San Antonio Medicine November 2016

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VOLUME 69 NO. 11

Inspirational Medicine

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Inspirational Medicine

NOVEMBER 2016

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VOLUME 69 NO. 11

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS).

All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement

by BCMS.

For the Patient’s Sake

By David Schulz, CHP ..........................................12 The 12th Man Connection: BCMS has ties to a Famous Texas A&M Tradition

By Mike W. Thomas ..............................................16

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

Spreading WINGS to fill the gap in breast cancer treatment By Mike W. Thomas ...........................20

Finding the Silver Lining — When the passion of physicians and federal regulations collide in concert By Alan M. Preston, MHA, ScD .........24

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

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BCMS Legislative News................................................................................................................10 In Real Time: Part 4 By Rajam Ramamurthy, MD. ...................................................................................26 BCMS Alliance General Membership Meeting........................................................................................30 Feature: What Cars do Doctors Actually Drive? By Fred H. Olin, MD .....................................................32 PrEP shown to reduce the spread of HIV By C. Junda Woo, MD............................................................36 UTHSCSA Dean’s Message By Francisco González-Scarano, MD ........................................................40 Med Pro: Medication Reconciliation ........................................................................................................43 Business of Medicine: Human Capital Development and Competency-Based Education

By Lee W. Bewley, PhD, FACHE, Jeffrey S. Sun, PhD, Ann H. Herd, PhD ...........................................44 BCMS Circle of Friends Services Directory .............................................................................................46 In the Driver’s Seat...................................................................................................................................51 Auto Review: 2017 Subaru XV Crosstrek By Steve Schutz, MD .............................................................52

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

DIRECTORS Rajaram Bala, MD, Member Jorge Miguel Cavazos, MD, Member Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member John W. Hinchey, MD, Member John Robert Holcomb, MD, Member John Joseph Nava, MD, Member Bernard T. Swift, Jr., DO, MPH, Member Francisco Gonzalez-Scarano, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Carlayne E. Jackson, MD, Medical School Representative Jennifer Lewis, BCMS Alliance President Roberto Trevino Jr., MD, Board of Censors Chair Jesse Moss Jr., MD, Board of Mediations Chair George F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTOR Stephen C. Fitzer

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

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

6 San Antonio Medicine • November 2016

PRESIDENT’S MESSAGE

Redesigning primary care is the first step

By Dr. Jayesh Shah, 2016 BCMS President

Last week, the Centers for Medicare & Medicaid Services

tical approach of redefining and deconstructing the primary care

(CMS) announced the final rule for MACRA (Medicare Access

practices and grouping the patients into subgroups. Chronic dis-

and CHIP Reauthorization Act). It replaces the old and flawed

eases account for 75 percent of our health care costs. If we sub-

sustainable growth rate formula for physician pay with a new

group all chronic disease management patients into subgroups

method meant to shift patients away from the fee-for-service

under primary care practices, such as end stage renal disease sub-

model to a value-based payment system, so physicians will get

group, coronary artery disease subgroup, diabetes mellitus sub-

paid by either a merit-based incentive payment system (MIPS)

group, etc. and then connect these subgroup teams with

or advanced alternative payment models. In MIPS, physicians’

telemedicine, it would definitely decrease cost and increase value.

pay is based on four performance categories including quality,

I agree with Porter and his colleagues that by dividing and or-

resource use, clinical practice improvement and advancing care

ganizing teams and providing specialty care around patients’ sub-

information.

groups will most likely make the provision of holistic and

CMS is actively making efforts to nudge physicians towards value-based care. The final rule developed some more exemptions

integrative care more efficient.

I also like his idea of creating an umbrella structure for small

which include exemptions for physicians who have less than

primary care practices so that they can redesign themselves. The

$30,000 in Medicare charges or physicians seeing less than 100

article suggests that the payment to the primary care practices

unique Medicare patients per year. CMS also pledged $100 mil-

should be in the form of monthly fees based on the complexity

lion in technical assistance to clinicians participating in MIPS

of patients, i.e. more monthly payments if a patient has more

who are in small practices, rural areas, and/or in areas with a

chronic diseases like diabetes mellitus, hypertension, hypercho-

shortage of health professionals.

lesterolemia and renal disease. This model also allows paying for

In spite of this hurricane effort by CMS to change the direction of health care towards value-based care, the majority of

episodic care if necessary, and gives incentives to physicians to take care of complex patients in a value-based scenario.

physicians working in the trenches are skeptical that this effort

Behavioral health care should not be considered separately.

will increase value or decrease cost. Some solo practitioners feel

Rather, it should be a part of chronic disease management be-

that this will be a last nail in the coffin for their practices and

cause many of the chronic diseases will be managed better when

will force them to close their practices.

these patients get treatment of their co-existing mental illness si-

I recently read an article by well-known business strategist and Harvard Business School Professor Michael Porter about, “How primary care needs to be redesigned.”

Porter and his colleagues define “value” as patient outcomes achieved relative to the amount of money spent. I like his prac-

8 San Antonio Medicine • November 2016

multaneously.

Redesigning primary care is necessary before any of the payment models will make a meaningful difference in health care reform.

BCMS LEGISLATIVE NEWS

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LEGISLATIVE AND SOCIOECONOMICS COMMITTEE CONTINUES VISITS WITH LEGISLATORS On Sept. 28, the BCMS Legislative and Socioeconomics Committee met with Rep. Lyle Larson (House District 122) and Candidate-elect Barbara Gervin-Hawkins (District 120) as part of the committee’s continued efforts to meet with our state elected officials in preparation for the upcoming legislative session which begins in January. Several issues of importance to medicine were discussed, including insurance issues, such as network adequacy, surprise billing and the Texas Dept. of Insurance.

REP. JOHN LUJAN OF TEXAS HOUSE DISTRICT 118 VISITS WITH BCMS PHYSICIANS

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Sept. 26, Drs. Alex Kenton and Jesse Moss, Jr., met with Rep. John Lujan (District 118) to discuss a number of issues of importance to medicine, including: health policy, insurance, Medicaid, network adequacy, managed care, women’s health, mediation, Affordable Care Act, physician ratings, surprise bills and TDI. 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 at mary.nava@bcms.org.

3 PHOTOS:

1. Members of the Socioeconomics Committee meet with State Rep. Lyle Larson.

2. State Rep. John Lujan (far right) discusses healthcare issues with Drs. Alex Kenton and Jesse Moss Jr..

3. State House Candidate Barbara Gervin-Hawkins meets with members of the Socioeconomics Committee.

10 San Antonio Medicine • November 2016

INSPIRATIONAL MEDICINE

Editor’s Note San Antonio has a great variety of wonderful, little known community health services, many created by doctors who also practice, research and teach. They see dire needs and are moved to address them directly, leveraging community strength through their volunteer leadership. San Antonio Medicine magazine will spotlight organizations in coming months, their service to the community, and the inspirations that guide them.

For the Patient’s Sake

By David Schulz, CHP

Can an abundance of healthcare be hazardous to one’s wellbeing?

The startling answer inspired Dr. Adam Ratner, along with family members and colleagues, to found The Patient Institute in 2008. It all began with a series of phone calls from strangers.

“It was really rather peculiar,” said Dr. Ratner, a diagnostic radiologist. “As a ‘picture-doctor,’ you don’t expect to get calls from lay people asking for general advice.”

But after completing medical training and establishing a practice here in San Antonio, he was getting calls from people around the country.

“It was always the same story,” he explained. “It was always about the parent of a friend, or a parent of a relative, or a parent of a relative of a friend, and they all had these in common: “All were of a high socioeconomic level; “All had insurance; “All had Medicare; “All had money; “All were seeing many specialists; “All were taking way too many medications.” He paused to drive the last point home.

“And they were all circling the drain, about to die.”

They were calling a stranger out of complete desperation. “I mean, why else would people in Florida and other places around the country be calling a radiologist in South Texas to talk about their parent.

They didn’t know what to do. And it was always the same thing… the same thing.”

12 San Antonio Medicine • November 2016

Fortunately, the answer was less elusive than it was obvious: there was no one in charge. Each patient had a variety of specialists; each prescribing a variety of medications; and there was usually no primary care physician involved.

“Or the primary caregiver wasn’t engaged,” said Ratner. “And with so many disparate medications, there was no way to know how they would combine. Between an orthopedist, an endocrinologist, a cardiologist and perhaps a psychiatrist, every patient became an uncontrolled clinical trial.”

Dr. Ratner is quick to point not to the specialists, but to a systemic lack of coordination from an expert who can see both forest and trees. “No one had the big picture. Each time it happened, we offered the same advice and it always worked. The first step was to find a good primary care physician. The second was to figure out how to work with them in an effective way and develop a long-term relationship.”

Recognizing the need for patients to educate and empower themselves, Dr. Ratner found a new sense of assignment and The Patient Institute, a 501(c)(3) nonprofit, was created in San Antonio to fulfill this strategic mission. Initially offering programs like, “Caring for Your Aging Parent;” “How to Talk to Your Doctor;” “Taking Control of Your Healthcare” and “Preparing for Your Appointment,” as a foundation, the Institute, thanks to a committed board and a community of volunteers, expanded in a variety of directions, all with a goal of establishing relationships between patients and caring doctors.

In fact, it was helping bridge the two groups that the Institute found its second project, and deepened its collaboration with the

INSPIRATIONAL MEDICINE Bexar County Medical Society.

Dr. Ratner explains, “One of our first Patient Institute educational programs was with a community organization. All the staff had health insurance; and when we went through the program and explained that they needed a primary care physician, literally half of them said, ‘I can’t find one taking new patients!’

That triggered a conversation with the Society, and working with the Institute, created an additional set of fields on their already well-established “Find a Doctor” website. Now, prospective patients can find providers that that are specifically accepting new commercially-insured patients, or new Medicare patients, or new Medicaid patients, or that accept cash paying patients. “It was a win-win situation,” said Dr. Ratner with satisfaction, “with patients the principal beneficiary, but also doctors looking to expand their practices.”

Identifying a problem and affecting its resolution comes naturally to the doctor, as it does to his siblings and family, a strong heritage drawn from his father …

Boston’s Thirteenth Pediatric Surgeon – and San Antonio’s first.

“My father grew up in Boston, the son of immigrants who were so proud to be able to send him to school,” says Dr. Ratner. “After med school, he joined the Air Force, becoming a flight surgeon before he became a pediatric surgeon.

“He finished his training in Boston, and in 1961, he became the thirteenth pediatric surgeon in Boston, which didn’t need more than a dozen; so he came back to San Antonio, which at the time, had none!”

When Dr. Irving Ratner settled in San Antonio, he envisioned a broader use for his training, and as a private pilot, flew to underserved parts of Texas and Central America, where he took care of patients and educated local physicians who didn’t have access to the level of medical care he could provide. He was a dedicated member of the Bexar County Medical Society. He held fast to the notion that the patient and their families come first.

“He was the kind of doctor that was common at the time, if you went to him, he would take care of you and because he took care of little children, he also had to address and care for whole family as well,” said Dr. Ratner.

“When my father passed away, we wanted to do something in his honor and memory. His legacy continues through The Patient In-

Dr. Irving Ratner was the inspiration for The Patient Institute.

stitute, created a year after his passing, at 78-years old, while making rounds on his patients.”

To improve health outcomes and the experience for both patients and physicians … the caregivers … you can’t just address the patients without the caregivers and providers, Ratner realized. The Patient Institute has expanded to help on the other end of the supply chain of good, caring physicians, in assisting young men and women to become better educated on the practical aspects of medical practice.

“I realized that physicians fresh out of training are idiot savants, we are exceptionally well trained in our specialty but as we get farther afield from our core specialty, our level of knowledge drops precipitously. So I wanted to do something for medical students and residents and other trainees to address the issue.”

Again, in collaboration with the Society, the Institute began a student enrichment program: WE LEAP, an acronym for wellness, leadcontinued on page 14

visit us at www.bcms.org

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INSPIRATIONAL MEDICINE continued from page 13

14 San Antonio Medicine • November 2016

“

When my father passed away, we wanted to do something in his honor and memory.

His legacy continues through The Patient Institute, created a year after his passing, at 78-years old, while making rounds on his patients.

“

ership, ethics, applied economics and professionalism.

“It’s a rubric for a spectrum of topics on which medical students are typically almost completely ignorant … not to make them expert but at least to know that it was out there, that they needed to know it, and they needed to have help when the time comes. Unfortunately, we found that once students are in their professional training, their curriculum has grown so tight and the pressure to focus only on ‘things being tested’ makes our program hard to schedule for medical students.” The answer?

“Our primary target became pre-med, pre-healthcare, undergraduate students who have turned out in great enthusiasm. We just finished a program for 75 students in 2015, and will be offering it in 2016-17 one night a month throughout the academic year.”

Moving forward, the Institute will have a renewed focus on seniors, with “A very august and distinguished body of experts serving on our Geriatrics Council – not only do we have geriatricians, but also home healthcare professionals, social workers senior attorneys; an entire spectrum.”

His father would be so proud.

— Dr. Adam Ratner

INSPIRATIONAL MEDICINE

The 12th Man Connection BCMS has ties to a famous Texas A&M tradition

By Mike W Thomas Just outside my office in the Bexar County Medical Society building hang several large collages with pictures of the doctors who were members of the society in the 1920s, 30s and 40s. There are many notable doctors on these boards but one name jumped out at me the other day – King Gill.

16 San Antonio Medicine • November 2016

I did a double take when I saw that name and memories of my years in the Corps of Cadets at Texas A&M University came flooding back. As a freshman in the Corps, you are required to memorize all sorts of historical facts about the campus, especially those pertaining to the cherished traditions of the school. One of those

INSPIRATIONAL MEDICINE facts imprinted in my head was the story of E. King Gill, the student who became the inspiration for Texas A&M’s famous 12th Man tradition.

In 1922, Gill was a student attending a football game between the Texas Aggies and Centre College. It was a hard fought game and many players were getting injured and hobbling off the field until there was almost no one left on the bench. That is when Coach Dana X. Bible looked in the stands and saw Gill, who had played football the year before but was now just on the basketball squad.

He waved Gill down and had him suit up in case he was needed in the game. As it turned out, Gill was not needed and did not enter the game. But the Aggies won and Gill’s willingness to come out of the stands and suit up in case he was needed became the inspiration for the 12th Man tradition.

That is the reason that A&M students stand up during football games — to demonstrate their “readiness, desire and enthusiasm” to come out of the stands and play if needed (the only time they sit down is when the opposing team’s band plays during halftime.)

There are now two statues of Gill on the A&M campus, one that was dedicated in 1980 and sat at the entrance to Kyle Field for many years has recently been moved to an honored spot next to the Memorial Student Center and was replaced with an even larger statue of Gill. And the tradition lives on in many other ways as well. In 1950, the 12th Man Foundation was formed to raise money for athletic scholarships.

In the 1980s, Coach Jackie Sherrill expanded on the 12th Man tradition by establishing a 12th Man Kickoff Team made up of nonscholarship, walk-on players. That was later scaled back to just one non-scholarship walk-on as the representative “12th Man” on the kickoff team and continues to this day. Students were encouraged to wave a white “12th Man Towel” during kickoffs. In 1988, huge letters spelling out “Home of the 12th Man” were added to the football stadium.

The 12th Man tradition has continued to grow in significance at the school and has become a major part of the school’s image and marketing program. The term was trademarked in 1990 and when the Seattle Seahawks professional football team began calling its fans the 12th man last year, they received a cease and desist order from Texas A&M and ended up paying the school a licensing fee to use the 12th Man name.

But one part of the story that had seemingly been missing all these years is what happened to Gill after he left school. Now I know. He attended Baylor School of Medicine and became a doctor in 1929 and joined the Bexar County Medical Society where he got his picture enshrined on our board in 1932. King Gill came from a family of doctors and the same collage includes a picture of his brothers, Dr. William D. Gill, and Dr. James P. Gill. continued on page 18

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INSPIRATIONAL MEDICINE continued from page 17

King Gill specialized as an ear, nose, throat specialist or ENT, and also worked as an ophthalmologist or eye doctor. His brother was also a prominent eye surgeon who did some of the first cornea transplants in South Texas.

King Gill moved to Corpus Christi in 1935 where he continued to practice medicine for the next 40 years. He also served in the U.S. Army as a flight surgeon during World War II. He was stationed at Majors Field in Greenville, Texas and achieved the rank of lieutenant colonel. In 1969, Gill was inducted into the Texas A&M Athletics Hall of Fame. Despite being best known for a game in which he did not even play, Gill was a talented athlete in school. He played football the following year and scored a crucial touchdown in an A&M victory over rival University of Texas. He earned All-SWC honors as a member and then captain of the basketball team in 1923-24 and he was a pitcher on the A&M baseball team.

Gill was frequently sought out by the media to talk about that one game in 1922. He was always very humble and deprecating and once said that it was probably a good thing that he did not get put into the game because the shoes he had to borrow were too big and he might have tripped over them if he had to run with the ball.

Gill died in 1976 and is buried in San Antonio at Mission Burial Park South.

Mike W. Thomas is the director of communications for the Bexar County Medical Society.

18 San Antonio Medicine • November 2016

E. King Gill was a talented athlete while at Texas A&M University, playing on the football, basketball and baseball teams. But he will always be best remembered for a game in which he did not even play.

There are currently two statues of E. King Gill on display at Texas A&M. The first was unveiled in 1980, a 6-foot-4-inch bronze sculpture that stood at the entrance of Kyle Field until 2014. It has since been moved to a spot near the Memorial Student Center and replaced with a much larger 12-foot - bronze statue of Gill.

INSPIRATIONAL MEDICINE

Spreading to fill the gap in breast cancer treatment

By Mike W Thomas Since 1999, a small San Antonio-based non-profit has been working to help uninsured women across South and Central Texas to have a fighting chance when dealing with breast cancer.

WINGS, which stands for Women Involved in Nurturing, Giving, Sharing, has provided more than $12 million in healthcare services to more than 900 women with breast cancer over the years. The organization works with a network of physicians and treatment centers to provide life-saving care against this deadly disease.

In 2016, the American Cancer Society estimated there will be more than 246,000 new cases of invasive breast cancer and more than 40,000 breast cancer deaths.

Kim Hinze, executive director of WINGS, said they currently have almost 900 women in the program with 56 in active treatment and the remainder in survivorship.

“All 900 women are eligible for WINGS services because once you are in the program you are in it for life,” Hinze said. “We have approximately 250 providers that we work with in the net-

work serving 46 counties.” In addition to its San Antonio base, WINGS has operations in Austin and Laredo.

WINGS was founded 17 years ago in San Antonio by a breast cancer patient and her surgeon, Dr. Kathryn Safford. Its purpose is to help women who have no insurance to cover the cost of fighting the disease. WINGS covers the cost of surgical procedures, chemotherapy, radiation, labs and physician visits for all of its patients.

To accomplish this, WINGS reached out to physicians and care givers from every part of the cancer industry to help work out a system that could be affordable and effective. One of the first doctors to come on board with the new program was Amy Lang, M.D., FACP, a medical oncologist in practice at the START Center for Cancer Care in San Antonio.

Lang donates her time and skills to help hundreds of patients in San Antonio who would otherwise go without care. WINGS also works with hospitals and treatment centers that donate time, rooms, nurses and equipment. continued on page 22

20 San Antonio Medicine • November 2016

INSPIRATIONAL MEDICINE continued from page 20

“The patients we treat are wonderful to work with,” Lang said.

“Most are incredibly grateful and compliant. They always show up for their treatments and when they are done many want to give back in some way by volunteering. It is some of the most gratifying work that I do.”

After treatment is completed, patients are moved into what is called WINGS II, where they are monitored and will be covered should they need further medical attention.

WINGS is a one-of-a-kind program unlike anything else in the country, Hinze said. The most unique aspect is its commitment to the women in its program long after their initial treatment is completed. Studies have shown the survival rate of WINGS patients far surpasses national averages according to the National Cancer Society statistics. Since its inception, WINGS has seen five-year survival rates for the women it serves increase from zero for untreated breast cancer to 100 percent for Stage I disease. More than 95 percent of the women treated through WINGS are still living as a result of the program.

In addition to treatment, WINGS provides opportunities for education and outreach. Women who come into the program have

22 San Antonio Medicine • November 2016

been turned away from regular treatment programs for one reason or another. The first thing the WINGS staff will do, Lang said, is try to get them qualified for Medicaid because that will cover more medical issues than just breast cancer.

In recent years, WINGS has expanded to assist women who lose their jobs with COBRA payments and to help women who can’t afford to pay their insurance premiums.

Lang said even as much good that the program has accomplished there is still more that can be done. “We are still a secret in San Antonio,” she said. “There are still women who are uninsured who do not know about us and we need to get the word out.”

The funding for WINGS comes mainly from private donations and grants from organizations including Susan G. Komen for the Cure and Methodist Healthcare Ministries.

For more information about WINGS call 210-946-9464 or visit the website at www.texaswings.org.

Mike W. Thomas is the director of communications for the Bexar County Medical Society.

INSPIRATIONAL MEDICINE

Finding the Silver Lining WHEN THE PASSION OF PHYSICIANS AND FEDERAL REGULATIONS COLLIDE IN CONCERT

By Alan M. Preston, MHA, ScD

There are many reasons why a person gravitates to the practice of medicine. In a LinkedIn post last year, an article suggested that there are 4 primary reasons why a person might want to become a physician. To paraphrase the four reasons, they are: There is a driving force from within to heal people, be of service and/or save the world. These people are motivated by the purpose and not necessarily by the money.

There is a need to have a lucrative career in addition to healing people. These people are motivated by both money and service.

There is a desire to be a part of a successful profession. These people know that being a physician is a high paying profession and they are mostly focused on the career and accolades that inure them in such a profession.

There is a family expectation to become a physician. One or both parents or grandparents were physicians and their family expected them to become a physician. They are doing their family duty.

Regardless as to the why people gravitate into the practice of medicine, once they are a practicing physician, there is an intrinsic reward in helping people. Obviously, some are more passionate than others in the practice of medicine.

Most physicians are seldom prepared for the onslaught of regulations that often distract from the practice of medicine. For many physicians, the constant regulatory environment is driving many to abandon their practice, sell it to a hospital or other entity, or become an employee of another entity as to attempt to avoid dealing with the plethora or rules and regulations that take away from the practice of medicine. All businesses must deal with increased regulations; however, many physicians enter the practice of medicine because of the passion of helping people, not to become entrepreneurs in running a complex business with complex regulations.

Recent surveys of physician satisfaction of the practice of medicine offer clear and compelling results. The Physician’s Foundation con24 San Antonio Medicine • November 2016

ducted a survey to understand the state of physicians in 2014. They received over 20,000 responses and many trends emerged.

The 2014 survey indicated that there is pressure on physicians to meet the demand for their medical services, as over 80 percent of physicians reported being overextended or at full capacity. To some degree, this is not surprising given the demands that the Affordable Care Act (ACA) has placed on existing doctors. Anytime the marketplace creates a greater demand for services and does not allow time for the supply to catch up, there will be providers who attempt to meet the higher demand loads. Thus, many doctors feel overwhelmed. The demands placed on doctors now are not just an increase of patients, it is a plethora of new rules and regulations.

And when there is rapid change to any business model, the market changes swiftly as to adapt to the change or get left out and perish. Those who wait too long to adapt in a changing healthcare marketplace can find themselves alone and with few options. As Plato said in the Republic, to paraphrase; “necessity is the mother of invention”. And the marketplace has responded to the maze of regulatory framework in ways that offer help to many independent physicians.

Nevertheless, physicians must maintain the highest standards of care as they manage over 1.3 billion patient encounters per year.

Physicians also must implement electronic medical records and a wide array of other medical and practice management technologies required by the ACA. Many physicians feel they must adjust to this new inverted business model that features large integrated health systems as opposed to small private practices.

For the small independent physician practices, the marketplace has created many options for continuing their services. Unfortunately, some physicians have decided to give up their “independence” and autonomy and have elected to go with an integrated delivery system. Others have found solace in participating in a

INSPIRATIONAL MEDICINE proven Independent Physician Association (IPA). Yet others are still independent. Seldom does the marketplace agree with one model over another, which is why there are many substitutes designed to accommodate the needs of a wide group of physicians and their respective philosophies in the practice of medicine. The regulatory environment will never go away; however, the market will allow many options for physicians as to how and with whom they want to align with to manage the maze of regulations.

Physicians should adapt to the increasing payment systems that continue to change. Now many physicians should pay attention to the outcome of patient services to be appropriately reimbursed instead of volume of services provided to patients. This new payment system, as part of the ACA, can be the silver lining of the ACA. Under the Medicare Advantage program, the health plans are paid based on the previous claims experience of the patients that have selected the doctor as their Primary Care Physician (PCP). The patient is assigned a Risk Adjustment Processing System (RAPS) score.

Thus, each patient has a dollar amount that correlates to the RAPS score. A patient that is “healthy” has a lower dollar amount assigned to the patient. A “sick” patient has a higher dollar amount assigned to the patient. A patient that does not have a lot of health problems or has health problems and has not seen a physician in a while will have a low “risk adjustment score” which will equate to a lower payment to the health plan from Center of Medicare and Medicaid Services (CMS).

The health plans often enter into various reimbursements with physicians in one of three broad categories. Physicians that are capitated by the health plans often see an adjustment in their capitation payment correlated to the RAP scores. A physician that receive FFS are largely unaffected on the front end on RAP scores since they are paid on a FFS basis. Physicians that enter into risk arrangements can be affected by the RAP scores. Physicians that accept risk from a health plan can be have their upside bonus money at risk for many factors including satisfaction levels of the patient. For Physicians that are passionate in providing the right level of care with a high level of service will ultimately receive, over time, increasing higher reimbursements for their patients when they enter into risk arrangements with health plans directly or via an IPA. The administration of this population based model is indeed complex; however, there are many companies and IPAs that have been created to assist independent physicians with managing the maze so physicians can do what they love; practice medicine and improve the outcomes of their patients.

The silver lining in this value based model is that most Primary Care Physicians (PCPs) can continue practicing medicine. They can treat the patient for co-morbidities if needed, follow-up on the progress of the patient’s care, and provide a high level of customer service. In other words, physicians can be rewarded for doing what they have been trained to do all along: treat the entirety of the patient and get appropriately paid for the services provided. Some of the IPAs create a model that works so well to incentivize physicians to spend more quality time with each patient and to participate in

the coordination of care for patients. Of course, the doctor must be in the right IPA model and in a risk sharing IPA to see upside financial potential in such a model.

The emphasis going forward will be on population based management, which is simply making sure that the patients under the care of a doctor are receiving appropriate outcomes and follow-up and that the interventions are indeed working. Yes, this will require additional management of the patients in a different manner than many physicians have been accustomed to managing. Nevertheless, the marketplace has responded to assisting the physician in the management of this population. There are many Accountable Care Organizations (ACOs) that can assist, though some ACOs do not have a proven track record. There are also various IPAs that have assisted physicians to receive up to 200 percent of the FFS Medicare equivalent when the PCPs perform the care that they were trained and motivated to perform.

It is true that the ACA has dramatically changed the way physicians must approach the practice of patients to keep their practice viable. And the ACA has created many unintended consequences for many physicians that have not been very positive. Nevertheless, they do not have to go it alone since the marketplace has adopted many delivery systems to help the physician manage the new regulatory environment. Medical Societies are one of the advocates for physicians in managing the new regulatory environment. Independent Practice Associations (IPAs) are yet another, that advocate for physicians. Physicians can select a “business” model that suits their practice, lifestyle, and philosophy and many will earn more income because of the ACA if they pay attention to the changes and adopt accordingly. In this one narrow space of the ACA, both the doctor and the regulators want the same thing; improved outcomes for patients and higher reimbursements for Physicians!

Seldom is regulation all good or bad. And there are times when it can be difficult to see any good of some regulation. In the case of the ACA, paying physicians for creating a good outcome for a patient is appropriate. Physicians can be rewarded for their passion with the value based payment system. Of course, no reimbursement system is perfect and though there can be rewards to the physician, there can also be pitfalls, which is why it can be helpful to seek assistance from organizations that can help the physician navigate through the maze of an increasing and hostile regulatory framework.

Finding the silver lining of a regulation is not easy; however, there are times when it does exist.

Alan Preston, MHA, Sc.D., is the Executive Director of IntegraNet Health, an IPA that helps physicians navigate through the difficult regulatory framework and helps them achieve higher reimbursements from insurance companies.

His experience has been divided between running HMOs, large physician practices, and academia. He earned both his Master’s and his Doctorate at Tulane’s School of Public Health and Tropical Medicine in Health Services Research and Epidemiology visit us at www.bcms.org

25

FEATURE: IN REAL TIME

Part 4

IN REAL TIME FRONTO TEMPORAL DEMENTIA Unravelling of a Beautiful Life

By Rajam Ramamurthy, MD

I stood in front of the shrine, a place that is created in most Hindu homes for personal worship, and repeatedly asked the question, why my husband? A man who has alleviated the pain of countless patients in his practice for 41 years as a pain specialist. Is this not a question everyone asks when they face adversity? Hindu philosophy has a palatable explanation for it. In this life the deeds of our previous life is played out as your ‘Karma.’ However, what you do in this lifetime is under your control and will determine what your next birth’s life experience will be. However Karma is not a state of passive 26 San Antonio Medicine • November 2016

acceptance of the cards dealt to you, but rather dealing with adversity and prosperity with equanimity, detaching yourself from both and striving to reach the plane of becoming one with a higher consciousness. I promised in the last chapter that I would talk about meditation and its role in N’s condition.

N’s treatment was started with a selective serotonin uptake inhibitor at a very low dose. Geriatric psychiatrists generally believe in medicating the patients gently. N was started on 25 mg, they tell me it is a drop in the ocean. I counted the tablets and made sure he

FEATURE: IN REAL TIME

took his tablet. One day I thought that he had taken more than one.

N would say that he does not need any medication and that he has reached a state of self-realization. Nevertheless he took it like an obedient child. I was reminded of the movie ‘One Flew Over the Cuckoo’s Nest’ where Jack Nicholson obediently takes the pill that the nurse puts in his mouth followed by a gulp of water, pretends to swallow, opens his mouth so the nurse can inspect while he hides the pill under his tongue and spits it out later. N did swallow the pill. Navigating everyday life was stressful in making sure he ate healthy food as he was eating uncontrollably especially sweet food, that he got some fresh air as he did not have any desire to step into the garden – his heaven before the illness, engaging him in activities so he won’t get to the computer, and worry about safety so he won’t get into the car and drive or go out of the gate on his own. To this day he has not crossed these lines.

During this trying period our children, extended family and very close friends were god’s gift to me. I constantly had someone visiting. We accomplished a lot each time the children came. Medical and financial power of attorney was in the works. Bank accounts were secured. Long term care insurance claim was being processed.

To digress a little, I highly recommend long-term care insurance for all young people. You start off at a very low premium and it really served us in a timely manner. N eagerly awaited his younger brother’s visit. His brother is an urologist, a person who is very religious and adheres to rituals very staunchly. He is well read in the Hindu scriptures and Upanishads and has a very deep understanding of the complex philosophies. Before he arrived he had long conversations with me explaining N’s symptomatology on the basis of meditation.

Researchers have long known that meditation changes the brains of those who practice it. N’s brother explained how through meditation one is raising the level of the ‘Kundalini,’ or consciousness, gradually to reach realization. He thought that N has reached a higher level of consciousness and that negative forces are pulling him down and this struggle has created a state of utmost tension, sleeplessness and anxiety. I suggested to N that he should stop meditation. He refused and continued to meditate. What was going through his mind during the meditation I will never know but I saw him coming back to bed tense and not being able to fall asleep. One of our good friends, also a man given to religion and spirituality, suggested that I do a certain ‘Puja’ worship every day where we offer water to the deity and drink a spoon of that water. He knows well that N does not believe in rituals so he suggested that I might mix

the water in the food.

N’s sisters in India were doing different ‘Pujas’ to their favorite deities praying for his recovery. They requested me to do a ‘puja’ to Shiva. My brother was with me that day. I asked N if he will participate since his sister had suggested this. He agreed and we chanted the name of Shiva 108 times. Being a very close family, my sisters in Los Angeles and Las Cruces and my sister-in-law in Houston all did the Puja with us from wherever they were. Whether it made a difference to N or not it made me feel good.

The use of yoga and meditation has increased in the U.S. in recent years. A study was done at the Beth Israel Deaconess Medical Center comparing two groups of patients with Alzheimer’s Dementia.

Group one did a combination of yoga and meditation and the other did memory enhancement exercises like crossword puzzles. At the beginning and end of 12 weeks of treatment both groups had a memory test and MRI of the brain. The yoga and meditation group demonstrated greater improvements in visual-spatial memory skills – the ability to navigate and remember locations – than those who engaged in memory enhancement training.

It was almost a month since medication was started. The dose was at 50 mg. N was getting worse. Driving with him was extremely stressful. He would constantly instruct me to turn, exit, speed or slowdown. Once when we were riding with our friends the driver had gone past the exit. N insisted that he knew where to go and we drove on 1604 for many miles before we stopped listening to him and turned around. It was very puzzling how three adults, all physicians, were unable to fathom the altered mental status of N. In thinking back I can’t explain why I or others faked the façade of normalcy when we were with him when he was so obviously unwell. It is important to pay attention to safety and, if the caregiver is not physically capable, to have help at home or nearby.

One more visit to the psychiatrist on a Friday and the dose of the medicine was doubled to 100 mg. On Monday N on his own said that he wanted to work in the yard, the yard being five acres of Texas wilderness except for an acre right around the house. N’s hobby was to grow fruit trees. In March he busied himself with grafting. Two days after the increased dose of medicine he was out grafting plants for nearly an hour. I kept an eye on him, very happy that he was back to an activity he loved. Is this the beginning of a recovery? The next day April 12, 2016 in the evening he again said he wants to go out and graft. That night our son and his family were coming home to spend their spring break. I was cooking and must have lost track of time for about 20 minutes. I looked through the window around continued on page 28

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27

FEATURE: IN REAL TIME continued from page 27

the same area he was the previous day and did not see him so went out and called. Our dog, Patch, walked to me with his head down.

Has he come back into the house? I looked inside the house and then went to the back of the house, still no sign of N. I called out loudly. I heard a groan very close by. He had fallen on the other side of a bush where he was grafting. I ran to him. He was not responding. His breathing was slow and labored, his pulse was strong but over 100, his normal pulse is in the 60’s. I felt his head and found no bumps or bruises and no bleeding. I thought of snake bite. There was nothing obvious. I had no phone or watch on me, so I ran in and called 911, then ran back to him with my cell phone. I tried to move him but couldn’t budge him even an inch. I could hear the ambulance at a distance. N was cold, sweaty, that touch that was all too familiar to a clinician. Then the ambulance arrived.

Rajam Ramamurthy, MD Professor Emeritus, UTHSCSA

28 San Antonio Medicine • November 2016

Suggested reading: Stress reduction through meditation may aid in slowing of progression of Alzheimers disease. Neuroscience Letters, Nov 2013.

Does Meditation Enhance Cognition and Brain Plasticity? Glen L. Xiong, P. Murali Doraiswamy. Annals of New York Academy of Science, 1196, 2009

BCMS ALLIANCE

2016 BCMS ALLIANCE

GENERAL MEMBERSHIP MEETING Former San Antonio Mayor Lila Cockrell was the featured speaker at the Bexar County Medical Society Alliance’s General Membership meeting on Sept. 30.

The meeting was hosted at the home of Dr. Bernard Swift and Mrs. Kathy Swift.

New officers were selected for 2017 with Jenny Shepherd selected as the next president to replace Jennifer Lewis.

Alliance President Jennifer Lewis introduces former Mayor Lila Cockrell at the 2016 General Membership meeting.

30 San Antonio Medicine • November 2016

BCMS ALLIANCE

The BCMS Alliance selected its new officers for 2017 including Jenny Shepherd, President-elect; Karen Bagg, 1st VP Membership; Carly Friedman, 2nd VP Communications; Anne Foster, 3rd VP Programs; Valerie Garrison, 4th VP Civic & Philanthropic; and Sandra Vela, 5th VP Social.

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31

FEATURE

WHAT CARS DO

DOCTORS ACTUALLY DRIVE An Unscientific Study (Vol. 2)

By Fred H. Olin, MD

About six years ago, I wrote an article with the same title that was published here. I recently bought a little pocket-sized voice recorder to help me remember things that came to mind while I was driving, to record talks I’ve given, etc. As I fiddled with it one day, I realized that it was ideal to do what I had done then: take an informal census of the cars in doctors-only lots and see if things had changed. So, here goes: some of the text is recycled from the original: I couldn’t seem to improve it.

MATERIALS AND METHODS: The author took his trusty Ford 150 (which was counted only once [and which he was driving six years ago]) and his ID card and made the rounds of five different hospital parking lots that require the card or an RFID for entry. These were at Methodist Main, St. Luke’s Baptist, Methodist Specialty and Transplant, Metropolitan Methodist and North Central Baptist. Although he visited at least two other hospitals during the study, these had open lots. There was considered to be too much risk of contamination by non-physicianowned vehicles. At each location, he took out the little recorder and undertook to record data about each of the cars parked there at the moment. This was done early in the day, usually between 7:30 and 9:30 a.m., when there were the maximum numbers available. As he walked through the lot, he dictated make, model (if available) and the first three characters of the license tag. No attempt was made to determine the model year, as the author is ignorant of this sort of thing. Later, at home, he listened to the recordings and entered the 32 San Antonio Medicine • November 2016

data into an Excel spreadsheet. Whilst perusing the data and rearranging it in various ways, he added a column for the national origin of the vehicle. It was decided that this would be specifically the home country of the manufacturer; for example, even though most Toyotas are made here in the USA, they were listed as Japanese.

RESULTS: A total of 283 different vehicles were counted last time, and 287 this time. There were more empty parking spaces than I remembered from before, and there has been the loss of some capacity here and there.

First, here’s a little table showing the national origin, number and percentage of all of he vehicles counted, and what has changed over the years:

2010

2016

Country

No.

Percent

No.

Percent

Japan

123

43.77%

121

42.16%

Germany

73

25.98%

78

27.18%

USA

64

22.78%

68

23.69%

England

12

4.27%

10

3.48%

Korea

2

0.71%

7

2.44%

Italy

2

0.71%

2

0.70%

Sweden

5

1.78%

1

0.35%

Total

281

287

FEATURE

It is evident that Japanese brands were and have remained the most popular among the physicians at these hospitals, but generally there isn’t a lot of difference. Now, let’s look at a breakdown of the brands I found: I don’t plan to give any detailed info about the model prevalence of those brands with fewer than five cars counted.

First, the Japanese cars by brand, then we’ll look at models for those where there was a sufficient number to differentiate. Please note that on occasion a vehicle would be backed in and up against a wall and there wouldn’t be a model name visible: It did not seem prudent to be poking around in the rear of someone’s car just to see the nomenclature.

Germany was represented by six different brands, with a near tie between the Mercedes and BMW in 2010 which changed a bit in Mercedes’ favor this time:

Brand

2010

2016

Change

Mercedes

28

34

+8

BMW

27

17

-10

Porsche

10

8

-2

Audi

5

13

+8

Volkswagen

2

6

+4

Brand

2010

2016

Change

Smart Car

1

1

0

Toyota

36

26

-10

Totals

73

79

+6

Lexus

33

29

-4

Honda

15

25

+10

Nissan

12

8

-4

Acura

11

9

-2

Infiniti

4

7

+3

Mazda

4

5

+1

Mitsubishi

4

0

-4

Subaru

2

1

-1

Isuzu

1

0

-1

Scion

1

0

-1

Totals

123

110

-13

This year the most numerous Toyota model was Camry, with six present. There were two each of Corollas and Avalons. Additionally, there were five Tundra and two Tacoma pickups, two Priuses (down from 13) and several different models of SUV, none of which had more than three specimens present. Lexus, the Toyota luxury brand, had a multitude of models (and, I assume, years) represented. There were four LSs, three each of ES, GS and RX types, two each of IS, NX and S. The remainder either had only one specimen present or were indeterminate for one reason or another.

Honda was represented by eight Accords, one Civic, three Odysseys, two CRVs and three other models, each of which had only one specimen present. The rest were indeterminate. Nissan had three Altimas, two Pathfinders and the rest were single representatives of their types. Acuras seen were three MDX SUVs, two TSXs, and one each of three other models. Mazda had two MX5s, two CX5s and a Miata. Each of the seven Infinitis was a different model.

The remaining Japanese brands had no multiple models present.

Mercedes was represented by no fewer than 26 different models.

There were five GL450s, three S550s and two E320s. The rest were either one of a kind or indeterminate. There were two 435i and two X5 BMWs, two were indeterminate, and the rest had only one specimen each. Each of the eight Porsches were different models. Audi was represented by three A6s and two each of the A4 and Q5s.

American-made vehicles came in third, wth a total of 12 different brands represented:

Brand

2010

2016

Change

Ford

15

23

+8

Chevy

13

9

-4

Cadillac

9

7

-2

GMC

8

9

+1

Dodge

5

7

+2

Buick

3

2

-1

Jeep

3

3

0

Chrysler

2

2

0

Lincoln

2

1

-1

Mercury

2

2

0

Hummer

1

0

-1

Pontiac

1

1

0

Tesla

0

2

+2

Totals

64

68

+4 continued on page 33

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33

FEATURE continued from page 33

All but four of the Fords I saw were either pickups or SUVs; the lone “outsiders” were two Mustangs, a Focus and an unlabled sedan.

There were 13 F150s, two F250s as well as two Expeditions and two Escapes. The Chevrolets included three Suburbans, two Cruzes, two pickups, a Traverse and a Corvette. The nine GMCs included five Yukons, two Sierras, a Denali and an Acadia. The Cadillac contingent was two Escalades and five other models, no duplicates. Dodge was represented by three Ram pickups, two Chargers, a Magnum and an anonymous sedan.

England sent us 10 vehicles versus 12 last time: there were four Jaguars, three MiniCoopers and three Range Rovers.

34 San Antonio Medicine • November 2016

The one Swedish car was a Volvo, five Hyundais and two Kias represented Korea and the Italians were both Maseratis.

CONCLUSIONS: There aren’t any really solid conclusions to be drawn here because of the limitations of the way the survey was done. I’m sure that it likely over-represents physicians in surgical specialties, anesthesiologists, cardiologists, radiologists, pathologists and hospitalists, and grossly under-represents such specialties as family practice, dermatology and ophthalmology. Nevertheless, it was interesting to do.

Just like last time I was approached by a couple of our colleagues who wondered why I was wandering about talking into my hand, given a bit of the “fish-eye” by a Methodist security guard, and confirmed that Buick, whose “Doctor’s Car” commercials started this whole thing six years ago, no longer reigned... if they ever did.

Fred H. Olin, M.D. is a semi-retired orthopaedic surgeon who tends to drive his vehicles until they are: a) wrecked, b) rusted, or c) both.

HEALTH CARE

PrEP shown to reduce the spread of HIV

By C. Junda Woo, MD

Four years after the FDA approved a pill to prevent HIV in 2012, many primary care providers remain unfamiliar with it. PrEP, or pre-exposure prophylaxis for HIV, consists of emtricitabine/tenofovir, taken by people who are HIV negative but at high risk of infection.

Taken consistently, PrEP cuts the chance of acquiring HIV by up to 90 pecent and could prevent 48,200 U.S. cases by the year 2020 [1].

The CDC recommends PrEP for people with an HIV-positive partner, or anyone else at high risk — for example, if a man who has sex with men (MSM) engages in condomless sex or had a recent sexually transmitted infection. Heterosexuals who have unprotected sex with intravenous drug users or with bisexual men also are candidates. And intravenous drug users who share needles should also be offered PrEP. In MSM and African-Americans, the prevalence of HIV is staggering. Literally half of African-American MSM in the United States will acquire HIV in their lifetimes. So will 1 in 4 Latino MSM and 1 in 11 white MSM (Figure 1). Among African-American men of any sexual orientation, 1 in 20 will acquire HIV in their lifetimes (Figure 2). The elevated risk for African-Americans comes mostly from having sex in a community where HIV is common, and not from unusually reckless behavior. Multiple studies show that black people actually are more likely to use condoms than people of other races [2].

36 San Antonio Medicine • November 2016

HEALTH CARE Figure 1:

We need to reach out to and test more adolescents, because new HIV diagnoses nearly doubled among 15- to 24-year-olds in Texas between 2005 and 2014 [3]. Unfortunately, only about 4 in 10 HIV-infected youths realize that they are infected [3].

These are chilling numbers. We in healthcare have a moral obligation to intervene, especially now that we have an effective preventive measure. PrEP falls squarely in the purview of family medicine and general internal medicine. It’s like any other medicine where you see a patient every three months and do a reassessment, not so different from managing high blood pressure or diabetes. The medication is covered by all major insurers and is free to low-income patients under the manufacturer’s Medication Assistance Program. Emerging evidence indicates PrEP may even be effective if taken only intermittently, before and after sex [4].

Figure 2:

For doctors, providing PrEP means being comfortable asking, “Do you have sex with men, women or both?” and “Is there anything you do to reduce your risk of sexually transmitted infections,” such as condoms, mutual monogamy, and avoiding alcohol and drugs before sex.

To become comfortable with these questions — and to understand why routinely inquiring about sexual orientation is important in primary care — consider taking free CME modules available at LGBThealtheducation.org.

For patients, asking about PrEP may mean coming out to their doctors. This can be scary, as many in the lesbian, gay, bisexual and transgender (LGBT) community have had negative experiences with the healthcare system. Doctors can signal that patients can feel safe coming out to them by something as simple as a rainbow sticker or LGBT-friendly waiting room materials.

Among both physicians and patients, we need an attitude shift. I hear people ask, “Won’t people be more likely to have unprotected sex if we give this medicine?” Consider how we manage other conditions that are less stigmatized than HIV. If I prescribe a statin for high cholesterol, might the patient start eating more ice cream? A few might, but most people either continue their current behavior or with luck continued on page 38

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37

HEALTH CARE continued from page 37

improve it after our counseling. We don’t withhold statins for fear of negligent behavior. Because we reassess PrEP patients every three months, the risk of developing drug-resistant HIV is low — it is estimated that 25 HIV cases are prevented for every drug-resistant infection caused [5].

The fact is that our highest risk patients already are having unsafe sex — otherwise the statistics wouldn’t be as grim as they are. We must perpetually counsel that condoms still matter, because PrEP’s 90 percent protection is not perfect. But let’s also provide PrEP to reduce harm. Together, we can change the course of HIV.

References: Centers for Disease Control and Prevention. (2016.) Four scenarios of the potential impact of expanded HIV testing, treatment and PrEP in the United States, 2015-2020. Retrieved from http://www.cdc.gov/nchhstp/ne wsroom/images/2016/ croi_four_scenarios_graph.jpg Reece, M., Herbenick, D., Schick, V., Sanders, S.A., Dodge, B., and Fortenberry, J.D. (2010). Condom use rates in a national probability sample of males and females ages 14 to 94 in the United States. Journal of Sexual Medicine 7(suppl 5):266–276.

Texas Department of State Health Services. (2015). New HIV Diagnoses in Texas by Age Group, 2005-2014. Retrieved from: http://www.dshs.state.tx.us/hivstd/reports/epiprofile/sec02.shtm Moline, J., Capitant, C., Spire, B. … Delfraissy, J.. (2015). On-demand preexposure prophylaxis in men at high risk for HIV-1 infection.

New England Journal of Medicine 373(23):2237-2246.

Grant, R.M., Liegler, T. (2015). Weighing the risk of drug resistance with the benefits of HIV preexposure prophylaxis. Journal of Infectious Diseases 2015;211(8):1202-4.

Resources: Treatment guidelines: http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf Counseling: http://www.cdc.gov/hiv/pdf/PrEPProviderSupplement2014.pdf Billing and coding: https://www.nastad.org/resource/billing-coding-guide-hiv-prevention Medication Assistance Program: 1-855-330-5479, http://www.gilead.com/responsibility/us-patient-access Gilead’s optional written agreement for patients and physicians: http://www.truvadapreprems.com/#

PrEP sites for general public in San Antonio: CentroMed (Santa Rosa Pavilion only), 315 N. San Saba, Ste. 103, 210-922-7000 Alamo Area Resource Center, 527 N. Leona St., 210-358-9995

Coming online by the end of the year: San Antonio AIDS Foundation, 313 S. Hackberry, 210-225-4715

Author information: C. Junda Woo, MD, MPH, is Medical Director of the San Antonio Metropolitan Health District (Metro Health). She provides training to community physicians on public health issues, LGBT-friendly healthcare, intimate partner violence and human trafficking.

38 San Antonio Medicine • November 2016

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39

UTHSCSA DEAN’S MESSAGE

UT SCHOOL OF MEDICINE:

AGING AND THE SAM AND ANN BARSHOP INSTITUTE

By Francisco González-Scarano, MD

According to the U.S. Department of Health and Human Services, approximately 10,000 Americans become 65 years old every day. This is a common talking point for many federal policy and planning discussions. Although this trend is currently fueled by the ‘baby boom’ generation, it will continue unabated because of the lengthening of life expectancy and the decreasing birth rate in our country. By the year 2040, it is estimated that older adults will represent more than 21 percent of the total U.S. population, and that by 2060, there will be 98 million Americans 65 and older.

With one of the largest elderly populations in the country, Texas is likely to feel the effects of this acutely. By 2030, older Texans will represent 5.9 million people, or 19.4 percent of the state’s population.

The longer life expectancies result in a population that is more likely to suffer from multiple and concurrent declines in health and with more chronic diseases. This could have a severe impact on long term healthcare costs and access, as well as have implications for 40 San Antonio Medicine • November 2016

many other social issues. This trend underscores the need to address the complex issues of longevity and aging.

One way to mitigate the ripple effect of care and costs is to find a way to reduce or limit the effects of the debilitating conditions and diseases associated with aging. That is the mission of the Sam and Ann Barshop Institute for Longevity and Aging Studies, part of The University of Texas Health Science Center at San Antonio. The Barshop Institute is one of the leading organizations in the country solely dedicated to aging research. It is also special in that it conducts studies from the bench through translational research.

The Institute was founded in 2001 through a leadership gift from Sam and Ann Barshop. Their vision in making the gift was to advance “leading edge” basic research for studies of aging and age related diseases and to establish The Sam and Ann Barshop Institute for Longevity and Aging Studies at the UT Health Science Center San Antonio. Mr. Barshop was a noted Texas businessman and Founder and Chairman of the Board of La Quinta Inns, Inc. He

UTHSCSA DEAN’S MESSAGE

Dr. Musi’s personal expertise is diabetes and metabolic disease, as well as the effects of aging on cellular metabolism and ensuing disease-causing abnormalities. This aligns with the Barshop Institute’s strategy of developing interventions that reduce the risk of, or prevent, an array of comorbidities at the same time.

Under Dr. Musi’s leadership, the institute has continued to be the only ongoing recipient of the Nathan Shock Center that uses state-of-the-art scientific infrastructure in multiple animal models to address questions about the basic biological mechanisms of aging. Last year the Nathan Shock Center was renewed for five years, with perfect scores in all categories of its assessment. was also the Founder and Chairman Emeritus of Barshop & Oles Company, a privately owned, Texas-based, full-service commercial real estate development and management company which has owned, developed or managed more than 5 million square feet of shopping centers, industrial and office properties, limited service hotels, and acclaimed mixed-use projects located in major Texas cities. A proud graduate of The University of Texas at Austin, Mr. Barshop served on the Board of Regents of The University of Texas System. Ann Barshop was a consummate community volunteer, and devoted wife and mother who greatly supported her husband’s legendary success.

The Barshop Institute is the only facility in the country to boast three major programs of the National Institute on Aging (NIA) (a division of the National Institutes of Health). These programs include The San Antonio Aging Interventions Testing Program which is comprised of the following components: (1) The Nathan Shock Center, which funds basic science research on small animal models; (2) The San Antonio Claude D. Pepper Center Older Americans Independence Center dedicated to translational research, and (3) the U.S Department of Veteran Affairs Geriatric Research, Education and Clinical Center (GRECC).

Since 2013, the Barshop Institute has been led by Nicolas Musi, MD. Dr. Musi is a Professor of Medicine, as well as director of the Center for Healthy Aging and the GRECC. The GRECC features both research and graduate medical education programs focused on geriatrics and other needs of the aging veteran community. GRECC programs include pharmacy, occupational therapy and physical therapy, as well as many of the complex and diverse needs of this group of veterans.

A Complex Array of Diseases and Conditions Aging is often a component of metabolic diseases such as diabetes, obesity, hypertension and heart conditions, as well as the most significant risk factor for other diseases like arthritis and cancer. The Barshop Institute is unique in that it is part of the relatively nascent field of “geoscience.” Dr. Musi explains this as a hypothesis based on targeting diseases from a broad approach where interventions can impact the risk or onset of multiple age-related conditions and diseases. The institute conducts research in humans and in non-human models such as small rodents, the experimental worm C. elegans, and fruit flies. It also has the world’s only facility with a barrier-protected marmoset colony.

While the Barshop Institute has a broad reputation on a number of levels, in 2009, Barshop researcher Randy Strong PhD, developed a Rapamycin formula that demonstrated the ability to extend the maximum life-span of middle-aged mice by 28 to 38 percent. This was the first pharmaceutical intervention shown to extend longevity in mice. Veronica Galvan PhD, built upon this foundational learning by demonstrating that Rapamycin improves learning and memory of mice engineered to have Alzheimer-like deficits. In 2013, Dean Kellogg, MD, PhD tested Rapamycin in a clinical trial with four military veterans who received the drug and four others who received a placebo thereby demonstrating the translational research methods of the Institute; the data obtained from these studies are being analyzed.

Another important aging condition is frailty. Frailty alone is a leading cause of falling, disability or the requirement of nursing home placement. Current work includes investigations by Sara Espinoza. MD, MSc to identify whether metformin treatment continued on page 42

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UTHSCSA DEAN’S MESSAGE continued from page 41

typically used for diabetes prevents or reduces frailty in pre-diabetic older adults.

Local Partnerships While the Barshop Institute’s many studies encompass a broad range of subjects, the potential impact to our local and regional community is significant. In an effort to bring the community closer to the process, a Community Advisory Board is being implemented with local partners such as the Bexar Area Agency on Aging, Morningside Ministries, Well-Med and others involved in the care of the elderly and the social issues involved in aging. The advisory board’s first order of business is to offer input on how best to engage the community in establishing a referral database for research that is comprised of adults of all ages.

The Barshop Institute has launched a South Texas Aging Repository database that will be comprised of adults of all ages interested in participating in research studies. It is anticipated that the data will cover everything from descriptions on the natural history of aging, identifying risk factors for premature aging and the effectiveness of life-extending therapies.

The issues of aging and declining health have impact at a national level. The elderly fighting chronic disease and cancers – along with

42 San Antonio Medicine • November 2016

their family members and caregivers, as well as the doctors and healthcare systems that treat them – are all just the tip of iceberg of this complex equation. This is to say nothing of the legislative/political issues wrapped around the funding and infrastructure of health care services.

The Barshop Institute plays a crucial role in the search for solutions as it looks at the bigger picture of aging and health. From the institute’s molecular and basic science research, to non-human and human treatment models and clinical trials, as well as educational programs to support the next generation of aging and disease researchers, the Barshop Institute will continue to play a crucial role in achieving this national priority: helping people grow older while maintaining their health.

To participate, to refer participants to studies or to become a part of the database referenced please contact 210-450-0020. You may also learn more about participating in the Community Advisory Board by calling that number.

Francisco González-Scarano, Dean, School of Medicine, Executive Vice President for Medical Affairs University of Texas Health Science Center San Antonio Professor of Neurology

MED PRO

Medication Reconciliation: A Vital Step in Patient Care

By MedPro Group Patient Safety & Risk Solutions In the practice of medicine, careful evaluation of patients’ medical history and current health status is an essential element of quality patient care and an important initial step for safe medication prescribing. Gathering and maintaining detailed and accurate information “is the first priority in medication safety, as it guides physicians to choose the appropriate medication, dose, route, and frequency.”1 One of the most important steps in patient evaluation is medication reconciliation. Given that an estimated 4 out of 5 Americans take at least one medication and almost a third take five or more medications,2 it ngerousrovider and taking any number of over-thecounter (OTC) products, supplements, or herbal remedies..riptions from more this reasonable to assume that patients are receiving prescriptions from more than one provider and taking any number of over-the-counter (OTC) drugs, supplements, or herbal remedies.

Comprehensively reviewing all medications and products that patients use — as opposed to only the medications prescribed at a single practice — and keeping up-to-date medical records can help physicians make informed treatment decisions and reduce the risk of dangerous or undesirable medication interactions.

The following risk management strategies offer guidance for managing and improving the medication reconciliation process.

• At each office visit, review all medications the patient is taking, including prescription drugs, OTC medications, herbal products, dietary supplements, vitamins, and alternative therapies.

• To assist with reconciliation, ask the patient to bring his or her medications, or a written list of medications, to the appointment.

• Document all information related to drug, material, or food allergies in a prominent and consistent location in the patient’s medical record. List the name of the allergen, the date the allergy was identified, and the patient’s reaction.

• Consider offering the patient medication management tools, such as wallet cards or forms to help assist with the reconciliation process. Various organizations offer these types of resources, including the Agency for Healthcare Research and Quality, the Institute for Safe Medication Practices (ISMP), and the American Medical Association.

• Document all medication orders, including refills, in the patient’s medical record. Ensure this information is located in a prominent place. Documentation should include ample information, such as drug name, dose, administration route, frequency, and purpose.

• When transferring patient care to another provider outside of your medical practice, send a thorough and detailed list of the patient’s medications to the new provider.

Prescribing medication is a complex process, particularly as the number of prescription drugs on the market continues to grow and the prevalence of polypharmacy increases. By implementing a sound and thorough medication reconciliation process, physicians can establish the basis for medication safety and quality patient care in their medical practices.

References: 1 Jenkins, R. H., & Vaida, A. J. (2007). Simple strategies to avoid medication errors. American Academy of Family Physicians. Retrieved from http://www.aafp.org/fpm/2007/0200/p41.html 2 The Centers for Disease Control and Prevention. Medication safety basics. Retrieved from http://www.cdc.gov/MedicationSafety/basics.html This article was produced by the Patient Safety & Risk Solutions Team at MedPro Group, a national leader in healthcare malpractice insurance coverage and risk solutions. For additional information, please visit the MedPro Group website at http://www.medpro.com/.

The information provided in this article should not be construed as medical or legal advice. Because the facts applicable to your situation may vary, or the regulations applicable in your jurisdiction may be different, please contact your attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal statutes, contract interpretation, or legal questions. © 2016 MedProGroup.® All rights reserved.

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BUSINESS OF MEDICINE

Human capital development and competency-based education

By Lee W. Bewley, PhD, FACHE, Jeffrey S. Sun, PhD, Ann H. Herd, PhD The healthcare industry has long been associated with human capital development aligned with requisite competencies to achieve certification and licensure. In order to achieve these market requirements, substantial personal and organizational resources are perpetually dedicated to achieving and then maintaining competencies and corresponding standing to practice medicine or serve in positions within healthcare organizations. Within the past decade, new developments in Competency-Based Education (CBE) have emerged with the promise to provide more cost-effective, efficient educational development for healthcare professional seeking degrees.

Graduate healthcare management has been at the vanguard of contemporary competency-based education since 2008 led by the Commission on Accreditation of Healthcare Management Education (CAHME). Since 2008, CAHME, the accrediting body for graduate healthcare management education, has required that curriculums and assessment methods be tied to a programmatic competency model aligned with the mission of the graduate program to better ensure that accredited programs are providing appropriate development for students that seek employment in healthcare management. CAHME programs include Masters in Healthcare Administration (MHA), Masters in Business Administration (MBA) with Health concentration, or Masters in Public Health (MPH) with Healthcare Management concentration. U.S. News regularly ranks 44 San Antonio Medicine • November 2016

graduate healthcare management programs that are CAHME accredited. These accredited programs have broadly incorporated the most basic elements of competency-based education ensuring that each traditional term-based course, e.g. a one semester, three-credit hour course in health economics, is directly tied to a healthcare management competency and that assessments in the course provide a substantive basis to evaluate whether students have attained the required level of competence. 1,2,3,4 Even more progressive forms of CBE have been introduced into the field of education in the past quarter century. Western Governors University, a public, regionally-accredited institution was founded in 1997 to provide online, CBE-based education. The CompetencyBased Education Network (CBEN) includes more than 17 higher education institutions providing education on more than 40 campuses across the country providing some form of CBE education in numerous academic program. These innovative programs extend beyond mapping specific courses to competencies and corresponding assessments to offer “non term” courses and direct assessment for credit. The promise of these new educational offerings is that students will be able to save time and money to complete their education by earning credit for competencies that they have already mastered and to focus time, as little or as much needed, on those competencies that they have not yet learned. 5,6,7,8

BUSINESS OF MEDICINE “Non term” courses in CBE programs generally mean that students are enrolled in a traditional one, two, or three-credit hour course that provides credit toward earning a degree; however, stu-

velopment within the CBE program match the human capital needs of the field, organization, or intended field of practice? Additionally,

dents are not bound by traditional time-based semester require-

what level of rigor and/or development is inherent within the pro-

ments. In these type of CBE courses, students may progress through course materials and exercises at their own pace, working with a faculty member for feedback and guidance, until they are ready to be assessed to determine if competency standards are met.

In the event that the student does not meet competency standard requirements, the student would resume further development within the course, following faculty member feedback and guidance until the student is ready for reassessment. Normally, these type of “non term” courses do not provide boundless time for students to complete enrolled courses because of financial aid requirements. Many CBE institutions set one-year as the maximum time to complete a “non term” course while some institutions offer CBE courses on a periodic, e.g. 6-month, subscription basis where students can complete as many competency-based courses as they are able within the subscription period.

Direct assessment courses in CBE programs is associated with varying forms of prior learning assessment and/or evaluation of competencies developed. The programs that provide direct assessment CBE offer courses or formal course-like assessments that students enroll to evaluate their specific level of competency attainment and corresponding credit earned toward a degree. Once students have been directly assessed, then a tailored schedule of courses is developed for each student, usually in traditional term-based, face-to-face or online format, to complete degree requirements.

Within the healthcare field, a number of Bachelors in Science Nursing degree completion (RN to BSN) programs have emerged in the CBE format such as those programs offered by Western Governors University, Brandman University, and the University of Wisconsin system. The University of Louisville will be offering a CBE healthcare leadership bachelor’s degree in the Fall 2016 based on the National Center for Healthcare Leadership competency model.

Other institutions are offering CBE degree programs in disciplines such as diagnostic imaging, health informatics, and healthcare management. Additionally, a number of CBE certificate programs in health-related disciplines are being offered.

Looking forward, healthcare organizations and healthcare professionals may benefit from the potential cost-effectiveness and efficiency of developing human capital through current and developing CBE processes. As potential students and employers evaluate CBE programs and institutions, a few key considerations should bear

gram of study? Finally, does the institution and CBE program hold appropriate institutional and\or programmatic\specialized accreditation necessary to establish validity within the healthcare field?

Finding CBE programs that fill valuable competency development needs with appropriate rigor that carry regional accreditation at the institutional level and programmatic\specialized accreditation as necessary will meaningfully increase the likelihood of leveraging CBE in the healthcare field.

upon their choices to attend or hire. First, does the competency de-

References: Beauvais, B., Wood, S., Brezinski, P., Kim, F., and Mangelsdorff, A. (2011). Adoption and Implementation of Competency-Based Education-The Army-Baylor Approach. Journal of Health Administration Education. Volume 28. Number 4. 299 – 313.

Broom, K. and Turner, J. (2015). A Competency-Based Approach to Functional Area Expertise. Journal of Health Administration Execution. Volume 32. Number 1. 25 – 46.

Commission on Healthcare Management Education. (2016).

Available at: http://www.cahme.org U.S. News (2016). Best Graduate Schools: Healthcare Management. Available at: http://grad-schools.usnews.rankingsandreviews. com/best-graduate-schools/top-health-schools/healthcare-management-rankings Kamenetz, A. (2013). Are You Competent? Prove it. Degrees Based on What You can Do, Not How Long You Went. New York Times. The Disrupters. October 29, 2013.

Kelchen, R. (2015). The Landscape of Competency-Based Education. American Enterprise Institute. Center on Higher Education Reform.

Porter, S. and Reilly, K. (2014). Competency-Based Education as a Potential Strategy to Increase Learning and Lower Costs. Maximizing Resources for Student Success Research Project. Sponsored

by HCM Strategists, LLC. Available at: http://www.hcmstrategists .com/maximizingresources/images/CBE_Paper.pdf The Competency-Based Education Network. (2016). Available at: www.cbenetwork.org Note: Jeffrey Sun is a professor at the University of Louisville. Ann Herd is an assistant professor at the University of Louisville.

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

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

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

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

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

ACO/IPA

ASSET MANAGEMENT

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

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

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

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

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

46 San Antonio Medicine • November 2016

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

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

Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions”

BANKING

BBVA Compass (HHHH 10K Platinum Sponsor) Our healthcare financial team provides customized solutions for you, your business and employees.

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

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

Broadway Bank (HHH Gold Sponsor)

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

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

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

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

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

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

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

Regions Bank (HHH Gold Sponsor) VP Physician Lending Group Moses D. Luevano, 512-663-7743 phone moses.luevano@regions.com

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

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

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

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

Commercial Services Luis Rosales 210-476-4426 lrosales@ssfcu.org Investment Services John Dallahan 210-476-4410 jdallahan@ssfcu.org Mortgage Services Glynis Miller 210-476-4833 gmiller@ssfcu.org Bank of America (HH Silver Sponsor) Bank of America provides people, companies and institutional investors the financial products and services they need to help achieve their goals at every stage of their financial lives.

Courtney Martinez 210-270-5494 courtney.martinez@baml.com Denise Smith 210-270-5058 Denise.C.Smith@baml.com bankofamerica.com Making financial lives better — one connection at a time

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

Competitive rates, favorable terms and local decisions.

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

CONTRACTORS/BUILDERS /COMMERCIAL

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

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

Steve Huffman 210-979-2500 Shawn Huffman 210-979-2500 www.huffmandev.com

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

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

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

Ray Branson 512-331-4669

branson@medmt.com www.medmt.com “The Med MT solution allows physicians to keep practicing just the way they like.”

EMPLOYEE BENEFITS

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

We help our partners concentrate on what they do best...Service their customers.

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

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!”

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

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

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

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

GRADUATE PROGRAMS Trinity University (HH Silver Sponsor) 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

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 47 Director 210-999-8132 amer.kaissi@trinity.edu https://new.trinity.edu/academics/departments/health-careadministration

HEALTHCARE REAL ESTATE

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

HIPAA/MANAGED IT/VOIP/SECURITY

Hill Country Tech Guys (HHH Gold Sponsor) Provides complete technology services to many different industries, specializing in the needs of the financial and medical industries.

Since 2006, our goal has always been to deliver relationship-based technology services that exceed expectations.

Whit Ehrich, CEO 830-386-4234 whit@hctechguys.com http://hctechguys.com/ “IT problems? Yeah… we can fix that!”

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"

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

HUMAN RESOURCES

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

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

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

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

INFORMATION AND TECHNOLOGIES

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

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

INSURANCE

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their

employees get the insurance coverage they need.

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

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

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

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

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

VP Community Relations Deborah Gray Marino 210-525-1241 DMarino@swbc.com Wealth Advisor Gil Castillo, CRPC® 210-321-7258 Gcastillo@swbc.com SWBC Mortgage Jon M. Tober 210-317-7431 JTober@swbc.com www.swbc.com

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Mortgages, investments, personal and commercial insurance, benefits, PEO, ad valorem tax services Catto & Catto (HH Silver Sponsor) Providing insurance, employee benefits and risk-management products and services to thousands of businesses and individuals in Texas and the United States.

James L. Hayne Jr. 210-222-2161 jhaynejr@catto.com Corey Huffman 210-298-7123 chuffman@catto.com www.catto.com

INSURANCE/MEDICAL MALPRACTICE

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

MedPro Group (HHH Gold 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

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” NORCAL Mutual Insurance Co. (HH Silver Sponsor) Since 1975, NORCAL Mutual has offered medical professional liability coverage to physicians and is “A” (Excellent) rated by A.M. Best.

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

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

class technology and communications that are highly reliable, flexible and priced specifically for the medical community.

Enterprise Account Executive West Region - Healthcare Sales Leader Medical Market Rick Garza 210-582-9597 rick.garza@charter.com “Time Warner Cable Business Class offers custom pricing for BCMS Members.”

MARKETING ADVERTISING SEO

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

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

MARKETING SERVICES

Digital Marketing Sapiens (HHH Gold Sponsor) Healthcare marketing professionals with proven experience and solid understanding of compliance issues. We deliver innovative marketing solutions that drive results.

Irma Woodruff 210-410-1214 irma@dmsapiens.com Ajay Tejwani 210- 913-9233 ajay@dmsapiens.com www.DMSapiens.com

MEDICAL BILLING AND COLLECTIONS SERVICES

INTERNET/ TELECOMMUNICATIONS

Time Warner Cable Business Class (HHH Gold Sponsor) When you partner with Time Warner Cable Business Class, you get the advantage of enterprise-

Kareo (HHH Gold Sponsor) The only cloud-based medical office software and services platform purpose-built for small practices. Our practice management software, medical billing solution, practice marketing tools and free, fully certified EHR has helped

30,000+ medical providers more efficiently manage their practice.

Regional Solutions Consultant Lilly Ibarra: 210.714.9815 lilly.ibarra@kareo.com www.kareo.com Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

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

MEDICAL SUPPLIES AND EQUIPMENT

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

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

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

MERCHANT CARD/CHECK PROCESSING Firstdata/Telecheck (HH Silver Sponsor) We stand at the center of the fastpaced payments ecosystem, col-

continued on page 50

visit us at www.bcms.org

49

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 49 laborating to deliver next- generation technology and help our clients grow their businesses.

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

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

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

same page.

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

SWBC (HHH Gold 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.

PHYSICIANS BUYING GROUP

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

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

50 San Antonio Medicine • November 2016

CASA Physicians Alliance (HHH Gold Sponsor) Locally owned, nationwide MultiSpecialty Physicians Buying Group which provides significant savings on Pediatric, Adolescent and Adult vaccines as well as other products.

Physician’s memberships are free.

Shari Smith 866-434-9974 shari@casaalliance.net Chris Dixon 866-434-9974 chris@casaalliance.net www.casaalliance.net “Providing meaningful vaccine discount programs, products and services.”

REAL ESTATE/ COMMERCIAL

CUSHMAN & WAKEFIELD (HHH Gold Sponsor) Jon Wiegand advises healthcare professionals on their real estate decisions. These include investment sales- acquisitions and dispositions, tenant representation, leasing, sale leasebacks, site selection and development projects Jon Wiegand 210-585-4911 jwiegand@sacadvisors.com www.sacadvisors.com

“Call today for a free real estate analysis, valued at $5,000”

Robbie Casey Commercial Realty (HHH Gold Sponsor) Robbie Casey Commercial Realty was founded on the principles of providing thorough market strategies, innovative advertising, superior service, and uncompromising integrity. Robbie is dedicated to each of her clients. She brings enthusiasm and creativity to each project and knows how to get the job done.

Robbie Casey 210-872-8453 robbie@robbiecaseyrealty.com http://robbiecaseyrealty.com

REAL ESTATE/RESIDENTIAL

Roslyn Casey Realty (HHH Gold Sponsor) My extensive experience and expertise in the San Antonio, Alamo Heights and Terrell Hills real estate market will benefit you whether you are looking to buy or sell a home in the area.

Realtor, ABS, ILHM, ALMS Roslyn Casey 210-710-3024 Roslyn@roslyncasey.com http://roslyncasey.kwrealty.com “Communication is key” Kuper Sotheby's International Realty (HH Silver Sponsor) My hometown roots are based in Fredericksburg while my home away from home is San Antonio. Local knowledge – exceptional results.

Joe Salinas III 830-456-2233 Joe.Salinas@SothebysRealty.com JoeSalinas.com “Embrace your new life ... I'll help you become a connoisseur.”

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

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

Ancira Volkswagen 6125 Bandera Road San Antonio, TX 78238

Jude Fowler 210-681-4900

Carl Carper 210-681-2300

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

Bill Boyd 210-859-2719

Hugo Rodriguez and Rick Tejada 210-824-1272

Coby Allen 210-625-4988

Bill Boyd 210-859-2719

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

Toyota of Boerne 31205 I-10 W Boerne, TX 78006

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Julie Herrera 210-681-3399

Gary Holdgraf 210-862-9769

George Ramirez 210-748-4412

Wayne Alderman 210-525-9800

Ingram Park Nissan 7000 NW Loop 410 San Antonio, TX

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

Alan Henderson 210-681-6300

Daniel Jex 210-684-6610

Frank Lira 210-381-7532

Richard Wood 210-366-9600

John Wang 830-981-6000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

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

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

Mark Castello 210-308-0200

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

Scott Brothers 210-253-3300

Esther Luna 210-690-0700

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Jose Contreras 210-308-8900

Justin Blake 888-341-2182

Sandy Small 210-341-8841

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

James Cole 800-611-0176

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

AUTO REVIEW

2017 Subaru XV Crosstrek

By Steve Schutz, MD Crossovers are taking over the automotive world. Regular readers know I’ve been saying that for years, as have most other industry observers. And it’s true. Established brands like Ford and Toyota sell a range of crossovers, as do luxury automakers like Audi and Lexus, and they’re all thriving. It’s the thing in 2016.

So if you don’t have crossovers you’re dead in the water, right? Yes, that’s right, unless you’re Subaru, one of the industry’s brightest stars over the past five or so years.

Despite an all-car lineup, Subaru has managed to grow their US sales from 263,820 in 2010 to 582,675 in 2015, an amazing 121 percent increase.

How did they do it? To be honest, they did it mostly by taking their cars and making them look like crossovers. The popular Outback station wagon that everybody loves? It’s really just a Legacy made to look like a mid52 San Antonio Medicine • November 2016

size crossover. The (also popular) Forester is actually an Impreza with a bigger, taller, and boxier body. And the subject of this review, the XV Crosstrek? It’s an Impreza hatchback raised by 5.7 inches and enhanced with body cladding, a roof rack, and off-road capable wheels and tires.

Pretty nifty trick, and it’s been working.

Whenever I look at a Crosstrek I feel like that guy eating the virtual steak in the Matrix movie. I know it’s just an Impreza with a trim package, but I don’t care. I like it a lot more than the Impreza. While the Impreza seems to tell people, “I bought this to keep my car payments low,” the Crosstrek announces, “I work so that I can support my rock climbing habit.”

Good thing the Crosstrek looks as cool as it does from the outside, because from inside this five-door hatchback things are less inspiring. For starters, there’s not a lot of space

for passengers and their gear — 22.3 ft3 with the seats up and 51.9 with them folded down — so forget about carrying a mountain bike in the back unless you’re riding alone. In addition, cabin materials are pretty plasticky and utilitarian as opposed to plush.

Most buyers won’t care — this is a $25,000 vehicle after all — but if you’re cross shopping the Lexus NX you’ll be tempted to stretch out the duration of your loan to get into the Lexus purely for the nicer interior.

Having said that, all of the tech Lexus owners have been enjoying for years can be had in the Crosstrek now. Bluetooth phone/audio, Satnav, keyless entry/ignition, and more are available in the Crosstrek, at least as options.

The Crosstrek’s driving experience is neither spirited nor exciting, but it’s not bad either. A low curb weight of 3150 lbs helps significantly, of course, but Subaru engi-

AUTO REVIEW

neers are to be commended for tuning the suspension so that the Crosstrek can move quickly when it needs to without compromising ride quality.

Predictably, I’m going to gently mention that, unless you make me happy and choose the six-speed manual transmission, you’ll be stuck with the squishy continuously variable transmission (CVT) that everybody tolerates and nobody loves. For the record, most people don’t care if they drive a car with a CVT, and it does get you better fuel economy and lower emissions. The result of all that virtue is that the Crosstrek is slow. With only 148 HP coming from a 2.0 L four-cylinder engine, the Crosstrek’s 0-to-60 MPH time is an unimpressive 10.3 seconds.

All Subarus come with standard AWD, and that’s a big plus in slippery conditions like a sudden rainstorm or if you find yourself on a dirt road trying to find your friend’s lake cabin, which you know is just around this corner. Or that one, or that one.....

As far as options go, the most significant one is a hybrid drive train for those who are looking for better fuel economy and lower emissions.

Naturally, many different trim levels and stand alone options are available for those so inclined. The most interesting is the “EyeSight” safety package, which adds steeringresponsive headlights, adaptive cruise control, lane-departure warning, and a forward collision avoidance system with automatic braking. Pretty Lexus-like.

As always, Phil Hornbeak will happily walk you through all of the possible permutations of the Subaru XV Crosstrek or any other vehicle you’re interested in exploring.

The 2017 Crosstrek isn’t a crossover, but it sure looks and acts like one, which is

enough for many buyers these days. While the Crosstrek is small inside and not very fast, it looks very cool and provides many of the pluses customers are looking for in a crossover, so I expect it will continue to sell well.

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

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

53

Welcome New Platinum Circle of Friends Member

THANK YOU

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

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of October 24, 2016.

54 San Antonio Medicine • November 2016