San Antonio Medicine January 2019

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VOLUME 72 NO. 1

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Celebrating 15 Years of Texas Tort Reform

By Joey Berlin, Texas Medicine .......................12

Expanding Forces in the Drug War

By Neal H. Gray, MD, BCMS Past President ...20

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BCMS President’s Message........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS News ............................................................................................................................................11 Business of Medicine: The Problem with Per Diems by Kathleen Barrow, Circle of Friends member ..........25 UTHSCSA: We Must End the Alzheimer’s Tsunami by William L. Henrich, MD, MACP...............................26 2018 BCMS Women in Medicine Award Honorees....................................................................................28 Feature: Sepsis Alert Alert by Robert G. Johnson, MD ..............................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 BMW M5 By Steve Schutz, MD .................................................................................44

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San Antonio Medicine • January 2019

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A Call to Arms for Physicians

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member John D. Edwards, MD, Member Vincent Paul Fonseca, MD, MPH, Member Michael Joseph Guirl, MD, Member David Anthony Hnatow, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones Jr., MD, Member David M. Siegel, MD, JD, Member Ryan D. Van Ramshorst, MD, MPH, FAAP, Member Kelly King, Alliance Representative George Rick Evans, Legal Counsel Col. Charles Gregory Mahakian, MD, Military Representative Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO, Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member J.J. Waller Jr., MD, Member

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San Antonio Medicine • January 2019

PRESIDENT’S MESSAGE

MOVING FORWARD TO RESTORE THE PRIMACY OF PHYSICIANS

IN MEDICINE

By Adam Ratner, MD, 2019 BCMS President

“Doctors are next to God,” my grandfather, who wasn’t a physician, told me more than 50 years ago. He wasn’t referring to economic power or social status but instead to the immense responsibility to their patients and awesome power to heal that physicians have in their sacred calling.

I started making rounds with my dad at the hospital, again, more than 50 years ago. With the exception of the rare grouch in the surgical lounge, I saw dedicated and happy physicians and surgeons, nurses, staff and even hospital administrators who found joy in their respective healing missions. They also seemed to be working together in teams for the benefit of their patients, and the patients came first.

We will never go back to those days in the last millennium, and that is overall for the good. Medical science and technology have advanced, and as a country we have far greater economic power available to expend on health. What we have lost, however, is the primacy of the individual patient and the physician as chief patient advocate and healer. We have been driven farther and farther away from God, my grandfather might say.

Many in politics and healthcare management and finance seem to believe that physicians are fungible commodities and will soon be largely replaced by artificial intelligence computers and robots.

As we know all too well, the consequences of their decisions lead to the increasing frustration and dissatisfaction with our profession and healthcare systems as well as adverse experiences and poorer outcomes for our patients.

The Bexar County Medical Society has been supporting and advocating for physicians and their patients for more than 165 years.

The BCMS has a strong foundation and has historically been very well served by our physician leadership teams, most recently under the presidency of Dr. Sheldon Gross. Our amazing and dedicated BCMS staff, capably led by our Executive Director, Mr. Steve Fitzer, insures the operational and financial success of the organization. The BCMS committees and their respective members and 8

San Antonio Medicine • January 2019

chairs working with staff are the vital force of BCMS, who in turn, serve our members.

To continue its long history of success, the BCMS must continuously improve and adapt not only to meet the current challenges of the day but also to maximize its effectiveness in the future. The BCMS must take the lead in advocating for as many Bexar County physicians as possible. To do this we must continuously find ways to add more value for current members and, just as importantly, attract new ones.

An excellent example of this is the Physician Leadership program spearheaded by Dr. Gross. We plan to expand and further develop this highly successful program. In the next few weeks we will invite participants in the leadership program as well as other motivated and visionary physicians to engage in a strategic planning program to find new ways we can best serve and advocate for Bexar County physicians.

We must find new ways to address the needs of employed physicians. More and more of us who were in private practices now find ourselves employed by organizations we don’t control or even significantly influence. Most new physicians out of training are also joining such organizations. Unfortunately, many of these employed physician jobs come with onerous one-sided contracts which disempower us, often making us relatively well-paid indentured servants.

Academic medicine is growing rapidly in Bexar County. We now have two vibrant and growing medical schools headquartered in San Antonio with at least two other schools bringing students to San Antonio for part of their training. We have a growing number of civilian and military residency and fellowship programs, but we need many, many more to meet the physician shortages in our community as well as nationally. I am heartened to see high levels of cooperation and synergy between the academic institutions with multiplier benefits for the institutions, their faculty, trainees and the community. One great example of this is the MEDCAST magnet high school project spearheaded by Dr. Ron Rodriguez, a senior

PRESIDENT’S MESSAGE

leader at UT Long School of Medicine and a BCMS board member. This magnet school will be located at Brooks City Base on the SE side of town near where the UIW School of Osteopathic Medicine resides.

I am also heartened by the increasing participation in BCMS activities and committees by medical students from both the UT Long School of Medicine and the UIW School of Osteopathic Medicine. That said, we need to attract more of the very busy residents and fellows and their spouses to the BCMS and the BCMS Alliance. These graduate medical trainees are the largest reservoir of future BCMS members and leaders.

San Antonio is one of the most important, if not the most important centers of military medicine on the face of the Earth. I look forward to working more closely with Col. Mahakian, General Hepburn, General Young and other local military medical leaders to better integrate military medicine with civilian private and academic medicine. This will not only benefit the physicians and their families, but also our respective patients including the large number of military veterans and retirees.

One of the hidden gems of the BCMS family is the BCMS Alliance. This group of physician spouses, both women and men, are an underappreciated and underestimated source of power and growth. I believe the BCMS and the Alliance should work far more closely together to improve the daily lives of physicians, their spouses and their families. I look forward to working with the Alliance leadership to achieve this vision.

The BCMS must also work to find new ways to support our traditional base of private practitioners. As market conditions change, BCMS and TMA must be in the forefront to assist us in adapting to challenging market and regulatory conditions as well as to explore new practice models.

Furthermore, when many of us become interested in slowing

down from our demanding full-time plus practices, the BCMS can help foster a happy transition to meaningful part-time lower stress but productive semi-retirements.

Finally, and perhaps most importantly, we must be in the forefront to address the burgeoning epidemic of physician misery, burnout and suicide. Enough is enough. I’m tired of seeing my partners, colleagues and friends become excessively stressed, unhappy, cynical, angry and worse.

It is our responsibility to stand up and do more. Working with the TMA we have made efforts to address and mitigate some issues, but we have very far to go to reverse decades of insidious loss of physician influence, respect and enjoyment of our practices.

Frankly, we haven’t been effective enough. We need to think out of the box and focus on one or two pivotal areas where we can have monumental influence, such as we did when we fought for and achieved tort reform more than 15 years ago.

In the next few weeks, we will convene a meeting of those of you who want to help lead this effort. We will also reach out to the leaders of other physician societies operating in Bexar County. If you or your group want to be part of this effort, please let me know. I can be reached at adam.ratner@bcms.org.

When I think about all of the members of BCMS, all of the supporting spouses and families, all of our staff, Circle of Friends, business partners and associates, I see an immense store of intellectual, emotional and political firepower which we can harness to reverse the course of physician and patient disempowerment.

We don’t need to accept the status quo. We can work together to free and energize physicians to more effectively do what we want to do, do what we are trained to do, and do with joy what we are struggling to do now: Take the best care of our patients!

Dr. Adam V. Ratner is the incoming president of the BCMS. He also serves as Professor and Assistant Dean at the University of The Incarnate Word School of Osteopathic Medicine and Chair of The Patient Institute. visit us at www.bcms.org

9

BCMS LEGISLATIVE NEWS

BCMS LEGISLATIVE AND SOCIOECONOMICS COMMITTEE MEMBERS ATTEND LEGISLATIVE RECEPTIONS State Rep. Barbara Gervin-Hawkins & Jesse Moss Jr., MD.

Alex Kenton, MD, State Rep.-elect Trey Martinez Fischer & Michael Battista, MD.

This past month was full with a variety of legislative events and several BCMS members attended to represent our organization and medicine’s issues. On December 4, members participated in a reception honoring State Rep. Diego Bernal (District 123) at the home of Charles Butt and also a dinner honoring State Sen.-elect Pete Flores (District 19), held at Periphery Restaurant. Then, in separate events and meetings on Dec. 6, members attended a breakfast meeting with State Rep. Lyle Larson ( District 122); a luncheon with State Rep.-elect Trey Martinez Fischer (District 116) and a holiday reception honoring State Rep. Barbara Gervin-Hawkins (District 120).

Many thanks to the following physicians who participated: Michael Battista, MD; Daniel Deane, MD; Leah Jacobson, MD; Alex Kenton, MD; Jesse Moss, Jr., MD; Gerardo Ortega, MD and Mary Wearden, MD. For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer and committee liaison at mary.nava@bcms.org.

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San Antonio Medicine • January 2019

BCMS NEWS

visit us at www.bcms.org

11

LEGISLATIVE ACCOMPLISHMENTS

COMING OF AGE: Celebrating 15 Years of Texas Tort Reform

By Joey Berlin, Texas Medicine

For many Texas physicians, the bad, pre-2003 memories may never go away. But those dark days have given way to a new Texas and a new reality.

T

Last year, he became medical director for the City of Robstown

Emergency Medical Service. In that role, he says, he’s realized how

much easier it is to obtain liability coverage in Texas versus other

states. As long as his medics are practicing their craft rationally and

reasonably, he doesn’t have to worry about a frivolous lawsuit.

“It’s no longer just me; it’s the people that I supervise. They’re

touching people every day,” said Dr. Hensley, president of the

Nueces County Medical Society. “They’re seeing people in every

housands of medical liability lawsuits — many dripping

situation, from car wreck to heart attack to children drowning, and

They’ve been replaced with an era in which doctors are

made me really improve our protocols and our standards for pre-

with frivolity — driving Texas physicians out in droves?

settling in Texas in record numbers, and specialists are filling voids

in rural areas.

Two decades ago, physicians might call the Texas Medical Asso-

ciation in tears because they had lost their medical liability coverage

and no one else would insure them. Now, insurance rates are at

things like that. Knowing that I’m protected from frivolity has

hospital medicine.”

MORE DOCTORS, LESS WORRY

House Bill 4, the Medical Malpractice and Tort Reform Act of

2003, went into effect on Sept. 1 that year, thanks to advocacy by

staggering lows, and dozens of companies are competing for the

TMA, the Texas Alliance for Patient Access (TAPA), the Texas

Physicians in Texas no longer face the same pressure to practice

voters approved Proposition 12, an amendment to the Texas Con-

doctors’ business.

defensively — what emergency physician Justin Hensley, MD, calls

“CYA-type medicine.” And it’s not nearly as likely a patient’s family member will take up arms in legal target practice, calling a Texas

doctor to shake him or her down for cash to make an anticipated lawsuit “go away.”

The TMA-backed tort reforms that went into effect 15 years ago

changed all that, and proponents say physicians and patients alike are in better shape because of it.

Seven years ago, because of tort reform, Dr. Hensley and his wife,

pediatrician Katherine Hensley, MD, moved to Corpus Christi from

Medical Liability Trust (TMLT), and others. The same month, Texas stitution that authorized the state legislature to cap noneconomic damages in health care liability cases.

That vote protected the law’s $250,000 limit on noneconomic

damages against individual physicians, and a total “stacked”

noneconomic cap of $750,000 if health care institutions also are

found liable. The law features other crucial protections, such as

providing personal immunity to physicians working for govern-

mental entities, including state medical schools. There is no cap

on economic damages.

A decade and a half later, the law’s power shows up in both the

North Carolina, a state where doctors were still ripe and constant

numbers and the attitudes of physicians across the state.

ment in their new home, and today, Dr. Justin Hensley says his com-

licensed record numbers of new physicians in the years post-tort

liability targets. They quickly appreciated the saner liability environfort level practicing in Texas may be even higher.

12

San Antonio Medicine • January 2019

Perhaps the most poignant statistic: The Texas Medical Board has

reform. (See “A Flood of New Physicians,” page 13.)

LEGISLATIVE ACCOMPLISHMENTS versation and worry and concern, and the top of everybody’s mind.

“We understand that it’s our job to practice

good medicine. We don’t need a lawyer to tell us that, or the threat or intimidation … of a lawsuit for that.”

Although she and her husband moved to

Texas post-2003, Dr. Katherine Hensley is a

good example of the typical Texas physician’s psyche post-tort reform.

“I don’t feel afraid of litigation practicing

here. I just don’t,” she said. “I try to practice

responsible medicine, because I feel like mal-

practice is real, and when it really happens,

those physicians need to be held accountable

Meanwhile, the number of physicians in Texas grew more than

and the people they harm need to be compensated. I’m not saying

and 2017, according to the Department of State Health Services. Plus,

feel like someone is going to come after me every time they have a

twice as fast as the state’s booming population growth between 2008

more specialists are practicing in communities where they’re needed.

that doctors should never be sued ever, by any means. But I don’t bad outcome.”

Overzealous intervening and test-ordering

can have detrimental results for patients’

health, she says, noting recent research on the

harms of ordering too many CT scans and overprescribing antibiotics.

“We act like, ‘Oh well, it’s not going to do

them any harm, so let’s just go ahead and do

it anyway, because we don’t want to miss

something and get in trouble,’” Dr. Kather-

ine Hensley said. “The reality is, we’re prob-

ably causing harm, so we need to get away from that. And I think tort reform has

helped with that a lot. Because it allows us

to make decisions based on what’s actually best for our patients, and not what’s going

Austin internal medicine physician Howard Marcus, MD, chair of

to keep us out of court.”

Corpus Christi neurosurgeon Mathew Alexander, MD, came to

TAPA’s board, says the mindset of practicing medicine has changed,

Texas in 2004 because of liability reform after completing his neuro-

are strong indicators. (See “Plummeting Lawsuits,” above)

icantly improved the litigation climate over the years, there’s still a

and statistics on medical liability lawsuits pre- and post-tort reform

surgery residency in Milwaukee. He says while tort reform has signif-

“Those frivolous lawsuits, by and large, are no longer occurring,

need to practice defensively, and access to neurosurgeons still has

psychological result of that is it’s no longer a topic of endless con-

“In Victoria, there’s no neurosurgeon coverage. In Laredo, there’s

because the system is now fair and balanced,” Dr. Marcus said. “The

room for improvement.

(continued on page 14)

visit us at www.bcms.org

13

LEGISLATIVE ACCOMPLISHMENTS (continued from page 13)

sparse (coverage); one guy is half-retired,” he said. “If you have a head

trauma or a head bleed, you’re probably not going to survive, because those critical 30 minutes to an hour, by the time you’re flighted out, you won’t survive that.”

Still, he views the reforms as important protections.

“It would kill any type of … neurosurgeon [practice] if tort re-

form is not in Texas. You would have to practice in academics, and

The 2017 TAPA report noted that in the two years before the

reforms, 14 of Texas’ 17 medical liability insurers disappeared.

TMA General Counsel Donald “Rocky” Wilcox recalls being on

the phone with physicians crying because their liability insurance

carrier had dropped them, and they couldn’t find anyone else to

insure them. And TAPA’s report notes the average hospital pre-

mium had spiked to $870,000 in 2003, more than double what it

then everybody’s kind of well-protected,” Dr. Alexander said. “But

was in 2000, according to Texas Hospital Association figures.

Antonio, you endanger a lot of people.”

times came from a would-be lawsuit he stopped. After the U.S. Food

THE DARK AGES

in 2000, a law firm representing one of Dr. Cardenas’ patients who

moved to Texas after 2003, may have no sense of what it was like

tient’s brother called Dr. Cardenas. He recalls the brother essentially

when we’re three hours – or two hours – flight to Houston or San

Many of the younger guard of Texas physicians, and some who

in the bad old days. But McAllen gastroenterologist and TMA Im-

mediate Past President Carlos J. Cardenas, MD, is one who will never forget what he calls the “lawsuit bonanza for the trial bar.”

In a TAPA-commissioned October 2017 report on the impact of

tort reform on Texans’ health care access, researchers noted some

areas of Texas saw 300 medical liability suits for every 100 physicians. While the vast majority of those suits were unsuccessful, the

report says, defending them still cost physicians thousands of dollars

and time away from their practice.

“Things had gotten to the point to where there were people that

were hiring staff just to do nothing

For Dr. Cardenas, one of the most memorable signs of those

and Drug Administration pulled a heartburn drug off the market

had taken the drug warned him a suit was coming. Then, the patold him, “‘I can make it all go away for a certain amount of money.’

“I couldn’t believe my ears,” said Dr. Cardenas, who then noted

the shakedown attempt in the patient’s chart. The law firm later

stopped pursuing the case.

“That was the atmosphere. That’s kind of what was going on; it

was open [season] on physicians down here,” Dr. Cardenas said. “We

were having difficulty recruiting and retaining [doctors]. Medical lia-

bility coverage had basically gone away for some subspecialties.”

The lawsuits grew to epidemic proportions for Texas physicians,

and the push for change began. On April 8, 2002, Dr. Cardenas and

but copy records, because back then it was all Xerox machines. And

you were getting a duces tecum [subpoena] almost every week to

every other week,” Dr. Cardenas recalled. “If it was a patient you had

seen, even if it wasn’t directly af-

fecting you, you had to provide records because somebody else is

being named in a liability claim.

“It was rampant, and things were

worse, I think, in South Texas than

they were in other parts of the state.

We were kind of the canary in the

coal mine, in that we were seeing it here before it became a problem

across the rest of the state.”

14

San Antonio Medicine • January 2019

(continued on page 16)

LEGISLATIVE ACCOMPLISHMENTS (continued from page 14)

other Lower Rio Grande Valley physicians led a

huge rally with patients and colleagues at the Hi-

dalgo County Courthouse, one of several simulta-

neous rallies to protest insurance rates and the litigation-friendly climate. Doctors also rallied in

Nueces County and elsewhere. Dr. Cardenas says at least 2,000 people joined forces at the Hidalgo

County rally.

“That rally was the spark that lit the fire that ulti-

mately, I think, ended in tort reform,” he said. “It

was a whole choir of folks that sang with one voice.”

FIGHTING FOR PRESERVATION

Looking at data through 2016, the TAPA report

also found that six of eight specialties saw an

uptick in physicians per-capita in Texas post-re-

form. Emergency medicine had the highest increase in number of

There are still ways around that; if you can prove that the doctor

capita increased by nearly 50 percent.

ways to compensate those patients when harm occurs,” he said. “But

icant impact on the supply of physicians per capita, and therefore

ulation to access health care.”

physicians at 120 percent. The number of pediatric surgeons per “The evidence does suggest that meaningful reform had a signif-

had a significant favorable impact on the access that Texas residents

knowingly or willingly provided bad care, then it provides additional

you also have to weigh the individual against the ability for the popTMA always looks for opportunities to smooth out rough edges

have to the medical services they need,” said William G. Hamm,

in the law, Mr. Whitehurst notes.

report. California’s $250,000 cap on noneconomic damages, passed

[to improve]. We really utilize the attorneys with TMLT and some

PhD, a California economics consultant who coauthored the TAPA

“We have conversations with the trial bar to see if there are areas

in 1975, served as the model for Texas’ tort reform.

of the other medical liability carriers to identify if we have problems,

passed over the opposition of trial lawyers. Unsurprisingly, since

work on some language that makes sense.

Preserving that access is a continuing battle. Liability reform

2003, plaintiff attorneys have fought the law both in the courthouse

and at the Capitol. But efforts to weaken it legislatively have failed,

and [if] the trial bar has similar types of problems, whether we can

“But bottom line is that tort reform has achieved what it was in-

tended to achieve, which was to improve access to care for services

and it has withstood numerous court challenges as well, even re-

in communities that weren’t being served in the past.”

35, www.texmed.org/protectionspreserved, and “The Right

be a blueprint for future initiatives that require a united front. He

cently. (See “Protections Preserved,” July 2018 Texas Medicine, pages 34Standard?”

October

2016

Texas

www.texmed.com/rightstandard.)

Medicine,

pages

47-51,

Under HB 4 the damages cap in wrongful-death cases was tied

to inflation, set at $500,000 in 1977 dollars. The legislature decided against indexing the noneconomic damages cap.

Dr. Cardenas says the advocacy medicine used 15 years ago can

fondly remembers the work that brought to an end that once-dark

era: “The empowerment of physicians to be able to do what we

were told over and over again was impossible — that we’d have to

rewrite the Constitution of Texas.

“What we ended up with was what’s been declared some of the

TMA lobbyist Darren Whitehurst says TMA would oppose any

best tort reform laws in the country,” he said. “It’s created the ability

“We set it at a number that we felt was fair and provided some

and talent that we need in different areas in our state — both rural

attempt to index that cap, as one failed bill attempted last session.

level of compensation but didn’t create a jackpot for the patient.

16

San Antonio Medicine • January 2019

for us to recruit in our state and retain in our state the physicians

and urban.”

LEGISLATIVE ACCOMPLISHMENTS

A CALL TO ARMS FOR PHYSICIANS

By Alexander Kenton, MD

ealthcare is one of the most regulated industries in the United States and as long as the largest share of national and state budgets go to healthcare and entitlements, more regulation and legislation over healthcare will follow. This is why physicians must be engaged in advocacy at every level.

It is important that physicians contribute to political advocacy organizations to support the patient and physician cause. In addition, close working relationships with state legislators are key if we want to have a say on how care is delivered to our patients and how we are compensated for the care we provide.

The single biggest example of what happens when physicians are not as engaged as other stakeholders is seen in the development of the Affordable Care Act and its financial affects on stake-

H

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San Antonio Medicine • January 2019

holders. Steven Brill outlines it well in his book, “America’s Bitter Pill.” In the book, he notes how the degree of lobbying combined with the amount of money contributed by the stakeholders to key policymakers had a direct effect on the financial outcome of the stakeholders.

Pharmaceutical Manufacturers Association of America (PhARMA) had the best connections and placed the largest amount of money into lobbying. Former congressman Wilbert Joseph Tauzin, PhARMA’s chief lobbyist, was the previous chair of the House Energy and Commerce Committee, which oversees national healthcare. That close relationship combined with $270 million worth of lobbying money ensured major concessions. As a result, Medicare was prevented from negotiating with pharmaceutical companies for drug prices and consumers were prevented

LEGISLATIVE ACCOMPLISHMENTS

from obtaining drugs from Canada. Through these concessions and others, pharmaceutical companies received $200 billion in profit over the next few years.

The American Health Insurance Plans (AHIP) also contributed significant amounts of cash and lobbying. Armed with $8 million from AHIP and another $100 million from other insurance organizations, the top-rate lobbyist Karen Ignani managed to negotiate a deal in which the insurance industry was subsidized for taking pre-existing conditions and they received a promise that everyone would be mandated to have insurance.

The hospitals also did fairly well. The American Hospital Association (AHA) and hospital organizations themselves contributed approximately $50 million in congressional and senate contributions. In return, they received $360 billion of new revenue as uncompensated care was converted to compensated care.

Physicians and their organizations were the least organized and contributed the least amount of money during the year that the Affordable Care Act was negotiated. They spent a total of $40 million. The only request physicians made was for a fix to the sustainable growth rate (SGR) to Medicare. Congress promised a fix, which did not come to fruition on the passage of the bill. To quote directly from “America’s Bitter Pill”:

If physicians continue to act in ways similar to how we acted during the development of the Affordable Care Act, then our ability to impact healthcare on a global scale will be left to non-physician actors.

“The decision to eliminate the SGR fix was emblematic of two important dynamics:

“First, the doctors – the players in the healthcare economy who, with the nurses, actually provide healthcare – had seen their influence evaporate compared to big-money industry stakeholders such as the drug companies, insurers, and hospitals. As a result, they could be trifled with in a way that would have been unimaginable.

Second, they had already gone on record as supporting the bill.”

Today, physicians are no longer allowed to have ownership in specialty hospitals. Nationally, we are targeted as the cause of high costs. Of all stakeholders, however, physicians as a whole have seen their incomes decrease since the Affordable Care Act was enacted and more requirements have been placed in order for us to get reimbursement for our services.

The next phases of healthcare reform are already taking place.

The Democrats are pushing for a Medicare for All Plan. Republicans are removing protections built into the Affordable Care Act. In Texas, Medicaid reimbursement continues to be constrained. Physician extenders are being granted more autonomy.

Insurance companies are being allowed to have extremely narrow networks, and physicians’ ability to bill for their services are being challenged.

“We must be engaged. Every physician should offer their time to serve on a regulatory committee or participate in organized medicine through the Texas Medical Association and their county medical society or another physician organization. Through those organizations, one can help advocate for patients and for physicians to craft beneficial legislation. And finally, every physician should contribute some money to a physician political action committee. Only with strength in engagement and money can we have a significant impact on the future of healthcare in this country and in our state.

Dr. Alexander Kenton is a neonatologist affiliated with Mednax, a multi-speciality physician management organization. He directs the Neonatal Intensive Care Unit at Methodist Children’s Hospital. He currently chairs the Bexar County Medical Society Legislative and Socioeconomics Committee and the candidate evaluation committee for TEXPAC.

visit us at www.bcms.org

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LEGISLATIVE CHALLENGES

EXPANDING FORCES

IN THE DRUG WAR

By Neal H. Gray, MD, BCMS Past President oliticians tell us that the war in Afghanistan is the USA’s longest war, and not yet won. If you consider our effort on substance abuse and addiction as a war, that started in 1784 with a pamphlet “Inquiry into the Effects of Ardent Spirits on the Human Mind and Body” by Dr. Benjamin Rush. He was probably the first to claim that the alcoholic could be restored to health through medical treatment. After 224 years, we have not won this war either.

The New York Times had a piece on September 10, 2018 by Jan Hoffman, “Most Doctors Are Ill Equipped to Deal with the Opioid Epidemic. Few Medical Schools Teach Addiction”. I agree. Looking back on my medical education at the University of Missouri in the early 1960’s, the curriculum included just one hour by the Department of Psychiatry that was presented by a local man from Alcoholics Anonymous that told his story. No faculty members were involved.

Has medical education in addiction improved? Not much, but some schools have at least begun. In 1991, The American Board of Medical Specialties approved a psychiatric fellowship in addiction.

Addiction Medicine, not psychiatry, began to be included in 2009 in the ABMS process and there are now 2,500 physicians who are board certified in Addiction Medicine. Currently, out of 6,260 residency slots across the country, only 52 are in Addiction Medicine.

The Center for Disease Control and Prevention states that 632,000 deaths from tobacco, alcohol, opioids and other drugs occur annually. It has been estimated that about a third of all patients in a county hospital are substance abusers or addicts. Taking care of addiction patients is a real challenge. The disease is a primary brain disease of disrupted, but reversible, neurochemistry

P

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San Antonio Medicine • January 2019

that is chronic, relapsing, progressive and too often fatal. It is not a mental illness: it is a brain disease. They often can co-exist. Their care is difficult and demanding.

There are about a dozen Addiction Medicine physicians in San Antonio and I don’t think that any of them are active full time. I am not aware of any facility in Bexar County that provides the whole spectrum of care needed. We have very good places in Hunt and Center Point, Texas to which we often refer patients.

Many of the affected physicians we see at BCMS are sent out of state for initial treatment. Our Physician Health Committee then follows them in recovery and reentry to practice.

LEGISLATIVE CHALLENGES There are an increasing number of store-front clinics offering addiction treatment, but these usually involve counseling by social workers or psychologists and few if any MD’s are included. Many prescription medicines are available. Some old ones like methadone and disulfiram are still used, but newer ones like buprenorphine, naltrexone and others are having a huge impact.

With the marked advance in brain chemistry research, more agents should surface soon. The availability of naloxone for opioid poisoning has certainly improved survival rates in this crisis.

Some of these issues we will just have to accept, but there are others that we can change.

HERE ARE SOME SUGGESTIONS FOR THE UNIVERSITY HEALTH SYSTEM AND MEDICAL SCHOOLS:

1. Include addiction medicine in undergraduate medical education.

2. Establish a separate Department of Addiction Medicine with faculty, clinics, inpatient space, staff and funding.

3. Initiate a residency program in Addiction Medicine with clinical, teaching and research activities.

4. Have staff at the University Health Centers question all patients about substance use, obtain lab support, diagnose.

5. Help local physicians deal with the opioid crisis.

6. Work with the Health Department to improve at-risk patient detection, referrals, data generation and follow up of cases.

AND TO THE BEXAR COUNTY MEDICAL SOCIETY:

1. Work with the Texas Medical Association to develop CME for all its members.

2. Coordinate local issues and problems with the TBM and DEA. 3. Assist in lobbying for new government funding in response to the opioid crisis.

4. Become available to assist the University Health System and the judicial and court entities of Bexar County.

Dr. Neal Gray is a retired anesthesiologist with a specialty in addiction medicine. He served as President of the Bexar County Medical Society in 1992 and currently serves on the BCMS Physician Health and Rehabilitation Committee.

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LEGISLATIVE CHALLENGES

Should Mob-Rule be the Litmus Test in Legalizing Marijuana?

Op-Ed by Alan Preston, MHA, ScD arijuana is becoming a popular ballot measure in many states in an effort to legalize it. There are a number of individuals that are ardent advocates of legal marijuana and claim that marijuana is safe and effective in treating a number of illnesses. Their claim is that it is, after all, a "natural" product. And if they "feel" it is effective and safe, then why not let the citizens decide the fate of such? The Nightshade (Atropa Belladonna) berry is also natural. Eat 3 to 5 of these, and you will die, naturally of course!

At the federal level, marijuana remains classified as a Schedule I substance1 under the Controlled Substances Act, where Schedule I substances are considered to have a high potential for dependency

M

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and no accepted medical use, making the distribution of marijuana a federal offense. The challenge is that while marijuana remains a Schedule 1 substance, the law was signed in 1970. There has been a lot of studies since then about marijuana, of which some are legitimate while others should never be considered a "study" given the poor design of the so-called study.

The question we should all ask ourselves is whether drug policy should be decided based on mob- rule or through the oversight of the Federal Drug Administration (FDA). Many states have allowed citizens to determine as to whether marijuana should be approved for medical and recreational use by a ballot measure of your average citizen. If a majority of voting citizens decide that marijuana is ap-

LEGISLATIVE CHALLENGES propriate, they can legalize marijuana through a process I call "mobrule." I am not convinced this is an appropriate way to legalize a Schedule 1 substance.

If I were to take at face-value all the positive, beneficial claims of medical marijuana, there would be a plethora of benefits. In 2017, the National Academies of Sciences, Engineering, and Medicine issued a report2 on the benefits and detriments of marijuana based on the review of over 10,000 scientific abstracts from marijuana health research. They also made 100 conclusions related to the health effects of cannabis and cannabinoid use. One would believe simply based on over 10,000 abstracts of marijuana use, that marijuana is a miracle drug that cures almost all diseases including;

• Antiemetics in the treatment of chemotherapy-induced nausea and vomiting, • Improvement of patient-reported multiple sclerosis spasticity symptoms, 1, 2 • Improvement of short-term sleep outcomes in individuals with sleep disturbance associated with obstructive sleep apnea syndrome, • Fibromyalgia, • Chronic pain, • Increasing appetite and decreasing weight loss associated with HIV/AIDS, • Improving symptoms of Tourette syndrome, • Individuals with social anxiety disorders, • Improving symptoms of posttraumatic stress disorder, • Traumatic brain injury, • Intracranial hemorrhage, • Improving intraocular pressure associated with glaucoma, • Cancers, including glioma, • Anorexia nervosa, • Symptoms of irritable bowel syndrome, • Epilepsy Spasticity in patients with paralysis due to spinal cord injury,

• Symptoms associated with amyotrophic lateral sclerosis, • Chorea and certain neuropsychiatric symptoms associated with Huntington’s disease, • Motor system symptoms associated with Parkinson’s disease or the levodopa-induced dyskinesia, • Dystonia, • Achieving abstinence in the use of addictive substances, • Mental health outcomes in individuals with schizophrenia or schizophreniform psychosis.

And this is by no means, a conclusive list of all of the beneficial "claims" of medical marijuana. Anecdotal evidence is a long way from empirical scientific evidence. That is not to suggest we should dismiss anecdotal evidence altogether. There may be some empirical evidence of benefits of some of these claims. Regardless, science MUST play a role in concluding the effectiveness and safety of any drug. And as every clinical drug trial has taught us, there are always side-effects with every approved drug, and we need to understand the side-effects of marijuana even if there is a true medical benefit.

We also need proper labeling of the detriments and limitations of any FDA approved drug.

Furthermore, when a pharmaceutical company applies for FDA approval of a particular drug, they must conduct a number of double-blinded clinical drug trials (phase 1-4) in a very controlled manner to assure the safety of patients while determining whether the drug actually performs as alleged by the pharmaceutical companies.

Double-blinded studies are the gold standards3 of statistical studies where neither the investigator nor the subject knows whether they are receiving a placebo or the active ingredient. Objective tests3 are then performed to determine the effect of the drug in treating the underlying condition. And even if a drug has some moderate success in the treatment of a particular condition, the question is whether the drug is also safe and statistically significant in its efficacy. The FDA has high standards4, and it is not easy for pharmaceutical companies to obtain approval given the high standards imposed on pharmaceutical companies. Why would we want to substitute the FDA process for a ballot measure of approval of a Substance 1 drug based on a majority rule?

Often the proponents of the legalization of marijuana state that there is no harm by using marijuana and those that use it "feel better." I do not doubt the claim of feeling better; however, if that becomes the new standard, we should legalize heroin given the tremendous benefit of "feeling good." Clearly, there is a big difference between heroin and marijuana; nevertheless, having average citizens legalize a drug through a ballot measure is not wise drug policy. (continued on page 24)

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LEGISLATIVE CHALLENGES (continued from page 14)

There are reasons why we have a federal government to help standardize and manage certain aspects of our civil society. States have separate rights, as enumerated in Article IV, The States, and the 10th amendment (powers reserved to the States) of the US Constitution.

The original Constitution, before the 17th amendment (Popular Election of Senators), Senators represented the states and were appointed by state legislators to represent the State's interest. Therefore, there are many areas of regulation that is reserved for the states and only the states. However, we cannot ignore the role of the Federal Government either.

As much as I believe in individual freedom and liberty as contemplated in the US Constitution, I do believe there are times when it is necessary to centralize policymaking. Article 1, Section 8.3, of the Constitution, gives broad enumerated power to the federal government to regulate commerce (i.e., the Commerce Clause). Many may remember that the Commerce Clause came under intense scrutiny under the passage of the Patient Protection and Affordable Care Act (aka, the ACA or Obamacare). Under the ACA, Congress attempted to pass a law that compelled commerce. It is one thing to manage commerce, it is, however, another thing to compel commerce. The Supreme Court ruled that the federal government cannot compel citizens to purchase a product as they attempted to do in the ACA. Though there have been a number of challenges to the commerce clause in the overreach of the federal government in regulating such, there has not been a challenge per se as to whether or 24

San Antonio Medicine • January 2019

not the federal government has the authority to determine which "drug" is legal and how to legalize drugs under the agency of the Federal Drug Administration. The FDA has a long history in advocating for the safety of public health that began in the 1930s5.

To abandon the role of the FDA in favor of a majority-rule ballot measure is neither wise nor prudent when there may be an unknown risk to the public. 4, 5 Furthermore, we are witnessing increasing nullification of federal laws by states and cities throughout the country. Our country was founded on the principals of law and order, and the nullification of federal law is a disturbing trend. What is the message to the average citizen when a city or state decides unilaterally not to obey a federal law? We have a process in place, and if one does not like the current state of affairs, then there is a proper way to make a change, and that is through the legislative process and if there is a consensus, then change will take place; however, not through mob-rule! Mobrule is the opposite of a civil society.

Resources 1 2 3 4

https://www.dea.gov/drug-scheduling https://www.nap.edu/read/24625/chapter/1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505292/ https://www.fda.gov/Drugs/ResourcesForYou/Consumers/ ucm143534.htm 5 https://www.fda.gov/AboutFDA/History/default.htm

BUSINESS OF MEDICINE

THE PROBLEM WITH PER DIEMS

By Kathleen Barrow, Circle of Friends member Federal tax law now prevents taxpayers from deducting business expenses incurred in connection with services rendered as employees. As a result, we expect employers to be directly paying a greater number of expenses incurred by employees in service to the employer. Direct payment of business expenses is also increasing because employers are finding it lucrative to provide “mobile” services to clients. Nationally and internationally, employers now provide services via employee physicians, nurses, pulmonary technicians, home health care aids, engineers, truck drivers and others who travel away from home to work. In fact, one website for “traveling nurses” I found when researching this article speaks to the “special perks” that can be obtained by nurses who travel to “vacation spots” they can enjoy when not spending time rendering services to clients.

All of this increases employers’ interest in using per diem allowances to facilitate reimbursement of the costs of meals, lodging and incidental expenses associated with employee travel. A “per diem allowance” is a payment for ordinary and necessary business expenses that an employer reasonably anticipates will be incurred by an employee for travel away from home in service to the employer. Per diem allowances are attractive to traveling employees because they typically receive the money in lump sum “up front,” and do not have to worry about advancing their own funds or tying up their own credit cards for business-related travel.

However, the problem with per diem allowances is that they can be excessive or abusive. For example, in one case I had years ago, the client’s engagement letter to a new surveying technician expressly stated “you will receive 40 percent of your compensation in per diem payments.” The per diem payments (in the aggregate) were labeled “business equipment and tools” on the client’s tax returns.

Clearly all this left the client and employees exposed to liability for unpaid income and employment taxes, but there were other liabilities that were not anticipated.

The payment of per diem amounts that were actually “wages,” rather than substantiated expense reimbursements, raised the nonexempt technician’s “regular rate” for purposes of calculating overtime pay. Money characterized as per diem allowances, rather than “wages” caused the technician and other employees to be denied the opportunity to make elective deferral contributions to the 401(k) plan. This resulted in an operational failure potentially disqualifying the plan. What a colossal mess!

Clearly per diem allowance programs can be beneficial, but they can also be problematic. So, you ask, “How does an employer do it right?”

The Tax Requirements

Code section 62(c) requires business expenses to be substantiated, and excess amounts returned to the employer in a reasonable period of time, in order to avoid reimbursements from being treated as wages. Treas. Reg. §§1.62-2(b)(2), 3121(a)-3(a). For a per diem allowance to satisfy this criteria the payment must: (i) reimburse ordinary and necessary business expenses for travel away from home; (ii) be reasonably calculated not to exceed the amount of expenses anticipated to be incurred; and (iii) be paid at or below the daily federal published rate applicable to the location of travel (for meals and incidentals, or lodging), at a flat rate, or via a specified schedule.

Rev. Proc. 2011-47.

Further, no matter what method of determining the amount of per diem is used, the expenses must be “substantiated,”— meaning that documentation must be maintained by the employer that shows the amount of the expenses, the business purpose of the expenses, and the date and time the expenses were incurred. Code § 274(d)(1).

To put it simply, any sums in excess of what can be substantiated, are treated as wages under the Code. A per diem allowance method of reimbursing employees is not intended to qualify as a “free pass” to a vacation destination. Thus, an employee who spends time enjoying the beach in Southern California must reimburse the employer for lodging and meals during time off, or take the value of such lodging and meals or incidentals into wages. In an audit, the burden is on the employer to make sure that whatever amount of per diem allowance is paid to an employee is “substantiated” as provided in guidance published under Code § 274(d)(1). Rev. Proc. 2011-47.

In sum, while per diem reimbursements are lawful under the Code, per diem amounts must be supported with documentation of actual expenses incurred, and reasons for the business travel to which they relate. Any employer using the per diem method of reimbursing expenses is wise to develop policies and procedures for how they will be used.

Kathleen Barrow is a partner with Constangy, Brooks, Smith & Prophete LLP in San Antonio. She can be reached at kbarrow@constangy.com. visit us at www.bcms.org

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UTHSCSA

WE MUST END THE ALZHEIMER’S TSUNAMI By: William L. Henrich, MD, MACP

In November 1988, President Ronald Reagan signed a joint resolution passed by Congress that brought attention to the “two and one-half million Americans” affected by Alzheimer’s disease and the $25 billion annual cost of nursing home admissions.

Today, 5.7 million Americans have Alzheimer’s disease, which costs the nation $277 billion a year. Nearly one-third of our senior adults die with a form of dementia, and every 65 seconds, an American develops Alzheimer’s.

Texas ranks fourth nationally in the number of Alzheimer’s cases at 380,000 and is second in Alzheimer’s-related deaths (9,135 in 2016). Mirroring a national trend, deaths among Texans with Alzheimer’s rose 180 percent between 2000 and 2015. Hispanics, who account for 40 percent of the state’s population, have a 30-50 percent higher risk of developing Alzheimer’s.

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More troubling, this tidal wave is intensifying.

Unless effective prevention and cures are discovered, the number of Americans living with Alzheimer’s disease is expected to nearly triple to 13.8 million by 2050. By that time, Texas families may be assisting 1 million of their loved ones affected by the disease.

Earlier this year, Sudha Seshadri, MD, founding director of the Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases at UT Health San Antonio, discussed these issues at a meeting of The University of Texas System Board of Regents. “Responding to the Alzheimer’s Tsunami” was the theme, which was fitting because we truly face a health care storm of immense proportions.

The loss of memories and decision-making skills by those who have Alzheimer’s is only part of the toll on families, Dr. Seshadri said.

This is because caregivers who manage their loved ones’ daily needs

UTHSCSA

also experience untold stress and anxiety.

Dr. Seshadri has worked as a dementia researcher for more than two decades, and she is a senior investigator in the Framingham Heart Study. This New England-based study has enrolled three generations of people since 1948. Investigators are learning valuable insights by analyzing the health outcomes of these participants, including associations between heart health and dementia.

In December 2017, we recruited Dr. Seshadri to UT Health San Antonio to serve as the founding director of the Biggs Institute.

It was quite a coup for our community. National Institutes of Health funding is very difficult to obtain in this era, and high-quality researchers typically have one or two NIH grants. Dr. Seshadri, a demonstrated leader in the field of dementia, is an investigator on no less than eight NIH grants. We could not have chosen a better leader to champion this cause in our city and region.

The Biggs Institute, backed by $50 million raised from the San Antonio community, will tackle the Alzheimer’s challenge from all sides — by caring for caregivers, by providing novel therapies in clinical trials, by understanding risk factors in Hispanics, and by identifying molecular signatures of the disease and new pathways to prevent and treat it.

This is an all-out commitment to quelling the rising tsunami. We do it for patients and families, in memory of a great friend to the San Antonio community, Glenn Biggs.

Known for his dedication and service to the community, Mr. Biggs was a prominent figure whose leadership influenced economic development across San Antonio. When he was diagnosed with Alzheimer’s disease, he and his family struggled to find comprehensive care. This search led him to approach UT Health San Antonio and community leaders to address the need for a comprehensive center dedicated to understanding Alzheimer’s disease. His vision of a center to transform care and advance discovery is now alive in the Biggs Institute at UT Health San Antonio.

From 3 to 5 p.m. Sunday, Feb. 24, 2019, the Biggs Institute invites the public to attend a free informational event in the Carlos Alvarez Studio Theater of the Tobin Center for the Performing Arts. I will moderate a panel discussion on “Protecting your brain from Alzheimer’s disease: role of sleep, diet and exercise.” Dr. Seshadri and other experts, including UT Health San Antonio’s Alan Peterson, Ph.D., who studies combat-related post-traumatic stress, will discuss some observed associations between aspects of daily living and long-term brain health. I encourage the public to save the date and attend this interesting presentation. Book your spot at: https://biggsinstitute.org/events/south-texas-alzheimers-conference-community-event/.

The same week, Dr. Seshadri will welcome leaders from the National Institutes of Health, the Alzheimer’s Association and other top academic medical centers for the inaugural “South Texas Conference on Transformational Care, Research and Therapeutics in Alzheimer’s Disease.” Health care providers are encouraged to reserve Monday and Tuesday, Feb. 25 and 26, and plan to attend this major symposium in our city. To register, visit: https://biggsinstitute.org/events/south-texasalzheimers-conference/.

Partnering with the community, the Biggs Institute will respond to the Alzheimer’s tsunami by understanding the biology of this complex disease, which will lead us to ways of preventing it and delivering personalized treatment. Our children and grandchildren will be the beneficiaries. In this way, we will honor the name of Glenn Biggs, his family, and all who have died of dementia and other brain diseases.

Dr. William L. Henrich is President and Professor of Medicine at UT Health San Antonio.

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2018 BCMS WOMEN IN MED AMBER LEVEL WINNERS

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San Antonio Medicine • January 2019

DICINE AWARD HONOREES EMERALD LEVEL WINNERS

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2018 BCMS WOMEN IN MED TOPAZ LEVEL WINNERS

UT HEALTH WINNERS

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San Antonio Medicine • January 2019

DICINE AWARD HONOREES UT HEALTH WINNERS

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2018 BCMS WOMEN IN MEDICINE AWARD HONOREES MILITARY CIVILIAN

PRACTICE MANAGER UNSUNG HERO OF THE YEAR

RISING STARS

The BCMS Women in Medicine Committee recognizes the hard work, dedication and commitment of local female physicians who serve the honored practice of medicine in Bexar County.

This year the Top 40 Women in Medicine leaders were recognized during the 2018 Women in Medicine Committee Dinner.

Congratulations to all the winners!

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San Antonio Medicine • January 2019

FEATURE

By: Robert G. Johnson, MD Okay. I get it. There are medical emergencies. If you’re not breathing or your ticker crumps, get off the couch, put down the day-old lemon Danish from the surgeon’s lounge and run like — #*!!! I preferred the old terminology of Code Blue. Sounded mysterious, important, like something you’d hear on ER or Grey’s Anatomy. To be followed by a stampede of smoking hot, perfectly coiffed, gleaming-toothed, freshly starched lab coats. And, of course, over chest compressions and barked instructions for calcium and epinephrine, McSteamy is flirting with McGorgeous, and before normal sinus rhythm is restored has secured a date and reservations at a dark corner table for later that same evening. Today, the drama has been down-graded to a watery “Medical Alert,” or “Rapid Response Team,” with regular folk in stained scrubs and bad-hair days.

So… I guess the ID and wound care and guys who lance boils or drain pus got to feeling left out. Why should the cardiologists and pulmonary docs have all the fun? Share the drama. Pass around the “We’re Important Too” casserole. Announce us over loud speakers so all will perk up, cock an ear, and clear the path.

Enter — ta-daaa — Sepsis Alert. Really? Hearing sepsis alert overhead is right up there with the green Chevrolet that’s left its lights on.

Alright. To be fair, true sepsis is a serious medical problem. Here is 34

San Antonio Medicine • January 2019

an honest-to-god true story: It was a quiet evening on the ward. My two-day post-op patient had an uneventful day — swallowed his oversalted broth without gagging, stood at the bedside, sucked on the incentive spirometer like he loved it. All was well — until 2304h (that’s 11:04 at night). At four minutes past the hour the door to my patient’s room is breached. Not sure if they used explosives or just a good kick. In floods a SWAT team of white coats and blue scrubs and RT’s and MD’s and even a few PhD’s. My patient is overwhelmed. Nobody explains the reason behind the ambush. He somehow manages to ring up his wife in New Braunfels and sputter: “I’m being transferred to the ICU”. His wife, understandably frantic, races into the hospital at breakneck speed (a 45-minute drive). She eventually gets to see her husband and was given some half-baked story about sepsis. Managing a grin, her comment to me later was: “I felt his face. It was neither hot nor room temperature.” (She figured it out without the ten years of medical training.) The next day I visit him in the ICU, sitting up, eating bacon and eggs. He quips: “I’m still above ground.” I ask the nurse in the unit why the patient was transferred. He shrugged.

“D***ed if I know.” After less than twelve hours in the unit he was sent back to the ward. It took that long for his family’s collective heart rate to return to double digits.

FEATURE Now the process of figuring out what happened. His nurse that night was gone — probably forever. The charge nurse handed me a neatly-printed sheet entitled Severe Sepsis Alert Worksheet.

Ohhhh. Now they throw in the “Severe.” That’s not what’s announced overhead. The hospital operator does not say “severe sepsis alert,” just (ordinary) “sepsis alert.” Next, I’m told that the patient’s temperature was 100-something degrees. Okaaaaaay. He just had surgery. Maybe a touch of atelectasis? A little metabolic upshift to deal with an inflammatory/healing response? Now — that’s not all. His heartrate was greater than ninety. Well duhhh — why didn’t you tell me? There’s this thing called pain (the fourth vital sign). It happens when a knife cuts through skin and muscle and bone and… There’s this other thing known as stress, anxiety, worry… His pre-operative heart rate was more than ninety. Now doctor, there’s no need for sarcasm. Did I mention that the patient’s respiratory rate was twenty and his WBC >12,000? The nurse pushes back, crosses her arms over her chest and gloats. Obviously, that explains it. Any fool can see that. Double Hmmmmm. There’s this thing called pain, stress, anxiety… wait a minute. I’ve already said that. Okay. There’s this thing called blood loss. It happens with surgery (most of the time and elevates both RR and HR). I consider a post-op hemoglobin of 10 gms/% a roaring success. A post-op WBC of 12 to 18 is the norm.

You get the point. The so-called-severe-sepsis-alert protocol requires two of the following four parameters: 1) temp >100.4 or <96.8 2) HR>90 3) RR>20 4) WBC >12 or <4. Congratulations.

You have just described a typical post-operative patient (at least mine). I might as well put “sepsis alert” in my post-op orders!

In case you missed it, some of the above is tongue-in-cheek.

Here’s my humble suggestion. Downgrade sepsis alert from Cat-5 Hurricane to tropical storm. Don’t announce it overhead to be followed by a D-Day style land invasion of a patient’s room (which nearly put my patient into V-tach and his wife in a car wreck as she rocketed to the hospital). Replace the SWAT team with a demure RN cradling a clipboard, who reviews the chart, knocks politely on the door, and has a civilized chat with the patient. If it’s true sepsis (which it rarely is by the way) then blow the whistle. If it’s not, then how about just phoning the attending to see what they wish to do.

(I’ve been involved in two such non-sepsis-alerts, and in neither case was I informed anything had happened.)

By the way, I just put in an application for a “Low Back Pain” Alert.

Robert G. Johnson, MD, is an orthopaedic surgeon, a BCMS member and a frequent contributor to San Antonio Medicine.

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35

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San Antonio Medicine • January 2019

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

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

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

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

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients.

Robert R. Biechlin, Jr., Partner (210) 581-0275 rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

ASSETS ADVISORS/ PRIVATE BANKING

BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future.

Claudia E. Hinojosa Vice President, Private Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

BANKING

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

We work hard and together with our clients to accomplish great things.

Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@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.

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@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 Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

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

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

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

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

Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

www.synergyfcu.org “Once a member, always a member. Join today!”

First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust.

Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

BUSINESS CONSULTING Waechter Consulting Group (HH Silver Sponsor) Want to grow your practice? Let our experienced team customize a growth strategy just for you.

Utilizing marketing and business development tactics, we create a plan tailored to your needs!

Michal Waechter, Owner (210) 913-4871 Michal@WaechterConsulting.com “YOUR goals, YOUR timeline, YOUR success. Let’s grow your practice together”

DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service.

Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations "We provide peace of mind, giving compassionate care to our community with integrity"

EMPLOYEE MANAGEMENT Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org

Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire em-

ployee life cycle. From online onboarding to certification tracking to payroll processing, manage your people anytime, anywhere.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney, Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

John M. Albert |The Farret Team | Financial Advisor 210.278.3816 john.albert@ml.com www.fa.ml.com/farretgroup “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll

services to securing employee benefits and P&C Insurance.

Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage – Sr. Loan Officer 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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!”

Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment pro-

continued on page 38

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

cessing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

Elizabeth Olney with Edward Jones ( Gold Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you.

Elizabeth Olney Financial Advisor (210) 493-0753 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to

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San Antonio Medicine • January 2019

help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning).

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans.

Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

viding none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

HOSPITALS/ HEALTHCARE SERVICES

210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in the Medical industry.

David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

INSURANCE

HEALTHCARE BANKING

Amegy Bank of Texas ( 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 EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE CONSULTING

Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for pro-

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

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager

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

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

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

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

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

LUXURY REAL ESTATE 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.”

MedPro Group (HH Silver Sponsor) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

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

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

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

Craig Browning

MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

MARKETING ADVERTISING SEO

Veerspace (HHH Gold Sponsor) We're a nationwide digital advertising agency that specialize in growing aesthetics practices through videography and social media. Office contact number is 210-969-7850.

Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Genevieve Pineda Business Development Director 210-386-7853 Genevieve@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

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

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

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold 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 to 50 percent.”

PHYSICIAN SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Leslie Barnett, SWBC Mortgage lbarnett@swbc.com Gil Castillo, SWBC Wealth Management, 210-321-7258 gcastillo@swbc.com Kristine Edge, SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza, SWBC Mortgage Sr. Loan Officer 210-386-0732 cleogarza@swbc.com Debbie Marino, SWBC Insurance & Benefits, 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tina Turnipseed, President Tom Tidwell, President-Elect info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land

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San Antonio Medicine • January 2019

for development Marcelino Garcia CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie@kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

RESIDENTIAL REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

RETIREMENT PLANNING

New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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.”

United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

TELECOMMUNICATIONS ANSWERING SERVICE

TAS United Answering Service ( Gold Sponsor) We offer customized answering service solutions backed by our commitment to elite client service. Keeping you connected to your patients 24/7.

Dan Kilday Account Representative 210-258-5700 dkilday@tasunited.com www.tasunited.com “We are the answer!"

For questions regarding services, Circle of Friends sponsors or Joining our program.

Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

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. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Rudy Solis 210-558-1500

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

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

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

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

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 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

Eric Schwartz 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

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

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Marty Martinez 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

Scott Brothers 210-253-3300

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Victor Zapata 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

AUTO REVIEW

2019 BMW M5

By Stephen Schutz, MD

Are we finally in an age when sedans can provide supercar performance? Yes, and you could argue we’ve been there for several years. In fact, we are entering a time when SUVs can provide supercar performance, as the introduction last year of a Lamborghini SUV and my recent experience with a Mercedes AMG SUV remind me.

Nevertheless, spending a week with the new 2019 BMW M5 was a revelation. It’s so fast that superlatives describing how rapid this super sedan is pale in comparison with the actual experience of driving the car. The M5 is rated at 600HP, but that’s not reality.

German automotive manufacturers are famous for understating their horsepower figures, and, while I’m not going to lie and tell you I can accurately gauge the power in the cars I drive, the M5 has a HUGE amount of oomph when you hit the throttle. (For the record, thedrive.com reported that a 2019 M5 produced just 44

San Antonio Medicine • January 2019

under 700HP on a dynamometer.)

It’s a cliche to say, “I hit the gas and when I looked down I was going 80MPH.” But when I did just that on a quiet stretch of highway and looked down, I was doing 125MPH. Seriously, this car is fast.

It’s a BMW, so naturally the new M5 handles well too. Autobahn speeds on a straight road are no sweat, naturally, but the newest (F90) is more nimble than the last generation (F10) was. The F10 was criticized by some for putting straight line performance ahead of cornering, and BMW addressed those concerns with suspension changes that make the F90 feel lighter than its 4,288 lbs curb weight would make you believe. This car loves the open road and high speed turns the most, but it does almost as well as the F80 M3 on tight B-roads, which is saying something.

Some of the credit for the blazing 2.8 second 0-60MPH time

AUTO REVIEW and improved handling goes to the new AWD system. The ability to spread some of the power to the front tires obviously improves traction, which helps optimize acceleration, but it’s still hard for me to process the fact that a luxury sedan that we can walk into a dealership and buy today can accelerate from 060MPH more than a second faster than a late 1970s Porsche 935 race car. It boggles the mind.

Anyway, AWD also helps handling through torque vectoring and other software tricks, which is presumably why the new M5 feels so much lighter on its feet than its predecessor did even though they weigh about the same.

The engine in all M5s is a twinturbo 4.4 liter V8 paired with an 8speed automatic transmission. No manual will be offered. (As I’ve written before, there’s a size of car above which a manual no longer really works, and that size is smaller than an M5.)

For around $7,000 an M5 Competition with suspension enhancements, a bit more power, and a few other tweaks is available.

As noted in detail above, the M5 hardly needs more power, but in case your neighbor just bought an M5 and you need bragging rights, this will do it.

At various times in the past, BMW has added a Competition package to M-cars for true enthusiasts. Now, rather than offer a package, BMW has created a separate Competition line to go with their M-vehicles. So far we have M2 and M5 Competitions available, with more to come later.

The styling of the new M5 is best described as subdued, which may be off-putting for some buyers. Even non-car people can look at an M3 with its aggressively flared fenders and big front intakes and tell it’s not a standard 3-series. That’s not the case with the M5, which blends in. If you’re OK being Clark Kent with just a faint hint of Superman, this is your sports sedan.

Inside the M5 things feel more special. The seats are very sporty and supportive with illuminated M5 emblems and beaucoup bolstering. Many M5 badges, electronic and otherwise, abound and even small details like meaty shift paddles and bright red (programmable) M1 and M2 buttons behind the steering wheel make driving the M5 more of an event than piloting a lesser 5-series.

This is a German car, so many options and trim packages are available for additional cash. As always, call Phil Hornbeak before

you buy an M5 (or anything else) for sound advice and the best BCMS pricing.

The 2019 BMW M5 provides supercar performance in a sedan.

And if you crave performance that’s even more OTT there’s a Competition version. Buyers looking for a more extroverted exterior may prefer the Mercedes E63 AMG or Porsche Panamera S, but otherwise the M5 remains the large performance sedan benchmark.

As always, contact Phil Hornbeak at 210-301-4367 to get information about options and your best BCMS deal on a Navigator.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 45 45 visit us us at at www.bcms.org

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San Antonio Medicine â&#x20AC;˘ January 2019