Early Establishment of Health Eating Habits in Childhood

Early Establishment of Healthy Eating Habits in Childhood:

A Preventative Measure Against Childhood Obesity

By Jocelyn Wey, Cynthia Bogran, Yi Fang, Darwin Nguyen and Adeel Sajid

Obesity in childhood has both immediate and long-term consequences. Preventable diseases, usually associated with adulthood, are occurring more frequently in the pediatric population, largely due to obesity.3 For example, type II diabetes mellitus, a disease usually associated with the older population, is now being seen more regularly in some settings, contributing to almost half of new pediatric diabetes cases.3 Obese children also have an increased risk for asthma, sleep apnea and even cardiovascular disease.10 Furthermore, obese children are also more likely to also be obese as adults, which is associated with similar health problems such as hypertension, gout, cardiovascular disease and stroke.3,10

While development of childhood obesity is multifactorial, major contributory factors such as dietary choices and parental influence on eating habits are impactful and tend to be established early in childhood.1 Additionally, the role of different eating patterns among racial and ethnic groups may also influence the development of obesity in childhood.1 In San Antonio specifically, there is a disproportionately high rate of pediatric obesity among the Hispanic community. A great percentage of these children reside in the south and central regions of the city, corresponding to lower socioeconomic status communities.2 This is important to keep in mind during office visits and while counseling parents and patients on healthy eating habits, as some studies have also found parents of lower socioeconomic status tend to engage in poor eating habits which are then transferred to their children.5

What, how and when food is consumed matters. Lindsay et al., found that children tend to develop their food habits early on through “exposure and repeated experiences.”4 Early exposure to healthy, nutrientrich foods, such as vegetables, fruits and whole grains increases the odds these types of foods will be eaten more often both in childhood and adulthood. Another key factor in establishing healthy eating habits at an early age relies on parents serving as role models. A number of studies have shown how the perceptions, beliefs, emotional status and even the BMI of the mother substantially influence dietary practices and weight of children.6,7,8

Early in development, children have a tendency to model and eat what their parents consume, especially developing preferences for what their mothers eat.4 Preschool-aged children tend to have a strong dislike of new foods. Low consumption of fruit and vegeta-

bles with high intake of calorically-dense foods in this age group corresponds to “weight status in later childhood stages.”1 There is a caveat to this, however; kids should not be made to ‘clean their plates’ or have extremely stringent control placed over their diet by their parents. Several studies have shown high maternal food control leads to a higher likelihood of the child becoming obese.9 Rather, children should be given healthy options to choose from and be allowed to decide for themselves how much food to eat from what they are given.4 Just as it is important what a child eats, it is also important how and when a child eats. Behaviors related to poor diet, including excessive snacking, frequent eating out, fast food consumption and eating while watching television, have been found to be associated with an increased risk of gaining weight.1 Conversely, eating dinner as a family throughout adolescence helps promote consumption of healthy food intake and reduces consumption of calorically dense foods.4

Although there have been several studies highlighting the importance of establishing healthy eating habits at an early age, there needs to be an active involvement of the parents in forming these behaviors which can then be continued into adulthood. Children’s dietary habits, food preferences and even physical activity levels are greatly influenced by their parents and home environment.10 It is crucial that parents acknowledge the importance of healthy eating and the ways in which they can contribute meaningfully to their children’s understanding of the same. Additionally, cultural habits and beliefs need to be considered when discussing pediatric dietary guidelines with parents, ensuring they have factual information regarding what a healthy weight and diet entails for the corresponding age of the child.10 These are important factors which should be addressed by pediatricians in an effort to further attenuate the risk associated with childhood obesity.

Authors left to right: Adeel Sajid, Darwin Nguyen, Yi Fang, Cynthia Bogran and Jocelyn Wey are Second-year Osteopathic Medical Students at the University of the Incarnate Word School of Osteopathic Medicine, San Antonio, Texas.

References 1. Sharon Kirkpatrick, PhD, MHSc, RD,

Amanda Raffoul, MSc, Measures Registry

User Guide: Individual Diet. National Collaborative on Childhood Obesity Research.

May 2017. http://nccororgms.wpengine. com/tools-mruserguides/wp-content/uploads /sites/2/2017/NCCOR_ MR_User_

Guide_Individual_Diet-FINAL.pdf 2. Byron A. Foster, Trevor M. Maness, Christian A. Aquino. Trends and Disparities in the Prevalence of Childhood Obesity in

South Texas between 2009 and 2015. Journal of Obesity, vol. 2017, Article ID 1424968, 7 pages, 2017. https://doi.org/ 10.1155/ 2017/1424968 3. Goutham Rao, MD. Childhood Obesity:

Highlights of AMA Expert Committee

Recommendations. Am Fam Physician. 2008 Jul 1;78(1):56-63. https://www.aafp.org/afp/ 2008/0701/ p56.html#afp20080701p56-f1 4. Lindsay AC, Sussner KM, Kim J, Gortmaker

S. The role of parents in preventing childhood obesity. Future Child. 2006;16(1):169-186. doi:10.1353/ foc.2006.0006 5. Lindsay A, Wallington S, Lees F, Greaney M.

Exploring How the Home Environment Influences Eating and Physical Activity Habits of Low-Income, Latino Children of Predominantly Immigrant Families: A Quali-

tative Study. International Journal of Environmental Research and Public Health. 2018;15(5):978-995.doi:10.3390/ ijerph15050978 6. Vollmer RL, Mobley AR. Parenting styles, feeding styles, and their influence on child obesogenic behaviors and body weight. A review. Appetite. 2013;71:232-241. 7. Kalinowski A, Krause K, Berdejo C, et. al.:Beliefs about the Role of Parenting in

Feeding and Childhood Obesity among

Mothers of Lower Socioeconomic Status.

Journal of Nutrition Education and Behavior. 2012;44(5):432-437. 8. Jang M, Owen B, Lauver DR. Different types of parental stress and childhood obesity: A systematic review of observational studies.

Obesity Reviews. 2019;20(12):1740-1758. doi:10.1111/obr.12930 9. Innella N., Breitenstein S., Hamilton R., et. al.: Determinants of Obesity in the Hispanic

Preschool Population: An Integrative Review. Public Health Nursing. 2016;33 (3):189-199. 10. Etelson, Debra, Donald A. Brand, Patricia

A. Patrick, Anushree Shirali. Childhood obesity: do parents recognize this health risk? Obesity Research. 2003;11:1362–1368. https://onlinelibrary.wiley.com/ doi/pdf/10.1038/oby.2003.184

The History of Food Safety in America:

A Tale of Deceit, Scandal and Poison

By David Alex Schulz, CHP

From milk to meat, we assume food from the market represents sanitary production, quality ingredients, truth in labeling, and if not, healthful nutrition at least—not poison. This complacency comes only at the end of hard-fought battles … and the war is not over. Indeed, it was a postmortem of the SpanishAmerican War that brought the nation’s abysmal state of food preparation and adulteration into sharp focus. At the dawn of the 20th Century, the War Department was accused of killing more soldiers than did the enemy, poisoning with tainted food. The army’s commanding general called for an investigation into the quality of the food supplied to his troops, accusing the military of feeding his men “embalmed beef.”

While standard practice at the time to preserve canned meat with formaldehyde, the army sought the Department of Agriculture Chemistry Division to analyze a can of corned beef that left a 19-year-old private convulsing and a day later, dead. “The analysis showed that the contents of the can had been saturated with the neurotoxic metal lead, which had apparently seeped out of the container itself. Lead was also found in his body.”

The fight to keep “poisons sold as food” from public knowledge is dramatically documented in Deborah Blum’s “The Poison Squad” (2018, Penguin Publishing Group). Blum recounts the single-minded focus of Agriculture Department Chemist Harvey Wiley in his obsessive pursuit of the landmark Pure Food and Drug Act of 1906, and the battles resulting from its implementation.

At the time, a typical day’s meals contained overly ample amounts of borax, alum, salicylic acid (not acetylsalicylic), sodium sulfite, coaltar-dyes, benzoic acid, saltpeter, sulfuric acid, formaldehyde, copper, methyl alcohol and boracic acid. More than forty doses of unregulated chemicals and dyes would be consumed in a day.

No food was untainted: “Dairymen, especially those serving crowded American cities in the nineteenth century, learned that there were profits to be made by skimming and watering down their product. The standard recipe was a pint of lukewarm water to every quart of milk—after the cream had been skimmed off. To improve the bluish look of the remaining liquid, milk producers learned to add whitening agents such as plaster of Paris or chalk. Sometimes they added a dollop of molasses to give the liquid a more golden, creamy color. To mimic the expected layer of cream on top, they might also add a final squirt of something yellowish, occasionally pureed calf brains.”

“Flour” was routinely extended with crushed stone or gypsum. Brown sugar contained ground insects. “Coffee” was anything but: More than 80-percent of ground coffee tested was adulterated. “One sample contained no coffee at all.”

Wiley’s team also found that processors had devised a way to make coffee-free “beans” by pressing a mixture of flour, molasses, and occasionally dirt and sawdust into molds. Counterfeit foods were a major concern in the spice industry, where a ground product may hide a high-proportion of adulterant. “One New York firm—a purveyor of pepper, mustard, cloves, cinnamon, cassia, allspice, nutmeg, ginger, and mace—purchased five thousand pounds of coconut shells a year for grinding and adding to every spice on that list.”

America is synonymous with ample meat supplies, but Upton Sinclair’s “The Jungle” dispelled any belief in hygiene or sanitation on the butcher’s floor. The meatpackers’ fight to keep it from publication is a turning point in the struggle. They focused on accusations of “fake news,” threatening to sue publishers. Doubleday and the Chicago Tribune launched their own investigation, much to the meatpackers chagrin: it showed the book was understatement. “Both men returned disgusted and horrified by what they’d seen.”

The case for regulation is also seen as a drive to limit freedoms, an immensely powerful argument. It took an equally powerful organization and unlikely hero to assure the passage of the 1906 Pure Food and Drug Act, also known as “Wiley’s Law” – the American Medical Association (AMA).

The AMA was determinedly nonpolitical and less interested in food safety than in the problem of snake-oil medicines, but the two issues were bonded together in the law which was bottled in committee. The AMA threatened Finance Committee-chair Senator Nelson Aldrich to rally all 135,000 physicians in the country, “including all of those located in the senator’s home state, to get the bill passed. The doctors would, if need be, contact every patient, county by county.”

In the end, it was by virtue of President Theodore Roosevelt’s Rough Rider experience in Cuba that he politically championed Chief Chemist Wiley and his team of “taste testers,” AKA, the Poison Squad. We can read labels of ingredients with some assurance today in large part because of Teddy’s Bully Pulpit and his belief that Americans deserved honest food. But times change, and rules must adapt: A year after the book’s publication, standards for labeling “organic” were finally established.

* All quotes from. The Poison Squad – One Chemist’s Single-Minded Crusade for Food Safety at the Turn of the Twentieth Century, by Deborah Blum, Penguin Publishing Group, 2018, Kindle Edition.

David Schulz is a community member of the BCMS Publications Committee.

“I WONDER WHAT’S IN IT”

We sit at a table delightfully spread And teeming with good things to eat. And daintily finger the cream-tinted bread, Just needing to make it complete A film of the butter so yellow and sweet, Well suited to make every minute A dream of delight. And yet while we eat We cannot help asking, “What’s in it?”

Oh, maybe this bread contains alum or chalk Or sawdust chopped up very fine Or gypsum in powder about which they talk, Terra alba just out of the mine. And our faith in the butter is apt to be weak, For we haven’t a good place to pin it Annato’s so yellow and beef fat so sleek Oh, I wish I could know what is in it.

The pepper perhaps contains cocoanut shells, And the mustard is cottonseed meal; And the coffee, in sooth, of baked chicory smells, And the terrapin tastes like roast veal. The wine which you drink never heard of a grape, But of tannin and coal tar is made; And you could not be certain, except for their shape, That the eggs by a chicken were laid. And the salad which bears such an innocent look And whispers of fields that are green Is covered with germs, each armed with a hook To grapple with liver and spleen. The banquet how fine, don’t begin it Till you think of the past and the future and sigh, “How I wonder, I wonder, what’s in it.”

HARVEY WASHINGTON WILEY, 1899

Read aloud by the author to Congress at hearings on the Pure Food and Drug Act Blum, Deborah. The Poison Squad (pp. xi-xii). Penguin Publishing Group. Kindle Edition.

Health Insurance Company Chicanery

By Neal S. Meritz, MD

The health insurance industry utilizes many tactics, some overbearing and some more subtle, but doctors and patients are invariably the victims. Physicians have always had a love/hate relationship with health insurance companies. This is the result of decades of dishonorable treatment of doctors, hospitals and patients in policy making and payment considerations. Health insurance companies have become multibillion dollar industries in part by refusing to pay physicians, care centers and hospitals fairly. Denying and delaying claims is the foundation on which the health care industry reaps those enormous profits.

Coding

Medical coding is how the physician’s practice turns services provided into billable revenue,1 and if that coding is deemed inaccurate by the insurer, reimbursements will be delayed, denied or only partially paid. The ICD system is complex and confusing with claims most frequently rejected due to alleged billing and coding errors. Medical coding is predominately payment related; it has almost nothing whatsoever to do with patient care. Any claim that results in non-payment or delay results in increased revenue for the insurer, and ICD considerations further that aim.

Denying Valid Claims

Healthcare insurers routinely make the business decisions to deny the claim and hope that the patient does not pursue the appeal.2 Faced with a denial, most patients and doctors will accept the insurer’s decision and pay the bills themselves, thus increasing the insurer’s profits.3 According to healthcare.gov, in 2019, 181 major ACA (Obamacare) medical insurers reported 232.2 million in network claims received, with 40.4 million denied, an average of 17.4%. Less than 60,000 of these denials were appealed, an appeal rate of less than 0.2%.4 The insurer agreed to overturn about 40% of that 0.2%. Former Kansas Insurance Commissioner Sandy Praeger states, “We think some companies are probably denying claims, counting on the hassle factor, so that people will just go ahead and pay out of their own pockets.” 5

COMPLEXITY Consumer Reports

The complexity of our health care structure is the reason that we have the most expensive, inequitable, inefficient and unpopular health care system of any developed country, with poor to mediocre outcomes. Reimbursement, with its mind-boggling payment rules, creates an enormity of administrative costs as well as many perverse incentives. Physicians and hospitals are insurance company prey. The system, with its intentional confusion, is designed to wear physicians down. An insurance company has nothing to lose and everything to gain by placing barriers in the physician’s path. The percent of premiums that an insurance company spends on claims and expenses that improve health care is called the “Medical Loss Ratio.”6 Thus, actually paying doctors and providing health care to patients are considered financial losses by an insurer.

Other Tactics

Health insurers employ many other deceptions to avoid paying doctors. They might claim that the procedure is experimental or cosmetic. Insurers have been found guilty of canceling, illegally and retroactively, policies of people whose medical conditions are too expensive to treat. Many denials are for procedures judged to be “not medically necessary.” Insurance companies rely on technicalities such as improper coding or demographic errors to deny valid claims. Insurers now perform what they refer to as “audits,” utilizing software known as “denial engines” because the programs are designed to purposely decrease payments to doctors and hospitals. Multiple industry sources have reported the automatic downcoding or denial of high-level evaluation and management services.7 And, of course, there is the hassle factor from: prior authorizations, exclusion of medications and intentional confusion.

The Float

According to Warren Buffet, “The Float” is the money the insurance company gets to hold onto between the time patients pay premiums and the time the insurer must pay out claims on their policies.8 Insurers receive premiums up front and pay claims much later, leaving large sums to be invested. If premium income exceeds the total of expenses and eventual losses, the insurer registers an underwriting profit that adds dramatically to the investment income produced by The Float.9 High volume denials based on idiosyncratic edits, made-up rules and contrived audits are commonplace. The rationale for insurance companies to not pay claims is obvious.

Conclusion

Many in the U.S. are struggling as a result of the pandemic, but health insurance companies are thriving. Multibillion dollar profits are reported by all the large insurers, with most revealing a doubling of profits in 2020 compared to 2019. Meanwhile, premiums have increased 57% since 2009. United Healthcare reported a Medical Loss Ratio (their phrase for The Float) of 70.2%, accounting for record profits in 2020 during the pandemic.10 There is no dominant entity to set administrative standards because the U.S. health care system is so fragmented. Meanwhile, insurers run amok, minimally regulated, collecting overwhelming profits at the expense of physicians, hospitals and patients. This dishonorable behavior has long been characteristic of the health insurance industry, and the likelihood is great that these deceitful practices will continue indefinitely.

Neal S. Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee. References 1 “A Brief History of Medical Coding” by Ben

Castleberry 5/11/16 Aviacode 2 “How to Fight Back When An Insurer Denies

Your Claim” 1/17/17 McKennon Law Group

California Insurance and Life, Health, Disability Blog 3 “Six Ways to Avoid Having a Healthcare Claim

Denied” by Orly Avitzur MD Consumer Reports 12/14 4 “Transparency in Coverage for 2020 Plan Year” 1/20/21 by Karen Pollitz and David McDermott Kaiser Family Foundation 5 Sandy Praeger Kansas Insurance Commissioner 2003-2015 LA Times 1/17/17 6 “How Insurers Deny Legitimate Claims” McKennon Law Group PC California Insurance Litigation Blog 7”Software Helps Insurers Profit From Denials” by

David Rosenfeld 6/14/17 Pacific

Standard/Grist 8 “Warren Buffet Explains the Genius of the Float” by Jacob Goldstein 3/1/20 Texas Public Radio

NPR 9 “Are Healthy Care Companies Profiting From

The Float?” By Milt Treudenheim 4/17/97 The

New York Times 10 “Transparency in Coverage for 2020 Plan Year”

Kaiser Family Foundation 1/20/21

Life Burns

By Emily Sherry

Good morning, and hot sauce flew into my eye from the breakfast I had tried to spice up. Thankfully, it didn’t burn.

Good afternoon, and walking into the VA I received the daily COVID-19 screen. Fortunately, I have no fever or signs for concern.

It’s time to get handoff for our shift and learn, our guy who’s supposed to go home on antibiotics, Is now on hospice, with DNR and prn narcotics.

From serving in Vietnam to working at the zoo, and running a business in horticulture too, He lived a flavorful and naturistic life, loved his work, family, and late wife.

Last shift I’d said, let’s get you home, you’ve got a lot more life to live. He agreed, let’s not let this infection be a deflection.

We’d chatted about all things - religion, politics, and living, Jokingly, I said, just in time to prep for what’s taboo at Thanksgiving.

He’d even shared his burial plans to eventually rejoin his wife in the urn. We just never knew that week would be his turn.

From man we are dust, and to dust we shall return. And oh boy, did that day fervently burn.

Reflection

I wrote the following poem, "Life Burns," from caring for one of our veterans from his initial presentation at the hospital to the end of his life. I write about this experience with the specific allegory of burning in order to juxtapose the actual “nonburning” events (of the day I walked into shift and learned of a 180º turn of events) with the heat of raw human emotions I experienced in learning that my patient now faced the end of his life in the coming days.

This man never struck me as a “dying” or even an at near “risk-ofdying” patient when he presented to the ED with pneumonia. Maybe it was because he didn't enter the hospital looking very sick, because he was relatively young, because he was conversing expressively and vividly, or because my clinical acumen is still developing, but he just didn’t fit my picture of someone in their final days. With that being said, I’m reminded that the time one has left on earth doesn’t look the same on everyone, and not everyone receives an advance notice.

My goal in this poem was to embody the things that were important to him as a person. In particular, he told me that he did not believe he would be remembered past his adult kids. He was disheartened that he would not "leave a legacy." Because of this, I wanted at the least to create something concrete, to put something on paper, if you will, that would remind me of our work together. I wanted to capture a piece of our time, including our expansive conversations on traditionally avoided topics—per his free-spirited personality—as well as some of the things that made him the person he was. In this way, I honor his memory, the time we shared, and maybe a little legacy too by sharing the poem with others.

Importantly, I also carry the lessons he taught me into caring for future patients: the impetus for strong patient communication, the power of stopping by the patient’s room again before going home, and the gravity that even a medical student’s advocacy can make for respecting end-of-life wishes. He walked into our hospital never expecting a days-left prognosis, and his dying wish was to make it home one last time to say goodbye to his family, feel the sun and fresh air, hug his dogs. After life only handed him this “daysnotice,” I saw tangible change in his eyes and voice in how he encountered every ounce of life. Going home had many steps, such as establishment of an oxygen tank at the house and a 24hour nurse. Hours and hours passed; he held onto life by the bridge of maximum flow oxygen. We didn’t leave his side until they brought the transport stretcher. At this point, our team didn’t know if he’d survive the drive. We cared for our other patients, and we kept praying…

Thanks be to everyone who fought for his wishes: he spent the final hours with his granddaughter and son at home. He died surrounded by the nature in which he’d made a living.

A Poem and Reflection by Emily Sherry, Medical Student, Class of 2022, UT Health, Long School of Medicine.

Respite Care for San Antonio’s Homeless

By Tori Brucker, Ryan Daly, Thomas Damrow, Thelmari Raubenheimer

The emergency room is a community’s medical safety net, often caring for the uninsured with no guarantee of payment. Low-income populations, including our city’s homeless population, increasingly rely on the emergency department for basic primary care.

Healthcare needs of the homeless are comparable to those of the general population, however, their circumstances often result in more acute presentations and require advanced measures to be taken during their treatment and continuation of care. The American Hospital Association found that hospital admission rates are five times greater amongst the homeless, and that these patients remain in the hospital for an average of four days longer.1 These extended stays result in increased costs without subsequently improved healthcare outcomes. A study measuring hospital readmission rates amongst the homeless found that homeless individuals have a 30-day readmission rate of 22% as compared to 7% among matched control patients from low-income backgrounds with similar primary reasons for admission.2 Significant contributors to the poorer outcomes amongst this population are a return to adverse living conditions, a lack of patient follow-up and difficulties with care coordination that collectively decrease compliance resulting in many patients “falling through the cracks.” With the discouraging information about readmission rates and costs of care in mind, the question arises as to what hospitals and communities could do to mitigate this burden and improve health care outcomes for our homeless neighbors.

The current approach to discharging homeless patients is both challenging and complex. The tasks of securing patient funding, establishing follow-up connections and locating stable housing places significant burden on hospitals and their staff. Many local shelters are already operating at maximum capacity and few are properly equipped to house and care for homeless individuals, post-discharge, who typically require more attentive care and specific follow-up services. To add to these difficulties, some shelters have acceptance criteria, such as physical ability and medical clearance, that excludes a significant number of discharged patients who may not have alternative housing options. Cumulatively, these factors frequently prevent the orchestration of a safe and cost-effective discharge plan for the homeless patient. As a result, hospitals typically are forced to absorb the costs of medical care and the patient is often left with no options other than a return to the streets. There is a consequent high likelihood of readmission due to inadequate healing.

Fortunately, many cities are beginning to explore new ways in which the homeless community can be helped after discharge. Programs such as respite care are an example of an intervention showing promising results. Respite care stands apart from traditional shelters in that it provides post-hospital care to homeless patients who are not sick enough to remain in the hospital, but still require monitoring and basic healthcare services.3 Medical respite programs have been shown to reduce future hospital admissions, 90-day hospital readmissions and hospital length-ofstay among homeless patients.4 Many also offer social services and housing placement assistance that eases these patients’ transition from the streets to stable housing situations. While respite programs alone are not a solution to the challenges the homeless population faces on discharge, they present a clear opportunity to improve health outcomes, mitigate healthcare costs and transition homeless individuals into reliable housing.

Currently, San Antonio community organizations work tirelessly to provide food and housing to the nearly 3,000 homeless individuals living within Bexar County.5 Despite these efforts, post-hospital discharge care for the homeless remains extremely challenging. Implementation of new projects to tackle homeless healthcare have the potential to drastically improve the health of our local homeless population and help the city progress towards decreasing homelessness here in San Antonio.

In December of 2020, the city released its 5-Year Strategic Plan to Respond to Homelessness in San Antonio and Bexar County. This plan outlined a broad expansion of homeless aid programs with specific focus on identifying ways to assist those “high-utilizers” of behavioral and medical health systems, follow-up with patients recently discharged from a hospital setting and providing dedicated respite/recovery beds and step-down facilities for chronically ill individuals.6

This call to address the issue of homeless healthcare comes at an important time as the city of San Antonio works to allocate the influx of local and federal funding resources towards tackling homelessness. Given the success and benefits of respite care programs, the city's exploration of this method of homeless care could greatly contribute to their future strategy.

References: 1. Health Research & Educational Trust. (2017,

August). Social determinants of health series:

Housing and the role of hospitals. Chicago, IL:

Health Research & Educational Trust. Accessed at www.aha.org/housing 2. Saab, D., Nisenbaum, R., Dhalla, I., & Hwang,

S. W. (2016). Hospital Readmissions in a

Community-based Sample of Homeless

Adults: a Matched-cohort Study. Journal of

General Internal Medicine, 31(9), 1011–1018. doi: 10.1007/s11606-016-3680-8 3. Tomita, A., & Herman, D. B. (2012). The Impact of Critical Time Intervention in Reducing

Psychiatric Rehospitalization After Hospital

Discharge. Psychiatric Services, 63(9), 935–937. doi: 10.1176/appi.ps.201100468 4. Doran, Kelly M, et al. “Medical Respite Programs for Homeless Patients: a Systematic Review.” Journal of Health Care for the Poor and

Underserved., vol. 24, no. 2, pp. 499–524. 5. South Alamo Regional Alliance for the Homeless (SARAH). (2019). Retrieved from https://www.sarahomeless.org 6. Strategic Plan to Respond to Homelessness in

San Antonio and Bexar County. December 2020. Retrieved from https://www.sanantonio.gov/Portals/0/Files/HumanServices/Ho melessServices/StrategicPlan.pdf

(L-R) Tori Brucker, Thomas Damrow, Thelmari Raubenheimer and Ryan Daly are all OMS III’s at UIWSOM.

BCMS Alliance Teams with BCMS to Hold Doctors’ Day Blood Drive

In honor of Doctors’ Day, the Bexar County Medical Society and the Bexar County Medical Society Alliance held a blood drive with the South Texas Blood & Tissue Center. The event was held on April 6 at the Bexar County Medical Society headquarters. The drive ended up with a total of 34 units of blood collected, far surpassing their goal of 25 units. The 34 units collected will help save the lives of 102 patients in South Texas. Special thanks to the volunteers and team who made it possible!

Above: Nichole Eckmann and April Chang with the Bexar County Medical Society Alliance and Raymond Hampton with the South Texas Blood & Tissue Center help with the blood drive.

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BBVA Compass (HH Silver Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services. Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services -- BB&T offers solutions to help you reach your financial goals and plan for a sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you"

Synergy Federal Credit Union (HH Silver Sponsor) 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!”

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity. Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

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"

Bertuzzi-Torres 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 http://fa.ml.com/bertuzzi-torres

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life. Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

Amegy Bank of Texas (HH Silver Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability. We work hard and together with our clients to accomplish great things. Jeanne Bennett EVP | Private Banking Manager 210 343 4556 Jeanne.bennett@amegybank.com Karen Leckie Senior Vice President | Private Banking 210.343.4558 karen.leckie@amegybank.com Robert Lindley Senior Vice President | Private Banking 210.343.4526 robert.lindley@amegybank.com Denise C. Smith Vice President | Private Banking 210.343.4502 Denise.C.Smith@amegybank.com www.amegybank.com “Community banking partnership”

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER

GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors. Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!” HOSPITALS/ HEALTHCARE FACILITIES

“We offer BCMS members a free insurance portfolio review.”

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu

INFORMATION AND TECHNOLOGIES

Humana (HHH Gold Sponsor) Humana is a leading health and well-being company focused on making it easy for people to achieve their best health with clinical excellence through coordinated care. Jon Buss: 512-338-6167 Jbuss1@humana.com Shamayne Kotfas: 512-338-6103 skotfas@humana.com www.humana.com

OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians. Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

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

TMA Insurance Trust (HHHH 10K Platinum Sponsor) Created and endorsed by the Texas Medical Association (TMA), the TMA Insurance Trust helps physicians, their families and their employees get the insurance coverage they need. Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org www.tmait.org 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

The Bank of San Antonio Insurance Group, Inc. (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Katy Brooks, CIC 210-807-5593

katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) 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 is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience. Clayton Brown - Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

MEDICAL BILLING AND COLLECTIONS SERVICES

PCS Revenue Cycle Management (HHH Gold Sponsor) We are a HIPAA compliant fullservice medical billing company specializing in medical billing, credentialing, and consulting to physicians and mid-level providers in private practice. Deion Whorton Sr. CEO/Founder 210-937-4089 inquiries@pcsrcm.com www.pcsrcm.com “We help physician streamline and maximize their reimbursement by 30%.”

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency. Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL PRACTICE

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner. Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL PHYSICS

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979. MEDICAL SUPPLIES AND EQUIPMENT

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

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.”

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”

PRACTICE SUPPORT SERVICES

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly! Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising. Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of health-

care real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

The Oaks Center (HH Silver Sponsor) Now available High visibility medical office space ample free parking. BCMS physician 2 months base rent-free corner of Fredericksburg Road and Wurzbach Road adjacent to the Medical Center. Gay Ryan Property Manager 210-559-3013 glarproperties@gmail.com www.loopnet.com/Listing/84348498-Fredericksburg-Rd-SanAntonio-TX/18152745/

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.”

TELEHEALTH TECHNOLOGY

CSI Health (HHH Gold Sponsor) CSI Health is a telehealth technology company providing customized solutions to healthcare professionals, assisted-living facilities, and more. CSI was founded in 1978, it was one of the first companies to move medical testing information from self-service kiosks into the cloud. Brad Bowen President, CEO 210-434-2713 brad@computerizedscreening.com Katherine Biggs McDonald Brand Development Manager 210-434-2713 katherine@computerizedscreening.com Bobby Langenbahn National Sales Manager 210-363-1513 bobby@computerizedscreening.com www.csihealth.net Extend the Reach of Healthcare. Elevate the Level of Remote Care. Enhance the Patient Experience.

Join our Circle of Friends Program

The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties. For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact:

Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

The Bexar County Medical Society is proud to welcome a Renewing Platinum Sponsor to our Circle of Friends program.

2021 BMW 530e

By Stephen Schutz, MD

Electric cars are coming. Like for real. They’re going to hit us from all directions, most notably China, and they are going to change our lives. This is an inevitability, and the only question is when it’s going to happen. Sandy Munro, a well-regarded automotive industry consultant, predicts that battery electric vehicles (BEVs) and plug-in hybrids will begin outselling internal combustion engine (ICE) powered cars and light trucks in 2028.

I have been and continue to be a BEV skeptic—BEVs comprised 2% of the U.S. automotive market in 2020, about the same as in 2015, so I’m not completely off base with my skepticism—but I’m starting to see how things may change quickly.

If you’re a true believer, you already have a Tesla, Nissan Leaf, Audi e-Tron or Porsche Taycan, but if you’re not, you are probably wondering how this big transformation is going to happen. I think it will happen gradually at first, and then quickly.

As for the gradual part, consider the BMW 530e. It is a plug-in car that does everything—an “almost BEV” that gives you most of the pluses of a BEV with few of the minuses.

Here is what I mean: Fully charged, the 530e will give you about 25 miles of all electric driving. For most people, that is enough to get you to work and back plus a couple of stops along the way (Starbucks, the store, soccer practice or yoga).

If you have a charger at work, which increasingly people do, you can do even better on electric power alone. For example, my GI practice just built a new endoscopy center and we installed two charging ports in the parking lot. Imagine never (or rarely) going to a gasoline station.

That’s what my week with the plug-in hybrid 530e was like. I drove to work at 7 every morning, did my doctor thing all day, ran a few errands, drove home, plugged in and then did it all again the next day. There was no “driving excitement,” and let’s face it, with any car you plug in there rarely is. Nevertheless, it was all very pleasant.

Road trips with the family or other long drives, which are generally exercises in range anxiety in BEVs, are no problem with the 530e thanks to its conventional four-cylinder engine and eight speed ZF automatic transmission. Both are there to back you up when you can’t charge.

The exterior design of the 530e is sleek and contemporary, exactly what you would think the BMW 5-Series would look like in 2021. In fact, I found myself glancing over my shoulder to admire it several times. The reason for this was its attractive design, but part of it was the Phytonic Blue Metallic paint which was eye-catching on its own. (I would not recommend getting your new 5-Series in white or silver, please. You’ll regret it).

It must be said, however, that BMW has regrettably gone back to its 1990s ways with its sedans by making “one sausage in three different lengths.” It takes a trained eye to tell the 5-Series from the 3 or even the 7, and I wish that weren’t the case. Having said that, if everyone is buying SUVs and crossovers, does it really matter anymore?

The interior of the 530e is a very nice place in which to spend time, as is the case with any new Lexus, Audi or Mercedes. As with those brands’ interiors, screens have replaced all of the gauges. Everything you need information-wise is either right in front of you or just a few taps on a touch screen away. All that tech can be overwhelming at first, but with a little study and practice it becomes easy. (Note to Lexus: study BMW and Audi’s user interface and make some changes.)

The cabin of the 530e is a quiet and comfortable cocoon that is as relaxing as any 1960s Cadillac. No, it is not as involving as its epic 535i predecessor of the 1980s, but after a long day cathing, operating or sitting down with 24 patients, doesn’t a quiet cocoon sound good?

Nevertheless, I miss cars that were “involving.”

As always with vehicles from Germany, many options and option packages are available to help you personalize your ride. My wellequipped tester carried a sticker price of just over $70,000, and I think that’s about where most transaction prices will end up.

As BEVs and plug-in hybrids begin to take over the market, I’d make a case for going with the latter over the former, at least for now. Plug-in hybrids give you the benefit of using just electricity most of the time, but won't leave you stranded if you can’t find a charger on a long road trip. And the 530e is an excellent plug-in hybrid.

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 since 1995.