apply to the continued existence of a subspecialty board certification for the duration of one’s medical career.

Over the years no fewer than 26 subspecialties have stopped issuing certificates. Anorectal Surgery issued its last certificate in 1954 12 San Antonio Medicine • July 2014

and Proctology in 1956; both of these are now fully contained within the American Board of Colon and Rectal Surgery (ABCRS) so that there are no longer subspecialties in the ABCRS. (Neurologic Surgery, Nuclear Medicine, Ophthalmology, and Allergy and Immunology are other current boards without subspecialties.) Therapeutic Radiology issued certificates from 1934 through 1986 until they changed the name of the certification to Radiation Oncology in 1987.

More than a simple name change, several other subspecialties under the American Board of Radiology have ceased issuing certificates as treatment techniques have changed. No longer can one limit their practice to Therapeutic Roentgenology (1935-1954) or Radium Therapy (1934-1960) which should not be confused with certification to practice X-Ray and Radium Physics (1947-1960) or Roentgen Ray and Gamma Ray Physics (1961-1975).

The ABMS is not the only certifying game in town. Doctors of Osteopathy (DOs) may become certified by either the ABMS or the American Osteopathic Association Bureau of Osteopathic Specialists (AOABOS). AOABOS has 18 specialty boards of its own which roughly parallel the ABMS and are open only to DOs. The American Board of Physician Specialties (ABPS) certifies both MDs and DOs in 18 different specialties although these certifications are not recognized in every state as they are in Texas.

There are frequent battles between the ABPS and ABMS over the validity of ABPS certifications with both sides accusing the other of engaging in political turf warfare.

TIME-LIMITED CERTIFICATES Outliers in certification are groups such as the National Board of Ophthalmology which objected to the limited time certificates currently issued by ABMS specialties and created its own board and certification process. Although most ABMS boards have “grandfathered”-in diplomats who received non-time-limited, “forever” certification, the trend over the last several decades has been to move to time-limited certificates with ongoing maintenance of certification (MOC) requirements appropriate to the specialty.

Being double or triple boarded used to look good on the business card and was good for the ego but now means having to keep up with the administrative, educational and financial requirements of MOC and recertification for each of the specialties and subspecialties.

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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PHYSICIAN AS PATIENT

Physician as Patient

EDITOR’S NOTE: This is the fourth 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 life-threatening illness.

Complications of treatment

By Jay Ellis, MD

The enthusiasm generated by my CT scan results was not a match for the reality of continued chemotherapy treatment. The excitement about my CT scan continued with my visit to Greg Guzley for my next chemo. I felt as if I had reached a major milestone. He tempered my enthusiasm. After my physical exam, I thanked him for saving my life.

"You aren't out of the woods yet," he replied.

"I know, but if we hadn't started treatment I wouldn't have lived more than two to three months."

Greg looked up from his computer with a quizzical look and said, "Two to three months? You weren't going to last two to three weeks." Some things are best learned after the fact.

My euphoria did not survive much longer. After my third round of chemotherapy the cumulative effects of treatment became manifest. The fatigue was oppressive and ever present.

No matter how much I slept, I always felt tired. I would go to the gym and try to exercise, but if my heart went over 100 bpm I worried that I would pass out and drop the barbell on my head. Two flights of stairs looked like Mount Everest. My fingers and toes became numb from the vincristine. I had a constant metal taste in my mouth and almost no ability to perceive the taste of food. I stopped drinking alcohol during chemotherapy, though the truth is I couldn’t discriminate Cabernet from Gatorade. Food had no taste, and I ate only because it was time to do so. I certainly had no appetite. I had the sex drive of the

14 San Antonio Medicine • July 2014

palace eunuch. It seemed that all of the sensual pleasures of life were gone. Worst of all, I feared that I would never ever feel well again, even though the chemotherapy nurses assured me that it would pass.

I tried to work a full schedule after taking a few days off after each session of chemotherapy. I normally keep health issues private (though these manuscripts would beg otherwise), but my patients knew something was up when I went bald and lost 25 pounds. Coupled with my office staff aggressively screening for anybody who appeared even remotely contagious, my secret was out. My patients were wonderful. Everyone wanted to hug and pray over me because this is Texas and that’s what we do. It was hard to get through clinic because everyone wanted to talk about my problem instead of theirs. Work remained a refuge, but in retrospect I should have cut back on my hours. I was completely spent at the end of each day.

In December I developed recurring fever, and the night sweats returned. I would go to the ER or to see Greg. The Methodist ER staff was wonderful with their oncology protocol. As soon as I hit the door, usually in the middle of the night or early morning, I would get my IV, blood cultures, lab studies, chest x-ray and my first dose of antibiotics. The professionalism and attention to detail of the ER staff was reassuring. The workup was always negative. I would feel better for a few days after the antibiotics, and then repeat the sequence a week later.

I secretly feared that despite the excellent CT scan, the lymphoma was making a comeback against chemotherapy.

PHYSICIAN AS PATIENT

My CT scan from Sept. 29, 2013, showing my mass and the lymphadenopathy from lymphoma.

With negative cultures and a negative chest x-ray, the most likely diagnosis was viral illness. That’s how I treated it, even though I was feeling worse. The day after Christmas I went to bed even earlier than usual, telling myself I would call Greg in the morning because I just felt awful. I would never make the call. At 3 a.m. I awoke in a drenching sweat with a searing headache.

I slipped out of bed so as not to wake my wife, Merrill. It is difficult to remember all the details after that. I remember being in the kitchen and feeling very ill. Somehow, I made it to the garage, getting my bag out of the car. I don't know how I got there or how I got my car keys. I made it to the couch and put my pulse oximeter on my finger. It read 66 percent. My first reaction was, "Crap, this thing is broken." I moved it from finger to finger to finger. The results were the same.

My saturation was 66 percent, my heart rate was 120, and if I coughed and breathed deeply I could get my saturation all the way up to 70 percent. The pulse oximeter wasn't broken, I was. I tried to consider my options, but I was not thinking clearly. I briefly considered the idea of Merrill driving me to the hospital, but I realized I might not be conscious much longer. I tried to call Merrill, but I didn't have enough wind to shout and wake her. On the third try I summoned all my breath, shouted and she heard me.

"Call 911," I told her. “Why?" she asked.

My CT scan from Dec. 6, 2013, after two rounds of CHOP-R chemotherapy. Arrows point to the mass.

Continued on page 16

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PHYSICIAN AS PATIENT Continued from page 15 "Because I can't breathe." Merrill sprang into action. Someone would later ask me if she "was freaking out." The answer is not once, not ever. She called 911, threw her clothes on and ran out to flag down the ambulance. I sat on the couch and wondered if this was the day I was going to die. I felt surprisingly calm, maybe from the intoxication of the hypoxia, maybe because lymphoma forced me to ponder my mortality for the previous weeks. I have had a great life. My faith tells me that I will die and go to a better place. If I have anxiety, it is about the possibility of being left a pulmonary cripple. We all die, but please, Lord, don't leave me an invalid.

EMS arrived quickly. I would remember a strange moment where they held the oxygen mask above my face with me waiting for them to apply it. Finally, I said, "I am ready for that when you are." With 100 percent oxygen my saturation quickly increased to 92 percent and my headache melted away. Better yet, the fog lifted from my brain. We made the ride to the hospital to find ER swamped with flu patients and the hospital census at 100 percent.

We waited four hours for a bed in the ICU. Greg saw me in the

16 San Antonio Medicine • July 2014

ICU and ER. My chest x-ray showed my lungs in white out with an overwhelming pneumonia. He suspected pneumocystis pneumonia, but we would need to make sure that we weren't missing something else.

Once in the medical ICU, I began to accumulate more doctors.

Dr. Manica Isiguzo and her partners, Drs. Quresti, Puente-Cuellar and McReynolds, were the critical care/pulmonologists caring for me. Dr. Richard Thorner and Dr. Richard Fetchik were my infectious disease doctors. Greg’s partner, Dr. Manuel Santiago, covered for him over the holiday as well. As my list of doctors got longer and longer, I remembered my old joke that the more doctors you have, the worse the prognosis. The nursing staff of the Methodist medical ICU was outstanding. They made me as comfortable as possible as I began to spend my first night in the hospital as a patient. Merrill insisted on staying in the ICU with me.

Both the nurses and I tried to explain to her why that was a very bad idea. She wasn’t leaving. I tried to explain to her that there was nothing that she could do and both of us had been up since 3 a.m.

PHYSICIAN AS PATIENT

“You need to go home and get some sleep,” I told her.

“What if you get scared?” she replied.

“I’m not scared,” I answered, and I truly wasn’t.

“Well, what if I am?” In the chaos of the day I neglected to stop and think about what all this was doing to her. Her love for me was never more obvious than in that moment. I promised myself that if I survived, I would work every day to make her feel as loved as I did that night.

I had spent the day on my iPad reviewing the medical literature on oncology patients who develop respiratory failure, especially that due to pneumocystis. I then used my iPad to check my own lab results. My doctors had many patients, but that day I had only one. I was surprised to find out that patients with HIV have a higher survival rate from pneumocystis pneumonia then do oncology patients. As I read further, I began to understand why. HIV patients developed the symptoms gradually over time. Oncology

patients, like me, develop a sudden respiratory illness with little prodrome. In retrospect, it seems like the diagnosis was obvious.

However, during the course of my febrile episodes I saw four different doctors, all of them diligent in looking for a source. Despite all our modern technology, some diagnoses present only on their own schedule.

Both of us had a rough night. Every time I fell asleep, my saturation fell, and the nurses came in to rouse me. Merrill would try to drift back to sleep, and I would lie awake staring at the ceiling, then watch Merrill wrestle with the recliner, trying to find a comfortable position. The recliner got the best of it, one time almost pitching her out onto the floor.

When you have nothing to do but think, you recall unusual events. For some reason, I began to think about a young woman I cared for during my first military assignment in Germany. She was admitted to our ICU with varicella pneumonia, and my partners and I cared for her while she gradually deteriorated, despite everybody’s best efforts. We tried truly heroic measures, but she Continued on page 18

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PHYSICIAN AS PATIENT Continued from page 17 eventually died from overwhelming pulmonary failure after a prolonged course on the ventilator. I remember thinking how tragic that she died from chickenpox. Something affected her immune system, and she never survived. I wondered if that was going to be my path.

In the morning, my mother arrived, and Merrill finally agreed to go home and get some rest. My mother just moved to Texas from Chicago to avoid, as she puts it, “bad weather and bad government.” She also spent years caring for my father as his health deteriorated, sitting in hospitals just like she was now. It had been my hope that when she moved here that we could care for her as she had cared for him. Now she was sitting in a hospital again, which just added to my distress.

“I never dreamed that you would have to sit in a hospital watching over me. I am so sorry things turned out this way,” I told her.

“There is no place I’d rather be,” she replied. Mothers always

18 San Antonio Medicine • July 2014

know the right things to say.

I was blessed with plenty of visitors while I was in the ICU. My partners Jim Growney, Tim Orihel and Arnold DeLeon came by.

My office manager Marta Reyna brought food and snacks, as did my running partner and travel companion Dr. Bob Johnson.

Friends from my military days came by, Dr. Bob Joyner, just reinforcing my idea that those ties formed during military service are some of the strongest. My son Nathaniel and his wife, Lindsay, sat with me and brought reading material. I communicated with my daughter Lauren in Germany and her family via my iPad. Their visits brightened my days and kept me from staring at the ceiling too long.

Merrill, of course, was a constant presence, leaving only when my mother was there, the only one she trusted to monitor me in her absence. She became upset with the quality of the hospital food and would call the nurses in to look at my dinner tray, something they of course viewed daily. Merrill would voice

PHYSICIAN AS PATIENT

her displeasure, and the nurses, ever diplomatic, would say, “I can understand why you feel that way.” Merrill finally got disgusted and just brought me food from Aldo’s, which I enjoyed even when critically ill. After I ate, I would read my lab results and my findings in the medical literature to her, which sometimes just increased her distress. All the culture results were negative. The only remaining possibility was pneumocystis and that would require bronchoscopy for definitive diagnosis. Neither Dr. Fetchik nor Dr. Quresti thought that I would get through bronchoscopy without ending up on a ventilator. My iPad medical research already taught me that if you have pneumocystis pneumonia and you’re on a ventilator, the mortality rate is 90 percent. For the first time, I felt a sense of anxiety.

Fortunately, they recommended that we stop all other antibiotics and start treatment with trimethoprim sulfa. Twenty-four hours later, my oxygen requirement decreased, and I slept through the night for the first time in weeks without a drenching sweat.

After five days of bed rest, I was well enough to leave the ICU and move to the rehab floor. I became friends with Thomas, my rehabilitation aid. He would come by several times a day and help me get up and walk so I could reach my goal of walking for six minutes without stopping and while keeping my oxygen saturation above 90 percent. On my first try, I made it 285 feet before I was gasping for breath and my saturation dropped to 85 percent.

Each attempt was better, and after two days, I made the sixminute walk, though Thomas still had to give me a pass on a brief period when my saturation hit 89 percent. I could now go home.

Greg gave me very strict instructions. I would do no activity more strenuous than walking at a 15-minute pace. I could lift light weights, but nothing heavy and nothing strenuous. Most importantly, he told me I would stay home and only at home for a month. If I were to come down with influenza, I would likely not survive. It would be a month of house arrest without the ankle bracelet, but it would be a step toward getting better.

Next: The economics of serious illness.

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19

HISTORY OF MEDICINE

A visit with Hippocrates ... and beyond Lecturer to discuss archaeology of health in ancient Mediterranean world

By J.J. Waller Jr., MD

The Southwest Texas Archeological Society (SWTAS), the local branch of the Archeological Institute of America, is organizing a series of lectures on the topic of ancient medicine. The topics will vary from examination of DNA in Roman skeletons to Civil War medicine.

One of the lectures will be presented by Dr. Alain Touwaide, a research associate of the National Museum of Natural History, part of the Smithsonian Institution in Washington, DC. He is also scientific director of the Institute for the Preservation of Medical Traditions.

Dr. Touwaide is a science historian who specializes in the history of medicinal plants in the cultures that flourished around the Mediterranean Sea from antiquity to the 17th century CE. He has devoted his career to unearthing lost knowledge. Dr. Touwaide, who is proficient in 12 languages, studies ancient texts in their original language (Greek, Latin and Arabic) and prepares editions of major works with English translations and critical

20 San Antonio Medicine • July 2014

analysis. He is a lecturer in universities in the United States and throughout the world.

Dr. Touwaide’s lecture, “The Archaeology of Health in the Ancient Mediterranean World,” will be presented at 7:30 p.m.

Monday, Oct. 20, in Chapman Hall at Trinity University. The event is free and open to the public.

ABSTRACT Medical archaeology usually deals with the dead and the identification of diseases, the consequences of stress on health, casualties and major traumas, or any other event that had an impact on ancient peoples’ lives and well-being. Rarely does it take into consideration the factors that contributed to populations’ health, from diet to medicines, apart from rare works devoted to the identification of foodstuffs and drinks on the basis of remains’ end – or traces on – archaeological mate-

HISTORY OF MEDICINE rial. I will show that a combined study of remains or traces of foodstuffs, medical literature, artistic representations, and also remedies provides unsuspected keys about ancient populations’ health, particularly if it is trans disciplinary and brings together cutting-edge laboratory techniques, massive data basing of textual data and, on this basis, quantitative analysis, botanical reading of texts and works of art, and geographical distribution and circulation of natural resources. Results are all the more significant if research covers a vast area and a long period of time, and is dynamic over both space and time so as to perceive local and chronological differentiations. The presentation will focus on both Classical Antiquity and Byzantium, and will be lavishly illustrated by visual material coming from a vast body of documents, including Byzantium manuscripts, representations of plants in books, mosaics and frescoes, archaeological material, and also living plants, dry specimina of herbaria, and natural environments in presentday Mediterranean.

We are particularly interested in alerting the medical community to Dr. Touwaide’s presentation because of the scope of his lecture and his topics related to the history of medicine,

which are of interest to many BCMS members. I also know him personally and have briefly visited with him and his lovely wife, Dr. Emanuela Appetiti, a cultural anthropologist, in Washington this past summer. He is a highly knowledgeable and delightful individual.

Not only do I wish to encourage attendance at his lecture but also am humbly soliciting financial support for this special occasion. It costs close to $2,000 to cover expenses, and any contributions (no matter how small), will be greatly appreciated by the SWTAS, which is a 501(c)(3) organization, and myself. Contributions can be sent to AIA SWTAS. The check should be mailed to: Laura Childs, 2858 Burning Log, San Antonio, TX 78247.

The check should stipulate Touwaide Lecture.

For more information on the Southwest Texas Archaeological Society, visit http://aiaswtas.org.

For more information on the Institute for the Preservation of Medical Traditions, visit http://medicaltraditions.org.

J.J. Waller Jr., MD, is a member of the BCMS Communications/Publications Committee.

visit us at www.bcms.org

21

BUSINESS OF MEDICINE

TRANSACTION COSTS: e friction in healthcare delivery

By Mark J. Bonica, PhD, and Lee W. Bewley, PhD, FACHE Accountable care organizations (ACOs) are a key element of the Patient Protection and Affordable Care Act (PPACA) of 2010.

Ideally, the incentives in the PPACA will encourage the formation of ACOs that will improve the coordination of care in our healthcare system by formalizing the relationship between fragmented, independent providers of health services. This increased coordination will be especially helpful to the chronically ill, whose care often comes from transactions with multiple specialists.

Uncoordinated efforts can result in conditions being missed, or perhaps contradictory treatments. By bringing the coordination of care under one organization, improvements in coordination of care can improve the quality of care delivered and do so in a less costly manner. Researchers at the Commonwealth Fund have found that initial applications of ACO principles can make meaningful enhancements to the delivery of healthcare.1

COORDINATION IS NOT FREE Unfortunately, as anyone who works in the healthcare field knows, coordination is not free. When the patient is treated by multiple caregivers, there is a cost to coordinating the various transactions the patient might have with the healthcare system.

These coordination costs are in addition to the actual cost of providing care. The costs of coordination across separate organizations, as opposed to the costs of production, are generally referred to as transaction costs by economists.

Transaction costs can be generally divided into three categories: search and information costs, bargaining and decision costs, and policing and enforcement costs. Let’s think about how each of these categories of transaction costs apply to the coordination of patient care.

Let’s assume a patient has a primary care manager (PCM) through his ACO – perhaps a family physician. The very idea of a primary care manager implies that the patient has recognized that his knowledge of the healthcare market is limited, and that he needs someone to help him navigate that market. If the patient has a complaint – perhaps pain in his shoulder that he cannot diagnose with his lay medical knowledge – he could begin going to specialists and seeking their advice. The source of the pain could be skeletal, in which case he might start with an orthopaedic sur22 San Antonio Medicine • July 2014

geon. The source might be neurological, though, in which case perhaps a neurologist would be more able to help. To figure that out, he probably should get some medical imaging, but which test? MRI? X-ray? Of course, he would need someone to help interpret that imaging. Without the help of a PCM, the patient could waste time and money trying to guess which services he needs and which provider might actually be able to help him. The traditional role of the PCM is to reduce the patient’s first form of transaction costs – search and information costs. A visit to his PCM is not free for our notional patient, but it is cheaper than the costs the patient would incur trying to navigate on his own.

Furthermore, the PCM not only helps the patient search, but also understand the information he gets back.

Now that the patient has had some initial diagnostic work, perhaps an MRI and an initial consult with an orthopaedic surgeon, the patient has to make a decision about treatment. If the diagnosis isn’t clear cut there might be several potential courses of action: surgery might be an option, a referral to physical therapy might be in order, or simply watching and waiting. Assuming the PCM is working with a network of specialists and facilities through the ACO, there is an incentive for the knowledge within the network to be focused on the least costly, best outcome for the patient. A well-run ACO will generate better decisions that result in better outcomes and less cost in order to remain profitable.

One of the complementary technologies mandated by the PPACA is the implementation of electronic medical records (EMRs). Although they are costly to implement, EMRs are transaction cost-economizing. They reduce transaction costs by making information freely available within systems, which can improve decision making. The large fixed costs of EMRs are best born by larger organizations that can spread the fixed cost over many patients – another reason why we will continue to see pressure on smaller organizations to merge into (or with) larger organizations.

ASYMMETRIC INFORMATION By working with an insurer, patients reduce their own efforts at bargaining, relying on the insurer to negotiate with the system for them. This service is partly what patients buy when they pay their premiums. Our patient can also reduce the third type of

BUSINESS OF MEDICINE transaction cost – those of policing and enforcement – by working with an insurer and ACO. When our patient works with these organizations, the insurer and the ACO are at risk for the cost of his care. Poor outcomes tend to lead to more expense, and therefore the insurer and the ACO have an incentive to ensure a high quality outcome. It is difficult for a patient without medical training to monitor the quality of the services he receives. This difficulty results from what economists call asymmetric information, or a situation where one party has more information than another.

Insurers have financial incentives to be just as informed as the providers, and therefore the cost of enforcement is lower for the insurer than it is for the patient. ACOs have an incentive to assemble the best collection of service providers, and enforce quality of care standards in each part of the patient experience.2 ACOs can be thought about usefully as transaction cost-economizing organizational innovations. Ronald Coase, the economist who popularized transaction cost economics with his 1937 paper, The Nature of the Firm, asked in his paper, if firms are so great, why don’t we just have one big firm and no market? His answer was ultimately that coordination within the organization is not free, as we can see with the high cost of EMRs, or the additional layers of administration necessary to ensure quality and internal coordination. We can save on transaction costs by bringing trans-

actions inside of organizations like ACOs. Nevertheless, the costs of coordinating within the ACO will ultimately limit ACO size.3

CITATIONS 1

Forster, A.J., Childs, B.G., Damore, A.L. et al., (2012) Accountable Care Strategies: Lessons from the Premier Health Care Alliance's Accountable Care Collaborative, The Commonwealth Fund. Available at: http://www.commonwealthfund.org/Publications/Fund-Reports/2012/Aug/Accountable-Care-Strategies.aspx.

2 Dahlman, Carl J. (1979). "The Problem of Externality". Journal of Law and Economics 22 (1): 141–162.

3 Coase, Ronald (1937). "The Nature of the Firm". Economica 4 (16): 386–405.

Lt. Col. Mark Bonica, PhD, is an assistant professor and deputy program director in the Army-Baylor University MHA/MBA program.

His focus specialties are economics, financial management and policy.

Lee W. Bewley, PhD, FACHE, is an Army officer, associate professor of healthcare management, and a board-certified healthcare executive. He is the program director of the Army-Baylor University MHA/MBA program, and serves as an adjunct faculty member at the University of Texas at San Antonio, Trinity University and University of the Incarnate Word.

visit us at www.bcms.org

23

BCMS NEWS

SPRING GENERAL MEMBERSHIP MEETING

Donna Kinney, director of research and data analysis at the Texas Medical Association, discussed the impact of healthcare reform on physician practices at the May 6 BCMS General Membership Meeting at the Embassy Suites Northwest.

24 San Antonio Medicine • July 2014

BCMS members attending the General Membership Meeting received free CME in ethics and enjoyed a buffet meal.

BCMS NEWS

BCMS LEGISLATIVE AND ADVOCACY NEWS Physicians support elected officials friendly to medicine

Event host Alex Kenton, MD (left), pauses for a photo with Texas House Speaker Joe Straus May 29.

(From left) Rodolfo Molina, MD; Alex Kenton, MD; Mary Nava; Janet Realini, MD; and Rep. Philip Cortez visit June 4.

With a very active election year under way, BCMS physicians have been busy attending and representing their profession at legislative receptions supported by TEXPAC, being held in honor of elected officials who are friendly to medicine. On May 29, Drs. Alex and Candace Kenton hosted a reception in their home in honor of Texas House Speaker Joe Straus (District 121). On June

4, a group of doctors attended a reception at Mi Tierra Restaurant in honor of Texas State Rep. Philip Cortez (District 117), who sits on the Texas House Committee on Public Health.

For more information, contact Mary Nava, BCMS chief governmental and community relations officer, at mary.nava@bcms.org.

BCMS ALLIANCE NEWS

Mary Sue Koontz Nelson (seated) chats with BCMS Alliance members BCMS Alliance member Jennifer Lewis donned a bee costume while signing copies of her cookbook, “Stolen Recipes.” Nelson was the guest to meet with children at the Pre-K 4 SA North Education Center Jan. 29 for a “Be Wise Immunize” influenza immunization speaker at the Alliance’s general meeting luncheon Feb. 14 at the Argyle Club, describing the health screenings offered by the AugustHeart organization. clinic sponsored by the BCMS Alliance. visit us at www.bcms.org

25

NONPROFIT

The “A” word:

By Denise Rizzo

Any Baby Can helps families facing an autism diagnosis by offering hope and support Diego was a preemie born six weeks early

to Rachel and Steve Trevino. At an early age,

SAFETY NET OF SERVICES

specialists informed Diego’s parents of the

Any Baby Can is a local

devastating diagnosis: autism. “I always

nonprofit that is dedi-

knew … you just know when there’s some-

cated to helping improve

thing wrong with your child,” his mom says.

the quality of life, thus

For families who have a child diagnosed

maximizing potential for

with autism spectrum disorder (ASD), life

every individual and fam-

is one scary rollercoaster with no end in

ily affected by autism and

sight. The newest statistical data available

other chronic health con-

suggests that more families are facing this

ditions. Any Baby Can

daunting ride filled with confusion and

has become the city’s lead-

challenges, with one in 68 being diag-

ing expert in autism serv-

nosed along the spectrum; a 29 percent in-

ices; a trusted entity that

crease since 2008.

fills in the gaps providing

There is an urgent need to assist this

financial and emotional

growing population with services begin-

support, education and

ning with early diagnosis that leads to var-

training to the entire fam-

ious interventions and therapy.

ily regardless of income

Families affected by autism represent a

and free of charge.

mixture of ethnicities, education and so-

Children with autism have a team of

cioeconomic status. Oftentimes these par-

highly trained physicians and therapists

Many people with autism go on to live

ents, in other areas of their lives, are

caring for them; however, when a child is

independent and fulfilling lives and de-

extremely resourceful with professions in

ill, it affects the entire family and the emo-

velop meaningful relationships. Although

medicine, law or education; however, they

tional and financial impact is immense.

there is no cure for ASD, there is signifi-

find themselves encountering the same dif-

Any Baby Can eases these burdens

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through Reaching Families Facing Autism

with intensive early intervention. With

fewer resources. Steve is a successful local

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agencies like Any Baby Can, parents like

architect, and as Rachel explains, “We were

program that offer many services for fam-

Rachel and Steve are equipped with re-

doing this all on our own; we didn’t know

ilies, such as parent training, counseling

sources and tools to best parent their child

about these wonderful services. Our lives

and education groups. “When I am at Any

with autism. “My husband and I are

opened up when we found Any Baby Can,

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blessed to have Diego in our lives, and we

this is where we blossomed.”

I’m not alone, and I always feel like I’m

will do everything we can to prepare him

26 San Antonio Medicine • July 2014

getting a big hug,” Rachel says.

NONPROFIT

for life,” Rachel says.

Families parenting a child with autism face the following challenges:

Any Baby Can provides the following solutions:

Many times parents are confused, isolated and overwhelmed and need help understanding what autism is and how to support their child.

A five-week parent training series helps skill-building in the areas of positive behavior supports, using Applied Behavioral Analysis (ABA) strategies in the home, social skills and school advocacy training.

Men and women grieve their child’s medical diagnosis very differently. Divorce rate as high as 80 percent for these families.

Individual and group counseling provided by a licensed psychologist helps parents work through some of the grief and confusion.

Communication skills are a common struggle for children with ASD. Children have difficulty understanding social cues and following instructions, leading to frustration and behavior issues.

A “toolkit” filled with visual supports help parents communicate what they expect and allows their child to express his or her wants and needs. This has been proven to decrease problem behaviors that result from difficulty communicating.

Children with autism typically receive the majority of financial and emotional support. Oftentimes, siblings are lonely and resentful toward the child diagnosed with ASD.

A sibling support group allows children to meet others who have a sibling with special needs. Led by a licensed counselor, children are given understanding into the disability. Research suggests this is one of the most effective ways of promoting wellbeing and positive adjustment in siblings of children with ASD.

Children with autism require additional expenses for healthcare, schooling, therapy and other services. It can cost a typical family more than $60,000 a year to raise a child with autism.

All services provided by Any Baby Can are offered at no charge regardless of the family’s income to ease the financial burden.

Sensory issues make eating regular foods challenging or impossible.

Extra-curricular activities are limited because of mobility or excessive time spent in therapy. Adolescents with autism are two times more likely to be obese, compared to children without this developmental disability.

Any Body Can is an exercise and nutrition program of Any Baby Can and was designed specifically for children with unique learning abilities and their family, complete with weekly visits from an adaptive fitness specialist, dietitian assessment and nutrition education.

Diego’s transformation has been incredible to witness. Initially he was emotionally isolated and unable to communicate; now he is a confident 7-year-old who has many friends and believes the party starts when he walks in. Currently in private school, he recently was awarded student of the month and can carry on a conversation with anyone. He loves eating pizza, playing with Legos, swimming and gymnastics. Rachel credits much of their success to Any Baby Can.

“Because of them, I am better equipped and empowered, so I can equip and empower Diego,” Rachel says. “There is no cure for autism but we can all learn to cope.”

Autism is a lifelong disability but can show much improvement. Upon diagnosis seek the following as soon as possible: • Early intervention • Intensive communication and behavioral therapy • Find an agency like Any Baby Can to guide you • Parent training • Counseling • Contact local school district.

Do you know a family that needs these services?

Contact Tisha Gonzalez, autism services director, 210-227-0170.

visit us at www.bcms.org

27

LIFESTYLE

Best bets for viewing bats

By Mauri Elbel Along with hundreds of others gathered on top, underneath and around downtown Austin’s Ann W. Richards Congress Bridge on a still June night, I wait patiently with my husband and our two young boys. As the sun sets, high-pitched squeaks begin to reverberate from beneath the bridge and our boys become impatient.

“Where are they? I want to see them!” my 5-year-old’s inquiry turns into a demand as a single bat simultaneously flies over our heads.

Within minutes, that bat is followed by several others, then a couple dozen more before a mass emerges from this wellknown downtown Austin roost. In Central Texas, we are lucky to be able to experience this phenomenon in numerous locations.

But what is even more impressive than the entertainment value bats bring us are the ecological benefits they provide. In Texas, and around the world, bats serve as natural enemies of night-flying insects.

In fact, according to Bat Conservation International (BCI), if we were to lose our bat species, the demand for chemical pesticides would increase, jeopardizing the entire ecosystem and harming human economies. Bats are the No. 1 eater of bugs at night, says Fran Hutchins, Bracken Cave Preserve director for the past eight years, adding that the millions of Mexican freetailed bats that call Bracken Bat Cave home eat up to 200 tons of insects nightly.

“This colony will eat over 100 tons of bugs every night, most of which are agri28 San Antonio Medicine • July 2014

cultural pests,” Hutchins says. “Those 100 tons of bugs are saving cotton farmers in Central Texas three-quarters of a million dollars in pesticides and crop dusting. In the U.S. overall, bats are saving farmers over $4 billion dollars a year.”

So where are the best places to go to view these magnificent mammals in all their splendor? This summer, head to these four convenient locations for your best bets at seeing bats:

BRACKEN CAVE

says. Bracken Bat Cave provides an ideal habitat for pregnant females due to hot, stable air temperatures –– an environment Hutchins compares to a giant incubator.

The females will come out earlier than at other locations because they try to eat at least their body weight in bugs every night, he adds.

“It is a natural wonder to see 15 million to 20 million bats pouring out of a cave,” Hutchins says. “It takes between three and three and a half hours for the bats to empty the cave each night. The mouth of the cave is at the bottom of a sink hole so they have to spiral up out of that sink hole to get out –– there is literally a tornado of bats in front of you.”

www.batcon.org/index.php/get-involved/ visit-a-bat-location/bracken-bat-cave

Bracken Cave, sitting just outside San Antonio in southern Comal County surrounded by a 700-acre natural preserve, is the summer home of the world’s largest bat colony. This maternity colony is full of 15 million to 20 million hungry females that need to generate about twice their body weight in milk every day to feed their Juneborn babies for about six weeks.

The babies are about a quarter of the size of their mothers when born, but four to five weeks later they are the same size and flying and hunting on their own, Hutchins

Book a Bracken Cave tour from May through September online at batcon.org.

Biweekly tours start at 6 p.m. and run until 8:30 p.m., providing an educational walk and talk for $25 a person and free for members. Here you will see nature in action –– predators such as snakes and raccoons wait at the mouth of the cave to catch bats for dinner, and hawks and owls hover in the sky above hoping for a meal.

“All of this is going on less than 100 feet away from you,” Hutchins says. “Seeing that is amazing. The emergence is so intense that shows up like a cloud on Doppler radar.”

LIFESTYLE

Photos © Merlin D. Tuttle, Bat Conservation International, www.batcon.org

CAMDEN STREET BRIDGE Check out the bachelor colony that roosts at Camden Street Bridge on the museum reach of the San Antonio River Walk.

Park at the Pearl Brewery and walk south along the River Walk toward Camden Street where you will find signage along the hike and bike trails fringing the river.

Emergence begins around 8 p.m., and starting the second week in July through Aug. 12, free educational talks take place every Tuesday at 7 p.m. –– a collaboration of Texas Parks and Wildlife Department, BCI and the San Antonio River Authority.

State Park to watch the bats emerge from the abandoned railroad tunnel which gave the park its name. Up to 3 million Brazilian freetailed bats (also called Mexican free-tailed bats) and 3,000 cave myotis bats can be seen nightly from May through October. Batviewing opportunities are available seven nights a week, and nightly educational presentations are given Thursday through Sunday. While people can come out any evening May through October, the largest population of bats can be seen in August and September, and they tend to come out earlier, making them easier to see then.

“The best months to visit Old “There are about 50,000 bats here,” Hutchins says. “It’s San An- Tunnel are August and September,” tonio’s version of Congress Avenue says park superintendent Nyta Brown, adding that the lower viewBridge.” ing area is the best place to view Make a night out of the event by heading bats. The lower area is open Thursto the Pearl Brewery, having dinner and day through Sunday evenings for a seeing the bats. The Bat Loco Bash takes place Aug. 12 at the intersection of Cam- $5 fee, while the upper viewing area den and Newell streets, featuring educa- is free. tional activities, food trucks, live music and bat presentations from experts, followed by an emergence of 50,000 Mexican freetailed bats.

OLD TUNNEL STATE PARK IN FREDERICKSBURG

“There is someone at Old Tunnel every night to answer questions, but the lower program is only on Thursday through Sunday evenings,” Brown says. Visitors should call 866-978-2287 to get the latest emergence time information.

More than a million Mexican free-tailed bats call the Ann Richards Congress Avenue Bridge in downtown Austin home by mid-August, but you can see them after dusk from April to October. Here up to 1.5 million bats form ribbons in the summer night skies, creating a beloved Austin attraction for tourists and locals alike.

These Mexican free-tailed bats have found the ideal roost in the middle of downtown Austin: the underside concrete crevices that stretch across the bridge. For the best lookout, bring along a picnic blanket and head to the Austin AmericanStatesman’s Bat Observation Center which sits adjacent to the bridge –– parking is available at the Statesman after 6 p.m. You also can view the evening emergence from a guided riverboat cruise, the top of the bridge, or enjoy a close encounter from underneath the bridge like we did.

Emergence times fluctuate from location to location. The bats at Bracken Bat Cave emerge earlier in the evening –– around 7 p.m. or 7:30 p.m. –– because there are many female bats that forage at least 60 miles from their roost in search of extra food to nourish themselves and their young, while bridge bats tend to take flight a bit later, often after dark.

But, as we discovered, it is well worth the wait to witness bats spiraling into the summer night sky.

www.tpwd.state.tx.us/state-parks/old-tunnel/bat-viewing

Head to Fredericksburg’s Old Tunnel

AUSTIN’S URBAN BAT COLONY www.statesman.com/s/bats

For more information visit: www.batcon.org. visit us at www.bcms.org

29

LIFESTYLE

Restaurant Week celebrates Lunch, dinner menus offer choices Aug. 16-23 San Antonio Restaurant Week is a celebration of the unique food scene this city has to offer. Foodies and those just wanting to dine out come together to enjoy various cuisines from some of the best restaurants in the area. Restaurant Week, set for Aug. 16-23, is the perfect excuse to inquire about a new restaurant or revel in an old favorite, and it promotes a unified time to go out and dine.

Each participating restaurant creates a prix-fixe menu for lunch and dinner and often gives chefs the chance to explore beyond their typical menus, utilizing specialty ingredients or experimenting with new trends. And, with the increasing popularity of Restaurant Week, organizers are offering even more options to appeal to an array of diners while allowing more casual-dining restaurants the opportunity to participate.

30 San Antonio Medicine • July 2014

Whether lunch or dinner, the restaurants still will feature a three-course menu, but new this year are two tiers from which to choose. Tier one is the same as it has always been: lunch for $15 and dinner for $35. Tier two is new and still offers a multiple-course meal, but prices are $10 for lunch and $25 for dinner. Visitors will not be losing any of that great San Antonio flavor – just some of the price.

MENUS WILL BE POSTED Participating restaurants and their tier level will be posted on the CulinariaSA.org website as they are confirmed. Along with each restaurant listed on the website will be the chef-prepared menu of lunch and/or dinner, so guests will know what will be served before they arrive. Some restaurants even include bev-

erage pairings for an additional price to allow for the exploration of the liquid side of the culinary arts. Reservations aren’t required to indulge in Restaurant Week but are strongly suggested to ensure seating.

Also, be sure to mention when making reservations that you intend to order from the Restaurant Week menu.

Restaurant Week on the Move is back again this year, after debuting last year and becoming a big hit. This portion of Restaurant Week includes many of the city’s favorite food trucks seen driving around town or parked in popular mobile kitchen parks. Restaurant Week on the Move features lunch for $8 and dinner for $15. This option is perfect for those short on time or for those hoping to get a taste of what the food trucks have to offer.

Food-truck mania is still in full effect, and these trucks turn out some of San Anto-

LIFESTYLE

s San Antonio’s food scene Special to San Antonio Medicine nio’s most talked-about dishes – gourmet grub on four wheels.

The restaurants asked for it and the diners asked for it, and Culinaria is answering back. Why not add a second Restaurant Week? Done. A second Restaurant Week has been added to the lineup of events for Culinaria. The second week will be Jan. 19-24, so guests can start off the year with exceptional food. No doubt, many of the restaurants included in the first week will return for the second restaurant week, and the same rules apply for this week: threecourse lunch or dinner. Both weeks offer the chance to relish great food in San Antonio.

While patrons of San Antonio Restaurant Week are exploring cuisine, they are also savoring every meal as a charitable contribution, as well. For each lunch purchased

on the Restaurant Week menu(s), the restaurants will donate $1 to Culinaria and its causes, and with each dinner purchased, restaurants will make a $2 donation. This money goes back into the San Antonio community through Culinaria’s many philanthropic means.

Culinaria is a nonprofit organization that can be explained with the mantra, Eat. Drink. Give. Restaurant Week is a vehicle that allows the organization to continue to enrich the city through these efforts and supports the organization’s mission to benefit the San Antonio community and promote San Antonio as an ideal wine and food destination.

COMMUNITY SUPPORT By way of providing culinary scholarships and aid to San Antonio’s chefs enduring personal hardships through the

Chefs 4 Chefs programs, Culinaria has long promoted its support of the community. Culinaria is ever-growing and trying to find new ways to enrich San Antonio, and its next big endeavor in aiding the community will take form in the Culinaria Urban Farm. The purpose of the farm is to hone in on true nutritional values and education to promote a farm-totable diet. With each San Antonio Restaurant Week bite, guests help keep these causes alive.

Tempted but want more information?

Visit the Culinaria website at CulinariaSA.org or call 210-822-9555. Participating restaurants, menus and additional events of Culinaria will be added as details become available. Culinaria also can be found on Facebook at CulinariaSanAntonio and Twitter @CulinariaSA. visit us at www.bcms.org

31

HASA

Patient information exchange shows value

By Gijs van Oort, PhD

Keeping track of your patient information through an electronic medical record (EMR) is slowly increasing among physicians and physician groups. While adoption among hospitals is in the 80th percentile, physician adoption in the South Central Texas area is estimated around 30 percent but growing. Converting from paper to electronic is a first step in the overall effort to allow patient information to be available for medical practitioners in a seamless way at the time a patient seeks care. As a next step to accomplishing that, health information exchange (HIE) is promoted locally through a nonprofit initiative led by local hospitals, physician groups, BCMS, the San Antonio Military Health System and other healthcare stakeholders. Well before the Accountable Care Act, it was recognized that the value of electronic medical records lies just in that fact – that information can securely flow to the right point of care at the right time.

Practicing physicians have approached this concept slowly. Concerns about cost and disruption to the office workflow are real, certainly with the difficulties and frustrations that many have had in converting to EMR. In the 2011 Rand Corporation physician satisfaction survey (www.rand.org) EMRs were supported in concept but with reportedly significant negative experiences because of rigid technology, wasted time, complex screens and greater expense than originally planned. However, more physicians are looking beyond these immediate challenges and can see upsides in the longer term.

Following are considerations that physicians are considering when embracing this next step in the electronic patient evolution.

HASSLE FACTOR In isolated physician offices, a lot of time and resources are expended on manual processes for sending referrals, copying records, and following up with other offices. Additionally, physicians frequently are restricted in timely diagnoses because of missing patient history. And a general patient complaint is the repetitive completion of patient information. Patient information sharing can address several of these issues by streamlining work flow issues.

More hassle can be avoided if submitted patient information can be automatically abstracted for submission to state offices (immunization, labs) or local health department officials. And with outcomes-based reimbursement, having an automated reporting capability for quality measures can greatly improve the time a physician can spend with a patient, without degrading these reporting requirements.

CMS has clearly and consistently laid out the pathway from feefor-service reimbursement to outcomes-based reimbursement. A recently published dashboard by CMS (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/Dashboard/Chronic-Conditions-HRR) for its Medicare population shows that San Antonio patients are increasingly likely to experience hospital re-admissions as more chronic co-morbidities 32 San Antonio Medicine • July 2014

exist. Physicians will soon have to show evidence of Medicare patient health status from their own EMR system, but also document how they have managed patient care outside their office, specifically these chronic conditions. Dashboard-driven reports that include patient information across providers can be of invaluable help for that. And, if history repeats itself, private insurers will follow CMS if cost and quality can be impacted favorably.

To encourage transitional care, physicians since January 2013 can bill under CPT-codes 99495 and 99496 for discharged Medicare patient communications and office visits within two days, and seven or 14 days, respectively. Reimbursement rates are higher than a routine office visit. By sharing health information, an alert from a HIE can notify your office at the time of discharge, allowing your office staff to contact the patient in time.

PATIENT COMPLIANCE A general complaint of physicians has been that patients ignore about half of what they have been advised to do after they leave a clinic. Tools are available to remind patients, educate them on their specific needs, and securely and economically communicate with their providers’ staff. Furthermore, patients are by law entitled to a copy of their medical information within 10 to 15 days following an event. Physicians can see this as a tool to engage patients, make them more accountable for their care, so that complications may be minimized and manageable conditions are indeed managed by the patient as well. Physicians who encourage the use of such a patient portal will undoubtedly benefit from a loyal and more educated patient base from more discriminate data sources than random Internet searches.

The journey to electronic health records has been all but easy or smooth. However, many physicians have made the trip and are now ready to reap the rewards. The RAND study for physician satisfaction also highlighted the fact that few physicians want to go back to the paper age; many are willing to persevere knowing that future performance will depend on electronic medical information sharing as the utility to effectively manage patient care. Then the question remains: Do you want to do it or have it done to you? The HASA board has taken the first approach since 2006 and invested in the sharing of patient information through a neutral entity. It now is up to the physician community to engage and help improve the quality and access to care for the Central Texas community without jeopardizing the business viability.

Gijs van Oort, PhD, is the executive director 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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33

UTHSCSA DEAN’S MESSAGE

BARSHOP INSTITUTE ON AGING AND LONGEVITY STUDIES Translating results ‘from bench to bedside’

By Francisco González-Scarano, MD When Sam Barshop passed away at 84 just six months ago, San Antonio lost one of its finest citizens. Mr. Barshop is best known in the business world for creating the La Quinta Inn hotel chain with his brother, Phillip. He also was a true philanthropist, contributing to the University of the Incarnate Word and founding the Barshop Jewish Community Center. In the world of science, the Barshop name is associated with one of the most prestigious and productive research centers on aging in America – the Barshop Institute for Longevity and Aging Studies.

Arthritis, Parkinson’s disease, cancer, osteoporosis, dementia, heart disease and diabetes are just some of the many diseases and conditions we are at much greater risk for as we age. In its many laboratories and programs, the Barshop Institute’s 150-plus faculty members are tackling research related to these conditions and nearly every aspect of aging. The faculty includes many geriatricians and other specialists who focus on elderly patients.

The institute was seeded in 2001 with a $4 million donation from Sam and Ann Barshop, and with financial support from the Brown Foundation and the National Institute on Aging (NIA), one of the National Institutes of Health (NIH). The Barshop opened its doors four years later with the completion of its main facility at the Texas Research Park. Due to the strength of the faculty and their diverse programs, it is a leading recipient of NIA funds and a prolific venue for discovery.

The Barshop Institute is directed by Nicolas Musi, MD, professor of medicine. Dr. Musi occupies the Sam and Ann Barshop Endowed Chair in Translational Research and directs the Center for Healthy Aging and the Geriatric Research, Education and Clinical Center (GRECC) within the South Texas Veterans Health Care System (VA). Trained in endocrinology and metab34 San Antonio Medicine • July 2014

olism at Harvard’s Joslin Diabetes Center, Dr. Musi sees diabetes patients at the VA while conducting translational research that focuses on aging and metabolism and the cellular and molecular effects of exercise.

“I want to make sure that the Barshop Institute maintains and even enhances its stature as one of the leading institutes in the basic biology of aging,” Dr. Musi said of his appointment. “As we do this, we will have a more comprehensive program that will include a strong translational component to move the research conducted at the lab bench and apply it at the bedside.”

Faculty at the Barshop Institute collaborate with hundreds of other researchers, including other faculty at the Health Science Center, the Texas Biomedical Research Institute, the South Texas Veterans Health Care System, faculty at UT San Antonio and UT Austin, as well as researchers from other institutions in the United States and around the world. There are so many programs that it would take more than the allotted space to list them all, so I will limit myself to several “core” programs: • The San Antonio Nathan Shock Center, one of the original Shock Centers founded by the NIH’s National Institute on Aging in 1995. The center is a national resource that provides a state-of-the-art scientific infrastructure and services used in the development and study of rodent models to address questions about the basic biological mechanisms of aging. The centers are named after Nathan Wetherell Shock, PhD, who formed the gerontology division of NIH in the 1940s; this division eventually evolved into the NIA during his 50 years of leadership. The Barshop Institute’s Shock Center is directed by Randy Strong, PhD.

UTHSCSA DEAN’S MESSAGE

• The San Antonio Aging Interventions Testing Program (ITP), which evaluates treatment strategies likely to prevent or delay adverse age-dependent changes in cells and tissues, and to diminish the burden of disease in old age. It is also directed

by Dr. Strong and co-directed by James Nelson, PhD; this program is funded by the Biology of Aging Program of the NIA. In 2009, the ITP and collaborators reported that mice given the drug Rapamycin had significantly increased lifespan. This was the first report ever to show that a pharmacological agent could increase the lifespan of a mammal. This study was selected by the journal Nature as one of the major scientific breakthroughs of 2009.

• The Marmoset Aging Center is centered around a highly controlled, pathogen-free environment to promote excellent health in these small primates to produce a large number of aged animals. This is the only facility in the world that has created this marmoset model (close genetic relatives to humans) for the study of aging and age-related diseases. It is directed by Suzette D. Tardif, PhD. • The Barshop’s Naked Mole-Rat Aging Center uses similar controls and environment (to the marmoset program) for its large colony of these unique animals. Rochelle Buffenstein, PhD, is the director of the center. The mole-rat is an extraordinarily long-lived rodent that she has found shows negligible aging of both cardiovascular and brain function. It is also very resistant to cancer, does not go through menopause and has several other interesting characteristics applicable to geroscience. The center has played a large role in mapping the genome of the mole-rat and determining its specific similarities with the human genomes.

The Barshop Institute continues to be a leader in aging research grants. Just a month after Dr. Musi’s appointment last year, the NIA announced a $3.4 million training grant for the Barshop Institute. The five-year grant will enable 10 graduate students and six postdoctoral fellows at the Barshop Institute to pursue innovative, ground-breaking research on the basic biology of aging.

Around the same time, a $200,000 gift from the Glenn Foundation for Medical Research was awarded to fund two Barshop fellows to participate in the PhD program focused on the biology of aging. Last summer, the Texas Legislature approved of $4 million in exceptional-item funding over the 2014-15 biennium to establish a Translational Aging Research Program within the Barshop Institute. This program will focus its efforts on developing the strategies, personnel, infrastructure and study populations to evaluate whether interventions targeting the fundamental processes of aging can delay the onset of chronic diseases and disabilities in humans.

In May, the American Diabetes Association awarded Dr. Musi a $600,000 grant for a clinical research study to test whether a high-fat diet causes changes in the gut bacteria that lead to an increase in endotoxins typically found in older people and patients with Type 2 diabetes. The study also will explore how the level of endotoxin might affect glucose metabolism, especially in context of insulin sensitivity.

Many of the Barshop faculty are cross-appointed from different departments in the school and see patients as well as doing research, hoping to translate the results "from bench to bedside" as soon as possible. One such faculty member is Alfred Fisher, MD, PhD, an associate professor of medicine who is the associate director for research at the Veterans Administration’s GRECC and the Center for Healthy Aging. He is also a geriatrician at the VA Audie L. Murphy Hospital. Another great example is a practicing geriatrician on the faculty – Sara Espinoza, MD – a professor in the department of medicine. She combines her geriatrics practice at the VA with teaching and research. Her practice and research focus on aging and frailty, proteomics and epidemiologic studies, including ethnic differences in aging and disease. Like many of the faculty, she collaborates with other providers and interdisciplinary team members to design and implement new models of care to improve healthcare for the aging.

The Barshop Institute recently enjoyed an important addition to its faculty with Erzsebet K. Kokovay, PhD, an assistant professor in the department of cellular and structural biology who joined the faculty in 2012 after a post-doctoral fellowship at the Neural Stem Cell Institute in Rensselaer, N.Y. She studies stem cells and brain function in the aging process as well as neurogenesis.

The Barshop Institute is one of the hidden gems of science – well known to relatively few in San Antonio – but known around the world for its collaborations and dedication to discoveries that promise to prolong healthy lives. My congratulations as well as my gratitude on behalf of myself and everyone who wishes for a life as healthy as it is long, which is the ultimate goal of all their efforts.

Dr. Francisco GonzálezScarano is dean of the School of Medicine, vice president for medical affairs, professor of neurology, and the John P. Howe III, MD, Distinguished Chair in Health Policy at the University of Texas Health Science Center at San Antonio. His email address is scarano@uthscsa.edu.

visit us at www.bcms.org

35

BOOK REVIEW

“An Officer and a Spy: A novel” Written by Robert Harris Reviewed by Fred H. Olin, MD What do you know about the “Dreyfus Affair”? Probably not a lot; maybe you never even heard of it, or you vaguely remember that it was a spy scandal of some sort in France in the 1890s, and it had something to do with a place called Devil’s Island. That’s what I remembered. Then I read a laudatory review of “An Officer and a Spy: A novel” by Robert Harris in the Wall Street Journal and decided that I’d take a look at it. I am so glad that I did.

Right up front, in an author’s note, Harris tells us that all of the characters in the book are taken from the historical record, and all of the events depicted actually happened, sort of. He admits that he had to modify things a bit, invent conversations, descriptions, etc., to turn what were probably pretty dry contemporaneous sources (except the Paris newspapers) into a novel.

Alfred Dreyfus was an up-and-coming officer in the French Army. He was from Alsace, which the French had lost to the Germans in their embarrassing defeat in the Franco-Prussian war of 1870. Dreyfus was wealthy and Jewish … facts that become a factor in the story. France was pretty rabidly anti-Semitic in those days, and when an agent working as a cleaning lady in the German Embassy in Paris produces a couple of documents that imply that there is a traitor somewhere in the Army, Dreyfus was singled out, tried by court martial, found guilty and sentenced to life imprisonment in solitary on Devil’s Island, a 1,200-by-400-meter rock in the southern Caribbean.

DEGRADATION CEREMONY The story is told in the first-person present tense in the voice of Col. Georges Picquart. At first, Picquart is an officer with the rank of major on the staff of the Minister of War. He is assigned to watch the trial and subsequent “degradation” of Dreyfus. This is the public ceremony where the prisoner’s insignia, uniform buttons and even the stripes on his trousers are ripped off, and he is marched away to his sentence. Soon after, Picquart is promoted and assigned to head the “Statistical Section” of the General Staff, which was the French term for the Intelligence Division. He takes over from an older officer who is dying of tertiary syphilis and is not welcomed by the other officers in this rather small outfit.

As the story develops, Picquart begins to have doubts about 36 San Antonio Medicine • July 2014

Dreyfus’ guilt. He notices that what little evidence exists is circumstantial, and that the court martial was not carried out with proper procedure: the prosecution and the seven judges were allowed to see a “secret document” but it was withheld from the defense. (It seems I’ve read about this sort of thing happening nowadays, right here in Texas.)

Picquart institutes surveillance of the German Embassy in conjunction with the Sûreté, the French version of the FBI. A French officer named Maj. Charles Ferdinand Walsin Esterhazy is seen (and photographed) entering the embassy with an envelope in his hand and leaving without it. Esterhazy is generally described by those who know him as what we might call a “scumbag.” When Picquart tries to tell his superiors about his suspicions, they refuse to allow him to follow up on his findings, and, in essence, go into full cover-up mode. When Picquart persists, he is transferred to a tiny outpost in Tunisia, and at one point, an attempt is made to send him on what amounts to a suicide mission into the desert.

There is no way I am able to write a compact summary of this novelized history: there are so many people, so many twists and turns in the story, such evocative descriptions of belle époque Paris and Parisians that I’d likely end up with a 20-page book report.

The last time I did one of those it was because Mrs. Lulu I. Moore made us write them when I was in the fifth grade in Chicago.

‘DRAMATIS PERSONAE’ I know a “critic” is supposed to be critical … but I didn’t find any real shortcomings in this book. In fact, there was a lot to love, not the least being the “Dramatis Personae” at the front of the book that helped to keep straight all of the characters and their positions in society. These include author Émile Zola, whose famous screed “J’Accuse” was instrumental in Dreyfus’s ultimate acquittal, Alphonse Bertillon, an early criminologist, and Georges Clemenceau, prime minister of France during World War I. Here’s something that made this book even more enjoyable: I used Google Images and saw photographs of all of the principal players. It helped to bring them to life in my mind.

Fred H. Olin, MD, is a semi-retired orthopaedist whose visual-based memory can still see Mrs. Lulu I. Moore, and he would still be intimidated by her. Dr. Olin is 2014 chair of the BCMS Communications/ Publications Committee.

BCMS GROUP PURCHASING AND SERVICE DIRECTORY Please support our sponsors with your patronage; our sponsors support us.

• ACCOUNTING Anderson, Johns & Yao CPAs (HH Silver Sponsor) We strive to provide a professional and friendly atmosphere for all your accounting and financial needs.

Ann Yao, CPA/PFS, 210-696-9400 yao@ajycpa.com www.ajycpa.com San Antonio-based CPA firm with 30-plus years of experience.

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

Vicky Martin, CPA, 210-828-6281 Vicky.Martin@Padgett-CPA.com www.Padgett-CPA.com Offering Service. More Than Expected. On every engagement

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

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

• ATTORNEYS

Carabin Shaw Law Firm (HHHH Platinum Sponsor) Texas prompt pay lawyers Paul L. Sadler, 210-222-2288 psadler@carabinshaw.com www.carabinshaw.com

Cox Smith & Matthews Inc. (H Bronze Sponsor) The largest Texas law firm headquartered in San Antonio and

one of the top 25 largest Texas law firms.

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Pulman, Cappuccio, Pullen, Benson & Jones (H Bronze Sponsor) The attorneys at Pulman, Cappuccio, Pullen, Benson & Jones LLP have over 150 years of combined experience providing exemplary representation for clients.

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• BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things.

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

Bank SNB (HH Silver Sponsor) Bank SNB combines the resources of a full-service bank with the expertise of healthcare specialists to deliver services that maximize your revenue and profit.

Sandy Cilone, 210-442-6145 sandycilone@banksnb.com www.banksnb.com The opportunity to work with a team of healthcare advisors to achieve the financial goals of your practice.

Baptist Credit Union (HH Silver Sponsor) It is Baptist Credit Union’s mission

to meet our members' needs by providing extraordinary service, quality financial products, and personal financial education.

Sarah Chatham, 210-525-0100, ext. 201 memberservices@baptistcu.org www.baptistcu.org We commend your dedication to the health and well-being of our community.

BBVA Compass (HHH Gold Sponsor) A multinational banking group providing financial services in over 30 countries and to 50 million clients throughout the world.

Commercial Relationship Manager Zaida Saliba, 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie, 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com Working for a better future.

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

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Broadway Bank (H Bronze Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community.

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

Citi Commercial Bank (HH Silver Sponsor) Chris McCorkle, 210-408-5014 christopher.a.mccorkle@citi.com www.citi.com

Crockett National Bank (HHH Gold Sponsor) Crocket National Bank is a leading Texas community bank specializing in mortgage, ranch and commercial real estate lending, and providing superior customer service and competitive financial products.

Lydia Gonzales, 210-384-9304 lydiagonzales@crockettnationalbank.com www.crockettnationalbank.com Doing what we promise.

Firstmark Credit Union (HH Silver Sponsor) We are a local San Antonio credit union that has a variety of loans to choose from to provide you with financial stability.

Gregg Thorne, SVP Lending, 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org

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

Lewis Thorne, 210-220-6513 lewis.thorne@frostbank.com www.frostbank.com Frost@Work provides your employees with free personalized banking services.

Jefferson Bank (H Bronze Sponsor) Full-service bank specializing in mortgages, wealth management and trusts.

Ashley Schneider, 210-736-7848 aschneider@jeffersonbank.com www.jeffersonbank.com continued on page 38

visit us at www.bcms.org

37

BCMS GROUP PURCHASING AND SERVICE DIRECTORY continued from page 37

Security Service Federal Credit Union (H Bronze Sponsor) Business financing, specializing in low-interest commercial real estate transactions.

Luis Rosales, 210-845-8159 lrosales@ssfcu.org BCMS members can get up to half a percent off the origination fee.

St. Joseph's Credit Union (HH Silver Sponsor) A credit union providing savings, checking, IRA, club and CD accounts. Plus auto, signature, lines of credit, MasterCard and real estate loans.

Debra Abernathy, 210-225-6126 lending@sjcusatx.net www.sjcusatx.com Better rates on auto loans, signature loans and Platinum MasterCard.

Texas Farm Credit (H Bronze Sponsor) Tiffany Nelson, 210-798-6280 www.texasfcs.com Rural, homestead and acreage lending

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

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

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com

• BUSINESS CONSULTING/ COACHING The Growth Coach – Kay Wakeham (H Bronze Sponsor) k.wakeham@thegrowthcoach.com www.thegrowthcoachsanantonio.com 210-492-2400

• CONTRACTORS/ BUILDERS Huffman Developments (HH Silver Sponsor) Steve Huffman, 210-979-2500

38 San Antonio Medicine • July 2014

Shawn Huffman, 210-979-2500 www.huffmandev.com San Antonio Retail Builders (HH Silver Sponsor) Specializing in remodeling/finishout of medical offices.

H.B. Newman, 210-446-4793 brett@texaspremiercapital.com Rick Carter, 210-367-7909 rick@texaspremiercapital.com Next six months: architectural space plan/rendering, no cost or obligation.

• CATERING Corporate Caterers (H Bronze Sponsor) Ricardo Flores 210-789-9009 Heavenly Gourmet Catering (H Bronze Sponsor) 210-496-9090 www.heavenlyg.com

• EDUCATION Alpha Bilingual Preschool (H Bronze Sponsor) Our mission is to provide young children with an integral early education in a Spanish immersion environment.

Tania Lopez de Pelsmaeker, 210-348-8523 tldp@hotmail.com Give your child the gift of speaking a second language.

• ELECTRONIC MEDICAL RECORDS

Greenway Health (HHH Gold Sponsor) Greenway Health offers a fully integrated electronic health record (EHR/EMR), practice management (PM) and interoperability solution that helps healthcare providers improve care coordination, quality and satisfaction while functioning at their highest level of efficiency.

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• FINANCIAL SERVICES

tvalenti@jhnetwork.com Eric Gonzalez, 210-998-5032 ericgonzalez@jhnetwork.com www.platinumwealthsolutionsoftexas.com Understanding the uniqueness of the financial life of a physician.

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence, and freedom to achieve more in life.

Jeffrey Allison, 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com Get what you deserve … Maximize your Social Security benefit!

Retirement Solutions (HH Silver Sponsor) Committed to providing comprehensive, reliable consultation to help you navigate the complex world of retirement planning.

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Richard A. Poligala, 210-998-5787 richard.poligala@natplan.com www.boldfinancialgroup.com Complimentary no-obligation retirement plan review for BCMS members.

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

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

Northwestern Mutual (H Bronze Sponsor) Eric Kala, 210-446-5755 eric.kala@nmfn.com Platinum Wealth Solutions of Texas LLC (HH Silver Sponsor) Comprehensive financial planning firm that assists medical professionals to protect their income, their wealth, their practice and legacy.

Tom Valenti, 210-998-5023

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• HEALTHCARE CONSULTING TNT Healthcare Consulting LLC (H Bronze Sponsor) We want physicians to concentrate on what they were trained to do, treating patients.

Tom Tidwell, CMPE, 210-861-1258 Thomas.tidwell@att.net Let TNT healthcare consultants evaluate your practice and improve efficiency and cost.

• HOSPITALS/HEALTHCARE SERVICES Elite Care 24 Hour Emergency Center (HH Silver Sponsor) We are a fully equipped emergency room open 24 hours a day and seven days a week, staffed by experienced emergency physicians. We provide the same level of emergency medical care that you would receive in a hospital ER. Clemente Sanchez, 210-269-8028 csanchez@elitercaremarketing.com Rosie Clark, 210-771-0141 rclark@elitecaremarketing.com www.elitecareemergency.com Get seen by an experienced physician within 10 minutes.

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We will offer convenient same-day or lunch appointments to BCMS members.

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lessen the burden of HR administration. We provide HR solutions to help you sleep at night and get everyone in the practice on the same page.

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• INSURANCE

• HUMAN RESOURCES

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

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

Employer Flexible (HHH Gold Sponsor) Employer Flexible doesn’t simply

Humana (HHH Gold Sponsor) Humana is a leading health and

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

Central referral line, 210-592-5350 Joint Commission COE

well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care.

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Nationwide Insurance Joel Gonzales Agency (H Bronze Sponsor) What matters to you, matters to us!

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Texas Drug Card (H Bronze Sponsor) The Texas Drug Card program is a FREE statewide Rx assistance program available to all residents.

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• INSURANCE/ MEDICAL MALPRACTICE API/ProAssurance (HH Silver Sponsor) ProAssurance is about YOU — and, more specifically, treating you fairly when it comes to professional liability insurance and related products and services.

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Medical Protective (HHH Gold Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

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Texas Medical Association Insurance Trust (HHH Gold Sponsor) Created and endorsed by the Texas Medical Association (TMA), the Texas Medical Association Insurance Trust (TMAIT) helps physicians, their families, and their

employees get the insurance coverage they need.

James Prescott, 512-370-1776 jprescott@tmait.org John Isgitt, 512-370-1776 www.tmait.org We offer BCMS members a free insurance portfolio review.

Texas Medical Liability Trust (HHHH Platinum Sponsor) Texas Medical Liability Trust is a physician-owned healthcare liability claim trust, providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 14,000 doctors in all specialties who practice in all areas of the state.

TMLT is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

Donald J. Chow, 210-979-2500 don-chow@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society.

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

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

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

The Doctors Company (HH Silver Sponsor) Medical malpractice insurance Kirsten Baze, 512-275-1874 KBaze@thedoctors.com www.TheDoctors.com continued on page 40

visit us at www.bcms.org

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BCMS GROUP PURCHASING AND SERVICE DIRECTORY continued from page 39

• INTERNET/ TELECOMMUNICATIONS Time Warner Cable Business Class (HH Silver Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterpriseclass technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Rick Garza, 210-582-9597 Rick.garza@twcable.com Time Warner Cable Business Class offers custom pricing for BCMS members.

• MARKETING SERVICES Phiskal LLC Marketing and Promotion (H Bronze Sponsor) A leading-edge marketing and development firm using proprietary artificial intelligence engines to enhance your presence with websites, apps and database applications.

Sundeep Sadheura, 210-865-4520 Sunnys@phiskal.com HTTP://PHISKAL.COM/

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

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

DataMED (HHH Gold Sponsor) Providing your practice with the latest compliance solutions, concentrating on healthcare regulations affecting medical billing and coding changes, allowing you and your staff to continue delivering excellent patient care.

Anita Allen, 210-892-2333 aallen@datamedbpo.com www.datamedbpo.com BCMS members receive a discounted rate for our billing services.

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PriMedicus Consulting Inc. (H Bronze Sponsor) A physician-founded and -built company, dedicated to your success.

Sally Combest, MD, 877-634-5666 s.combest@primedicusconsulting.com www.primedicusconsulting.com PriMedicus Consulting for the health of your practice.

Urgent Care Billing Solutions LLC (H Bronze Sponsor) UCBS provides superior practice management services and revenue optimization services to the healthcare community in a virtual office environment.

Ann DeGrassi, CMIS, 210-878-4052 adegrassi@ucbillingsolutions.com www.urgentcarebillingsolutions.net

• MEDICAL SUPPLIES & EQUIPMENT

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

Tom Rosol, 210-413-8079 tom.rosol@henryschein.com www.henryschein.com/medical BCMS members receive GPO discounts of 15%-50%.

• PAYMENT SYSTEMS/ CARD PROCESSING Heartland Payment Systems (HH Silver Sponsor) Sherry Willis, 210-885-0201 sherry.willis@e-hps.com

• PUBLICATION MANAGEMENT FIRM Traveling Blender (H Bronze Sponsor) Publication management firm Janis Maxymof, 210-413-9731 janismaxymof@gmail.com 10% discount on display advertising in magazine for members.

• PRINTING SERVICES SmithPrint (H Bronze Sponsor) SmithPrint offers custom printing, branding, graphic design, signage and more!

Robert Upton, 210-846-5268 Robert@smithprint.net www.smithprint.net/ New customers: 10% discount on print materials at SmithPrint.

• REAL ESTATE/ COMMERCIAL Newmark Grubb Knight Frank (H Bronze Sponsor) Commercial real estate Darian Padua, 210-804-4841 Dpadua@ngkf.com Stream Realty Partners (H Bronze Sponsor) Carolyn Hinchey Shaw, 210-930-3700 cshaw@streamrealty.com www.streamrealty.com

• REAL ESTATE/ RESIDENTIAL Becky Aranibar Realty Group – Keller Williams (H Bronze Sponsor) Offering real estate services to the San Antonio medical community.

Carlo G. Aranibar, MBA, 210-862-4022 BARgrouptx@gmail.com www.beckyaranibar.com Offering free comparative market analysis to determine your home's value.

pany offering and managing real estate investment funds in the South Texas area.

H.B. Newman, 210-446-4793 brett@texaspremiercapital.com Rick Carter, 210-367-7909 rick@texaspremiercapital.com www.texaspremiercapital.com

• REGULATORY COMPLIANCE Hildebrand Regulatory Compliance (H Bronze Sponsor) HEDIS, Accreditation, PCMH, ICD-10.

Patricia Hildebrand, 432-352-6143 Pati.Hildebrand@HildebrandHealthcare.com www.hildebrandhealthcare.com

• RESEARCH STUDIES/ BIOTECHNOLOGY

ICON Development Solutions (HHHH Platinum Sponsor) We are a respected clinical research organization that has an extensive reputable history in diabetes research. Depending upon the current studies, ICON may establish working relationships with local physicians. Your expertise may be invaluable to our efforts to identify subjects.

Dr. Dennis Ruff, 210-283-4572 dennis.ruff@iconplc.com www.iconplc.com Find out how ICON can help your practice.

• STAFFING SERVICES SA Luxury Realty (HH Silver Sponsor) Effective real estate transactions (buy, sell, lease, syndicate, etc.) within the shortest time possible and for maximum results!

Matin Tabbakh, 210-772-7777 matin@saluxuryrealty.com www.saluxuryrealty.com Accredited luxury home specialist – call us today.

• REAL ESTATE INVESTMENTS Texas Premier Capital (HH Silver Sponsor) A real estate development com-

Favorite Healthcare Staffing (HHHH Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency, and protect their revenue cycle!

Brian Cleary, 210-301-4362

BCMS GROUP PURCHASING AND SERVICE DIRECTORY BCleary@FavoriteStaffing.com www.favoritestaffing.com Favorite Healthcare Staffing offers preferred pricing for BCMS members.

• TITLE COMPANIES Alamo Title Company (HH Silver Sponsor) Corina Cashion, 210-698-0924 Corina.Cashion@fnf.com

• TRANSCRIPT SERVICES Med MT Inc. (H Bronze Sponsor) Narrative transcription is physicians’ preferred way to create patient documents and populate electronic medical records.

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

BECOME A VENDOR/SPONSOR Are you trying to reach the 4,700-plus physician-members of the BCMS with your business message?

Consider joining the BCMS Circle of Friends program.

By underwriting society events and programs, Circle of Friends members help fund BCMS’ mission of enhancing the practice of medicine for healthcare providers and Bexar County residents.

“The Circle of Friends program is the most efficient and direct method to reach the medical community.”

– August C. Trevino, BCMS Development Director

For more information, call 210-301-4366, email August.Trevino@bcms.org, or visit www.bcms.org.

BCMS does not endorse businesses and involves inself only in services and programs that benefit members and their patients.

visit us at www.bcms.org

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42 San Antonio Medicine • July 2014

Tom Benson Chevrolet 9400 San Pedro Ave. Gunn Acura 11911 IH-10 West

* Fernandez Honda 8015 IH-35 South

* North Park Lincoln/ Mercury 9207 San Pedro Ave.

Porsche Center 9455 IH-10 West

Gunn Honda 14610 IH-10 West (@ Loop 1604) Ancira Chrysler 10807 IH-10 West Cavender Audi 15447 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ancira Ram 10807 IH-10 West * Gunn Infiniti 12150 IH-10 West

Ingram Park Auto Center 7000 NW Loop 410

Ingram Park Auto Center 7000 NW Loop 410

Ancira Dodge 10807 IH-10 West BMW of San Antonio 8434 Airport Blvd.

Ingram Park Auto Center 7000 NW Loop 410

Mercedes-Benz of Boerne 31445 IH-10 W, Boerne Ancira Jeep 10807 IH-10 West

Ancira Elite Motorcars 10835 IH-10 West

Mercedes-Benz of San Antonio 9600 San Pedro Ave.

Ingram Park Auto Center 7000 NW Loop 410 Cavender Toyota 5730 NW Loop 410

Cavender Buick 17811 San Pedro Ave. (281 N @ Loop 1604) Northside Ford 12300 San Pedro Ave.

North Park Subaru 9807 San Pedro Ave.

Ancira Kia 6125 Bandera Road

* Mini Cooper The BMW Center 8434 Airport Blvd.

* Ancira Volkswagen 5125 Bandera Rd.

Batchelor Cadillac 11001 IH-10 at Huebner Cavendar Cadillac 801 Broadway

Cavender GMC 17811 San Pedro Ave.

* North Park Lexus 611 Lockhill Selma

Ingram Park Nissan 7000 NW Loop 410

* The Volvo Center 1326 NE Loop 410

visit us at www.bcms.org

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AUTO REVIEW

Subaru Forester: Boxy but good

By Steve Schutz, MD One of the reasons I enjoy following the automotive industry is that there’s a neverending stream of storylines that bubble up, evolve, and then die, only to be replaced by other compelling narratives. In the saturation coverage of world luxury brand leadership (Audi’s ahead by a nose), CEO news (Mary Barra of GM is all anyone’s talking about now), and the full-size pickup wars (the F150’s upcoming aluminum architecture is terrifying GM and Ram), there’s a remarkable story that is getting very little press. Subaru is absolutely crushing it in the United States these days.

Some numbers: in 2008, Subaru sold 187,699 vehicles in this country. In 2013, it sold 424,683, a gain of 126 percent com44 San Antonio Medicine • July 2014

pared with an increase of 18 percent for the overall market. Interestingly, Subaru made that huge leap with virtually no help from an SUV. It was all cars. Furthermore, every car sold by Subaru comes with all-wheel drive, a novelty considered to be a Snow Belt feature, not something for mainstream buyers. (For the record, Subaru does actually offer an SUV, the unloved Tribeca crossover, but that vehicle sells in very small numbers and will be dropped after the 2014 model year.)

SECRETS TO SUCCESS So, how did Subaru take an almost all-car lineup with a boutique drivetrain to such heights? By creating attractively designed cars, pricing them moderately and advertis-

ing them skillfully. Doing that is easy in theory, but unbelievably difficult in practice.

The Subaru Forester I tested recently is a good place to understand why this company has been so successful. As the most utilitarian vehicle in the Subaru lineup, the Forester can be forgiven for being uninteresting to look at. And to some extent its styling is uninspiring, but it’s a functional and honest design nevertheless. Boxy -- though not as boxy as the first-gen model -- the latest Forester looks like what you’d get if you mated the original Forester and the new youth-oriented Subaru XV Crosstrek. The windshield is more raked than it used to be, the greenhouse is more tapered, and the detailing is thoughtful.

Thoughtful also describes the interior,

AUTO REVIEW which is well laid-out and easy to use. The focus of the center stack is, as it is invariably in new cars these days, the navigation screen, which displays audio, HVAC and other information whether or not you actually selected the navigation option. Interestingly, the Forester’s backup camera displays on a second information screen located higher up on the dash.

While the utilitarian nature of the Forester is reflected in its shape and the excellent use of space in the cabin, it’s also evident that Subaru worked hard to make their price point as the look and feel of the interior materials are not up to Outback standards.

Driving the Forester is less fun than the XV Crosstrek, as you’d expect since the XV is smaller. Still, the Forester is nimble and quick, thanks to a curb weight of just 3,296 pounds. Maximizing the fun factor requires selecting the manual transmission, though, as the only clutchless option available is the continuously variable transmission (CVT), which is not the enthusiast’s choice.

It should be noted that another important reason the Forester is selling so well is because of excellent advertising. Subaru’s recent advertising campaign called “Love” shows young couples using their Subarus to explore the outdoors in various ways, such as visiting a hot springs where one duo encounters annoying, aging hippies prompting the wonderful line, “We shouldn’t have done that.”

Obviously advertising is a tricky business, but successfully connecting Subarus to young love is something that can make even cynical viewers like me smile.

Pricing depends on how loaded you want your Forester, but the MSRP starts at under $23,000 and stretches up past $30,000 if you check off all the boxes. The base engine is an old Subaru standard, the 2.5-liter flat four, which makes just 170 HP. The upgraded engine like the one in my test car is the gutsier 2.0-liter turbo flat four that makes a more palatable 250 HP. Fuel economy is 24 mpg city/32 mpg highway for Foresters with the base engine, and 23/28 if the turbo is selected.

SIX TRIM LEVELS OFFERED The 2014 Subaru Forester is available in six trim levels: 2.5i, 2.5i Premium, 2.5i Limited, and 2.5i Touring, all with the 2.5-liter engine, and 2.0 XT Premium and 2.0 XT Touring, both with the turbocharged 2.0liter motor. As always, Phil Hornbeak is available to help BCMS members with any auto purchasing questions or needs they may have (see information below).

At some point, business writers will spread the word about Subaru’s amazing sales success over the past five years. In the meantime, we can enjoy their excellent products, such as the boxy-but-good 2014 Forester. Here’s

hoping Subaru continues to create attractively designed cars, price them moderately, and sell them with great advertising.

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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46 San Antonio Medicine • July 2014