San Antonio Medicine September 2017

SAN ANTONIO

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VOLUME 70 NO. 9

Innovations in Medical Practice

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Stuck in Transition? Insights for New Physician Leaders

By Amer Kaissi, PhD ......................................14

A Proposal for Better Access to Care

By R.V. Osbourn, MD .....................................21 Diagnosing and Treating our Healthcare System

By Darren Donahue, JD, MD Candidate UT Health San Antonio ............................18 BCMS President’s Message ....................................................................................................8 BCMS Alliance News.......................................................................................................................10 BCMS Legislative News...................................................................................................................12 Book Review: Last Days of Night by Graham Moore, Reviewed by J.J. Waller Jr., MD .....................24 Feature: Who was Floyd Curl? By David P. Green, MD.....................................................................26 Legal Ease: Defective Physician Covenants Not to Compete in Texas By Mark F. Weiss, JD ............28 San Antonio Tricentennial: Tricentennial Commission Gets Under Way By Fred H. Olin, MD.............31 Financial: How to Choose a Financial Advisor By Joseph Quartucci, ChFC......................................32 BCMS News....................................................................................................................................33 BCMS Circle of Friends Directory.....................................................................................................34 In the Driver’s Seat...........................................................................................................................38 Auto Review: 2017 Volkswagen Golf Alltrack By Steve Schutz, MD ................................................40

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VOLUME 70 NO. 9

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

Improving Patient Care Through Real-Time Data Sharing

By Gijs van Oort, Executive Director HASA .....18

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Innovations in Medical Practice

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

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

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

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

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

6 San Antonio Medicine • September 2017

PRESIDENT’S MESSAGE

A State of Affairs — The 85th Texas Legislative Session

By Leah Jacobson, MD, 2017 BCMS President

― John Capecci and Timothy Cage

“Be an advocate for the people and causes important to you, using the most powerful tool only you have—your personal stories.”

As I prepared to write this article, the Texas State Legislature remained in Special Session and there was still no passage of a Sunset Bill regarding the Texas Medical Board (TMB) and the Texas Medical Practice Act. What a daunting thought! Could the practice of medicine be "up in the air" as of Sept. 1, 2017? Could we, as physicians, be without a governing board? I do not believe that it is so much an issue of whether the State Legislators want to approve passage of such legislation, but more that our interests, as physicians and the practice of medicine, are being caught up in the politics of the State Legislature. Many questions remain, but I do have faith that when you read this there will have been passage of legislation renewing the TMB and the Texas Medical Practice Act.** As you may or may not know, one of the main benefits of your BCMS membership is advocacy, particularly as it pertains to State issues. With regards to this year's legislative session, I was fortunate to be able to attend all of the Texas Medical Association's "First Tuesdays" with many of your colleagues and alliance members, as well as BCMS's chief government affairs officer, Mary Nava. I am happy to report that at least 15-20 members were at each event representing you, the members of BCMS. We worked hard to lobby on many issues, including step therapy measures, balancedbilling, ban on texting while driving, clarifications on telemedicine, increase in GME funding and residency positions, vaccination issues, and many more. Overall, I feel that organized medicine was successful in their endeavors.

While the Sunset Bill(s) remain the top priority during the Regular and Special Sessions, many bills were passed that influence the practice of medicine for physicians and our patients. A few highlights of bills passed, include: • HB 10 which seeks to establish a state mental health parity work group, as well as designate an ombudsman as an advocacy source and clarify benefits for mental health and substance abuse: • SB 507 expands the billing mediation process for out-of-network facilities and providers; • SB 680 which empowers the physicians to override health plans' step therapy protocols; 8 San Antonio Medicine • September 2017

• SB 1066 requires new medical schools to offer new GME positions to keep pace with their medical graduates; • SB 1107 establishes a statutory definition for telemedicine and clarifies standard of care; • SB 1148 prohibits the state from using maintenance of certification (MOC) as a requirement as a requirement for state licensure, hospital privileges or insurance participation; and • HB 1600 will allow Medicaid to pay physicians for mental health screenings during annual well-child exams just to discuss a few.

• It also appears, at the time of this drafting, that the Legislature will approve an extension of the Maternal Morbidity and Mortality Task Force.

It is important that we continue to stay abreast of the ongoing changes to the practice of medicine, both at the state and national level. Also important is talking to your patients, but not just about their medical conditions. Patients have lots of questions with regards to healthcare, insurance issues, etc. It is important to keep them involved in the legislative process and update them on things that may affect them and their families. To help with this, the BCMS General Membership Fall Meeting co-sponsored with UT-Health will be focused on an update of the 85th State Legislative Session, and possibly some national issues as well. It will be Thursday, Oct. 12 in the Holly Auditorium at UT-Health SA. There will be one hour of ethics CME associated with this event. I invite and encourage you to attend this informative meeting.

Sincerely, Leah H. Jacobson, MD 2017 BCMS President **Addendum: Gov. Greg Abbott signed the Senate version of the Texas Medical Board (TMB) Sunset bills — SB 20 (which extends the life of TMB) and Senate Bill 60 (which provides funding for the agency) on Friday, Aug. 11, the same day they passed on third reading in the House.

BCMS ALLIANCE

Painting with a Twist – For a Purpose!

By Lori Boies, 2017 BCMS Alliance President

At the end of May 2017, a dark cloud shaded the BCMS Al-

into the retired years.

liance family as we unexpectedly lost our VP of Social, Sandra

After the passing of our dear friend, we decided to go forward

Vela. The shock and grief hit many of us, as we could not com-

with the Painting with a Twist event, in honor of Sandra. Dona-

prehend how such a young, vibrant, and sweet friend was no

tions were made to the BCMSA Scholarship Fund in memory of

longer with us.

Sandra Vela. We were able to raise money for a good cause and

Sandra and I had been working to plan a fun social event for

reminisce about the wonderful times we had with Sandra.

our membership during the summer. Painting with a Twist seemed

Some BCMSA members are working on a book of memories of

like the perfect way to bring everyone together for some fun! We

Sandra to share with her family. If you have any memories that

were even more excited when Painting with a Twist offered to do-

you

nate a portion of the proceeds to the BCMSA Scholarship fund!

bcmsalliance@bcms-alliance.org.

Everything was coming together, and the date for the end of July was set! Sandra picked a beautiful picture for us to paint: two open

would

like

to

share,

please

submit

to

Sandra was such a caring friend with an amazing soul. I will miss calling her and hearing her answer, “Hello, my friend!”

hands that served as an island for a tree, showing all the seasons.

The picture spoke to her; she felt it showed the support the Al-

All the Best,

liance provides to medical family – from those early training years,

Lori Boies

starting off as a young physician, the established years, and leading

2017 Bexar County Medical Society Alliance President

10 San Antonio Medicine • September 2017

them

BCMS LEGISLATIVE NEWS

Special Session Adjourns The first called Special Session of the 85th Legislature adjourned sine die one day early on Aug. 15.

On Aug. 11, the Texas Medical Board (TMB) Sunset bills were passed by the Texas House and were signed by Governor Abbott the same day. Senate Bill 20 extends the life of the TMB and Senate Bill 60 provides funding for the agency. TMA President, Carlos J. Cardenas, MD thanked the Governor and lawmakers for their actions to avert what would’ve been a health care catastrophe.

At the time of this writing, other healthcare-related legislation signed by the Governor included: SB 11, which will restrict the application of donot-resuscitate orders to competent patients when it is contrary to their wishes and death is not imminent; SB 17, which will study trends and conditions associated with pregnanacy-related deaths and also extends the life of the Maternal Mortality and Morbidity Task Force by four years; and HB 215 which pertains to additional reporting requirements for abortions.

For more information on the special session, visit www.bcms.org or texmed.org.

12th Annual Border Health Conference held in Edinburg On Friday, Aug. 4, members of the Border Health Caucus (BHC), of which BCMS is a member, hosted their 12th annual conference at the Edinburg Conference Center at Renaissance in Edinburg. Numerous topics were discussed, including: access to care; critical health care needs and challenges on both sides of the border; public health infrastructure; and Affordable Health Care Act (ACA) reform and the future.

On the topic of cross border health issues, the importance of Texas collaborating with health officials in Mexico was highlighted because many of the health issues and concerns patients face along the border also affect Texas and other parts of the nation. The conference was led by BHC Vice Chair Luis Benavides, MD of Laredo; TMA President and founding BHC member, Carlos J. Cardenas, MD of Edinburg and honorary conference chair, U.S. Rep. Filemon Vela (D-Brownsville). U.S. Rep. Vicente Gonzalez (D-Corpus Christi) and U.S. Rep. Michael Burgess (R-Flower Mound) also attended and provided remarks from their perspectives in Congress. Representing BCMS were Jesse Moss, Jr., MD and Mary Nava, BCMS chief government affairs officer.

U.S. Rep. Michael Burgess (R-Flower Mound) speaks to attendees about the future of the ACA during the Border Health Conference in Edinburg on August 4.

For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer and lobbyist at mary.nava@bcms.org.

12 San Antonio Medicine • September 2017

INNOVATIONS IN MEDICAL PRACTICE

STUCK IN TRANSITION? Insights for New Physician Leaders

By Amer Kaissi, Ph.D.

It is no secret that many clinicians are burnt out and resentful. Recent studies have concluded that only 20 percent of physicians are engaged (Kaissi, 2014; Sweeney-Platt, 2016). Older physicians complain about administrative burdens, electronic medical records and lack of autonomy, whereas younger ones are dissatisfied with their work-life balance and incomes (AMA, 2017). As a result, some physicians are transitioning into management positions because they think management will be easier, more lucrative or because they want to change the system from the inside, according to Dr. Todd Thames, staff physician at Grand Rounds Inc. and Adjunct Professor at Trinity University (Thames, 2017).

About 96 percent of health systems have a system-level physician executive, with the majority of these executives having been in their positions for two years or less (Advisory Board, 2016). Health systems pay their physician executives generously, with median compensation at about $350,000 per year (AAPL, 2016). However, once in executive positions, physicians face significant challenges. Many health systems just throw them into administration with no formal management education or leadership experience. They wrongly assume that just because the physician is an excellent clinician or researcher, he/she will automatically become an excellent leader.

14 San Antonio Medicine • September 2017

As a Professor of Healthcare Administration and Executive Coach, I have worked with many physicians who have found themselves stuck in transition: their clinical training and experience have ill-prepared them to the new realities of administration and leadership.

“What makes the situation even more challenging is that other practicing physicians do not see you as one of them anymore, while nonphysician executives do not see you as one of them yet,” says Dr. Richard Marple, Chief Medical Officer at Stone Oak Methodist Hospital and Northeast Methodist Hospital (Marple, 2017).

In the face of these challenges, what can physician executives do to get unstuck and fulfill their potential as high-performing healthcare leaders? Here are some suggestions that physicians could benefit from considering:

Seek a Masters’ degree in Healthcare Administration (MHA) Physicians go through long years of formal education and residency, so the idea of going back to school may not be that appealing.

However, if you are serious about a career in leadership, then a graduate degree is a must. Physicians are used to being the experts in their specific area, so the lack of knowledge in the technical components

INNOVATIONS IN MEDICAL PRACTICE

of management can create pressure and stress. Even physicians who already have some experience serving as a clinical department chair or director of a clinical area often find themselves severely lacking in terms of basic management and financial competencies. An MHA from the right program can help those clinicians gain a more comprehensive understanding of the wider healthcare system, while gaining crucial skills in strategic thinking, accounting, economics and organizational behavior. Each physician comes in with a deep knowledge of their specific area, or tree, but an MHA allows them to grasp the whole system and be able to see the entire forest.

Participate in a Physician Leadership Program (if possible) Many progressive health systems today are offering in-house leadership development programs or contracting with external consulting companies. In the past, many of these programs consisted of “periodic seminars, intermittent speakers and lightweight instructions” (AAPL, 2015) with only a modest effect on performance (Straus, 2013). However, recent programs are starting to focus more and more on actionlearning through problem-solving and special projects within the organization (Duberman et al, 2015). Most new physician leaders do not have a deliberate leadership style, other than the autocratic style of “my way or the highway” (Lee, 2010; Winters, 2013; Minor, 2017).

A report comparing physician and business executives concluded that physicians’ leadership style included behaving like a subject matter expert and not engaging in consulting others, while their thinking style was action-oriented with a strong desire to move towards solutions quickly. Business executives, on the other hand, are more flexible and explore different options before acting (Campbell, 2007). So if your organization offers a leadership program, make sure that you are considered for participation. Not only will you gain valuable leadership skills, but you will also get the opportunity to meet many of the current and up-and-coming leaders in your organization, which will significantly facilitate your transition.

Work with an Executive Coach In the old days, executive coaches were hired by health systems to work exclusively with so-called “problem physicians” who engaged in disruptive and abusive behaviors. While these rescue missions are still necessary in some situations, most executive coaching today is done to help physicians maximize their leadership potential by gaining a better understanding of themselves and improving their management of others. When I work with physician leaders in transition, one of the first things that I do is have them take a personality assessment such as the Birkman Method and an emotional intelligence test such as the EQi 2.0. For most of them, that is the first opportu-

nity in their career to take the time to better understand themselves and their own leadership style.

Dr. Eric Appelgren, anesthesiologist and Vice-President of Operations and Clinical Services at St. Anthony's Medical Center in St Louis, asked his organization to hire an executive coach for him when he transitioned into his new position. “The Executive Coach helped me work through some important things that I was going through,” he explains. “For example, as a physician, you are used to getting instant feedback every single day from patients, family members and nurses. In management, that daily feedback or affirmation goes away.

You don’t get anything for weeks or months- it is huge. I didn’t see that coming and it was frustrating. Some will back off from administration because of that. For me, it was shaking the patients’ and their family members’ hands before and after surgery. I had 20 years of training that allowed me to take care of them and make them feel better. They thanked me all the time. It becomes like a drug, you get addicted to that feeling. The coach helped me recognize that feeling and work on ways on which I can get gratification in my leadership position” (Appelgren, 2017). In addition to discussing feelings and taking steps to deal with them, it is well documented that coaching can result in measurable improvement in behaviors and outcomes.

In one study, 96% of organizations reported to have seen individual performance improve since coaching was introduced, and 92% reported seeing improvements in leadership and management effectiveness (Coaching Counts, 2007). In another study, coaching contributed to the development of important competencies such as leadership behavior (82%), building teams (41%), and developing staff (36%) (Parker-Wilkins, 2006). Moreover, the effects of coaching are far-reaching: it can impact individual skills and behavior, team performance, and organizational outcomes. About 77% of coached executives indicate that coaching had a significant or very significant impact on at least one of nine business measures, with productivity (60% favorable) and employee satisfaction (53%) topping the list (Anderson, 2001).

The importance of smooth physician transition into leadership positions in healthcare cannot be overstated (Goodall, 2011). Physician executives who are serious about their intention to change the system from the inside can benefit from formal management education, leadership development and executive coaching.

Amer Kaissi is Professor and Director of the Executive Master’s Program in Healthcare Administration at Trinity University. He is a Certified Physician and Executive Coach and is the author of the book “Intangibles: The Unexpected Traits of High-Performing Healthcare Leaders” (Health Administration Press, August 2017).

The Executive Master’s Program at Trinity is ranked in the Top 10 programs nationally. The part-time, hybrid-learning format is decontinued on page 16

visit us at www.bcms.org

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INNOVATIONS IN MEDICAL PRACTICE continued from page 15

signed for physicians and managers currently working in a healthcare setting who have decided to pursue a graduate degree while continuing to work full-time.

References - Kaissi, A. (2014). Enhancing Physician Engagement: An International Perspective. International Journal of Health Services.

44(3), 561-586.

- Sweeney-Platt, J. (2016). Can strong leadership boost engagement?

Athena Health.

Available at https://insight.athenahealth.com/strong-physician-leaders-keytackling-change - American Medical Association (2017). Survey: U.S. Physicians Overwhelmingly Satisfied with Career Choice. Available at https://www.ama-assn.org/survey-us-physicians-overwhelminglysatisfied-career-choice - Thames, T. (2017). Personal Interview, San Antonio, Texas.

- American Association for Physician Leadership (2015). Survey: Physician Leadership Development.

Available at http://www.physicianleaders.org/news/surveys/physician-leadership-development - Marple, R. (2017). Personal Interview, San Antonio, Texas.

- Straus S.E., Soobiah C., Levinson W. (2013). The impact of leadership training programs on physicians in academic medical cen-

16 San Antonio Medicine • September 2017

ters: a systematic review. Academic Medicine. May; 88(5):710-23.

- Duberman, T., Mulford, G., Bloom, L. (2015). Learning by Doing: Developing Physician Leaders through Action. Physician Leadership Journal. September-October, pages 32-37.

- Lee, T.H. (2010). Turning Doctors into Leaders. Harvard Business Review. April, pages 2-9.

- Winters, R. (2013). Coaching Physicians to Become Leaders. Harvard Business Review. October 7.

- Minor, L. (2017). What Being a Doctor Did–and Didn’t–Teach Me About Leadership. Wall Street Journal. April 11.

- Campbell, J. (2007). Star Physician Executives Are Created through Formal Training. Executive Insight, Korn Ferry International.

- Appelgren, E. (2017). Phone Interview - Coaching counts. (2007). London: Chiumento Research Report.

Retrieved from http://www.chiumento.co.uk - Parker-Wilkins, V. (2006). Business impact of executive coaching: Demonstrating monetary value. Industrial & Commercial Training, 38, 122.

- Anderson, M. C. (2001). Executive briefing: Case study on the return on investment of executive coaching. Retrieved from http://www.metrixglobal.net - Goodall, A.H. (2011). Physician-leaders and hospital performance: is there an association? Social Science and Medicine.

73(4):535-9.

visit us at www.bcms.org

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INNOVATIONS IN MEDICAL PRACTICE

IMPROVING PATIENT CARE

THROUGH REAL-TIME DATA SHARING

By Gijs van Oort, Executive Director HASA The center for Medicare and Medicaid (CMS) has embarked on a multiphase, multi-year overhaul of the healthcare system, in which the focus shifts from feefor-service to value-based care. The “Triple Aim”, promoting better care and better access at affordable rates drives CMS to set goals of delivering 50 percent of care in Alternate Payment Settings by 2018 and 85 percent of all Medicare fee-for-service payments to be based on quality and value. These initiatives preceded the Affordable Care Act and have had bipartisan support.

The new administration has been insistent on repealing Obamacare. While no clear alternative plan is in place, there have been indications that interoperability will continue to be in play. Tom Price, now the head of HHSC, agreed that electronic medical records 18 San Antonio Medicine • September 2017

can hurt productivity. He was quoted during his Jan. 18 confirmation hearing to say, “We’ve turned many physicians and other providers into data entry clerks and it detracts … from their productivity but it detracts greatly from their ability to provide quality care.” He went on to defend their benefit, especially for patients, saying, “The electronic medical record and electronic health records are so important from an innovative standpoint; [they] allow the patient the opportunity to have their health history with them at all times and be able to allow whatever physician or other provider access to that. We in the federal government have a role in that, but that role ought to be interoperability; to make certain that different systems can talk to each other so that it inures to the benefit of the patient...”

In addition, 90/10 federal funding for connecting Medicaid

INNOVATIONS IN MEDICAL PRACTICE

providers to Health Information Exchanges has not been defunded, maintaining hope that during the 2017 year, financial assistance for Texas physicians in deferring interface costs may be available.

Exchanging patient information in a clinical setting is not new. Historically, much of that sharing was done via fax, telephone calls, through hard coded records or giving records to patients to take to a referring physician. The electronic version of data sharing consists of a combination of electronic medical record (EMR) and a health information exchange (HIE). This concept was promoted federally in 2010 in a three-stage multiyear approach called Meaningful Use, with incentives for physicians and hospitals to engage. The first step, converting physician practices from paper to electronic records, has been painful, but has advanced to a level where virtually every hospital currently uses electronic data capturing and, according to a study done by the Office of the National Coordinator for Health Information Technology (ONC), as of 2015, 79 percent of physicians in Texas reportedly use EMRs1. Contrast that, however, with a mere 15 percent taking advantage of their EMR to exchange patient information to other providers. The latter has been a critical element of stages 2 and 3 of Meaningful Use. For many practitioners, the transition to an EMR has been difficult, disruptive, and sometimes costly due to retraining and technical downtime. Federal incentives, however, made it worthwhile for many. Now that incentives for furthering the user of EMRs have decreased, it is not surprising that physicians are skeptical and cautious to take next steps to fully explore the capabilities of their EMR. At the same time, more providers and physicians realize that in order to participate in the new payment options, electronic data sharing will be a requirement. An example is the newly introduced MACRA reporting for Medicare.

MACRA reporting (or as it now is called the Quality Payment Program or QPP) allows physicians to participate individually or in groups (MIPS program) or as part of an Alternate Payment Models (APM) where physicians accept risk for reimbursement. CMS anticipates that in its first year (2017) most eligible professionals (EPs) will qualify for MIPS. The program consolidates quality measures (PQRS), Meaningful Use, and Value Based Payments requirements into three simplified areas. In addition, CMS is expanding the ways in which the information can be submitted. CMS considers the program a zero sum gain and expects it to have winners (EPs who meet

and exceed the measurement goals) and losers (those that don’t). Further expectations are that small independent practitioners will have a greater challenge to meet these reporting requirements.

Since 2011, HIEs have developed regionally with the intent to support clinical patient information exchange in that region. Currently, seven HIEs are operating in Texas in specific regions. While not covering the entire state, these initiatives have attained a critical mass in several communities. As an example, HASA, a community nonprofit HIE, started developing data exchange in South Texas and has expanded this support into the North Texas region.

With a core function to aggregate patient information in real time from multiple organizations and provide a single longitudinal patient record to practicing physicians, HASA has since broadened its support to the community.

Recognizing the uniqueness of its data for a community, HASA uses its analytics capabilities to provide critical reports to many organizations: discharge and ED visit alert reports for payers, readmissions and readmissions forecasting reports for hospitals and clinics, and quality and MIPS reports for physicians, to name a few.

HASA is the first HIE in Texas to apply for Qualified Registry status with CMS so that it can assist MIPS participants in submitting their reports.

With a state-level technology layer to connect the multiple HIEs to each other, collectively HIEs are a source for care continuity during disasters. And by leveraging community reporting, HIEs can assist continued on page 20

visit us at www.bcms.org

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INNOVATIONS IN MEDICAL PRACTICE continued from page 19

public health agencies in monitoring disease prevalence and identify ‘hotspots� of clinical activities. In the future, HIEs can be a simple solution for providers to submit required patient information to the many state agencies as well.

Once information is flowing, and a critical mass has been attained (HASA currently has over 3.5 million unique patients in its system), the value of HIEs is limitless. The ongoing challenge, of cybersecurity and safeguarding against inappropriate use, however, remains. Each HIE operates within federal, state, and contractual guidelines to address these challenges and most work with community advisory groups on data security and other needs, to ensure that local ownership of this resource is acknowledged and sustained.

While hospitals and health systems have been first to commit to this information exchange, physicians have been slower to adopt.

Concerns about patient privacy, cost, workflow disruption and competition keep many clinics on the sideline. However, with the aforementioned reimbursement changes, they will soon need to come on board as CMS (and likely, the commercial insurers) will continue to insist on care transparency and care continuity. To accomplish that, data sharing is a critical component.

An equally strong argument for physicians to engage in secure in-

20 San Antonio Medicine • September 2017

formation sharing is the impact on the patient. HIEs have the potential to provide patients value by offering a comprehensive patient view through a single patient portal. When properly implemented, this portal can become a venue for provider-patient communication, patient education, and patient self-care. Each of these are critical components of the previously mentioned MIPS reporting.

Cost barriers to information sharing remain, both from the EMR provider and the HIE side. Data sharing in the next few years will take on multiple forms, from low-cost secure messaging (email in a specific environment), to seamless data exchange between certain EMR vendors, to the more comprehensive interface-driven HIE option. The latter having the greatest value to a physician.

The opportunity to deliver quality and cost-effective care to all patients is closer than ever and appears to have continuous support from the government. Timely patient information sharing in a secure way will greatly contribute to this ideal and allows physicians to go back to what they do best; taking care of patients.

1 Health IT Data Summaries Web Application. (n.d.). Retrieved February 07, 2017, from https://dashboard.healthit.gov/dashboards/health-information-technology-data-summaries. php?state=Texas&cat9=all%2Bdata#summary-data

INNOVATIONS IN MEDICAL PRACTICE

OPEN LETTER TO TEXAS US SENATORS AND CONGRESIONAL REPRESENATIVES Now that Repeal and Replace is on hold, I would like to introduce myself and submit suggestions for an effective health care program. I am a Vietnam veteran who developed an interest in medicine as a result of military service. After a long, arduous processes I became a primary care physician. As primary care is problematic, I developed an understanding of the administrative process as I earned a Master’s in Public Health (MPH) and boar certification in Preventive Medicine and Urgent Care. Today I am semi-retired and provide primary care services to various Texas correctional facilities.

My suggestion is that any program must be based on the concept of physician-directed health care. Physicians have the education, training and experience to provide so-called quality health care leadership. All health care should be physician-directed. Mid-level providers should continue to function under physician supervision and not be independent practitioners.

Whether health care is a right or a privilege, any health care program must involve a cooperative relationship between our citizens, private enterprise, the health insurance industry and all levels of government, federal, state and local. Almost every county in the U.S. has a health department and, as such, it can be an effective site for implementation. Physicians can be recruited to provide primary care services such as health screenings, immunizations and health care counseling. Local health departments should be staffed with administrators and social workers who can refer to specialty care providers and coordinate payments.

However, there are many false conjectures often advertised on television. Many are of little or no benefit. Some are actually harmful and may enhance infection, promote chronic illness and are actually toxic. Thus, it is essential that a health care program works to prevent the advertisement of medications and treatments of questionable value. This is especially relevant now that our society has recognized the persistence of the iatrogenic opiate addiction.

What I am proposing is a health care initiative to be developed by the U.S. Public Health Service. New agencies do not need to be invented. What I recommend is enhanced funding for the USPHS Reserve. I recommend that this funding be through non-appropriated monetary assets such as state lotteries and a possible federal lottery. Additional assets may come from criminal fines or the interest on FHA loans. The USPHS may also be tasked with sponsoring Health Saving Accounts and in the purchase of health insurance across state lines and most favorable for the purchaser.

I was able to publish my ideas in a letter to the Texas Medical Association in Texas Medicine June 2014. See below.

Sincerely, Raymond V Osbourn, MD,MPH 211Tranquil Oak San Antonio, Texas 78260 June 2014 TEXAS MEDICINE

A PROPOSAL FOR BETTER ACCESS TO CARE

By R.V. Osbourn, MD As the Affordable Care Act has been partially implemented, it is evident that it is neither affordable nor simplistic. Yet the question from the pundits remains: “Do Republicans have any ideas about health care?”

This proposal, from a conservative Republican physician, concerns the principle of access to care by a physician. Health care needs supervision by physicians, not midlevel practitioners. As such, it is essential for a fully licensed physician to evaluate and to implement investigations, patient education, and treatment. Ancillary health care professionals assist physicians and have sufficient knowledge to present information to a supervising physician and aid in treatment. Also, it will be beneficial to involve social workers in this endeavor, for they have knowledge of health care funding and resources. I am concerned about access to care by a physician and would like to propose a community-based health care program. In the United Stated, there are four levels of government: local, county, state, and federal. In many instances, the resources of the first two are combined.

Traditionally, most counties have health departments. State governments also have health departments funded by the legislatures. There is also funding for health activities, such as state hospitals and professional schools. The federal government has assisted state and local public health activities mostly through granting processes. The objective in proposing a simplistic health care system is to provide public health services to the public by using all levels of government. With a cooperative intergovernmental relationship, it may be possible to provide for the severely impaired and the catastrophically ill, as well as the uninsured and underinsured. Emergency and disaster services should also be included.

The local government could provide the facilities in which health care services can be delivered; the states can provide funding, as well as health personnel from professional schools. The federal government should be able to position itself in the development of a professional cadre of health care professionals as commissioned officers of the U.S. Public Health Service (USPHS).

The Commissioned Corps of the USPHS has been in existence since 1798. Currently, it provides medical support to the Coast Guard, the National Institutes of Health, the Food and Drug Administration, and other agencies. USPHS has a reserve component that may be funded to develop a reserve component similar to the Reserve Components of the Armed Forces. It may then be integrated into the National Guard for community service. As such, professionals could provide services on a part-time basis, and earn a salary, retirement credits, and military privileges. Those who participate would be able to receive their own complimentary health care insurance for themselves and their dependents. Their professional activities would also be covered by the Federal Tort Claims Act. Patients should be charged on a sliding-scale basis. No one should be refused for lack of resources. Novel methods of funding from no appropriated sources should be encouraged, such as lotteries, court fines, seized assets, and lease of government assets. There may be many other ways of funding. I’d like to hear your suggestions. You may email me at rvosbournmd@aol.com or call 210 403 2176. visit us at www.bcms.org

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INNOVATIONS IN MEDICAL PRACTICE

DIAGNOSING

AND TREATING

OUR HEALTHCARE SYSTEM

By Darren Donahue, JD, MD Candidate UT Health San Antonio

If the healthcare debate of the past six months is any indication, it is that many support comprehensive reform or replacement of the ACA, while others worry about what that might mean for physicians, patients, and the indigent. Surely this will be the topic of much discussion at the local, state, and federal levels in the coming years. This is, after all, a subject where reasonable minds can and do differ. In anticipation of these inevitable differences, I would like to make a modest proposal for how we in the medical community should approach these conversations no matter whether they include legislators, healthcare providers, family, or friends. I propose that as we participate in this ongoing debate that we act like doctors.

In diagnosing and treating their patient’s health conditions, physicians assemble a differential diagnosis composed of several conditions which might be causing the patient’s symptoms. The systematic approach of eliminating possible causes one-by-one before being left with the most likely diagnosis ensures that treatment is narrowly tailored and specific to the underlying etiology. Shouldn’t the same approach be used when addressing the conditions and diseases of the healthcare system that policy makers say they are so eager to cure?

This begs the question of how one might construct a differential diagnosis for a healthcare system. The Patient Institute’s Conditions and Diseases of Healthcare Systems (“CDHS”)1 was created to name and describe specific characteristics of the healthcare system, doctors, and patients that lead to poor outcomes in medical treatment. We name these conditions for the same reason that we name diseases in medicine: Precisely identifying a condition is a prerequisite to communicating about it and studying its distribution and pathophysiology. Of course, the end goal is to remediate, cure, and prevent these conditions from occurring. While still a work in progress, the CDHS is an excellent resource for constructing such a differential.

Take for instance, the spectrum of disease called Hypermetricosis.

This condition results from the voluminous and inefficient collection and use of data that can distract providers from delivering care to individual patients. As Hypermetricosis is a spectrum of disease, each 22 San Antonio Medicine • September 2017

individual instance can vary in severity and consequences. In the case of Dissociative Hypermetricosis, the data collection distracts and burdens the physician and provides no added benefit to the individual patient.

In the most severe form — Malignant Dissociative Hypermetricosis — inefficient collection and use of poor quality and inaccurate data can impair the delivery of care and even directly harm individual patients. For example, some electronic medical record systems warn staff against providing cefazolin — a standard preoperative antibiotic therapy — to patients who report penicillin allergies despite the fact that cross-reactivity between penicillin and cephalosporins is very low. As a result, patients are given clindamycin instead which can and does, in many cases, cause a Clostridium difficile enterocolitis.

Since the healthcare system is replete with hypermetricoses, curing of this disease would be an excellent target of reform.

Or consider Benefit Managementosis where due to the common structure of healthcare payment and reimbursement, a third or fourth-party uses the (pre)authorization process to control whether a patient receives a particular test or therapy. Alarmingly, benefit

INNOVATIONS IN MEDICAL PRACTICE

managers make these decisions without any formal clinical training or a state medical license. It is these individuals who are strangers to the doctor- patient relationship that have the final say in the type and extent of care the patient receives.

While benefit managers came into existence in an effort to control costs by reducing unnecessary medical procedures, their role in healthcare adds uncompensated administrative burdens on providers and delays needed care to patients. Benefit Managementosis is also a spectrum disease that can proceed to malignancy where the delay attributable to the authorization process or the complete refusal of authorization causes added or prolonged pain and suffering. Tragically, Malignant Benefit Managementosis sometimes results in the death of a patient. Restoring physician autonomy in the treatment of their

patients is one area that the medical community ought to be able to unanimously support.

These are just a couple examples of diseases that affect the healthcare system but of course, there are many more worth treating. Ultimately, the goal of this proposal is not to expand the vocabulary of the public debate but rather to encourage the medical community to leverage its training and professional judgment when engaging in regulatory advocacy. As in medicine, we ought to strive for efficacious and specific treatments that remedy only that which we wish to cure.

1 The current copy of the CDHS can be found on the Patient Institute’s website at: http://www.patientinstitute.org/healthcarepolicy/.

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23

BOOK REVIEW

LAST DAYS OF NIGHT

By Graham Moore Reviewed by J. J. Waller Jr., MD It is 1888 in New York City, and the “gas” lighting of the city (homes, businesses, and street lights) is barely beginning to be replaced by the early electric “light bulb.” Two companies are in deep competition to control the production and distribution of electricity and the new electric “bulb.” One is the Edison Electric Company and the other is the Westinghouse Company. Great controversy exists between the two as to the patent rights to the electric light bulb. The original patent was awarded to Thomas Edison, but a slight modification by George Westinghouse has resulted in Edison suing Westinghouse for one billion dollars for infringement on his patent. The winner of the suit will control all the production of the “bulb,” and distribution of the electricity nationally.

Paul Cravath, a young Columbia Law School graduate, is a legal prodigy graduating at the top of his class. He is hired by a prominent firm which is being considered by Westinghouse as their legal representative against Edison. After extensive interview of multiple lawyers, Westinghouse selects the young Cravath to defend his company versus Edison. Thomas Edison meets with Cravath in an attempt to discourage him by revealing all the extensive information he possesses and law suits he has filed, but Paul remains steadfast in his commitment to continue against all odds.

Thus begins several years of suits, countersuits, dispositions, secrete investigations, arson attempts, attempted murder, corporate spies, and multiple other above board and undercover activities by both sides in this extremely important battle. The narrative eventually involves most of the wealthy magnates of the era, including John Rockefeller, Alexander G. Bell, J.P. Morgan, a beautiful Metropolitan Opera star, and the Huntington elite of California.

All the events and individuals are woven into a tremendously fascinating historical novel. As Cravath pursues his all-consuming endeavor he becomes involved with the brilliant, eccentric, scientist and inventor (from Croatia) Nikola Tesla. This rare individual first assisting Edison and then Westinghouse in their labs, independently, with the assistance Cravath, develops the application of alternating current. This compounds the controversy, with Edison advocating direct current and Westinghouse alternating current as the means of electrical transmission.

After many legal and personal disappointments and failures Cravath finally develops a scheme to resolve the issues legally confronting the two great inventors, Edison and Westinghouse. The eventual resolution assumes a form no one could ever have anticipated, and results in the eventual electrification of the United States.

24 San Antonio Medicine • September 2017

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25

FEATURE

For eight years in the 1970s, while on the faculty at the Medical School, my office address was 7703 Floyd Curl Drive and for that entire time no one could tell me who Floyd Curl was. Finally, with the help of the archivist of the Health Science Center Library, the mystery was solved. The Rev. Floyd Curl was a Methodist minister and, in his capacity as executive secretary of the Southwest Texas Conference, he presided over the first meeting of the Board of Trustees of the Methodist Hospital on Jan. 24, 1955. When that building was completed, it faced the only existing road within the proposed Medical Center, and the Board decided to name that street for him.

A few of the streets in the Medical Center are named for internationally prominent scientists such as Louis Pasteur, who helped to develop germ theory and gave us the term pasteurization, and Jonas Salk, who developed the first polio vaccine. But most of the street names honor men whose efforts helped create the beginnings of the South Texas Medical Center.

John Smith Drive Active in medical politics for his entire career (President of Bexar County Medical Society [BCMS] in 1967 and also the Texas Medical Association [TMA] in 1977) and having personal access to important members of the UT Board of Regents and in the Texas Legislature, Dr. Smith was instrumental in coordinating the ef26 San Antonio Medicine • September 2017

forts of these disparate organizations and also in securing Hill-Burton funds to supplement the inadequate funding provided by a local bond issue to build the Bexar County Hospital. His cardiovascular surgeon son, Dr. Marvin Smith, was later elected President of the Bexar County Medical Society in 1998, making them the only father-son duo to have had that distinction.

Merton Minter Drive Also an effective medical

FEATURE

politician, Dr. Minter was at one-time Chairman of the UT Board of Regents and also a trustee of the TMA. He founded the Minter Clinic in 1922 and was Chairman of the San Antonio Medical Foundation in its early years.

Tom Slick Drive A true Renaissance man, Tom Slick was a millionaire oilman, philanthropist, rancher, author, art collector, adventurer, and inventor. He is most widely known as the Founder of the Southwest Research Institute and the Southwest Foundation for Biomedical Research and was also an original member of the Medical Center Foundation Board. He died in a private plane crash at age 46 when plans for the Medical Center were still mainly on the drawing board.

was strong support to have them be adjacent to the Robert B. Green Hospital downtown, closer to the indigent population that the hospital would primarily serve. Others were convinced that a much larger area was needed than could be accommodated downtown, and four investors who owned large tracts of land where the Medical Center now resides (one of whom was Edgar von Scheele) donated 200 acres in northwest San Antonio for the center.

L.E. Fite Drive This very short “street” that connects Floyd Curl and Ewing Halsell between St. Luke’s Baptist and Methodist Plaza was named for a man who, along with Sid Katz and Melrose Holmgreen, acquired an additional 400 acres for the Medical Center. Fite refused to have anything named for him during his lifetime, so the Board had to wait until after his death to name this street.

Melrose Holmgreen Drive. President of Alamo Iron Works, a firm started as a small blacksmith shop by his Prussian immigrant ancestor in 1878, Holmgreen was one of seven trustees of the original Medical Foundation. The Alamodome now stands on the site of the expanded Alamo Iron Works plant. Holmgreen also helped establish the San Antonio River Authority and United Way of San Antonio.

Ewing Halsell Drive Sid Katz Drive It may seem somewhat ironic that one of the major fundraisers for the Methodist Hospital (and Chairman of the Medical Foundation’s land acquisition committee) was born of Jewish immigrant parents. There was no synagogue in the small town of Clinton, Kentucky where he grew up, so the family attended the local Methodist church, which likely explains his affinity for that denomination.

Von Scheele Drive In the late 1950s and early 60s, a bitter fight raged about where the medical school and new county hospital should be built. There

Halsell himself was never directly involved with the Medical Center Board, but his charitable foundation contributed substantial amounts of money through the efforts of its board chairman, Gilbert Denman. Halsell’s money came from ranching – his father owned the 7,500 square mile XIT ranch in the Panhandle and he himself owned the 90,000 acre Farias Ranch in Maverick County.

All of these “mini” biographies and nearly 1,000 more can be found in Place Names of San Antonio (3rd Ed) by David P. Green, MD, Maverick Publishing Company, San Antonio 2011. visit us at www.bcms.org

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LEGAL EASE

UNHOLY COVENANTS Defective Physician Covenants Not to Compete In Texas

By Mark F. Weiss, JD

Is that covenant not to compete in your physician employment agreement an illegal restraint of trade or an enforceable restriction that you’ve willingly agreed to?

The issue is as highly complex as it is contentious, so much so that the Texas Supreme Court has changed its interpretation of covenants not to compete (CNTC) in general several times over the past few decades.

To make matters even more complex, Texas law imposes additional, special requirements on physician covenants not to compete.

Although only the judge or arbitrator in your hypothetical (or is it?) case can tell you whether your CNTC is unenforceable, the 28 San Antonio Medicine • September 2017

chances are high that it’s defective.

In this article, we’ll explore some defects commonly seen in Texas physician CNTCs.

Lack of Separate Consideration of the Right Kind For any CNTC to be enforceable, there must be specific consideration (i.e., something of value given) for your agreement not to compete. Additionally, the type of consideration given impacts the enforceability of the CNTC. Under current Texas law, the consideration given must be reasonably related to an interest worthy of protection, such as trade secrets,

LEGAL EASE

confidential information, or goodwill.

Employers often attempt to meet this requirement by promising to give the employee trade secret information, other confidential information, or specialized training that impacts the employer’s goodwill. For example, the employer medical group promises to provide you with access to certain trade secrets.

A problem, that is, lack of consideration, thus arises if the employer promises to provide access to confidential information and promises to give specialized training, but never actually carries through with providing it This, of course, is highly fact specific. What did or didn’t your employer actually provide? Often, the employer provided nothing, thus obviating the entire CNTC. There’s another potentially interesting issue here that can arise in the context of an addendum or amendment to a previous agreement.

Consider the following hypothetical: The Jones Medical Group enters into an employment agreement with Dr. Ecks. The agreement contains promises by the group to provide Dr. Ecks with confidential information and specialized training.

Dr. Ecks promises to keep any such information confidential. Three weeks later, the group provides Ecks with a training session on the Jones Technique, a breakthrough means of patient treatment.

A year passes, after which time Jones Medical Group presents Dr. Ecks with an amendment to the employment agreement. The amendment contains similar promises of providing confidential information and specialized training and now, for the first time, a CNTC. Another six months pass and no additional confidential information reasonably related to protecting the group’s trade secrets or goodwill is actually provided. Has there been any consideration for the CNTC thus rendering it enforceable if Dr. Ecks leaves the group and joins a competitor across the street? Very arguably, the answer is “no;” the CNTC has been blown.

Similarly, although not as clear, what if the medical group had given Dr. Ecks confidential information a week after entry into the amendment to the employment agreement. Was that delivery of the separate consideration for the CNTC or was that delivery of information that Jones Medical Group was already bound to deliver under the terms of the original employment agreement? If it’s the latter, then there was no separate consideration for the CNTC and it fails.

Unreasonable Time, Area, or Scope In order for a CNTC to be enforceable, its restrictions must be reasonable as to time, geographic area, and the scope of activity to be restrained.

Additionally, the limitations placed on the physician by the CNTC can’t impose a greater restraint than is necessary to protect the good-

will or other business interest of the employer.

Time restrictions are usually not an issue, because Texas courts have enforced covenants that run from 1 year to 5 years or even longer.

However, geographic scope is a common problem area. For example, it’s common in physician CNTCs to see restrictions that prohibit competition with the business of the employer in a rather broad area, such as “within Bexar County.”

Of course, the reasonableness of any geographic restriction turns on the specific facts of your situation. But query whether a broad geographic restriction such as an entire county is either reasonable or necessary to protect the business interests of an employer medical group in the situation in which the medical group operates by way of exclusive contracts at specific facilities only.

Is it reasonable to prevent a certain former employee physician, say an anesthesiologist we’ll call Dr. Zee, who worked for the Jones Medical Group at only one facility, St. Mark’s Community Hospital, from later working for the Smith Medical Group at another hospital 10 miles away? What if Smith holds the exclusive contract at that other facility, one at which the Jones Group cannot provide services due to the grant of exclusivity to Smith?

In fact, depending on the physician’s medical specialty, it might be held unreasonable to prevent Dr. Zee from working at any facility at which he didn’t work for Jones.

To be readily enforceable, CNTCs should be tied to the specific geographic area in which the physician provided services. Prohibitions as to entire counties, for example, or to wide mile-radiuses such as “22 miles from any facility served by Jones Medical Group” may be attacked as over-broad. Similarly, CNTCs that effectively prevent the physician from earning a living are overbroad and unenforceable.

Similarly, the scope of activity prohibited by the covenant is often overbroad. Consider the issue of a physician practicing within a particular subspecialty for the Jones Medical Group. Let’s assume that the employment agreement contains a covenant not to compete that prohibits the physician from any employment with a competitor in the County. If the physician were, for example, a cardiac anesthesiologist for Jones, can he be prohibited from practicing non-cardiac anesthesia for the competing Smith Group?

In addition to, as mentioned above, the fact that the employer has the burden to prove the reasonableness of a CNTC, under some circumstances surrounding overbroad restrictions, the employee may be entitled to an award of attorneys’ fees even if the agreement with the employer doesn’t contain an attorneys’ fees clause.

Blown Buy-Out Provision To be enforceable, a physician CNTC must provide a right for the physician to buy out of the covenant at a reasonable price or, at the option of either party, as determined by a mutually agreed upon arcontinued on page 30

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29

LEGAL EASE continued from page 29

bitrator or, in the case of an inability to agree, an arbitrator of the court whose decision is binding on the parties.

Many physician CNTCs are void out of the starting gate due to the lack of any buy out provision.

The dollar amount of the buy-out leads many medical groups into trouble. Although what amounts to a “reasonable” price is not specified by law, the price must have some relevance to the amount of damages that the employer would otherwise suffer as damages from breach, which is, by its very nature, the amount of lost profits.

This puts into significant doubt the enforceability of physician CNTCs that set the buy out in the amount of the entire annual salary paid to him or her by the former employer. Equally suspect are buy outs tied to future gross collections, even measured only by collections from those patients who are “poached.”

Additionally, it’s common to see employers blow the buy-out provision by getting “too cute by half:” They don’t set out “a buy-out price,” such as $30,000; instead they set alternative buy out prices.

For example, fearing that large number of their employed physicians may “jump ship” to a competitor, they set a second, alternative, higher buy out price in the event that other employed physicians also leave the group’s employ within some time period, say within 60 days of each other.

Despite other defects, such as failing to account for how the 60day time period is measured (backwards or forwards in time?), how does the fact that other physicians leave the medical group’s employ change the damages that the employer would suffer if the single physician wishing to exercise his or her buy out right does so?

Such provisions are highly suspect and likely destroy the entire enforceability of the CNTC.

Ignored Patient Protections Last, for any physician CNTC to be enforceable, it must contain specific patient- protective provisions.

Specifically, the CNTC must: 1. Not deny the physician access to a list of his patients whom he had seen or treated within one year of termination of the contract or employment.

2. Provide access to medical records of the physician's patients upon authorization of the patient and any copies of medical records for a reasonable fee as established by the Texas Medical Board.

3. Provide that any access to a list of patients or to patients' medical records after termination of the contract or employment shall not

30 San Antonio Medicine • September 2017

require such list or records to be provided in a format different than that by which such records are maintained except by mutual consent of the parties to the contract.

4. Provide that the physician will not be prohibited from providing continuing care and treatment to a specific patient or patients during the course of an acute illness even after the contract or employment has been terminated.

The Bottom Line Over the past decades, covenants not to compete in general have gone from out of favor to in favor. At the same time, very specific requirements must be met, especially in connection with physician CNTCs. Medical group employers often overreach in connection with CNTCs. Additionally, the often become over aggressive in their buy out provisions in order to attempt to moot a physician’s statutory right to pay his or her way out of the restrictions.

It’s important to note that in any challenge to the enforceability of a physician CNTC, whether in the context of a suit by the employer to enforce the covenant or in the context of a suit by the physician employee to have the CNTC declared unenforceable prior to actually engaging in competition, the employer medical group, not the employed physician has the burden of proving that the CNTC is enforceable.

Additionally, under some circumstances the employed physician may be entitled to an award of attorney’s fees, even if the CNTC is not found completely invalid but only reduced as to time, geographic area, or scope of restriction.

There are plenty of rumors as to the enforceability of physician CNTCs in Texas. Just like rumors of Bigfoot sightings, they might not be true. Especially in your instance.

That’s because each the enforceability of each CNTC turns on the specific facts. Any physician questioning whether his or her CNTC is actually valid should seek qualified legal counsel: Your CNTC may simply be a paper tiger, designed to bully you from thinking of jumping ship, but without any actual teeth.

Mark F. Weiss is an attorney who specializes in the business and legal issues affecting physicians and physician groups on a national basis. He served as a clinical assistant professor of anesthesiology at USC Keck School of Medicine and practices with The Mark F. Weiss Law Firm, a firm with offices in Dallas, Texas and Los Angeles and Santa Barbara, California, representing clients across the country. He can be reached by email at markweiss@advisorylawgroup.com.

SAN ANTONIO TRICENTENNIAL

Tricentennial Commission Gets Under Way

By Fred H. Olin, M.D.

BCMS member Alfonso Chiscano, M.D. has been selected as one of the five Commissioners of the San Antonio Tricentennial Commission. In addition to his duties as the Vice-President of the Commission, he is organizing a one-day seminar to be titled “300 Years of History and Advances in Medicine in San Antonio.” Currently the seminar is scheduled for Saturday, May 12, 2018, in the Holly Auditorium on the Medical Center Campus of the Long School of Medicine. In 1992, Dr. Chiscano had organized a similar seminar on “500 Years of Medicine in the New World.”

The first organizational meetings for the seminar were held on May 31st. Present at the luncheon meeting at Aldo’s were Dr. Chiscano Leah Jacobson, M.D, Bexar County Medical Society (BCMS) President.; Sheldon Gross, M.D., President-Elect.; Stephen C. Fitzer, BCMS CEO; Jaime Wesolowski, Methodist Hospital System CEO; Harold H. “Trip” Pilgrim, III, Baptist Hospital System CEO; Sister Martha Ann Kirk, Professor of Theology, University of the Incarnate Word; Dan Rosenthal, M.D., and your not-particularly-humble correspondent. The CEOs of the Nix, Santa Rosa and University also were invited.

This meeting was a brainstorming session, working from a tentative, detailed program for the seminar supplied by Dr. Chiscano. It was noted that, counting mid-session and lunch breaks, the program could be conveniently broken into four modules. There was considerable discussion about what should be included in each section.

About the only semi-solid conclusion was that the final afternoon

period should include a speaker with experience in predicting future trends in medicine. Mr. Pilgrim suggested Jeff Goldsmith, a professor at the University of Virginia, who has made predictions in the past…and then, after the passage of time, gone back and sort of scored himself on his accuracy. He has acted as keynote speaker at many meetings, and may be invited to fill that position at this event.

If any of our readers have an interest in the history of medicine in San Antonio, Texas and/or the Americas in general, please let me or Dr. Chiscano know of your interest: there may be a place for you in the proposed program.

Later the same day, Dr. Chiscano convened a meeting at the medical school for the purpose of working out some of the needed details for the administration of the program. Present, besides Dr. Chiscano and me, were Raul Ramos, M.D., who had assisted with the 1992 seminar, Melody Newsom, BCMS Chief Operating Officer, and Mary Anthony, M.S., Manager of Special Events in the Office of the President, UT Health. Several other people had been invited but were unable to attend: these included persons associated with granting CME credits and an illustrator for the proposed announcement brochure, etc. Among the subjects discussed were arranging for a box lunch and the fees to be charged to participants, along with further explorations into how to arrange the program.

As time goes on, we will have more updates on progress being made towards successful participation by BCMS and its members in the celebration of San Antonio’s 300th birthday. If you or an organization you are part of is planning to join in with a special event, please let Mike Thomas, the BCMS Director of Communications know and we’ll help you publicize it. visit us at www.bcms.org

31

FINANCIAL

How to choose a financial advisor

By Joseph Quartucci, ChFC®

For medical professionals, it can be very difficult to find time to take care of your “wealth health”. Like many busy Americans, doctors may want to engage the services of a financial firm to help them take care of their business or personal economy. The question that many doctors face is how to choose such a firm. The financial world can be just as complicated as the medical world. There are many different types of planners and disciplines in financial planning, such as fee based, commission, fee only, tax investment and insurance.

One way to help you decide is to seek out a firm that has a stated purpose, process and philosophy. This allows you to ensure that your financial values align well with the firm you choose to have a relationship with. Be careful to avoid transactional based advisors over those looking to have a relationship with you. The more your advisor knows you the better chance he or she can properly advise you. Just like a doctor the more information he or she possesses the better job they should be able to do.

One final way to help you choose is compensation methods. Most advisors are compensated in 1 of 3 ways.

1. Fee Only: This advisor charges by the hour and writes a financial plan. It will be up to you to implement that plan. Most busy professionals do not have the time to implement their own plan, which is why they seek help to begin with.

32 San Antonio Medicine • September 2017

2. Fee Based Advisors: This advisor charges a percentage of assets (usually 1%-2%) to watch over investments and give general business and financial advice. As your accounts/worth goes up so does advisor compensation. However, this advisor still is paid when your accounts decrease in value. This is the most common form of advisory.

3. Commission Based: This type of advisor is paid by institutions to offer you their products. Sometimes the money paid to the advisor comes directly from your account and sometimes it doesn’t. The concern here should be “is my advisor acting in my best interest or just selling products her or she gets paid on the most”?

It is probably advisable to seek out a comprehensive wealth advisor that can utilize any and all of the options above. This allows the advisor to maintain objectivity and place compensation concerns where they belong . . . a distant second to your goals and needs.

Joseph Quartucci, ChFC® is a Managing Partner with e3 Wealth, LLC. Our team can be reached at 165 Elmhurst, Suite B, Kyle, TX 78640; 512-268-9220 or jquartucci@e3wealth.com. Please visiti our website at www.e3wealth.com for more information.

BCMS NEWS

MedDropSA is the safe, easy way to dispose of unwanted, expired over-the-counter and prescription medications.

Simply bring any unwanted medicines along with other household hazardous waste items to the City of San Antonio’s mobile collection events.

Medications will be accepted at no charge, and disposed of in a safe, legal way – keeping these drugs off our streets and out of the environment.

September 16 • 8 a.m. - 1 p.m.

Alamo City Church • 6500 Interstate 35 North

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33

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

ACCOUNTING FIRMS RSM US LLP (HH Silver Sponsor) RSM US 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@rsmus.com www.rsmus.com “Offering service more than expected — on every engagement.”

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

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

ACO/IPA

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

ASSET MANAGEMENT

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

34 San Antonio Medicine • September 2017

vestment challenges and help achieve financial objectives.

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

The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions.

From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com

Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

Norton Rose Fulbright (HHH Gold Sponsor) Norton Rose Fulbright is a global law firm. We provide the world’s preeminent corporations and financial institutions with a full business law service. We deliver over 150 lawyers in the US focused on the life sciences and healthcare sector.

Employment & Labor Mario Barrera 210 270 7125 mario.barrera@nortonrosefulbright.com Life Sciences and Healthcare Charles Deacon 210 270 7133 charlie.deacon@nortonrosefulbright.com Real Estate Katherine Tapley 210 270 7191 katherine.tapley@nortonrosefulbright.com www.nortonrosefulbright.com “In 2016, we received a Tier 1 national ranking for healthcare law according to US News & World Report and Best Lawyers”

Strasburger & Price, LLP (HHH Gold Sponsor) Strasburger counsels physician groups, individual doctors, hospitals, and other healthcare providers on a variety of concerns, including business transactions, regulatory compliance, entity formation, reimbursement, employment, estate planning, tax, and litigation.

Carrie Douglas 210.250.6017 carrie.douglas@strasburger.com Cynthia Grimes 210.250.6003 cynthia.grimes@strasburger.com Marty Roos 210.250.6161 marty.roos@strasburger.com www.strasburger.com “Your Prescription for the Com-

mon & Not-So Common Legal Ailment”

BANKING

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

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

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

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

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

Commercial Relationship Manager — Zaida Saliba 210-370-6012 Zaida.Saliba@BBVACompass.com Global Wealth Management Mary Mahlie 210-370-6029 mary.mahlie@bbvacompass.com Medical Branch Manager Vicki Watkins 210-592-5755

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY vicki.watkins@bbva.com Business Banking Officer Jamie Gutierrez 210-284-2815 jamie.gutierrez@bbva.com www.bbvacompass.com “Working for a better future”

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

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

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

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

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

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

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

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more.

Novie Allen Business Solutions 210-650-1738

nallen@rbfcu.org www.rbfcu.org Firstmark Credit Union (HH Silver Sponsor) Address your office needs: Upgrading your equipment or technology? Expanding your office space? We offer loans to meet your business or personal needs.

Competitive rates, favorable terms and local decisions.

Gregg Thorne SVP Lending 210-308-7819 greggt@firstmarkcu.org www.firstmarkcu.org Frost (HH Silver Sponsor) As one of the largest Texas-based banks, Frost has helped Texans with their financial needs since 1868, offering award-winning customer service and a range of banking, investment and insurance services to individuals and businesses.

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

BUSINESS SERVICES

New York Life Insurance Company (HHH Gold Sponsor) We believe that any great relationship starts with great core values: Attention, Accountability, Appreciation, Adaptability and Attainability Financial Consultant Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com

CONTRACTORS/BUILDERS /COMMERCIAL

Cambridge Contracting (HHH Gold Sponsor) We are a full service general contracting company that specializes in commercial finishouts and ground up construction.

Rusty Hastings Rusty@cambridgesa.com 210-337-3900 www.cambridgesa.com

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

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

Steve Huffman 210-979-2500 shuffman@huffmandev.com Lauren Spalten 210-667-6988 lspalten@huffmandev.com www.huffmandev.com

FINANCIAL SERVICES

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

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

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

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

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

e3 Wealth, LLC (HHH Gold Sponsor) Over $550 million in assets under management, e3 Wealth delivers truly customized solutions to indi-

viduals and businesses while placing heavy emphasis on risk minimization, tax diversification, proper utilization and protection for each client's unique financial purpose.

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

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

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

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning).

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

continued on page 36

visit us at www.bcms.org

35

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 35

HEALTHCARE TECHNOLOGY The Mani Johnston Group at UBS (HHH Gold Sponsor) Advice Beyond Investing, Dedicated Client Service Team, 4 decades serving the Bexar County medical community. Specialization in customized asset management and lending services supported by the strength of the UBS Global Bank.

Senior Vice President – Wealth Management Senior Portfolio Manager Carol Mani Johnston 210-805-1075 Carol.manijohnston@ubs.com www.ubs.com/team/manijohnston "UBS is honored to be named Best Bank for Wealth Management in North America for 2017 by Euromoney."

First Command Financial Services (HH Silver Sponsor) Nigel Davies 210-824-9894 njdavies@firstcommand.com www.firstcommand.com

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) The Executive Master’s Program in Healthcare Administration is ranked in the Top 10 programs nationally. A part-time, hybrid-learning program designed for physicians and healthcare managers to pursue a graduate degree while continuing to work full-time.

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

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

36 San Antonio Medicine • September 2017

RubiconMD (HH Silver Sponsor) RubiconMD enables primary care providers to quickly and easily discuss their e-Consults with top specialists so they can provide better care - improving the patient experience and reducing costs Shang Wang Business Development (845) 709-2719 shang@rubiconmd.com Cyprian Kibuka VP of Business Development (650) 454-9604 cyprian@rubiconmd.com www.rubiconmd.com “Expert Insights. Better Care."

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

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

HOSPITALS/ HEALTHCARE SERVICES

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

Quality awards include accredited centers in: Chest Pain, Primary Stroke, Wound Care, and Bariatric Surgery.

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

Warm Springs Medical Center Thousand Oaks Westover Hills

(HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com Select Rehabilitation of San Antonio (HH Silver Sponsor) We provide specialized rehabilitation programs and services for individuals with medical, physical and functional challenges.

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

INFORMATION AND TECHNOLOGIES

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com Mortgage Kristie Arocha 210-255-0013 karocha@swbc.com SWBC Mortgage www.swbc.com Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services

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

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

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

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

INSURANCE/MEDICAL MALPRACTICE

INSURANCE

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

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

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

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

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

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

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

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

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

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

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

INTERNET TELECOMMUNICATIONS

Network Alliance (HHH Gold Sponsor) We are experts in managed IT services, business phone systems, network security, cloud services and telecom carrier offerings, located in the heart of the medical center at Fredericksburg & Medical Dr. Rod Tanner (210) 870-1951 rtanner@network-alliance.net Carl Lyles (210) 870-1952 clyles@network-alliance.net www.network-alliance.net “Delivering solutions through technology”

OFFICE EQUIPMENT/ TECHNOLOGIES

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

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

PAYROLL SERVICES

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

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

MEDICAL SUPPLIES AND EQUIPMENT

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

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

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

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

New York Life Insurance Company (HHH Gold Sponsor) Our Goal, increase patient & employee satisfaction, generate more free time for practitioners and mitigate both business and personal financial risk. (No Cost Financial and Business consulting including HIPAA audit evaluations, BCMS members only).

Doug Elley 210-961-9991 delley@ft.newyorklife.com www.newyorklife.com “20+ years helping Physicians to increase practice profits and efficiencies, reduce operations stress”

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, non-profit, R&D, healthcare delivery, professional services and more!

President Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Program Coordinator Valerie Rogler 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

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

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

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

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

To join the Circle of Friends program or for more information, call 210-301-4366 or email August.Trevino@bcms.org Visit www.bcms.org

visit us at www.bcms.org

37

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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

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

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

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

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

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

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Infiniti 12150 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Bill Boyd 210-859-2719

Pete DeNeergard 210-680-3371

Hugo Rodriguez and Rick Tejada 210-824-1272

Coby Allen 210-625-4988

Abe Novy 210-496-0806

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Sean Fortier 210-681-3399

Gary Holdgraf 210-862-9769

Wayne Alderman 210-525-9800

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230

Ancira Nissan 10835 IH 10 West San Antonio, TX 78230

Jarrod Ashley 210-558-1500

Jason Thompson 210-558-5000

GUNN AUTO GROUP

GUNN AUTO GROUP

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

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

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

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

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

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

Richard Wood 210-366-9600

John Wang 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

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

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Land Rover of San Antonio 13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Sandy Small 210-341-8841

AUTO PROGRAM

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

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA Clinical Pathology Associates Dermatology Associates of San Antonio, PA Diabetes & Glandular Disease Clinic, PA ENT Clinics of San Antonio, PA Gastroenterology Consultants of San Antonio General Surgical Associates Greater San Antonio Emergency Physicians, PA Institute for Women's Health Lone Star OB-GYN Associates, PA M & S Radiology Associates, PA MacGregor Medical Center San Antonio MEDNAX Peripheral Vascular Associates, PA Renal Associates of San Antonio, PA San Antonio Gastroenterology Associates, PA San Antonio Infectious Diseases Consultants San Antonio Kidney Disease Center San Antonio Pediatric Surgery Associates, PA Sound Physicians South Alamo Medical Group South Texas Radiology Group, PA Tejas Anesthesia, PA Texas Partners in Acute Care The San Antonio Orthopaedic Group Urology San Antonio, PA WellMed Medical Management Inc.

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of August 24, 2017.

visit us at www.bcms.org

39

AUTO REVIEW

2017 Volkswagen Golf Alltrack

By Steve Schutz, MD

AUTO REVIEW

After two very difficult years caused by

added numerous body embellishments

senger room, but the wagon configuration

getting caught cheating on emissions tests in

which give the car a decidedly Patagonia-ish

adds significant utility. With the rear seats

the U.S., Volkswagen has decided to claw

vibe. It is to the Golf Sportwagen as the

folded down I was able to fit my 29” moun-

their way back onto the shopping lists of

Crosstrek is to the Subaru Impreza, but don’t

tain bike in the back without any difficulty.

American car buyers by, at least partially, fol-

be surprised if the Alltrack sells far better

It’s worth noting that Volkswagen proba-

lowing Subaru’s example.

than the Sportwagen.

bly can’t take this whole Subaru-ization

Regular readers may recall that I’ve been

Driving the Golf Alltrack is a lot like driv-

thing too much farther. The Passat sedan

impressed with Subaru’s ability to grow their

ing the Sportwagen, not surprisingly. All All-

would look dumb lifted and dressed up as a

sales in the U.S. despite having no SUVs or

tracks are AWD, so they’re slightly heavier

sorta SUV, and I don’t think Golf hatchback

crossovers in a market where SUVs and

and better in inclement weather, not that I

would look much better. Volkswagen has a

crossovers are king. How did they do it?

encountered any during my week with the

“Dune” version of the New Beetle which

They took their cars, added AWD to all of

car. Toodling around town and cruising on

looks pretty good, but it’s FWD only and re-

them, and then made most of them look like

the highway were easy in this car, as was

ally just an appearance package rather than

sorta-SUVs even though they weren’t. The

driving on twisty back roads. Volkswagens

a legitimate attempt to add off-road func-

result? Huge sales success. In 2013, Subaru

generally offer a more athletic driving expe-

tionality.

passed VW in vehicle sales in the U.S., and

rience than their Asian and American com-

Having said that, selling just one Subaru-

in 2015 they sold more cars than Volkswa-

petitors, and that’s true for the Golf Alltrack.

ized car is probably enough now that the all-

gen had ever sold in this country (582,573

That means it has more verve when you ac-

new Atlas SUV is here to battle the Ford

in 1970, in case you were wondering).

celerate and sharper handling than competi-

Explorer, Toyota Highlander, and Honda

tors like, umm, the Subaru Crosstrek.

Pilot, and a redone Tiguan with more space

Naturally, being a smart and successful multi-national company, VW hasn’t enjoyed

For the record, the Alltrack actually has an

is just around the corner. As always, Phil

watching Subaru et al. eating their proverbial

off-road driving mode that you select using

Hornbeak is available through the BCMS to

lunch, so they’ve decided to do something

the touchscreen. No, it doesn’t turn the car

help you buy the right car or SUV for the

about it, which brings me to the subject of

into a Land Rover, but it does engage hill de-

best possible price.

this month’s review – the Golf Alltrack, a

scent control and change throttle and trans-

The Volkswagen Golf Alltrack is an attrac-

Subaru wannabe if there ever was one. Car

mission settings to better handle non-tarmac

tive vehicle that borrows a page from Sub-

buyers in 2017 want SUVs and crossovers

situations.

aru’s playbook and will likely succeed in the

first and foremost, yes, but they’re also ok

Most Alltracks will come with a six-speed

market for all the reasons outlined above.

with cars that look like they could go off

dual clutch automatic, but, Alleluia!, a 6-

Given the serious (self-inflicted) problems

road. They just don’t want compact hatch-

speed manual is available. I respect any dual-

Volkswagen has been dealing with for two

backs, large sedans, or, OMG no, minivans.

clutch gearbox and am grateful that VW is

years, they need every sales hit they can get.

A quick aside: in the late 1980s Toyota

staying strong and avoiding CVTs. The only

If you’re in the market for this kind of ve-

added the word Altrac to all of their cars with

engine choice is a 1.8 liter turbo four that

hicle, call Phil Hornbeak at 210-301-4367.

AWD. They dropped the term in 2000, but

makes 170 HP.

you’d think they would take exception to VW

The interior is better than most other cars

Steve Schutz, MD, is a

using the same word with different spelling

in this class, though it won’t make the design-

board-certified gastroenterolo-

for their AWD wagon. Apparently not.

ers at Lexus or Audi lose any sleep. The ma-

gist who lived in San Antonio

To their credit, Volkswagen made sure the

terials and ergonomics are nice, and the

in the 1990s when he was sta-

Golf Alltrack was a good looking car. Yes, it’s

touchscreen is much better than previous

tioned here in the U.S. Air

essentially a Golf Sportwagen, but they’ve

Volkswagen efforts. We’re talking about a

Force. He has been writing auto reviews for

lifted it by 1.4 inches – a la Subaru – and

Golf here, so naturally there’s not a lot of pas-

San Antonio Medicine since 1995.

visit us at www.bcms.org

41

42 San Antonio Medicine • September 2017