San Antonio Medicine January 2023

BCMS TOGETHER WE STAND

San Antonio Medicine Magazine – 112 Years of Service

By John J. Seidenfeld, MD 12

A Look Back and Ahead with Dr. Phillip W. Voltz, Jr. Interview by Monica Jones, BCMS, COO 14

The Importance of Dermatologic Access for Lower Socioeconomic Communities By Christina Pierce, Rebecca Wang and Tue “Felix” Nguyen 16

When It’s Better to Be Under More Pressure

By John J. Feldmeier, DO, Jayesh B. Shah, MD, John S. Peters, FACHE 18

Surprise Medical Billing Litigation Update –TMA on Offensive to Support Our Patients

By Jayesh B. Shar, MD, MSc, UHM ABPM, CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP 22

“The Match” - A Brief History of Training Physicians in the US By Mark Andrew Tobias 24

The BCMS Physician Coaching and Wellness Program –Year-In-Review By Nora Vasquez, MD, CEO & Founder of Thriving Leaders iin Medicine Coaching Program 26

The San Antonio Orthopedic Group (TSAOG) – 75 Years of Tradition in Medicine and Innovation

By The San Antonio Orthopedic Group 27

Three Tax Savings Strategies to Start Using This Year

By Oakwell Private Wealth Management, Platinum Circle of Friends Sponsor of BCMS 28 Welcome Stranger: Alzheimer’s Caregivers Guide

By Mr. Sherman P Macdaniel, Review by Adam V. Ratner, MD, FACR 30

Preventing Physician and Medical Student Suicide: An Urgently Important Conversation By Alissa Roemer, Emily Heydemann and Veronica Gonzalez 31

BCMS President’s Message 8

BCMS Alliance Message 10

The Time Machine Poem By Alissa Roemer 32 Falling Leaves By Nisha Kalyanpur; Put on A Happy Face By Emily Heydemann, Is She Brave? By BMH 33-34 Check Claims Dates for Drug Administration as Coding Updates Loom By Alisa Pierce 35 2023 BCMS Installation of Officers, 2023 BCMS Alliance Installation of Officers 36-39

BCMS Vendor Directory 40

Auto Review: 2023 Audi S3 By Stephen Schutz, MD 44 Recommended Auto Dealers 46

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BCMS BOARD OF DIRECTORS

ELECTED OFFICERS

John Joseph nava, Md, President Brian t. Boies, Md, Vice President Ezequiel “Zeke” Silva iii, Md, Treasurer John Shepherd, Md, Secretary Brent W. Sanderlin, do, President-elect rajeev Suri, Md, Immediate Past President

DIRECTORS

Col. tim Switaj, Md, Military Representative Keiko McManus, Md, Board of Ethics Representative George F. “rick” Evans, Jr., General Counsel Jayesh B. Shah, Md, TMA Board of Trustees Melody newsom, CEO/Executive Director Jenny Case, Alliance Representative Cheryl pierce-Szender, Alliance Representative ramon S. Cancino, Md, Medical School Representative lori Kels, Md, Medical School Representative robert leverence, Md, Medical School Representative John pham, do, Medical School Representative ronald rodriguez, Md, phd, Medical School Representative Woodson "Scott" Jones, Md, Member Sumeru “Sam” G. Mehta, Md, Member priti Mody-Bailey, Md, Member lubna naeem, Md, Member lyssa n ochoa, Md, Member Jennifer r. rushton, Md, Member raul Santoscoy, do, Member John Shepherd, Md, Member Amar Sunkari, Md, Member lauren tarbox, Md, Member

BCMS SEnIOR STAFF

Melody newsom, CEO/Executive Director Monica Jones, Chief Operating Officer Yvonne nino, Controller Mary nava, Chief Government Affairs Officer Brissa vela, Membership Director phil Hornbeak, Auto Program Director August trevino, Development Director Betty Fernandez, BCVI Director Al ortiz, Chief Information Officer

PUBLICATIOnS COMMITTEE

norys Alexandra Castro-pena, Md, Co-chair John Joseph Seidenfeld, Md, Co-chair louis doucette, Consultant david Schulz, Community Member Elizabeth Clanton, Md, Member Kristy Yvonne Kosub, Md, Member neal Meritz, Md, Member Jaime pankowsky, Md, Member Alan preston, phd, Member rajam S. ramamurthy, Md, Member

Adam v ratner, Md, Member Faraz Yousefian, do, Member Moses Alfaro, Student Member Winona Gbedey, Student Member tue Felix nguyen, Student Member niva Shrestha, Student Member nancy Salas, Editor

United We Stand, Divided We Fall

By John J. Nava, MD, 2023 BCMS President

Martin Luther King, Jr.

These last few years have been tough. Some physicians may feel like the family of medicine has been treading water, others are of the opinion that we have been merely drifting. In either case, people would agree that progress was elusive. We are AmeriCAN doctors, not AmeriCAN’T! We must be goal directional in our activities, correct? All this sitting around waiting has been too frustrating for many physicians.

As we continue to respond to an evolving pandemic that has become endemic, the routine of daily life is being reinvented. Whether this most recent episode of a novel virus affecting multiple body systems is “over” is debatable. At least we can hope that the debate will lead us to more effective evidence-based responses for populations most affected by Covid19 and future pathogenic infectious agents.

I am happy to tell you that during this time, your Bexar County Medical Society (BCMS) and Texas Medical Association (TMA) have not been idle. Instead, both groups have been working closely on the issues which affect physicians most. Since the Texas legislature only meets every two years on odd years, physicians have a chance in 2023 to speak directly with their lawmakers at First Tuesdays. Physicians can assume the role of lobbyist for a day, and the sea of white coats visiting legislators at their Capitol offices is impressive. Organized by the TMA, recruitment for First Tuesdays is underway for Texas physicians interested in this form of advocacy for patients and the profession of medicine. TMA has published ten advocacy priorities, and our collective voices can impact the understanding of those issues for the legislators.

• Scope of Practice/GME Funding

• Women’s Reproductive Health

• Medicaid Rate Increases

• Enhanced Coverage for Women and Children on Medicaid

• Protection of Tort Reform

• Physician Autonomy/Corporate Practice Protections

• Prior Authorizations

• Protect Vaccine Laws/Modernization of ImmTrac

• Network Adequacy and Protecting the Texas Surprise Billing Law

• Regulation and Taxing E-cigarettes

At the last Fall Conference on September 17, TMA reintroduced Wellness First, a program promoting physician wellness by moving the focus from primarily individual factors to national, organizational and systemic sources of burnout and stressors. Coincidentally, that day was the National Physician Suicide Awareness Day. Helping physicians care for themselves helps them care for patients, and without our patients, we have a much-diminished purpose. I anticipate the successes of Wellness First will enhance our approach to patients suffering from anxiety, depression and burnout in their own lives.

TMA has provided direction, and this is definitely a robust list of opportunities to be heard. Faced with this moment, each of us has a decision to make. We each will decide to follow or lead, or perhaps just watch from the sidelines, depending on our individual situations. This is truly an individual choice as each can be appropriate at different times. I am honored to promote TMA’s published list of legislative priorities for advocacy, but this list is just the beginning. It can stimulate each member to develop their own interests and work together with other members of TMA, or more locally, within the BCMS committee structure. I welcome any member interested in becoming more involved, and pledge to try to facilitate those connections. To learn more about committee volunteer opportunities and how you can get involved, please call (210) 3014371 or visit our website at www.bcms.org.

I look forward to serving as your BCMS President in 2023.

John J. Nava, MD, is the 2023 President of the Bexar County Medical Society. He is interested in Primary Care, Clinical Research and Public Health.

“We must learn to live together as brothers or perish together as fools.” –

Message from the BCMS Alliance Co-President

By Jenny Case, MSN, MBA, RN

Over the past few years, COVID-19 has put unprecedented stress on the medical profession and world at large but has also shown the strength of the medical community to unite and support the greater good. Whether it be sharing PPE between clinics and hospitals to large scale innovative designs to develop vaccines and treatments, the medical community worked to save lives and get through the pandemic together.

As we step back and reflect about the past few years, we can see that the ability for our medical providers and their families to fall back on a community of other medical families is paramount. It is also clear that the stress on the medical community is not going away anytime soon. With surges of other illnesses, staffing issues and general misinformation abound, the need for support continues to be great. The support system that the Alliance and the BCMS have helped curate over the years played a vital role in backing the medical community through this pandemic and will continue to do so going forward.

The mission of the Alliance is to support families, advocate for the physician-patient relationship, and to be a source of volunteers to make a difference in Bexar County. While the social aspects of the Alliance were put on hold during the pandemic, the members stepped up to a more mission driven purpose such as collecting PPE, supporting immunization clinics and hosting blood drives. “Hard Hats for Little Heads” was a program to educate children and parents about the importance of helmets and safety gear in order to prevent head injuries. Additionally, just a few weeks ago on Christmas Day, children here in San Antonio received new beds and stockings made by Alliance members while working through the Sleep in Heavenly Peace program.

We are looking forward to getting back out there, to not only helping with initiatives here in Bexar County, but also to our fun social events and making new friends in our medical community. As we slowly opened up this past year with our events, we realized how the friendships and bonds from the Alliance are lifelong. No one quite understands a call schedule like other medical family members. So, if you (or your spouse) aren’t yet a member of the Bexar County Medical Society (BCMS) or the Alliance, let me be the first to invite you to join! Our medical community is stronger when working together towards the same goals and we look forward to getting to know everyone and continuing our mission.

Jenny Case, MSN, MBA, RN. She is the 2023 Co-President of the BCMS Alliance.

San Antonio Medicine Magazine112 Years of Service

By John J. Seidenfeld, MD

As I write these reflections, I am thankful to the medical society and Melody Newsom, CEO, the committee membership and administrative staff (Monica Jones, COO, and Nancy Salas, editor), the sponsors, the board and the publisher. I am grateful to the student and graduate doctors who contribute their thoughts and research to the magazine, and our readership which has access to this locally produced, Bexar County focused source of medical information. Students, community members and physicians volunteer their time and insights to the society. Both San Antonio schools of Osteopathic and Allopathic medicine from the University of the Incarnate Word and the UT Health San Antonio have been involved as authors and editors. We hope that their contributions help them in future endeavors as they continue with graduate medical education. Their significant thoughtfulness and creativity have been fundamental to our mission. Our practicing, retired physicians and committee members have also been major contributors with unique insights and perspectives.

The committee chair and staff reviewed the 2011 edition of San Antonio Medicine magazine (SAM) (100-year anniversary) in preparing this reflection. In that magazine are familiar faces, and “voices” from decades of resolute volunteers. I am impressed by the concern to not only stay on the right track but keep moving in the right direction. A consistent aspiration is to supply useful practice information to improve the health of the citizens of Bexar County. Thousands of won-

derful doctors and their families have contributed to SAM and sharing of essential information. Over the past century SAM has documented the Spanish flu (treated by masking, distancing and hand washing) to COVID treatment with anti-viral medications and mRNA vaccines, wound care before and after the advent of antibiotics, and inherited disease and the advent of gene therapy which promises profound changes by replacing inherited DNA segments with new gene editing techniques. Contributors have written about the development of new anesthesia techniques and robotic surgery, new non-invasive diagnostic techniques, the growing recognition of cancer to a time of research into cancer cell biology with the promise of malignant cell extinction, the AIDS epidemic, the birth and growth of two medical campuses and an ever-changing and enlarging healthcare facility and practice landscape. The Bexar County Medical Society has moved from French Place to Highway 1604 and will continue to be vigilant to the business and practice of medicine in years to come. Its members will continue to write of their past and present, and to predict their future.

Controversies arise periodically and the board and committee with the guidance of the CEO and COO thread the needle and try to stay topical, current and factual. Not all articles will be a good fit. If you feel there is information you would like to consider or directions you would like us to take, please share with us in letters to the editor. Our goal is to support your practices both in the science and business of medicine

so that you successfully care for your patients. Our student contributors often bring fresh ideas to the magazine in art, poetry or other creative work. They help us to understand what Medicine looks like from their perspective. We have a web presence under the publication tab to the right on the entry page to BCMS.org. There you will find ways to contact us, upcoming themes, past journals and articles.

We hope our themes and articles are of value to our readers and we always welcome your thoughts either in letters to the editor or articles given for publication. All of you have a challenge deciding what most warrants your attention and time. Whether you pick up a copy in the doctor’s lounge between patient encounters or read SAM magazine sent to your home or office, we appreciate your direction and suggestions. We review themes and develop a tentative list for the coming year well in advance. At monthly meetings, the committee members edit and review articles in detail slated for the next magazine six weeks before publication. In addition, the committee membership reviews the future four to six editions for suggested content and contributors. Our staff regularly consults with the Texas Medical Association (TMA), community members, medical groups and sponsors to recommend a particular author or topic. Over the past two years we have all been in the thrall of the COVID pandemic and it will be a topic as well as a cause of suffering for years to come. The society magazine has responded with prompt articles, reminders from the TMA and critical

information from the Centers for Disease Control and Prevention. Legislative updates, end of year reviews, wide ranging topics from Veteran and Military Medicine to issues of Primary Care and Specialty Physicians, board information, the President’s message, Public Health, Alliance information, book reviews and automotive insights are regular features.

Our goals are to be of value to our membership, listen to the voices of young authors, serve all Bexar County populations and communities, distribute information for improvement of the health of all Bexar citizens and communicate issues of greatest interest to our membership. Let us know how you think we are doing with a letter to the editor. I promise we will carefully consider all submissions and all issues raised. My thanks and gratitude to you for your lifelong learning and dedication to the profession to which we are committed.

John J. Seidenfeld, MD is the Chair of the BCMS Publications Committee.

A Look Back and Ahead with Dr. Phillip W. Voltz, Jr.

Phillip W. Voltz, Jr., MD is

Almost 70 years of being a member of the Bexar County Medical Society (BCMS), Phillip W. Voltz, Jr., MD, Radiation Oncology Specialist, and a BCMS member for life visited the BCMS office. During a very candid interview, Dr. Voltz took us back when he was the 77th BCMS President in 1973.

At 93 years old, Dr. Voltz is the eldest living BCMS President today. He became a member of BCMS in 1959, Vice President 1973, Presidentelect 1974 and President in 1975. Dr. Voltz has six kids, seven grandchildren, four great grandchildren. He was accompanied by his wife Geneva. Dr. Voltz discussed many notable events during his Presidency, but there was one that stood out. In February of 1975 BCMS tackled the professional liability insurance (malpractice) concerns. There were several problems: rising premiums for each physician, particularly those certain “high risk fields”, more suits (70 in Bexar County, unofficially in 1975), physicians practiced defensive medicine and ordered tests and x-rays which probably were not necessary, inability of some physicians to obtain insurance, resulting in some physicians practicing without insurance. There was a change in attitude of patients and their families to include even hostility. Dr. Voltz stated that the causes of these problems include the “age of miracles”, the patient is immortal and if the patient dies or had a bad result, they had the wrong doctor. The “Nada” attitude – questioning every act of “lack” of action in our practice. It was a time of economic stress; many people were looking for the fast buck and the number of lawsuits were increasing. The insurance companies were problematic in that the patient considered them to be rich and that a suit really wouldn’t hurt their doctor. The insurance company pays and then raises the rates the next year. Their profit and overhead continue. To resolve these issues the TMA and BCMS formed a special task force addressing concerns. The task force would work on the following: better rapport with the patient, National and State legislation, establish our own local, state or national insurance company to fight every nuisance or unfounded claim to the bitter end, drop our professional liability insurance and own no property in our own name, write a release form stating that once patient selects a physician as his physician realizing his human frailty, varying skills, training, judgment, knowledge, or lack thereof, in his care, that we are liable only for gross negligence.1 Four bills were introduced and general hearings on the professional liability problem were held on March 4, 1975. Under the supervision of the TMA’s Legal Counsel, a major effort was made to present the physician’s case from all standpoints at the state

by Monica Jones, BCMS COO

legislature. BCMS physicians were selected to testify and offer prepared remarks and documented cases. In the July 1975 president’s message, Dr. Voltz said, “The professional liability insurance crisis in Texas and the nation has done more than anything I have ever seen to stimulate our members into activity, involvement, and unity. I haven’t met or communicated with a single member who hasn’t volunteered to work in every way possible to help alleviate this situation to help our society, medicine, and our patients. This interest and activity are, and has been, happening all over the state. With unity there is strength.”2 Unfortunately, Dr. Voltz did not see the “Patients Insurance Compensation Act of Texas” approved during his term as BCMS President, but in 1977 Texas Legislature (Both Houses) passed the “Medical Liability and Insurance Improvement Act of Texas” in the closing hours of the legislative session on May 30, 1977. Governor Briscoe signed the bill June 16, 1977.3 Another notable event, was the first time both the scientific sessions and the TMA House of Delegates met together under one roof. This gave the delegates a chance to spend more time in the exhibit hall and to attend the scientific sessions as well as gave members a better idea of how the business of TMA is handled by the House of Delegate. Dr. Voltz explains in his May 1975 President’s Message, “This will be an excellent opportunity for BCMS members to attend the reference committees, and if you don’t know what a reference committee is, then this is the time to participate and find out!” 4

Current Events during his time on the Board

• 1973 Last US troops leave Vietnam

• 1973 Dallas Chaparrals basketball team moves to San Antonio and changed name to Spurs

• 1974 Two Italian gynecologists create the blunt tunneling technique known as liposuction

• 1974 First vaccine for chicken pox developed

• 1975 Lila Cockrell, wife of the BCMS Executive Director, Sid E. Cockrell, was elected the first female Mayor of San Antonio

• 1975 DNA sequencing is born as researchers at Harvard and Cambridge simultaneously develop different methods for determining the sequence of bases in DNA

• 1976 Apple Computer founded by Steve Jobs

• Dean Kamen develops a portable insulin pump for mass market

Positions held in 1975

President of the United States, Gerald Ford; Governor of Texas,

interviewed

Dolph Briscoe; San Antonio Mayor, Lila Cockrell and the Executive Director of BCMS was Sidney E. “Sid” Cockrell, Jr.

Dr. Voltz was born in Pittsburgh, moved to Tennessee when he was seven years old and attended the University of Tennessee. He earned his medical degree at 22 years of age. Dr. Voltz came to Texas in 1959 just out of residency. He joined the group at Christus Santa Rosa Hospital (CSR). His specialty was diagnostic radiology but also had a certificate in nuclear medicine. As a physician, looking back, one of the biggest hurdles was the change in separate billing. “The original way was that the hospital would bill and the physicians would get a percentage. Patients were not use to getting a bill from the doctor. This was a big nuisance because we then needed to provide collections for our services which took more time away from patient care.”

While in office, Dr. Voltz was able to get the administrators of all the hospitals to come to his house to start a blood bank. He said they would have their administration meeting, watch TV, chat all while giving blood. He said the funny part is that he often passed out during these meetings, because after donating the amount of blood they gave you were supposed to rest. At that time, he was the youngest BCMS President and thought he was “good”. There were other doctors that passed out ending the home blood drive meetings.

Dr. Voltz acknowledged the BCMS programs and presentations that occurred every week on different studies such as cancer, prostate, medical school scientific tests, estrogen positive or negative and so many more. They were informative, educational and a way to socialize with your peers. How has medicine changed through the years? “As far as the therapies go, all we had was the old x-ray machine, and everyone said it burned them. If you got the right treatment, you got a reaction. In the years to come we got a Cobalt unit in the radiation center at CSR. The dedication of this very expensive, revolutionary advanced radiotherapy machine was done by Ronald Reagan. Former President Reagan was the spokesman for GE and spoke to the CSR radiologist specialist and

staff, a couple of years before he ran for US President. The Cancer Therapy and Research Center was opened in 1974. We have seen so much working with a medical oncologist on what we can do for a patient and the combinations of therapy. With the newer machines and computers, we could better localize a tumor and therapy. We saw nuclear medicine go from a tiny Geiger counter to a big stress test machine. Radiology has changed so much. Dr. Voltz said that he has an aortic graph, hip replacement, hearing aids, stints, upper plates, and takes about eight meds. “People like me shouldn’t be 93 years old. When I was growing up anyone that was 65 was old. I am alive because of the innovations in medicine. Medicine keeps us all running.”

Dr. Voltz message to future physicians and membership, “Pledge us your time and your talents. Keep involved. The difficult can easily be accomplished. The impossible will take a little longer.”

References

1. The Medical News, Bexar County Medical Society, Volume 28, Number 3, March 1975, page 4.

2. The Medical News, Bexar County Medical Society, Volume 28, Number 7, July 1975 page 3

3. Texas Medicine Volume 73, July 1977

4 The Medical News, Bexar County Medical Society, Volume 28, Number 5, May 1975 page 3

Jones, BCMS Chief Operating Officer

Monica

Dr. Voltz and wife enjoying the Auto Show event and the Elvis Impersonator

The Importance of Dermatologic Access for Lower Socioeconomic Communities

By Christina Pierce, Rebecca Wang and Tue “Felix” Nguyen

What role does low socioeconomic status have in access to care for dermatologic conditions?

Dermatologic complaints are common in the United States, with 85 million patients in 2013 visiting physicians for their skin complaints. Dermatologic care can help reduce mortality and hospitalization for patients with skin conditions.1 However, access to dermatologists is widely variable and dependent on many factors such as poverty, rurality, insurance status, age, sex and travel burden. One study found that poor, near-poor, and low-income individuals were less likely to have a dermatology visit in one year compared to middle-income individuals. Additionally, uninsured patients or those with Medicaid or Medicare had fewer odds of visiting the dermatologist than privately insured patients.1 Based on the 2020 Census, 17.6% of the San Antonio population are persons in poverty, and 19.3% of individuals under the age of 65 in San Antonio were without health insurance. Lack of health insurance and lower income decrease the likelihood of these individuals receiving dermatologic care. Dermatological conditions and diseases, such as squamous cell carcinoma and melanoma, are prevalent. Lower socioeconomic status (SES) creates a barrier for patients to seek and receive the care or treatment they need. Fortunately, there are studentrun free clinics affiliated with UT Health San Antonio that are of no cost to those seeking care and serve as a resource to address dermatological concerns. However, we are advocating that awareness of these free clinics be more widespread to inform patients who would benefit from visiting.

Where are these clinics located, and what do they offer?

Travis Park Dermatology Clinic is a free dermatology clinic run by students and faculty within the UT Health San Antonio system located in downtown San Antonio. This clinic is open on the second and

fourth Tuesday of every month, between 3:45 to 6:00 pm and is a walkin clinic with an effort to see all patients who need care. Travis Park also serves as a valuable learning opportunity for medical students, they are able to manage the dermatologic concerns of many patients by conducting focused skin histories, and physical exams and reporting their findings to the present dermatology residents and attendings. The team then formulates a treatment plan with the patient’s financial situation in mind. Therefore, free clinics serve as a resource that increases accessibility to quality care and enriches the medical school curriculum by allowing students to assess and treat patients holistically.

While Travis Park is an excellent opportunity for patients with lower income or unstable healthcare to address their skin complaints, many still encounter barriers that prevent them from seeking care. Some of these barriers include lack of transportation, mistrust of the medical system, other time constraints and language barriers. Additionally, knowledge of these free clinics may not be available to everyone in San Antonio who may benefit from visiting these clinics.

What can we do to improve access?

An idea we suggest to improve accessibility and address barriers to care would be establishing more operating clinic locations in the San Antonio area, especially in communities that lack healthcare. This proposition could be accomplished by using a geographical mapping tool such as PHATE to identify lower SES regions that may greatly benefit from having a clinic nearby. Once the clinic locations have been chosen, students and faculty will set a date and time to provide consistency. For example, the free clinic will be open on the first Wednesday of every month at 3:00 pm at the south side location and on the third Wednesday of every month at 3:00 pm at the downtown location. This scheduling would provide more opportunities and options for patients

of disadvantaged communities to pursue having their skin concerns addressed without the burden of worrying about transportation, payments or other time obligations. Eventually, with the medical institution's support, establishing more available clinic times would provide flexibility and reliability to cultivate stronger relationships with our patient communities.

Another way to increase the utility of free clinics is to broadcast their existence to primary care practices. Many free clinics are often only known by word-of-mouth, so many primary care practices may not be aware of these resources. At Travis Park, patients occasionally walk in after being referred to by their primary care providers. These patients were typically referred because they could not afford a visit to a regular dermatology practice or get an appointment until much later; however, they still needed treatment for their skin conditions. Thus, improving free clinic visibility to the San Antonio medical community may help provide physicians with more options to recommend to their patients.

Closing thoughts - how can we stand together?

Addressing dermatological concerns or questions is essential for all patients. However, by recognizing the barriers that exist, it is imperative to ensure that patients with lower SES have the opportunity to have

access to dermatology providers. With this article, we hope to encourage awareness and stand together as medical professionals, healthcare volunteers and community service providers to improve community health and patient wellbeing.

References:

1. Tripathi, R., Knusel, K. D., Ezaldein, H. H., Scott, J. F., & Bordeaux, J. S. (2018). Association of Demographic and Socioeconomic Characteristics With Differences in Use of Outpatient Dermatology Services in the United States. JAMA dermatology, 154(11), 1286–1291. https://doi.org/10.1001/jamadermatol.2018.3114

2. U.S. Census Bureau quickfacts: San Antonio City, Texas. (n.d.). Retrieved November 21, 2022, from https://www.census.gov/quickfacts/fact/table/sanantoniocitytexas/LND110210

Christina Pierce, Rebecca Wang and Tue “Felix” Nguyen are all medical students at UT Health San Antonio Long School of Medicine.

When It’s Better to Be Under More Pressure

By John J. Feldmeier, DO, Jayesh B. Shah, MD, John S. Peters, FACHE Table

1

The medical discipline of clinical hyperbaric medicine had its origins in the 1960s with seminal work done in both Holland and the United States. One of the early applications employed hyperbaric oxygen delivered in large chambers configured as operating theaters. By operating under pressure and delivering significantly increased oxygen doses to the patient, open-heart surgery was possible because the enhanced hyperoxemia permitted a tolerance to a longer period of asystole than would be possible for patients operated at normal surface pressures.1 Once heart and lung machines became available, there was no need for surgery under pressure. The very first application of hyperbaric or recompression treatment was its application to the treatment of decompression sickness (commonly known as the bends) and other diving injuries.2 This treatment is still the definitive intervention for decompression sickness and injury due to rapid changes in pressure for divers, including traumatic air embolism also known as barotrauma.

In the intervening years, hyperbaric oxygen has evolved to be a studied and effective therapy for many disorders, often as an adjunct to the primary treatment (See Table 1. for the list of accepted indications). These applications are based on a large body of supporting literature and research, much of it level-1 evidence. Some in other medical disciplines still think of hyperbaric oxygen as an “alternative medicine.” It is certainly an unusual medical treatment because it does not come as a pill or capsule nor is it delivered intravenously. Hyperbaric oxygen has been recognized as a medical subspecialty by both the American Board of Preventive Medicine and the American Board of Emergency Medicine both of whom offer board-certification in this discipline. Hyperbaric oxygen is most commonly employed now for non-healing wounds in the lower extremities of individuals with diabetes and delayed complications of therapeutic radiation. In both of these applications, hyperbaric oxygen can often permit avoidance of major disfiguring and disabling surgeries. Randomized controlled trials sup -

port its application in both these pathologies. One mark of its acceptance is the declaration that hyperbaric oxygen should be considered an intervention supported by Level 1 evidence published in the article laying out clinical guidelines by the American Society of Colon and Rectal Surgeons for the treatment of chronic radiation proctitis. Most thirdparty payers including Medicare will reimburse for hyperbaric oxygen treatments for the indications provided in Table 1.

The Undersea and Hyperbaric Medical Society (UHMS) has been the premier professional organization for the hyperbaric medicine community for over 50 years. This organization seeks to provide support for education, research and communication, and offers a forum for continuing education and exchange of the latest updates at its national and regional meetings. The UHMS has conducted a practice accreditation program for 20 years that seeks to promote high standards of practice within the hyperbaric medicine community. Hyperbaric oxygen is a unique treatment that offers unique benefits in certain cases but also introduces unique concerns regarding safety in this very specialized environment involving high pres -

sures, high oxygen content and the attendant risk for both fire and explosive decompression. It is vital that the equipment involved in treatment, especially the pressure vessel itself, be designed, manufactured, installed and maintained to the highest standards. This requires adherence to established hyperbaric design and operational standards provided by the NFPA (National Fire Protection Association) and the American Society of Mechanical Engineers Safety Standards for Pressure Vessels for Human Occupancy (ASME PVHO-1). Perhaps, most importantly the chambers should be cleared in accordance with the Pre-Market Notification Process (FDA 510k) by the FDA.

Over the past decade or so, “mild hyperbaric” facilities have proliferated in the U.S. and internationally. These “mild hyperbaric” centers are mostly located in Spas, Wellness Centers, and even shopping center store fronts. They are not being operated as medical facilities or even doctors’ offices. They frequently operate with minimal or no physician involvement. Staff are often inadequately trained. Many, if not most, employ pressure vessels to deliver mild hyperbaric “treatment” that fail to meet the safety standards of the NFPA or ASME and frequently they are not FDA cleared. Many use zip-up chambers made of non-rigid material very much akin to a canvas bag. Some of the soft-sided chambers have FDA clearance for the treatment of acute mountain sickness but are not cleared for the range of disorders scientifically supported by the UHMS (Undersea and Hyperbaric Medical Society) and are not cleared when combined with oxygen. Even more recently we have seen rigid chambers manufactured in other countries and exported to the U.S. in parts and pieces to be assembled. In this piecemeal fashion, these uncleared chambers are often not detected by inspectors and pass into the country to be used without FDA awareness. Standard, main stream hyperbaric medicine requires treatment most often at ambient pressures of 2.0 to 3.0 ATA (atmospheres absolute) with oxygen delivery at those pressures exceeding 95% of the breathing gas mix. The “mild” hyperbaric facilities typically treat their patients - more prop -

Class B Monoplace FDA-approved Chamber

Class A Multiplace FDA-approved Chamber. The door is sealed for treatment.

This photo shows a soft-sided chamber typical of chamber used for “mild hyperbarics.” This type of chamber can only be approved by the FDA for the treatment of mountain sickness. The photo also shows an oxygen concentrator which is not approved for usage with hyperbaric treatments.

Copyright Undersea and Hyperbaric Medical Society (UHMS) Photography.

continued from page 19

erly clients, at pressures of 1.4 ATA or lower. While many “mild” centers treat with compressed air only, some “mild” facilities attempt to increase the oxygen concentration for patients in their noncleared chambers and compound safety issues by adding oxygen concentrators. The oxygen concentrators employed are themselves often imported without 510K clearance. Since both hyperbaric chambers and oxygen concentrators are classified as Class 2 medical devices, they have to be reviewed and cleared individually and in any joint usage.

In websites and promotional brochures, some of these facilities have intentionally usurped the large body of published scientific articles reporting the results of standard and properly dosed and delivered hyperbaric oxygen. These include the 14 indications listed in Table 1. The mainstream hyperbaric community, as does the FDA, considers hyperbaric oxygen to be a “drug.” As such, it must be delivered by prescription in adequate doses with proven protocols to be effective. Ineffective treatments can delay the appropriate application of hyperbaric oxygen. Just recently, in Great Britain, a diver was treated for decompression sickness (the bends) ineffectively in a “mild” hyperbaric facility. The diver did not have resolution with the “mild” treatment and subsequently required retreatment at a standard hyperbaric recompression/hyperbaric facility. Severe, improperly treated decompression sickness can result in death for the diver if treatment is inadequate or delayed.

“Mild hyperbaric medicine” centers are targeting a vulnerable population of patients with disorders for which there is no established role for hyperbaric oxygen at any pressure in any treatment protocol. Desperate parents will pay large sums of money to these centers to treat children with cerebral palsy, autism or other unproven, often neurologic indications. “Mild hyperbarics” is portrayed as an innovative new therapy. Another vulnerable group includes stroke patients who may be months or years post stroke. Although the treatment of stroke patients with hyperbaric oxygen has been and continues to be studied, this treatment is investigational and not reimbursed by health insurance carriers. Therefore, when treated in unsafe chambers and with ineffective doses, these patients accumulate a substantial debt with virtually no hope of improvement.

Both the American Medical Association (AMA) and the Bexar County Medical Society have approved resolutions calling for a cessation of “mild hyperbaric” treatments. As you may know, the Bexar County resolution was recently communicated to the Texas Medical Board (TMB). The TMB took prompt action to issue a cease-and-desist order to two “mild hyperbaric” activities in state. Each were operated by dentists. These operations were shutdown based on the determination that these individuals were practicing medicine without a medical license.

In summary, “mild hyperbaric” advocates and providers offer a du-

plicitous presentation to their potential clients and regulators. On one hand, they claim that their chambers need not adhere to the long-established standards for safe design and operation required for clinical hyperbaric installations because of the “mild” doses delivered at pressures just slightly elevated above sea level pressure. On the other hand, they attempt to convince their potential customers that these mild pressures will be as effective as the established higher pressures combined with essentially 100% oxygen offered by mainstream hyperbaric facilities. All too often, the current “mild hyperbaric” operators promote their therapy to vulnerable populations for unproven indications. Until and unless, these “mild hyperbaric facilities” comply with all appropriate safety regulations and select appropriate treatment pressures and protocols along with safely delivered and approved oxygen delivery systems to treat scientifically supported disorders, they should be required to cease and desist treatments. The delivery of hyperbaric medicine is the practice of medicine. Nonphysicians must not be permitted to deliver this very specialized medical treatment without the involvement, prescription and oversight of properly trained and licensed physicians. Nurses and staff working under the direction of trained and preferably board-certified physicians must be adequately trained to understand and respond to their patients’ unique hyperbaric environment and their patients’ reactions and special needs in this environment.

Physicians of the UHMS would gladly welcome new colleagues to our discipline if indeed they were committed to practice safe and effective hyperbaric oxygen treatments. As it now stands, we are a discipline which aims to police itself and seeks to support safe and effective treatments by professional and technical staff who are prepared and trained to deal with the unique complications that can occur in the hyperbaric realm and do so with greater frequency when the treatments are improperly delivered.

References

1.Leopardi LN, Metcalfe MS, Forde A, Maddern GJ. Ite Boerema-surgeon and engineer with a double-Dutch legacy to medical technology. Surgery. 2004 Jan;135(1):99-103. doi: 10.1016/j.surg.2003 .08.022. PMID: 14694306.

2. Acott C. A brief history of diving and decompression illness. South Pacific Underwater Medicine Society Journal. 1999 29 (2). ISSN 0813-1988.

3. Paquette IM, Vogel JD, Abbas MA, Feingold DL, Steele SR; Clinical Practice Guidelines Committee of The American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Chronic Radiation Proctitis. Dis Colon Rectum. 2018 Oct;61(10):11351140. doi: 10.1097/DCR.0000000000001209. PMID:

4. Moon, R. UHMS Hyperbaric Oxygen Therapy Indications, 14th Ed. 2019. Best Publishing Company. North Palm Beach, FL. ISBN: 978-1-947239-16-6.

John J. Feldmeier is the retired Chairman of Radiation Oncology at the University of Toledo Medical Center. He is boardcertified in both Radiation Oncology and Hyperbaric Medicine. He is a Past President of the Undersea and Hyperbaric Medicine Society (UHMS). He currently serves as Co-chairman of that Society’s Research Committee and Chairman of its FDA Liaison Committee.

Jayesh B. Shah is Immediate Past president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, Texas. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society and is currently on the Texas Medical Association Board of Trustees.

John S. Peters is the Executive Director of the Undersea and Hyperbaric Medical Society (UHMS). He is a board-certified healthcare executive and a Fellow of the American College of Healthcare Executives (ACHE). He has spent over thirty years in the undersea and hyperbaric medicine field, originally in the acute care setting and later leading teams to success in several different organizations involved in the Specialty.

Article published with the permission of the Undersea and Hyperbaric Medical Society (UHMS).

Surprise Medical Billing litigation update –TMA on Offensive to support our patients

By Jayesh B. Shah, MD, MSc, UHM ABPM, CWSP, FAPWCA, FCCWS, FACHM FUHM, FACP

Historically, health plan payments have not covered the entirety of an out-of-network patient’s bill. As a result, a patient could be left with a “balance bill” for the remaining amount representing the difference between the health plan’s payment and the physician’s billed charge (after patient cost-sharing).

Patients sometimes expect to receive balance bills (e.g., when they are using their out-of-network benefit and choose an out-of-network physician). Other times, patients have been “surprised” to receive a balance bill for out-of-network services. These surprise medical billing scenarios have occurred when a patient was receiving out-of-network emergency care or receiving out-of-network services at an in-network facility.

Surprise medical billing can stem from insurance companies having narrow or inadequate physician networks. A narrow physician network means insurance companies do not have enough doctors, providers, and facilities that are in the network, which also causes a problem for the patient with access to care.

In 2020, Congress stepped in to address surprise medical bills at the federal level. The No Surpises Act (NSA) was enacted on December 27, 2020 as part of the Consolidated Appropriation Act of 2021. The NSA’s surprise billing provisions apply to certain out-of-network medical bills for patients covered by certain plans, e.g., self-funded ERISA plans. (Texas’ surprise billing law, SB 1264 (86- R), remains in effect as a “specified state law” for the state regulated plans subject to its provisions).

Among other patient protections, for most emergency services, as well as non emergency services provided at in-network facilities (with certain exceptions), the NSA restricts out-of-network physicians from billing a patient for more than the patient’s in-network cost sharing amount. The health plan has 30 days to make an initial payment or notice of denial of payment after receiving a bill from the physician. A physician who is unhappy with the initial payment may initiate open negotiations and independent dispute resolution (IDR) with the plan. The patient is not involved in the IDR.

The federal law specified various factors that must be considered during the IDR process. The IDR process that was enacted by Congress incentivized both insurers and providers to act in good faith and resolve disputes amongst themselves. Under the law, factors that the arbiter must consider include:

• the “qualifying payment amount” for comparable items or services furnished in the same geographic area

• prior contracted rates during the previous four plan years

• market share of both parties involved

• provider’s training and experience

• patient’s acuity/complexity of furnishing the item or service

• if the provider is a facility, teaching status, case-mix and scope of services

• demonstration of good faith efforts by providers and facilities to enter into a network agreement

However, on September 30, 2021, the US Department of Health and Human Services (HHS) and other agencies released an interim final rule (IFR) that unfairly benefitted commercial health insurers. According to the rule, arbiters were required to rebuttably presume that the offer closest to the qualifying payment amount (an amount that is supposed to be the median in-network rate under the law but is deflated based upon the rulemaking methodology) was the appropriate out-of-network rate.

On October 28, 2021, the Texas Medical Association (TMA) filed a lawsuit challenging the IFR’s presumption language. On February 23, 2022, the court released an opinion finding in favor of TMA. The court found that the federal agencies had improperly bypassed notice and comment in implementing the challenged provisions of the rule, and that the IFR conflicted with the terms of the NSA. The federal agencies appealed the decision, which was stayed pending the release of final rules.

On August 19, 2022, the Departments released the long-awaited final rule. While the new rule removed the rebuttable presumption language of the prior rule, it included new language that still elevates the QPA, tilting the scales in the health plan’s favor once again. On September 22, 2022, TMA filed a second lawsuit, challenging certain provisions of this final rule. A hearing has been scheduled in TMA’s second lawsuit for December 20.

On November 30, 2022, TMA filed a third lawsuit against the federal agencies related to rulemaking under the No Surprises Act. In this lawsuit, TMA is challenging portions of the federal agencies’ July 2021 interim final rules that artificially deflate the QPA, which results in underreimbursements from health plans.

Unfair rules regarding the IDR process and the calculation of the QPA can reduce access to care by discouraging meaningful contracting negotiations and reducing provider networks.

Hopefully, TMA’s legal challenges will ensure that the agencies’ rules

follow the law so patients can receive the best care that is affordable and accessible.

References

1. Centers for Medicare and Medicaid Services. Ending surprise medical bills. https://www.cms.gov/nosurprises

2. Harris PA. AMA says surprise billing proposal in Congress is a step forward. American Medical Association. https://www.amaassn.org/press-center/press-releases/ama-says-surprise-billing-proposal-congress-step-forward . Published May 23, 2019.

3. Texas Medical Association. TMA moves for victory in challenge to unfair arbitration rule. https://www.texmed.org/Template.aspx?id =58365&terms=Surprise%20medical%20billing . Published Dec. 13, 2021.

4. Texas Medical Association. TMA sues feds over unfair rule for surprise billing law. https://www.texmed.org/Template.aspx?id =58062&terms=Surprise%20medical%20billing . Published Oct. 29, 2021.

5. Robeznieks A. Federal action on surprise medical bills: what doctors should know. American Medical Association. https://www.amaassn.org/delivering-care/patient-support-advocacy/federal-action-

surprise-medical-bills-what-doctors should?utm_medium=ppc& utm_campaign=pe-digital-ads-surprise-billing&gclid=CjwKCAiAxJSPBhAoEiwAeO_fP_R_2xDIVRQl02oMWi3tUf2IvgU0fK0 7SSEoVSqIWNzemAy9eM1zXRoCYusQAvD_BwE . Published Jan. 26, 2021.

Jayesh B. Shah is Immediate Past president of the American College of Hyperbaric Medicine and serves as medical director for two wound centers based in San Antonio, Texas. In addition, he is president of South Texas Wound Associates, San Antonio. He is also the past president of both the American Association of Physicians of Indian Origin and the Bexar County Medical Society and is currently on the Texas Medical Association Board of Trustees.

“The Match”- A Brief History of Training Physicians in the US

By Mark Andrew Tobias

One day after the drafting of this article, September 27, 2022, roughly 47,675 medical school seniors will have submitted their applications to about 36,627 US PGY-1 residency positions through the National Resident Matching Program (NRMP), also called “The Match.”1 This year marks the 70th anniversary of the Match in the US2 and as of 2022, will have generated around 6.5 million dollars a year for the NRMP from student application fees alone. This process is one of the most important annual events in modern medicine in the US. It’s the source of pride, excitement, fear, disappointment and many other emotions for medical students across the world, but what exactly is “The Match,” what did we do before? and how did we get to this point?

“The Match” process itself is a real-life example of the “Stable Marriage Problem” in mathematics. It is defined as “the problem of finding a stable matching between two equally sized sets of elements given an ordering of preferences for each element.” Another example of this type of algorithm would be a speed dating event with two equal numbered groups, split by attraction to the other group, all getting matched with a date by the end of the night. Additionally, the Stable Marriage Problem is called stable, because “there does not exist any pair (A, B) which both prefer each other to their current partner under the matching,”

which means that all the pairs are as happy as possible with their partners given all of their preferences and how they were matched up. This algorithm is not to be confused with the “Stable Roommates Problem,” where instead of two groups being matched to a member of the opposite group, there is instead one group matched within themselves by order of preference to each other. So, how did we end up using this algorithm to play cupid between medical student and residency, in order to explain the birth of the match we must travel far back in time.

Let us begin in the ancient times where there was no such thing as the Match, medical school or even acetaminophen! During these times “physicians,” if one could call them that, were usually men, who declared themselves pupils to the philosophy of medicine, anatomy and illness. Notable figures included Hippocrates of Kos, Alcmaeon of Croton and Charaka of ancient India and others. This style of “physicianhood” continued for many years until during the renaissance, religious control of the profession decreased, medical discovery was more evidence based and most physicians took up apprenticeships under established physicians to learn the trade. Fast forward to 1765 when the first medical school in the US, the College of Philadelphia, was founded by John Morgan and Willian Shippen after they finished learning and teaching medicine abroad. By 1813, Yale School of Medicine was

founded, marking the 5th medical school in the US after which there was an explosion of new medical schools opening up, many of which were done so by individual physicians with no affiliation to any hospital or university. States began to respond to the increase in medical schools and decrease in education quality by creating medical examiner boards that required state exams to be taken for physician licensure, beginning with the state of Connecticut in 1821 and culminating with the founding of the American Medical Association (AMA) in 1847.

Around 40 years later in 1889, two men by the names of Dr. William Halstead and Dr. William Osler devised the first residency programs in the United States for surgery and medicine, respectively, at Johns Hopkins University.3 This concept would spread across the country and laid the foundation for all modern residencies as we know it. Only graduating medical students at the top of their class would have the privilege of being accepted to the early residencies and there was no formal system in place to acquire a position.

While American medical education suffered from its growing pains due to events like the Flexner report, the state of medical residency matriculation continued to deteriorate. Up until 1945, hospitals would commonly scout medical students for residency, even into their second year of medical school and lock them into one sided contract, which students would take as the only other option was to risk graduating without a residency position. To finally combat the recognized problem the Association of American Medical Colleges (AAMC) implemented the “Cooperative plan,” where medical schools would not release student information until a specific date in their senior year. Although well intentioned, this led to residencies offering spots with a time limit on a reply, and by 1949 residency offers lasted less than 12 hours with some hospitals requiring an immediate reply via telephone.

To combat this new problem Dr. F.J. Mullun, the dean of students at UChicago School of Medicine proposed a rank-order list solicited from students and residencies that would be used to produce a centralized match. Thus in 1952, the first American medical residency match was performed. This of course was not without its own set of problems, biggest of all, was the match algorithm used for the first match which could lead to students losing all matches or matching very low on their list if they decided to pick a “reach” program as their top program. This problem was fixed with the implementation of the Boston-Pool algorithm and then fixed again in 1998 with the switch to the Roth-Peranson algorithm which prioritizes students lists over program’s ones.4

More recently in the history of the Match, couples were officially able to match together starting in 1990 whereas before, in the 1970s, couples would ask permission from their schools’ dean to rank together. The Match was extended to medical fellowships in the ‘80s and ‘90s leading to a more systematic approach to continued education. Before 2010, if one did not match during match day, they would enter a period of time known as “The Scramble,” in which they would have hours to

days to get in contact with as many programs as possible to pander for an unfilled position. This chaotic and stressful breakdown was changed in 2010 with NRMP replacing it with the Supplemental Offer and Acceptance Program or “SOAP,” where all forms of communication for unfilled positions are done through the Electronic Residency Application Service (ERAS).5 Lastly, as of this year, 2022, supplemental applications are being implemented in 15 specialties, up from only 3 last year and United States Medical Licensing Examination (USMLE) Step 1 and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) level 1 are pass and fail.6

To paraphrase the Greek philosopher, Heraclitus, “The only constant is change” and this holds true for not only the practice of medicine, but also the journey to becoming a physician. There have been many changes over the years in the process of training physicians and it seems that there will continue to be for the foreseeable future. There is now talk of increased use of exams such as Casper, which are designed to test “situational awareness” for use in residency applications among other things. As a current 4th year medical student in the United States, I feel the process still needs major revisions, that at present are above my head, but moving forward with the knowledge of the past makes things a little more bearable by putting it all in perspective.

References

1. National Resident Matching Program, Results and Data: 2022 Main Residency Match®. National Resident Matching Program, Washington, DC. 2022.

2. 2. Roth AE. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909.

3. Cameron JL. William Stewart Halsted. Our surgical heritage. Ann Surg. 1997 May;225(5):445-58. doi: 10.1097/00000658199705000-00002. PMID: 9193173; PMCID: PMC1190776.

4. Roth AE. The Origins, History, and Design of the Resident Match. JAMA. 2003;289(7):909–912. doi:10.1001/jama.289.7.909

5. “Eras Soap® Information.” Students & Residents, AAMC, 2022, https://students-residents.aamc.org/applying-residencies-eras/erassoap-information.

6. “Specialties Participating in the Supplemental ERAS® Application.” Students & Residents, 2022, https://students-residents.aamc.org /applying-residencies-eras/specialties-participating-supplementaleras-application.

Mark Andrew Tobias is a medical student at the University of Incarnate Word School of Osteopathic Medicine, Class of 2023. He is interested in Psychiatry.

Year-In-Review

The BCMS Physician Coaching and Wellness Program

By Nora Vasquez MD, CEO & Founder of Thriving Leaders in Medicine Coaching Program

Happy New Year! As we begin 2023, I’d like to reflect on the past year to see how much we’ve accomplished in our mission to advance physician wellness so that we can both celebrate and put forth new intentions. Last year, the Bexar County Medical Society launched an innovative wellness initiative with the support from a Texas Medical Association Foundation grant. As an advanced certified physician coach and internist, I developed and led the Physician Coaching and Wellness Program. The mission of this coaching program was to empower physicians with evidenced-based coaching strategies to mitigate burnout and enhance physician well-being. We did this by creating a physician-led, safe and virtual space for doctors to meet and learn how to recognize and mitigate the effects of burnout while also providing meaningful support for the BCMS community. After leading over 14 CME Coaching and Wellness webinars, each month it is apparent that we heal and thrive in community.

The coaching sessions provided a unique opportunity to discuss the real-life concerns that physicians encounter daily. The physicians acknowledged the evolving challenges of practicing medicine especially over the last two years. The necessary protocols put in place because of the COVID pandemic isolated many of us from family, friends and colleagues. The chronic stress and trauma of bearing witness to our patients’ suffering further added to the distress. The BCMS Physician Coaching and Wellness program provided an important way for the community of healthcare professionals to talk about these challenges while normalizing and supporting their human experience. In fact, during this past year we were able to help restore a sense of meaning and enjoyment in the daily medical practice of many participating physicians.

Many of the topics discussed addressed critical issues related to leadership, work and home life integration, as well as insights on how to better manage the daily stressors of practicing medicine. Many of the physicians who participated enjoyed discussing a variety of topics, including:

• How To Overcome Burnout & Thrive

• Time Management for Busy Healthcare Professionals

• Processing Grief: Emotional Healing for Healthcare Professionals

• How To Overcome Perfectionism Pitfalls

• How To Overcome Imposter Syndrome

• Efficient Charting Tips

Physicians found these coaching and wellness sessions valuable in creating a growth mindset. Some shared their reflections recognizing that, “Perfectionism is unattainable. Focus on growth and progress. Learn from your experiences. Self-affirmation is important to maintain healthy progress.” Another participant added, “This was a good reminder that we are in charge of our experience at work. We can choose to make changes and see this in a different light.”

While the challenges in medicine continue, I am encouraged by the overwhelming positive feedback that was shared by the hundreds of physicians we served. As we look forward to expanding this resource, I encourage you to reach out and participate in the Physician Coaching and Wellness webinars in 2023. You can find more information by signing up for our calendar of events at the BCMS website found at www.bcms.org.

As an active member of the Bexar County Medical Society, I am honored to have led this initiative and look forward to expanding the program as we continue to advance physician wellness this year and beyond!

Nora Vasquez, MD is a Certified Physician Coach and a Board-Certified Internal Medicine Physician with over a decade of experience. She developed the Physician Wellness Webinar Series for BCMS physician members to empower physicians with evidencedbased coaching strategies to mitigate burnout and enhance physician well-being. You can learn more about Dr. Nora Vasquez at www.renewyourmindmd.com. Dr. Vasquez is a member of the Bexar County Medical Society and Texas Medical Association.

The San Antonio Orthopedic Group (TSAOG) –75 Year of Tradition in Medicine and Innovation

By The San Antonio Orthopedic Group

The San Antonio Orthopedic Group has been providing orthopedic care in Bexar County since 1947, specializing in diagnosis and treating musculoskeletal diseases and injuries at eight clinical locations and two outpatient surgical centers citywide.

John J. Hinchey, MD, founded The San Antonio Orthopedic Group in 1947. Originally from Pennsylvania, Hinchey’s Texas ties began at Texas Tech University where he received his undergraduate education. He later went on to the Mayo Clinic in Rochester, Minnesota for his residency but was called to World War II. After the war, he returned to the Mayo Clinic to complete his residency, then he made his way back to Texas, where he had previously completed his internship at Robert B. Green Hospital in San Antonio. Dr. Hinchey enjoyed the San Antonio community so much and he decided to make this city home.

Dr. Hinchey was the first orthopedic surgeon in South Texas. During his early years, he traveled to hospitals as far west as Midland and as far south as Brownsville, carrying his own instruments with him, so he could perform surgeries.

Over the years, Dr. Hinchey grew his practice by partnering with a number of well-respected surgeons who all shared his vision of providing the highest quality orthopedic, medical and surgical care to the San Antonio and South Texas community.

Today, TSAOG Orthopedics & Spine continues Dr. Hinchey’s vision with more than 42 orthopedic specialists and over 100 providers that are experienced, skilled and subspecialty trained to treat and care for the full range of musculoskeletal disorders.

TSAOG has spent the past two years making their Ridgewood Orthopedic Center, near the Encino Park neighborhood, into a surgical education and research hub.

TSAOG has partnered with Michigan medical technology company “Stryker” to open the “Stryker Educational Showroom” at the 100,000square-foot Ridgewood facility in summer 2021.

The “Stryker Educational Show Room” can accommodate education spaces and training programs, for example, the Burkhart Bioskills Lab. This Florida-based health care training network opened this spring, according to TSAOG officials.

“The lab is named after Dr. Stephen Burkhart, a retired TSAOG physician and a pioneer in shoulder arthroscopy. The Burkhart Bioskills Lab enables medical trainees and different types of health care providers to participate in comprehensive clinical trainings.” Derek Pupello, CEO at US Bioskills.

The showroom features a mock operating room, where patients and medical staff can view implants, equipment and an interactive board demonstrating what happens to a patient before and during their procedure. “The partnership between TSAOG and Stryker allows us to innovate and provide the best outcomes for our patients.” Dr. Kevin Kirk, Board-Certified Orthopedic Surgeon, specializing in Foot and Ankle.

References

1. TSAOG Website and Community Impact Newspaper – North San Antonio Edition

Photography Copyright of The San Antonio Orthopedic Group

Three Tax Savings Strategies to Start Using This Year

By Oakwell Private Wealth Management, Platinum Circle of Friends Sponsor of BCMS

Tax savings strategies can help you keep more of what you have earned. There are many types of strategies that could apply to your personal situation and help you protect and grow your wealth.

This guide by your Oakwell Private Wealth Management team provides a brief overview of three tax savings strategies physicians can start using for this year and beyond. Please consult with your CPA on what is right for your specific circumstances.

Invest in the right retirement vehicles

Investing in your retirement is beneficial both now and in the future. When you put money into tax-deferred retirement accounts, you lower your taxable income. That money then gets invested, tax-deferred, from whenever you contributed until you take money out.

It can be challenging to choose the right retirement vehicle for your situation. Each option has its own benefits, both tax-related and otherwise. If you need help understanding which retirement vehicle might be right for you, reach out to your CPA or Oakwell experts for guidance.

You should know that contributions to most IRAs, including Roth IRAs, must be put in by the 2022 tax deadline. SEP IRA and profit sharing and cash balance contributions can be submitted later if you file a tax return with an extension. However, all employee contributions need to be made before the end of the actual tax year.

Consider changing business entity types

Changing business entity types could improve your tax burden. For example, if you have an LLC generating income, there may be benefits to converting it to an S corporation. If you have multiple partners or shareholders, consider if a partnership structure makes more sense for you.

Of course, you will have to pay some taxes regardless of which business entity type you choose. However, there may be value in changing your corporate structure to suit your personal situation.

Another business-related tax strategy involves planning your business deductions. For example, you may reach the end of one tax year and realize you need to purchase new equipment. Consider and compare your projected income for that year and the next one. This step will help you decide when to purchase the equipment and take the deduction for that expense.

Engage in tax-smart philanthropy

Charitable giving can be a tax-effective strategy, especially if you have experienced or expect to experience any potential taxable events. These

events can include rebalancing your investments, converting your Roth IRA, income changes, withdrawing from retirement accounts and more. Here are a few ways to be tax-smart as you give back:

• Donate appreciated non-cash assets instead of cash. This strategy can help eliminate the capital gains tax typically incurred by selling or rebalancing assets before donating.

• Combine two years of contributions into one year if your itemized deductions for one year are slightly below the standard deduction level.

• If you are over the age of 70.5, make Qualified Charitable Distributions to reduce your IRA balance and potentially reduce future tax liabilities.

• Establish a charitable remainder trust, a charitable lead trust, or a donor-advised fund account. These strategies can be complicated, and their benefits may depend heavily on your specific situation, so ensure you consult with your tax or legal advisors before taking action.

Philanthropic donations have risen to historic levels in recent years. Talk to your CPA about whether these charitable deductions and strategies could help offset some tax liabilities on any potential taxable events you might experience.

Let us help you keep more of what you have earned by coordinating with tax professionals and wrapping a complete financial strategy around you to protect and grow your wealth. To learn more about how we can root physicians’ financial success in our collective knowledge, contact Brian T. Boswell, CFP, QKA at 800.556.2593 or send an email to bboswell@oakwellpwm.com.

Brian T. Boswell, CFP®, QKA is a

Sr. Private Wealth Advisor and Partner with Oakwell Private Wealth Management.

The information contained in this article represents the opinion of Oakwell Private Wealth Management and should not be construed as personalized or individualized financial advice. Oakwell Private Wealth Management is not a CPA Firm. Any strategies presented in this article should be discussed with the appropriate tax or legal advisors before any action is taken.

Welcome Stranger: Alzheimer’s Caregivers Guide

By Mr. Sherman P. Macdaniel A Brief Review by Adam V. Ratner, MD, FACR

Dementia is increasing in prevalence as our population ages. By default, many dementia patients are cared for by their spouses and family members who may be your patients. The burdens on caregivers are enormous and most are unprepared to succeed in this role. Caregivers, though well-meaning, are typically frustrated and not optimally effective in dealing with loved ones with dementia. As physicians, we are often at a loss to help our patients navigate the challenges of becoming and sustaining the role of caregiver.

Mr. Sherman Macdaniel, the grandson of 1917 BCMS president, Alfred McDaniel, MD, wrote this brief guide to begin to address the challenges of being an Alzheimer’s caregiver. He states that the purpose of this book is to help Alzheimer’s caregivers reduce stress and anxiety. He does this by relating his personal challenges and experiences of taking care of his late first wife and provides very practical yet compassionate and spiritual suggestions for caregivers in similar circumstances.

In addition to practical tips on caring for the dementia patient, he also provides insights on managing guilt, frustration and sadness often experienced by caregivers. In addition to his own experiences, he also draws on the wisdom and experiences of knowledgeable friends to create this brief guide.

I am sad to say that Mr. Macdaniel recently passed away this past October, near the end of his ninth decade of life. He spent much of his final decade researching, writing, distributing and updating Welcome Stranger, as well as speaking to other caregivers of dementia patients.

You and your patients can also download and read a free copy of the book in English or Spanish by going to The Patient Institute website (http://www.patientinstitute.org/alzheimerscaregivers-guide/)

Physical copies of Welcome Stranger may be obtained by contacting:

The Patient Institute PO Box 781971 San Antonio, TX 78278-1971

Adam V. Ratner, MD, FACR is Professor of Radiology, Health Policy & Medical Humanities and Assistant Dean of Strategic Initiatives at UIWSOM, and served as the 2019 President of BCMS. He is also an active member of the BCMS Publications Committee.

“A Powerful Book to Help Your Patients Care for Their Loved Ones Suffering from Dementia”

Preventing Physician and Medical Student Suicide: An Urgently Important Conversation

By Alissa Roemer, Emily Heydemann and Veronica Gonzalez

On the evening of September 29, 2022, students and residents from UIW School of Osteopathic Medicine, UT Health Lozano Long School of Medicine and Texas Institute for Graduate Medical Education and Research (TIGMER) joined together to bring awareness to the significant issue of physician suicide. Tragically, 300 to 400 physicians die by suicide every year, and physician burnout has become an even more serious problem as a result of the pandemic. The purpose of this event was to raise awareness, teach us how to recognize and help colleagues in distress, provide us a forum for ending stigma and promote healing in our community. The event featured expert speakers, personal reflections and offered students the opportunity to ask questions and share their concerns about mental healthcare access.

Following the event, a gallery of student and physician-created artwork was displayed, some of which we would like to share with you now. Through this creative outlet, medical students and physicians were able to express their emotional responses to a difficult topic. By continuing the conversation, we hope that those in our field will feel empowered to openly discuss and share their own mental health challenges. Together we can continue to cultivate a supportive environment and work to reduce physician suicide.

Alissa Roemer is a student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2025

Emily Heydemann, MSW, is a student at UT Health San Antonio Long School of Medicine, Class of 2023

Veronica Gonzalez, LPC, LCDC is a student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2025

The Time Machine Poem

By Alissa Roemer

The Time Machine

Time has a way of slowing down just when you’re ready for it to speed up.

What if I sped past this part?

The bad part the part I didn’t like the part I didn’t want to experience the part that made life hard to live. Living there feels like living in a  time machine.

A time machine eternally stuck in the same spot. There’s no past, no future, just this moment of eternal suffering.

The time machine is a cruel master to me.

The time machine does not let go. The time machine is relentless.

I want to let go.  Let me go. Each day starts the same. I wake,  I am paralyzed by fear.  Can’t move, can’t breathe, can’t get up. Surely you can get up.

A 21-year-old woman.  Surely surely you can get up—what are you back in second grade? Helpless, alone, isolated, surrounded, crowded, no hope, no light. Depression.  Depressed. Depressing. Depression. Each day is the same agony. Little reprieve from the agony.  The time machine whirls to life the only sign of life for miles  here we go again  the tape starts. My past in four dimensions plays all around me. Stop Rewind  Play  Stop

Rewind  Play Play Play

Where did the stop button go? It’s gone without a trace. Play Rewind  Play Rewind

Everyday is the same: playing old tapes in my head. Just stop the tape they say Place it in a corner of your mind they say  Leave it there they say  Why? How?

I want to I can’t  I need to  I need to get out Fine, help me. Fine, yes, I need help. Long talks, sterile halls, little oblong pills.  Suddenly a fissure breaks the time machine in two. I’m free.  I step out into the new world Everything glistens under my watchful gaze.  Was this here the whole time?

I cast a backward glance toward the broken time machine.  Sad, dilapidated pieces on the ground. Goodbye old world. Hello to the new world.

Artist Note: This piece symbolizes the hardest part of my life. It represents how it feels to experience suicidal ideation, which is a fine term to throw around in a chart, but actually represents a deep gnawing pain that is almost too hard to put into words. This was my attempt.

Alissa Roemer is a student at the University of the Incarnate Word School of Osteopathic Medicine, Class of 2025

Falling Leaves

By Nisha Kalyanpur

Nisha Kalyanpur is a student at UT Health San Antonio Long School of Medicine, Class of 2023

Put On A Happy Face

By Emily Heydemann

Artist Note: This photograph has two meanings to me, first, as medical trainees, we must present ourselves as perpetually bright and shiny even if we feel otherwise. Second, sometimes I feel held back by my own beliefs about myself. This photo represents how we are often capable of more than we realize.

Emily Heydemann, MSW, is a student at UT Health San Antonio Long School of Medicine, Class of 2023

Is She Brave?

By BMH

When the passion has been replaced by exhaustion and politics

When the exhaustion is guised as petty mistakes

When the mistakes manifest as insecurities

When politics only enforce the insecurities, she already harbored

When you tell her she can’t handle it,

Will you call her brave when she stands against it?

Will you support her even if it means the light is temporarily not on you?

Will you support her when she shines the light on your injustices?

Will she be brave when she stands up the only way she knows how?

Will you recognize strength in taking the step most spend their entire life evading with fear?

Will you hear the message in her action that cannot be undone?

Will it be brave enough for you to take action?

Perhaps brave enough for you to listen?

Or maybe just brave enough for your thoughts and prayers.

This poem was inspired by Dr. Jing Mai, a resident physician who took her life on September 5, 2022.

Check Claims Dates for Drug Administration as Coding Updates Loom

By Alisa Pierce

With annual updates to billing codes for medications set for January 1st, physicians are reminded to use the most current National Drug Code (NDC) and Healthcare Common Procedure Coding System (HCPCS) combinations when filing claims for drug administration.

Each drug product is identified by a universal NDC and assigned an HCPCS billing code from databases that publish each year on January 1st.

Physicians can utilize resources like the NDC-to-HCPCS Crosswalk, which is available for clinician-administered drug processing. The Texas Health and Human Services Commission (HHSC) publishes the crosswalk, based on additions to the Centers for Medicare & Medicaid Services’ list of rebate-eligible drugs and new drugs. Clinicians can check the site each month for updates and are encouraged to reference the national database of NDC and HCPCS codes in the meantime.

When billing for administration of a drug, physicians must pull from the vial a specific NDC number that correlates with the payable HCPCS code in the national database. The crosswalk aids physicians

in identifying those relationships between NDCs and HCPCS codes.

However, Texas Medical Association experts caution practices to make sure the NDC used is valid for the date of service. The effective date of the NDC must correlate with the date of service used on the claim. This is because NDCs can expire, change, or be prematurely removed from the national database. For instance, for a prescription administered prior to the Jan. 1 publication, use the prior NDC number. To ensure correct payment, the NDC code on the claim must correspond to that on the medication vial.

If you are receiving claims denials, contact TMA’s payment specialists for help.

Alisa Pierce is a reporter for Texas Medicine, Division of Communications and Marketing.

Copyright Texas Medical Association. Reprinted with permission from TMA Publications.

2023 BCMS Installation of Officers

First

First

First

First

John Joseph Nava, MD 2023 BCMS President

Brian T. Boies, MD Vice President

Ezequiel "Zeke" Silva, III, MD Treasurer

John Shepherd, MD Secretary

Brent W. Sanderlin, DO President-elect

Rajeev Suri, MD Immediate Past President

Woodson “Scott” Jones, MD

Appointed to fill Board of Directors

Term 2021-2023

Sumeru “Sam” G. Mehta, MD Board of Directors

Term 2023-2025

Priti Mody-Bailey, MD Board of Directors

Term 2023-2025

Lubna Naeem, MD Board of Directors

Term 2021-2023

Lyssa Ochoa, MD

Board of Directors

Second Term 2023-2025

Jennifer R. Rushton, MD

Board of Directors

First Term 2022-2024

Raul Santoscoy, DO

Board of Directors

First Term 2022-2024

Amar Sunkari, MD

Board of Directors

First Term 2021-2023

Lauren Tarbox, MD

Board of Directors

First Term 2022-2024

Jayesh B. Shah, MD

Board of Directors

TMA Board of Trustees, Representative

Ramon S. Cancino, MD Board of Directors Medical School Representative

Col. Timothy Lawrence Switaj, MD Board of Directors Military Representative

Robert Leverence, MD Board of Directors Medical School Representative

John Pham, DO Board of Directors Medical School Representative

2023 BCMS Installation of Officers (continued)

Kels, MD Board of Directors Medical School Representative

Rodriguez, MD Board of Directors Medical School Representative

McManus, MD Board of Ethics, Chair

Lori

Ronald

Keiko

Melody Newsom BCMS CEO/Executive Director

George F. “Rick” Evans, Jr. General Counsel

2023 BCMS Alliance Installation of Officers

Jenny Case Co-President Cheryl PierceSzender Co-President Victoria Kohler-Webb President-Elect Heather Davila Membership Team

Brittany Garcia Vice President Communication

Stephanie Stewart Vice President Programs/ Social Team

Tatiana Sweeney Vice President Comminity Outreach Team

Virginia Profenna Treasurer

Julia Halvorsen Secretary

Shop Vendors Who Support BCMS

BCMS Vendor Directory

We encourage you to use our supporting vendors whenever you or your practice needs supplies or services.

ACCOUNTING FIRMS

ASSETT WEALTH MANAGEMENT

Synergy Federal Credit Union (HH Silver Sponsor)

Sol Schwartz & Associates P.C. (HHH Gold Sponsor)

Sol Schwartz & Associates is the premier accounting firm for San Antonio-area medical practices and specializes in helping physicians and their management teams maximize their financial effectiveness.

Jim Rice, CPA 210-384-8000, ext. 112 jprice@ssacpa.com www.ssacpa.com

“Dedicated to working with physicians and physician groups.”

ACCOUNTING SOFTWARE

Bertuzzi-Torres-Fernandez Wealth Management Group (HHH Gold Sponsor)

We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

Mike Bertuzzi

First Vice President Senior Financial Advisor 210-278-3828

Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

Synergy FCU Member Services

210-750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

CLINICAL DIAGNOSTICS

Managing Partner (210) 503-0003 www.genicslabs.com “Accurate results in record time.”

CREDENTIALS VERIFICATION ORGANIZATION

Bexar Credentials Verification, Inc. (HHHH 10K Platinum Sponsor)

Bexar Credentials Verification Inc. provides primary source verification of credentials data that meets The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA) standards for health care entities.

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 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

ATTORNEYS

Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres Will C. Fernandez, CEPA Senior Portfolio Advisor Financial Advisor 210-278-3812 wfernandez@ml.com https://fa.ml.com/texas/san-antonio/bertuzzi-torres-fernandez

BANKING Broadway Bank (HHH Gold Sponsor)

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

Thomas M. Duran

SVP, Private Banking Team Lead 210-283-6640

Livingston Med Lab (HHHH 10K Platinum Sponsor)

High Complexity Clia/Cola accredited Laboratory providing White Glove Customer Service. We offer a Full Diagnostic Test Menu in the fields of Hematology, Chemistry, Endocrinology, Toxicology, Infectious Disease, & Genetics.

Robert Castaneda (CEO) 210-316-1792

Robert@livingstonmedlab.com

Joey Martinez (Director of Operations) 210-204-7072

Joey@livingstonmedlab.com

Dwight Chapman (Account Manager) 210-591-2649

Dwight@livingstonmedlab.com www.livingstonmedlab.com/home “Trusted Innovative, Accurate, and STAT Medical Diagnostics”

Betty Fernandez Director of Operations 210-582-6355

Betty.Fernandez@bexarcv.com www.BexarCV.com

“Proudly serving the medical community since 1998”

FINANCIAL ADVISORS

Oakwell Private Wealth Management (HHHH 10K Platinum Sponsor)

Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113

Kreager Mitchell (HHH Gold Sponsor)

At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice.

Michael L. Kreager 210-283-6227

mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com

“Client-centered legal counsel with integrity and inspired solutions”

TDuran@Broadway.Bank www.broadwaybank.com

“We’re here for good.”

Genics Laboratories (HHH Gold Sponsor)

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

Genics Laboratories offers accurate, comprehensive and reliable results to our partners and patients. Genics Laboratories is committed to continuous research, ensuring our protocols are always at the peak of current technology.

Yulia Leontieva Managing Partner, Physician Liaison (210) 503-0003 (Phone) yulia@genicslabs.com (Email) Kevin Setanyan Managing Partner (210) 503-0003 kevin@genicslabs.com Artyom Vardapetyan

SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

Elizabeth Olney with Edward Jones (HH Silver 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 210-858-5880

Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

FINANCIAL SERVICES

HEALTHCARE BANKING

Amegy Bank of Texas (HH Silver Sponsor)

at locations throughout San Antonio and the Hill Country.

Bertuzzi-Torres-Fernandez

Wealth Management Group ( Gold Sponsor)

We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning.

Mike Bertuzzi

First Vice President Senior Financial Advisor 210-278-3828

Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828

Ruth.torres@ml.com

Will C. Fernandez, CEPA Senior Portfolio Advisor Financial Advisor 210-278-3812 wfernandez@ml.com https://fa.ml.com/texas/san-antonio/bertuzzi-torres-fernandez

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”

HOSPITALS/ HEALTHCARE

FACILITIES

UT Health San Antonio Physicians Regina Delgado Business Development Manager (210) 450-3713 delgador4@uthscsa.edu

UT Health San Antonio MD Anderson Mays Cancer Center Laura Kouba Business Development Manager (210) 265-7662 norriskouba@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000

UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

Live Confidently. Every financial dream deserves a well-crafted plan.

Ned Hodge 210-332-3757 ned@nedhodge.com www.nedhodge.com | www.Opesone.com “Take care of today then plan for tomorrow”

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.

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.

Michael Clark, President 210-268-1520 mclark@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

GERIATRICS/PRIMARY

CARE Conviva Care Center (HHH Gold Sponsor)

Conviva’s value-based care model allows physicians to deliver high quality, personalized care and achieve better outcomes, while feeling free to focus on health equity and patient outcomes.

Kim Gary

Senior Physician Recruiter (812) 272-9838

KGary4@humana.com www.ConvivaCareers.com

“Fuel Your Passion & Find Your Purpose”

Nexus Neurorecovery Center (HHH Gold Sponsor)

A post-acute rehabilitation facility focusing on brain injuries. Programming provides individual and group physical, occupational, cognitive, and speech therapy. We help residents return to lives of productivity and meaning.

Sydney Kerr Liaison 346-339-2654

skerr@nhsltd.com

Caitlyn Tewksbury ctewksbury@nhsltd.com Justin Sanderson CEO 210-854-4732

jsanderson@nhsltd.com

Nexus Neurorecovery Center 227 Lewis St, San Antonio, TX 78212

https://nexushealthsystems.com

“To return patients to lives of productivity and meaning”

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 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

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

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor)

With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians.

Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org

Recommended partner of the Bexar County Medical Society

TMA Insurance Trust (HHHH 10K Platinum Sponsor)

TMA Insurance Trust is a full-service insurance agency offering a full line of products – some with exclusive member discounts and staffed by professional advisors with years of experience. Call today for a complimentary insurance review. It will be our privilege to serve you.

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor)

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor)

UT Health Physicians, the faculty practice of UT Health San Antonio, provides our region with the most comprehensive care through expert, compassionate providers treating patients in more than 140 medical specialties

Wendell England Director of Member Benefits 512-370-1776 wendell.england@tmait.org 800-880-8181 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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)

Guardian (★★★ Gold Sponsor)

Rated A++ by A.M. Best, MedPro Group has been offering customized

insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-658-0262

Kirsten.Baze@medpro.com www.medpro.com

ProAssurance

(HH Silver Sponsor)

ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group’s rating is AM Best A (Excellent).

Mike Rosenthal Senior Vice President, Business Development 800-282-6242

MikeRosenthal@ProAssurance.com www.ProAssurance.com

INVESTMENT ADVISORY REAL ESTATE

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 (HH Silver 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.”

PRACTICE MANAGEMENT

Wave Online

(★★★ Gold Sponsor)

Our team of professionals will act as your extended AR office enhancing your revenue through our proprietary metrics and claim management systems. In addition, you keep 100% control of your RCM. Contact us today for a no cost evaluation.

Saranraj (Raj) Venkatesh Vice President – RCM | Sales and Client Relations 726-228-1097 saranraj@wavemt.com https://rcmwave.com/ “Innovation towards Solutions”

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor)

Alamo Capital Advisors LLC

(★★★★ 10K Platinum Sponsor)

Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and financial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Wave Online

(★★★ Gold Sponsor)

Our team of professionals will act as your extended AR office enhancing your revenue through our proprietary metrics and claim management systems. In addition, you keep 100% control of your RCM. Contact us today for a no cost evaluation.

Saranraj (Raj) Venkatesh

Vice President – RCM | Sales and Client Relations 726-228-1097

saranraj@wavemt.com https://rcmwave.com/ “Innovation towards Solutions”

Commercial & Medical Credit Services

(HH Silver Sponsor)

A bonded and fully insured San

MILITARY

San Antonio Army Medical Recruiting office (★★Silver Sponsor)

Mission: Recruit highly qualified and motivated healthcare professionals for service in the Army Reserves or Active Duty Army, in support of Soldiers and their families.

1LT Thomas Alexandria 210-328-9022

Alexandria.n.thomas12.mil@army. mil

https://recruiting.army.mil/mrb/ “Service to Country, Army Medicine, Experientia et Progressus”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx

( Gold Sponsor)

Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

Dr. Niti Vanee Co-founder & CEO 210-257-6973

nvanee@iGenomeDx.com

Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com

“My DNA My Medicine, Pharmacogenomics”

“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!

Kevin Barber, President 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 Medical Group Management Association (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. Lindsey Herman Nolan, MHR, CMPE, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

nancial restructuring (equity, debt, and partnership updates).

Jon Wiegand, Principal 210-241-2036 jw@alamocapitaladvisors.com www.alamocapitaladvisors.com

RETIREMENT PLANNING

Oakwell Private Wealth Management

(HHHH 10K Platinum Sponsor)

Oakwell Private Wealth Management is an independent financial advisory firm with a proven track record of providing tailored financial planning and wealth management services to those within the medical community.

Brian T. Boswell, CFP®, QKA Senior Private Wealth Advisor 512-649-8113 SERVICE@OAKWELLPWM.COM www.oakwellpwm.com “More Than Just Your Advisor, We're Your Wealth Management Partner”

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.

Cindy M. Vidrine

Director of Operations- Texas 210-918-8737

cvidrine@favoritestaffing.com

“Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

★★★★ 10K Platinum Sponsor)

Alamo Capital Advisors LLC (

Focused on sourcing, capitalizing, and executing investment and development opportunities for our investment partners and providing thoughtful solutions to our advisory clients. Current projects include new developments, acquisitions & sales, lease representation and fi-

Audi S3

By Stephen Schutz, MD

The letters MQB won’t mean much to most readers, but to automotive insiders they represent the designation for the most adaptable automotive platform ever developed. Encompassing a wide variety of transversely configured front-engine, front- or all-wheel drive Volkswagen group vehicles, the MQB platform underpins models as disparate as the very small (and not sold here) VW Polo to the Audi Q3 to the mid-size VW Atlas SUV. In fact, an astounding 45 distinct models around the globe are MQB-derived vehicles.

The brainchild of late-great engineer and executive Ferdinand Piech, the MQB platform enables Volkswagen to manufacture many distinct vehicles in the same factories depending on local, national or regional demand. That means that if a country or region has lots of young families, a factory can produce lots of Audi Q3s and VW Atlases, but if gas prices suddenly spike, the same factory, with relatively little effort, can manufacture more VW Golfs and T-Rocs.

I recently had the chance to get behind the wheel of one of the sportiest MQB cars, the Audi S3 and it was a good experience. The S3 is a compact sports sedan, which utilizes surprising power and quattro AWD to produce an entertaining drive. Its main competitors are the Mercedes CLA35 and BMW M235i Gran Coupe.

All 2023 S3 models come with a potent 306-hp 2.0-liter four-cylinder engine, seven-speed automatic transmission and Audi's noted quattro all-wheel-drive system. It’s fast and composed in all types of driving, but rarely exciting.

Does that sound contradictory? It isn’t. The S3 kills it in a straight line—0-60 MPH runs take just 4.3 seconds—so merging onto any highway or freeway is no sweat. But the evolved quattro AWD system coupled with advanced software which limits wheelspin and keeps the car moving forward (and not sideways) means that you’re always driving with a digital adult who’s there to make sure nothing untoward happens. All of the software “nannies'' can be turned off, of course, but that takes time and effort and I’m sure most owners will leave them on.

To maximize the fun factor, keeping the S3 in Sport mode is recommended. I found that Comfort mode meant that the car was almost sleep walking, and hitting the accelerator felt like waking up a hungover friend from a deep slumber and saying, “hey dude get up, we gotta go to the gym!” The gym wasn’t happening nor was any kind of quick response from the S3’s drivetrain. Keeping it in Sport like I did every time I got behind the wheel resulted in a much better driving experience.

Fuel economy is 23MPG City/32MPG Highway, which is very

good for a car with this level of performance.

Most S3s outside of North America are hatchbacks, but Audi found that the sedan body style of the A3, upon which the S3 is based, sold much better here than the hatch so only sedan versions of both cars are offered here.

The S3 looks sporty and very Audi thanks to a prominent grille, chiseled head- and taillights and generally understated styling everywhere else.

Given its modest footprint, it should surprise no one that the S3’s interior is small and cargo capacity is, umm, small. The rear seats in particular are tight, and trying to squeeze three adults back there is not advised.

Nevertheless, the compact Audi S3 is still an Audi, which means that it has a beautiful interior. Everything you see and touch looks and feels like quality, with the electronic gauges and flat-bottom steering wheel worthy of extra kudos.

One thing in the cabin seemed odd to me: instead of a beefy and sporty looking gear selector, Audi went with a tiny toggle switch thing that looks like it was stolen from a Prius. Hmm...

Pricing for the S3 starts at just under $47,000 for the base “Premium” model, climbs to just under $50,000 for “Premium Plus” S3s, then peaks out at around $54,000 for “Prestige” versions. All 2023 S3s come with Apple CarPlay/Android Auto, a panoramic sunroof, and three-zone automatic climate control. As always, calling BCMS’ Phil Hornbeak will get you your best deal on an Audi S3 or any other new vehicle.

Volkswagen Group’s MQB platform is an impressive bit of automotive engineering, and I was pleased to sample another one of its many progenies, the 2023 Audi S3. It’s small in size but provides a luxurious Audi ownership experience along with an appealing level of athleticism. Anyone looking at the Mercedes CLA35 or BMW M235i Gran Coupe shouldn’t sign anything until they’ve test driven the newest S3.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

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

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