San Antonio Medicine August 2020

S A N A N TO N I O

EQUALITY IN HEALTHCARE rminates Social Dete h of Healt redity DNA & He

PAID

NON PROFIT ORG US POSTAGE

ctices Healthy Pra

SAN ANTONIO, TX PERMIT 1001

ise Diet & Exerc

MEDICINE SAN ANTONIO

TA B L E O F CO N T E N T S

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

•

WWW.BCMS.ORG

•

$4.00

Equality in Healthcare

Cover designed by Wendy Fitzer

We can address Health Disparities in San Antonio

By Carlos Roberto Jaén, MD, PhD, FAAFP....................................12 Economics and Healthcare Availability: Medical Deserts and Challenges in the COVID-19 Pandemic

By Abhinav Suri, BS and Rajeev Suri, MD, MBA............................14 Disparities in the Time of COVID-19

By Sekinat K. McCormick, MD ......................................................16 COVID-19 Risk Assesment Chart

By Texas Medical Association .......................................................18 Equality, Health Policy, and the Real World

By Linda G. Solis, PhD and Adam V. Ratner, MD, FACR................20 Mothers & Children at the Intersections of Pregnancy and Incarceration

By Allison Crawford, RN, BSN, PhD Candidate ..........................................................................................22 White Coats for Black Lives

By William L. Henrich, MD, MACP, President, UTHSA and Professor of Medicine .......................................24 Communication Interrupted: The Spread of Misinformation and How Do We Do Better?

By Kalli R. Davis and Maria Batchinsky .......................................................................................................26 Stress Management and Resiliency By Ajeya P. Joshi, MD .....................................................................28 Art – Do Your Part By Nichol C. Henkes.....................................................................................................31 BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10 The Business of Medicine: Updates Make PPP Easier for Physicians By Jim Rice, CPA .........................................32 BCMS Circle of Friends Physicians Purchasing Directory........................................................................................34 Future Cars Worth Waiting For By Stephen Schutz.................................................................................................38 Recommended Auto Dealers .................................................................................................................................40

PUBLISHED BY: Traveling Blender, LLC. 10036 Saxet Boerne, TX 78006 PUBLISHER Louis Doucette louis@travelingblender.com BUSINESS MANAGER: Vicki Schroder vicki@travelingblender.com ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@travelingblender.com

4

SAN ANTONIO: Madeleine Justice madeleine@travelingblender.com Gerry Lair gerrylair@yahoo.com PROJECT COORDINATOR: Amanda Canty amanda@smithprint.net

For more information on advertising in San Antonio Medicine, Call Traveling Blender at 210.410.0014 in San Antonio and 512.385.4663 in Austin.

San Antonio Medicine • August 2020

•

AUGUST 2020

•

VOLUME 73 NO. 8

San Antonio Medicine is the official publication of Bexar County Medical Society (BCMS). All expressions of opinions and statements of supposed facts are published on the authority of the writer, and cannot be regarded as expressing the views of BCMS. Advertisements do not imply sponsorship of or endorsement by BCMS.

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

MAGAZINE ADDRESS CHANGES: Call (210) 301-4391 or Email: membership@bcms.org

SUBSCRIPTION RATES: $30 per year or $4 per individual issue

ADVERTISING CORRESPONDENCE: Louis Doucette, President Traveling Blender, LLC. A Publication Management Firm 10036 Saxet, Boerne, TX 78006 www.travelingblender.com

For advertising rates and information Call (210) 410-0014 Email: louis@travelingblender.com

San Antonio Medicine is published by SmithPrint, Inc. (Publisher) on behalf of the Bexar County Medical Society (BCMS). Reproduction in any manner in whole or part is prohibited without the express written consent of Bexar County Medical Society. Material contained herein does not necessarily reflect the opinion of BCMS, its members, or its staff. San Antonio Medicine, the Publisher and BCMS reserves the right to edit all material for clarity and space and assumes no responsibility for accuracy, errors or omissions. San Antonio Medicine does not knowingly accept false or misleading advertisements or editorial nor does the Publisher or BCMS assume responsibility should such advertising or editorial appear. Articles and photos are welcome and may be submitted to our office to be used subject to the discretion and review of the Publisher and BCMS. All real estate advertising is subject to the Federal Fair Housing Act of 1968, which makes it illegal to advertise “any preference limitation or discrimination based on race, color, religion, sex, handicap, familial status or national orgin, or an intention to make such preference limitation or discrimination.

SmithPrint, Inc. is a family owned and operated San Antonio based printing and publishing company that has been in business since 1995. We are specialists in turn-key operations and offer our clients a wide variety of capabilities to ensure their projects are printed and delivered on schedule while consistently exceeding their quaility expectations. We bring this work ethic and commitment to customers along with our personal service and attention to our clients’ printing and marketing needs to San Antonio Medicine magazine with each issue.

Copyright © 2020 SmithPrint, Inc. PRINTED IN THE USA

BCMS BOARD OF DIRECTORS ELECTED OFFICERS Gerald Q. Greenfield, Jr., MD, PA, President Rajeev Suri, MD, Vice President Rodolfo “Rudy” Molina, MD, President-elect John Joseph Nava, MD, Treasurer Brent W. Sanderlin, DO, Secretary Adam V. Ratner, MD, Immediate Past President

DIRECTORS Michael A. Battista, MD, Member Brian T. Boies, MD, Member Vincent Paul Fonseca, MD, MPH, Member Danielle Hilliard Henkes, Alliance Representative David Anthony Hnatow, MD, Member Lyssa N. Ochoa, MD, Member Gerardo Ortega, MD, Member Manuel M. Quinones, Jr., MD, Member John Milton Shepherd, MD, Member Richard Edward Hannigan, MD, Board of Ethics Co-chair Nora Lee Walker, MD, Board of Ethics Co-chair Charles Gregory Mahakian, MD, Military Representative George Rick Evans, Legal Counsel Jayesh B. Shah, MD, TMA Trustee

6

San Antonio Medicine • August 2020

Ramon S. Cancino, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative Stephen C. Fitzer, CEO/Executive Director (ex-officio)

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

PUBLICATIONS COMMITTEE Kristy Yvonne Kosub, MD, Chair John Joseph Seidenfeld, MD, Vice Chair Louis Doucette, Consultant Charles Hirose Hyman, MD, Member Tzy-Shiuan B. Kuo, MD, Member Fred H. Olin, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam V. Ratner, MD, Member David Schulz, Community Member Alexis A. Wiesenthal, MD, Member Tyler Adams, Student Member Chinwe Anyanwu, Student Member Darren M. Donahue, Student Member Donald Bryan Egan, Student Member Christopher Hsu, Student Member Aishwarya Devesh Kothare, Student Member Anirudh Madabhushi, Student Member Anjali Surya Prasad, Student Member Teresa Samson, Student Member Cara Jillian Schachter, Student Member Stephen C. Fitzer, Editor

PRESIDENT’S MESSAGE

Equality in Healthcare

By Gerald Q. Greenfield Jr., MD, 2020 BCMS President

Equality in healthcare across all levels of society is a long sought-after goal. Universal healthcare may be the closest that we in the US get to this goal for the time being. The question is whether universal health care is equality in healthcare; or is equality in healthcare a panacea.

Universal health care was a major part of multiple political platforms in recent elections.

The Affordable Care Act, or Obamacare, was the first attempt at such an equalization in the United States. While more progressive members of Congress seek to extend many of the protections of the ACA, the conservatives have tried many times to abolish the entire act. However, as of this report many of the aspects of the ACA continue to be in effect in a number of jurisdictions. Some argue that the level and degree of infection and death in the ongoing pandemic would have been less in a universal health care situation. But on closer inspection, the rate of infection in Italy argues againstå that premise. Similarly, the resurgence of the virus in Great Britain demonstrates that medical care alone is not insurance against illness or death, even in a pandemic.

Equality in medical care requires both social and personal responsibility on part of all concerned. These responsibilities are long-lasting and must be constantly exercised. Social responsibility includes voting for and supporting legislators who will make appropriate decisions and laws. These will form the basis for federal funding of the expenses involved with such a program. The expansion of Medicaid, which failed in Texas, would have been a step along the route to some equality in medical care. The Childhood Health Insurance Program (CHIP) is available in Texas but has not been accessed by many eligible parents. Parents who have essentially decided to play a game of roulette with providing healthcare for their children; most of whom cannot legally decide for themselves.

8

San Antonio Medicine • August 2020

Personal responsibility requires the investment in universal and equal care when it is available with either personal or tax dollars. Social networks often have a significant effect on personal or individual decisions. The situation is similar to the classic question from our parents about everyone jumping off the bridge. Mask wearing in today’s society is an example of the effect of social networks on individual decisions. Even in the presence of accurate, objective information decisions may be guided by emotion or politics. The same “herd mentality” can be an obstacle if equality in healthcare is to be attained.

True equality in healthcare will require equality of services, care, and medical expertise for all who invest. There cannot be a state where all animals are equal, but some are more equal (from the book Animal Farm). If indeed all animals are equal, there will be equality in decision-making. Here there is a union of social and personal responsibility. The society has provided the opportunity. The individual must elect to invest in the opportunity provided. No matter the reason, equal healthcare availability does not necessarily mean equality in healthcare for the individual. Physicians have been in a perpetual search for the magic bullet; only by continuing to seek it can we make it a reality.

Gerald Greenfield, MD, is an Orthopedic Surgeon in Bexar County and is the 2020 President of the Bexar County Medical Society.

BCMS ALLIANCE

10

San Antonio Medicine • August 2020

As we continue to mask and shelter ourselves to protect our families on the COVID-19 frontline, the Bexar County Medical Society Alliance has adapted to reach out to our members in creative ways.

EQUALITY IN HEALTHCARE

We can address Health Disparities in San Antonio

By Carlos Roberto Jaén, MD, PhD, FAAFP

I have lived and practiced in San Antonio since 2001 and often reflect on the wicked problem of health disparities in our community.

By definition, a health care disparity is not simply a difference in health care outcomes by race or ethnicity, but a disproportionate difference attributed to variables other than access to care1. It is a wicked problem because it eludes simple solutions, involves structural changes, is a large economic burden and is interconnected with many other problems in our community 2. The problem eludes simple solutions and is more than just an individual responsibility.

For example, motivation to change to a healthy diet and be more physically active is not enough if you live in a food desert and are not able to walk around your neighborhood because of safety concerns. You need motivation and opportunity to be able to change health behaviors 3. It is not simply resolved by increasing access to health insurance and/or access to health care services.

Our city, like many cities in our country, suffers from a legacy of economic segregation and systemic racism that can be traced to redlining during the Depression Era 4. At that time, specific neighborhoods were excluded, by design, from access to government supported mortgages and thus the ability to accumulate wealth in home ownership. This legacy of segregation has affected multiple generations of families that are trapped in poverty, poor education and living environments that are a barrier to health. This segregation is evident in the rates of poverty, diabetes, amputations and differences of 20 years in life expectancy between specific zip codes in San Antonio (Figure 1). We also live in a state that has the highest rate of uninsured population in the country and that refuses to expand Medicaid under the Affordable Care Act, a decision that disproportionately affects Blacks; 16% earn too much to qualify for Medicaid and too little to qualify for tax credits, compared to 9% Non-Hispanic 12

San Antonio Medicine • August 2020

Whites (https://www.kff.org/infographic/health-and-health-carefor-blacks-in-the-united-states/).

Estimates from the Kaiser Family Foundation (KFF) show that 29% of the non-elderly uninsured in Texas are Hispanic, 16% are Black and 13% are Whites; most uninsured families in Texas have at least one member working full-time (18%) or part-time (29%). The situation has drastically worsened with the job losses related to the current economic crisis. In May 2020, an analysis of the KFF projected that 1.6 million Texans had already lost health insurance along with their jobs and estimated the number of uninsured Texans falling into the Medicaid expansion income gap will surge past 2 million by January 2021 https://www.kff.org/coronavirus-covid-19/issuebrief/eligibility-for-aca-health-coverage-following-job-loss/.

In a recent JAMA viewpoint, Dan Berwick, former director of CMS, challenged us to transition to the Moral Determinants of Health because “when the fabric of communities upon which health depends is torn, then healers are called to mend it.” 5. What role and responsibility, if any, do we as physicians have when confronted with this local reality? How can we address these issues if we are barely surviving under the weight of this pandemic? The day is not long enough to complete our charting and bankruptcy looms as our clinical practice is restricted, so how can we possibly address these issues?

What is our professional duty in this context? Can we use the current pandemic crisis to move in this direction? How can we influence the creation of health systems that better respond to this healing imperative? Any efforts to address health disparities must also challenge us to question the current structures of the health systems where we work and live. What concrete actions can help address health disparities? Remember, the solutions must include actions beyond just the health care sector.

EQUALITY IN HEALTHCARE

FIGURE 1

Here are some suggestions: 1. Support policies that increase health insurance coverage for Texans, whether by Medicaid expansion or other approaches that expand coverage. Medicaid expansion stimulates the Texas economy and can support your practices.

2. Support value-based approaches that deliver quality health care in the context of longitudinal relationships with patients. Support innovative payment models that support primary care, not just urgent care.

3. Build primary care systems with advanced primary care teams that include integrated behavioral health. These teams can be virtual or present in the clinic.

4. Partner with local community organizations to link patients with resources to address their social needs. You or your clinic staff do not need to provide the services your patients need, but you can provide the link. For example, https://www.growhealthytogether.com/ 5. Recognize that your patients live in a context that may not support your recommendations and changes. Listen to their personal stories.

6. Support local organizations that are directly addressing these disparities. For example, the Health Collaborative of Bexar County or the San Antonio Food Bank.

7. As outlined in the 2019 Health Collaborative Report 6, income and poverty, education and literacy, housing stability and homelessness, mobility and transportation, and crime and violence have a direct effect on health. See how their recommendations may resonate with your values and preferences and support them if they do.

Our broken healthcare system needs to reclaim a mission of compassionate response to suffering ahead of profit to effectively attend

to the needs of our communities. We need to help transform our health care systems into places where accountability is ahead of accounting and resources are allocated to optimize personal and patient health. We have a moral and professional responsibility to address the root causes of health disparities, to embrace efforts in all fronts and to practice in deliberate ways that address these disparities. We can do this.

Dr. Jaén is Chair of Family and Community Medicine at the Long School of Medicine and a member of the Bexar County Medical Society and the National Academy of Medicine.

References 1. Gomes C, McGuire TG. Identifying the source of racial and ethnic disparities. In: Smedley B, Stith AY, Nelson AR, eds. Unequal Treatment. National Academies Press; 2003.

2. Blackman, T., Greene, A., Hunter, D. J., McKee, L., Elliott, E., Harrington, B., … Williams, G. (2006). Performance Assessment and Wicked Problems: The Case of Health Inequalities. Public Policy and Administration, 21(2), 66–80. https://doi.org/10.1177/095207670602100206 3. Ferrer, R. L., Burge, S. K., Palmer, R. F., & Cruz, I. (2016). Practical opportunities for healthy diet and physical activity: relationship to intentions, behaviors, and body mass index. The Annals of Family Medicine, 14(2), 109-116.

4. Drennon, C. (2017, December 23). Economic segregation in San Antonio: how we got here, is it real? San Antonio Express News.

Retrieved from: https://www.mysanantonio.com/ 5. Berwick, D. M. (2020). The Moral Determinants of Health.

JAMA. 6. The Health Collaborative (2019). 2019 Bexar County Community Needs Assessment Report. San Antonio, TX: The Health Collaborative. visit us at www.bcms.org

13

EQUALITY IN HEALTHCARE

Economics and Healthcare Availability: Medical Deserts and Challenges in the COVID-19 Pandemic

By Abhinav Suri, BS, and Rajeev Suri, MD, MBA

In September 2019, the Washington Post published an article titled “Out here, it’s just me: In the medical desert of rural America, one doctor for 11,000 square miles”, featuring a day in the life of Dr. Ed Garner, medical director of Culberson County and sole physician for three counties. His story is just one of many among physicians who serve in medical deserts. This issue is especially prevalent in Texas. Out of 1062 Texas areas recognized by the Health Resources and Services Administration, 324 (30.5%) are designated as high priority physician shortage areas.

In these places, we find doctors (like Dr. Garner), who are faced with serving thousands of individuals without the resources to do so. Yet, it is not just the rural areas of the US that face physician shortages. As we have seen so far in the coronavirus pandemic, even populous areas face issues with healthcare accessibility, with effects amplified in minority enclaves where residents face disproportionately large COVID-19 infection and fatality rates.

In the midst of a pandemic, the effects of these medical deserts and other underserved areas present challenges to millions of Americans and the healthcare providers who serve them. However, there are potential solutions being put into practice that can alleviate obstacles in delivering effective care. The purpose of this article is to provide a brief overview of the causes of medical deserts, the effects they have on communities, and the initiatives that can yield solutions to this issue of healthcare accessibility.

Causes and Effects of Deserts: The problem of the medical desert is primarily an economic one that stems from the age-old principle of supply and demand. This section describes the two most common types of medical deserts (rural and urban) and explores the reasons (often economic) for their existence.

Rural Medical Deserts: In rural medical deserts, the supply and demand discrepancy creates a destructive cycle as the lack of patients and the lack of physicians practicing in these areas exacerbate healthcare inaccessibility.

The high proportion of uninsured individuals in the rural population and the comparatively low volume of cases make it a near economic impossibility to sustainably run a practice, leading to more than 100 rural hospital closures since 2010. To alleviate the economic strains associated with running rural hospitals, the Center for Medicare and Medicaid Services (CMS) instituted policy changes in 14

San Antonio Medicine • August 2020

August 2019 that increased reimbursements to underserved areas and expanded rural telehealth services available to these regions.

However, it is yet unclear whether this change will yield favorable results and make these centers economically viable to run.

While these policy-based solutions seek to minimize costs associated with patient care, the lack of physicians interested in practicing in rural areas presents a larger threat to the availability of medical care in these areas. In 1992, the Bureau of Health Professions reported that only 9% of the nation’s physicians practice in rural communities, a shortage compared to the 20% of the US population who live in these areas. In 2017, a survey found that only 3% of final-year medical residents would prefer to practice in communities with < 25,000 people, with nearly 68% preferring to practice in communities with over 250,000 people. Reasons cited for not preferring less populated areas include lack of cultural opportunities, food diversity, and reduced financial prospects. These issues are, in part, economic ones caused by higher rates of unemployment, lower salaries and greater poverty amongst rural residents.

These issues lead to increased strains on the small number of regional care centers, especially in times of pandemic where access to intensive care services and diagnostics is critical for saving lives. It is likely that COVID-19 hospitalizations could push nearly 400 at-riskof-closure hospitals towards financial insolvency, exacerbating an already detrimental healthcare accessibility issue.

Urban Medical Deserts: Urban medical deserts are also caused by economic issues of supply and demand, even in areas where population exceeds 1 million individuals. In a cross-sectional study of 3,932 census tracts in Chicago, Los Angeles, and New York City, black-majority tracts were more likely to be located in trauma deserts (defined as being > 5 miles away from a trauma center) compared to their white-majority counterparts. This pattern is all too common with these underserved

EQUALITY IN HEALTHCARE neighborhoods often having high poverty and unemployment rates.

Even with the advent of Urgent Care centers that were predicted to increase accessibility to healthcare in large cities, new medical facilities tend to open in areas with wealthier residents. In Washington D.C., multiples of these community-based facilities opened in boutique malls and retail outlets (serving richer suburban neighborhoods) whereas none were established in areas like Wards 7 and 8 (which have the highest poverty rates in the city and urgently need medical care).

Overall, these trends indicate that even in populous cities with a plethora of medical professionals, medical resources are allocated to richer areas instead of poorer ones because of supply and demand economics. It is important to note that these poorer areas often colocalize with minority and ethnic enclaves, perpetrating larger issues in healthcare inaccessibility. These issues tragically manifested themselves as news outlets reported that majority-black counties have higher rates of COVID-19 infections and deaths compared to majority-white counties.

Potential Solutions: Proposals and current solutions in place to address the issues caused by medical deserts could work to increase accessibility to healthcare. Notably, for rural areas, Telemedicine technologies have given residents access to medical professionals who are located further away. These consultations allow physicians to perform regular checkups on individuals and possibly minimize the number of medical emergencies. However, widespread adoption of telemedicine visits is partially hindered by economic viability (because physicians have different expectations for compensation that patients might not be able to meet, and underserved populations have lesser access to internet and online services) and regulatory obstacles (as lawmakers attempt to find lasting ways to adapt existing legislation to this new technology). Telemedical solutions can also apply to urban healthcare deserts since physicians can see more patients, including those from economically-strained neighborhoods. Telemedicine needs to be expanded from having physicians providing care remotely not only to patients in outpatient and inpatient facilities but also to specialists from large urban/tertiary hospital settings providing guidance to understaffed intensive care units in the medical deserts. Technology needs to be more HIPAA compliant, and legislation needs to mandate reimbursement for these services not just as emergent reaction to a pandemic but also as a more lasting outcome.

Recruitment of physicians to rural medical deserts is handled by

the Office of Rural Health Policy, which has put incentives in place to give prospective physicians low-interest home loans, sign-on bonuses, and competitive retirement packages. In the urban environment, more Freestanding Emergency Centers (FECs) are being established in dense urban communities, increasing access to healthcare for poorer residents.

Conclusion: The efficacy of the aforementioned solutions is being put to the test right now as underserved areas face increased healthcare needs as a response to increasing COVID-19 cases. Accordingly, new variants on these solutions will come to fruition, potentially yielding better options for residents of rural and urban medical deserts.

While economics may have played a role in the development of medical deserts, there are still opportunities to reverse the deleterious effects these trends have had on millions of residents across the US. With the advent of governmental regulations, novel technologies, incentives for new physicians, and the development of healthcare facilities, we might create an oasis in a medical desert in the future.

Rajeev Suri, MD, MBA, FACR, FSIR is Vice President of Bexar County Medical Society, Professor and Vice Chair Radiology at UT Health San Antonio, Chief of Staff at University Hospital Medical, and Director of Radiology at University Health System; and Abhinav Suri, BS is currently an MPH student at Columbia University. visit us at www.bcms.org

15

EQUALITY IN HEALTHCARE

Disparities in the Time of COVID-19

By Sekinat K. McCormick, MD The current severe acute respiratory syndrome Novel Coronavirus 2019 (COVID-19) global pandemic has brought with it a repeated, but underacknowledged hard truth that often disease has a disproportionate negative effect on people of certain ethnic origins. Although many aspects of COVID-19 have been difficult to analyze and quantify due to the speed and relative severity of its spread, this aspect of COVID-19 is being felt especially hard by minority communities. The health disparities that COVID-19 brings remind us we must continue to push forward systemic change necessary to battle disparate health outcomes for our patients of color.

As the COVID-19 pandemic has taken root across the country, underlying health diseases including hypertension, diabetes, asthma, and obesity as well as advanced age have been repeatedly cited as risk factors for increased morbidity and mortality from the disease.

As data and demographics of those affected by the disease have become available, being African-American has emerged as a risk factor for increased morbidity and mortality from COVID-19. Although most states do not report ethnographic data on COVID-19 cases, 16

San Antonio Medicine â&#x20AC;˘ August 2020

the few that have done so paint a bleak picture. In Michigan, 40% of COVID-19 deaths are black, despite representing only 14% of the general population. In Georgia, 80% of hospitalized COVID19 patients are black, even though only 31% of the stateâ&#x20AC;&#x2122;s population is black.

While the cited underlying health conditions that result in increased morbidity and mortality due to COVID-19 are recognized to disproportionately affect black and brown communities, this alone cannot account for the marked difference in outcomes. When addressing the racial difference in outcomes, a thorough discussion must also address the issues of environment and the effects of the social determinants of health on outcomes.

While a viral global pandemic should be indiscriminate in its infection, the systems and environments within which the people it is affecting live are not equal, highlighting the systemic and environmental discriminate factors that have long preceded the arrival of COVID-19. Environmental injustices are recognized as poor environmental conditions such as air pollution, lack of clean water, ex-

EQUALITY IN HEALTHCARE

posure to toxic pollutants coming from refineries, coal mines, and landfills, amongst other things. The residents in the areas more commonly exposed to these environmental pollutants tend to be minorities and low-income individuals. A Harvard study looking at air quality was able to link air pollution with higher COVID-19 death rates. Similarly, St. John the Baptist Parish in Louisiana, which is home to several chemical plants and oil refineries, was noted in midApril to have the highest death rate per capita for coronavirus in the country.

In addition to the environmental issues facing these marginalized communities are the socioeconomic issues. A central strategy for containment of COVID-19 is social distancing. A key tenant of social distancing is the ability to work from home, which is not as available to many low wage earners. Often these low wage earners are disproportionately people from minority communities.

In Moore County Texas, a large cattle processing plant has been inundated with cases. The plant disproportionately employs socioeconomically disadvantaged people, many are of color and immigrants. This plant, until recently, had not followed proper social distancing nor did it provide adequate masking. As a result, these workers were disproportionately exposed to the risk of acquiring COVID-19.

Here in Bexar County, death rates are lower than other major metropolitan areas in the state. However, the confirmed death rate for positive white patients with COVID-19 is 3.0%, while in Hispanics it is 1.1%, and in Blacks it is 3.2%. Black persons with COVID-19 only represent 5.7% of those infected, while whites and Hispanics represent 15% and 77% respectively. Proportionally, black people with COVID-19 are more likely to die from the disease.

The issues of environment and the social determinants of health are complex. This pandemic has brought them to the forefront on a global scale. When addressing policy to guide systemic response, these issues can be the difference between life and death. As health care providers, we must continue to consider how to address chronic health conditions in ways that change policies to break down the long standing systemic and environmental issues at play.

In the example of the pandemic response, greater efforts should be made to ensure minority communities have full understanding of the health risks and ways to mitigate contracting the virus. Our response to the disparate death rate experienced by minority communities must be part of our commitment to the health of all our patients and needs to grounded in efforts to address ongoing environmental and social determinants of health. Without a focus on these issues, communities of color and the poor will continue to remain disproportionately vulnerable and subject to worse health outcomes.

Sekinat McCormick, MD is a clinical associate professional at UT Health San Antonio. Her clinical practice is as a pediatric orthopedic surgeon specializing in scoliosis and general pediatric orthopedic conditions. Dr. McCormick is a member of the Bexar County Medical Society.

Resources Boston, 677 Huntington Avenue, and Ma 02115 +1495 1000. “Air Pollution Linked with Higher COVID-19 Death Rates.” News, 7 Apr. 2020, https://www.hsph.harvard.edu/news/hsph-in-thenews/air-pollution-linked-with-higher-covid-19-death-rates/.

CNN, Ashley Killough and Ed Lavandera. “This Small Louisiana Parish Has the Highest Death Rate per Capita for Coronavirus in the Country.” CNN, https://www.cnn.com/2020/04/15/us/ louisiana-st-john-the-baptist-coronavirus/index.html. Accessed 11 May 2020.

“Connecting the Dots Between Environmental Injustice and the Coronavirus.” Yale E360, https://e360.yale.edu/features/connecting-the-dots-between-environmental-injustice-and-the-coronavirus.

Accessed 11 May 2020.

Environmental Justice, or Rather Injustice — The Collaborative on Health and the Environment. https://www.healthandenvironment.org/environmental-health/social-context/history/environmental-justice-or-rather-injustice. Accessed 11 May 2020.

Experience. https://experience.arcgis.com/experience/ 05e43c8748c44d418ce6c028b8681e55. Accessed 11 May 2020.

Healthline, Anna Almendrala |. California. “It Was Clear COVID19 Would Hit Black People Hard. Yet Experts Stayed Silent.” Vice, 7 May 2020, https://www.vice.com/en_us/article/n7wjq7/it-wasclear-covid-19-would-hit-black-people-hard-yet-experts-stayed-silent.

How Environmental Justice Connects to COVID-19 | Green America. https://www.greenamerica.org/blog/how-environmentaljustice-connects-covid-19. Accessed 11 May 2020.

Racial Disparities in the Time of COVID-19. https://labblog.uofmhealth.org/rounds/racial-disparities-time-ofcovid-19. Accessed 11 May 2020.

Raifman, Matthew, and Julia Raifaman. “Disparities in the Population at Risk of Severe Illness FromCOVID-19 by Race/Ethnicity and Income.” American Journal of Preventive Medicine, doi:https://doi.org/10.1016/j.amepre.2020.04.003.

US EPA, OA. “Environmental Justice.” US EPA, 3 Nov. 2014, https://www.epa.gov/environmentaljustice.

Why Are Blacks, Other Minorities Hardest Hit by COVID-19? https://medicalxpress.com/news/2020-05-blacks-minorities-hardest-covid-.html. Accessed 6 May 2020.

visit us at www.bcms.org

17

EQUALITY IN HEALTHCARE

Equality, Health Policy, and the Real World

By Linda G. Solis, PhD and Adam V. Ratner, MD, FACR As professors of health policy and applied humanities we’re often asked about our healthcare system and navigating its many challenges, inadequacies, and inequities. Below are a few questions we’ve been asked regarding this edition of San Antonio Medicine, “Equality in Healthcare”. The opinions are our own with no warranties expressed or implied. Please feel free to disagree and write a follow-up article or letter to the editor (Editor@bcms.org).

What is healthcare equality?

Dr. Solis: Let’s start by defining equality. Equality says that everyone gets the same resources. When we think about this objectively, we can see there are inherent problems. No two people are the same, so providing equal access to a resource doesn’t make a lot of sense.

Rather than focusing on equality in access to care, perhaps we should consider equity in access to care. Equity means that each individual will receive what is appropriate and adequate. Thinking about this from a healthcare access point of view, it’s clear that equitable access to healthcare is what is needed.

Dr. Ratner: From birth, and as we grow and age, each of us have unique needs and desires which are constantly in flux. As long as each person is a unique individual, there will never be absolute equality. This is why we need physicians to be able to practice with the necessary freedom and resources (with healthcare system support) so we can work with each patient as an individual, promptly, effectively, and with compassion. Absolute equality implies a rigid one size fits all answer to the delivery of healthcare. No one wants everyone, including themselves, to have equally poor health or equally poor health care. I would reframe the question to ask; “when will everyone have adequate and appropriate healthcare which will be delivered in a humane and sustainable way?”

Physicians can’t be all things to their patients, so how can they help with inequality or adverse social determinants of health when they are struggling financially to just see patients for short visits?

Dr. Solis: Physicians will never be able to be all things to every patient.

However, physicians can and should be open minded to the 20

San Antonio Medicine • August 2020

unique needs of each patient they see. These needs might be based in the patient’s culture or socioeconomic level or language; regardless, the physician who is humble enough to acknowledge that each patient brings their entire cultural identity with them into the examination room will be more likely to make positive connections with the patients. A physician who can listen to a patient explain the cultural reason they are “non-compliant” and acknowledge that those cultural reasons are important, indeed vital to the patient, will be able to treat the patient in a more equitable way. A culturally humble physician acknowledges that they have much to learn from every patient, and that the physician’s culture or way of being isn’t the best or even the only culture or way of being. None of this costs money, but it creates a vital relationship between physician and patient. This relationship, once cultivated, will allow patients to see the physician as an ally in seeking optimal possible health.

Dr. Ratner: For the majority of physicians in typical practices, it is difficult, if not nearly impossible, to directly address adverse social determinants affecting our patients. That said, we as physicians are constantly trying to find work-arounds and practical diagnostic and treatment alternatives for our socioeconomically disadvantaged patients. Most physicians would be in a stronger position to be more helpful if we were less hamstrung by well-intentioned but overbearing and outdated rules and regulations as well as mispriced payments and billing hassles. Furthermore, so much of the healthcare dollar is spent on building the administrative infrastructure to ensure compliance with inefficient and outdated rules. As a recent example, in order to ensure compliance with HIPAA and state patient privacy rules, the health department requires all mandated COVID-19 notifications from physicians to be submitted

by FAX and not by email or other more modern communication modality. Imagine how much economic growth and happiness would be unleashed if we could redeploy just half of the administrative and compliance expenses and inefficiencies currently in the healthcare system and apply it to direct patient care, disease

prevention, wellness incentivization, and precisely addressing other adverse social determinants of health.

Regarding equality, what are people’s reactions to wearing masks and social distancing telling us?

Dr. Solis: Choosing whether to wear a mask has become contentious. Mask-wearers of my acquaintance equate wearing a mask with “the greater good” – they’ll tell you they don’t just wear a mask to protect themselves; they wear it to protect others as well. Non-mask-wearers of my acquaintance equate wearing a mask with being controlled. They see it as an individual choice and if they choose not to protect themselves and then get sick, so be it. In my opinion and experience, mask-wearers tend toward deep belief in the need for equity. Equity too is for the benefit of the entire community, turning our focus from “me” to “we”. If we are truly seeking equity – in healthcare and in society at large – then we should always put the community’s needs first. Wear your mask!

Dr. Ratner: As best as we can tell at this early stage in the pandemic, all humans are more or less equal in our innate potential to serve as viral vectors for COVID-19. The virus couldn’t spread as it has without the critical help of us humans. Out of ignorance, blind defiance, or perhaps even malice, some of our fellow humans seem to want to help the virus spread, potentially sickening and killing themselves and others with whom they have some contact. In that case, there is no equality or equity, just bad behavior. This is not a political issue; it is moral one. Yes, there are economic consequences of physical distancing, but how much does it really cost to wear a mask? The immediate, adverse economic consequences of physical distancing become comparatively smaller when balanced against the cost of each hospitalization and lost productivity and misery from illness or completely moot for those who lose their lives or those of their loved ones. Don’t be an accomplice to the virus! You are either with the virus or against it.

Linda G. Solis, PhD is Assistant Professor of Applied Humanities at the UIW School of Osteopathic Medicine.

Adam V. Ratner, MD, FACR is Professor of Radiology, Health Policy, and Medical Humanities and Assistant Dean of Strategic Initiatives at the UIW School of Osteopathic Medicine, Chair of The Patient Institute, and Immediate Past President of the Bexar County Medical Society. visit us at www.bcms.org

21

EQUALITY IN HEALTHCARE

Mothers & Children at the Intersections of Pregnancy & Incarceration

By Allison Crawford, RN, BSN, PhD Candidate

On May 17, 2018, a baby boy named Cashh was born prematurely on the floor of an Ellis County Jail cell located in northeast Texas.

His mother was incarcerated for a minor drug charge with a bail amount too steep for her to afford. Thus, Cashh’s mother was forced to spend the last two trimesters of her pregnancy confined in jail.

The days prior to Cashh’s delivery, his mother had reported complaints of pain but was reassured by unlicensed personnel in the jail she was not in labor. As the days progressed, her pains intensified and despite her concerns, she was never seen by a licensed obstetrician/gynecologist (OB/GYN) nor transported to a hospital. Following a precipitous delivery alone in jail, mother and baby were finally transferred to a nearby healthcare facility where Cashh passed away due to prematurity and inadequate medical attention. This story is all too common to system-impacted mothers and their children; however, the issue continues to go unnoticed. To understand the complexity of this health inequity there has to be an understanding of incarceration.

Incarceration Mass incarceration is a term coined in 2001 to reflect the increasing numbers of people in the United States being incarcerated, which is attributed to the “War-on-Drugs” legislation passed in the 1980s. Three pieces of Federal legislation hyper-criminalized and punitively punished those who are arrested for low-level drug offenses, resulting in 20% of all incarcerated individuals being there as a result of a drug offense. Unfortunately, these laws led to increasing numbers of incarcerated pregnant mothers as well. In fact, the rate of women impacted by incarceration has risen over 800% over the past thirty years in the United States. To evaluate the barriers impacting health equity of system-impacted mothers, healthcare in jails must be critically analyzed.

Healthcare in Jails Jail systems have been shown to have limited language, policies and procedures addressing the distinctive needs of pregnant women resulting in repeated reports of system-impacted mothers delivering without medical assistance and their babies dying in jail. The con-

22

San Antonio Medicine • August 2020

tinued lack of adequate policies and procedures addressing the reproductive and civil rights of women agitates an already compromised situation.

Medical standards and best practices have been written to be applicable to all individuals regardless of incarceration status. However, pregnant, jailed women have special needs, and reproductive healthcare in our jail systems is usually insufficient and even dangerous for women. Jail budgets are limited in their ability to have on-site licensed obstetrical providers (OB/GYNs) trained in highrisk reproductive healthcare, resulting in inadequate care.

Mothers and Children at the Intersections of Incarceration The impact of chronic stress can alter the way the body handles stress (known as the Allostatic Load, which is "the wear and tear on the body" which accumulates as an individual is exposed to repeated or chronic stress) forming ineffective coping mechanisms.

These ineffective coping mechanisms over time can cause genetic mutations and lead to chronic disease processes across generations, indicating they could have higher rates of morbidity and mortality with pregnancies considered “high-risk”.

We know the importance of maternal/child bonding is essential for proper neurodevelopment and high-quality attachment behavior between children and their caregivers. As such, we can anticipate the impact of the systemic removal of nurtured and attached mothers and babies can negate health equity.

Help for System-Impacted Mothers and Children Despite the Supreme Court’s ruling in Estelle vs. Gamble in 1976 that incarcerated people have the Constitutional Right to healthcare, there is no agency adequately overseeing healthcare in jails. In addition, there is limited legislation mandating jails give basic healthcare services, including pregnancy care. There is no comprehensive push at the local, state or federal levels trying to preserve the integrity of nuclear families. The severing of attachment between mothers and children denies mothers their right to nurture during the most formative years of their child’s life, a health inequity.

Table 1: Call-to-Action for Healthcare Providers 1.

EQUALITY IN HEALTHCARE

Collaborate with patients, specialties, systems, and governments to form programs that keep mothers, babies & families together with high-quality mental health and medication assistance therapy services

2. The Centers for Disease Control (CDC) (2019).

Preventing Adverse childhood experiences. What are adverse childhood experiences: Retrieved from: 2. Promote breastfeeding and bonding in incarcerated mother/baby dyads https://www.cdc.gov/violenceprevention/childabuseandneglect/aces/fastfact.html 3. Develop meaningful data (qualitative and quantitative) specific to the intersectionality (gender, class and race) of system-impacted mothers and families 3. Hayes, C., Sufrin, C., & Perritt. (2020). Reproductive Justice Disrupted: Mass Incarceration as a 4. Create valid and reliable screening tools for the clinical setting that include quesDriver for Reproductive Oppression. AJPH Pertions regarding incarceration history and status spectives, Supplement 1, 2020, 110 (S1) 4.

Kajstura, A. (2017). Women’s mass incarceration 5. For incarcerated pregnant populations, solitary confinement is dangerous, instead, : The whole pie. Prison Policy Initiatives. Retrieved advocate for jail diversion programs from: https://www.prisonpolicy.org/reports/ 6. Create continuous training for healthcare providers to learn about incarcerated pie2017women.html populations, their rights and healthcare needs 5. March of Dimes (2016). Maternal, Infant, & Child Health in the Unites States. Retrieved 7. Consider the social determinants of health (housing, education, income, marital from:https://www.marchofdimes.org/March-ofstatus, food resources, access to healthcare, etc.) and any prior trauma when giving Dimes-2016-Databook.pdf care 6. McEwen and Stellar, 1993.

8. Advocate for common-sense laws mandating evidence-based care in jails and the 7. Nadal, K., Griffin, K., Wong, Y., Davidoff, K., proper reporting of adverse health outcomes & Davis, L. (2017) The Injurious Relationship Between Racial Microaggressions and Physical 9. Help alleviate stigma by using less punitive language such as: Health: Implications for Social Work, Journal of • “mothers” versus “inmates”, “criminals”, “drug addicts” Ethnic & Cultural Diversity in Social Work, 26:1• “system-impacted mothers” versus “mothers in jail” or “incarcerated mom” • “institutions of incarceration” versus “jail”, “prison”, “correctional facility” 2, 6-17, DOI: • “substance-use-disorder” versus “drug addiction” 10.1080/15313204.2016.1263813 8. Sawyer, W. & Wagner, p. (2020). Mass Incarcer10. Use all of the tenants of Reproductive Justice in all healthcare initiatives ation: The Whole Pie 2020, The Prison Policy Initiative. Retrieved from: https://www.prisonpolicy.

11. Contact nonprofits to assist them in policy reform: org/reports/ pie2020.html?c=pie&gclid=Cj0 • The American Civil Liberties Union Texas (ACLUTX) https://www.aclutx.org • The Texas Jail Project https://www.texasjailproject.org KCQjw_ez2BRCyARIsAJfg-kv96MjbqlHJo3XSb• The Texas Criminal Justice Coalition https://www.texascjc.org nMyZTgmhqoni AgihwINBUPgTsj3hbxyWOGC • Zero to Three https://www.zerotothree.org jvEaAvxxEALw_wcB • The Prison Policy Initiative https://www.prisonpolicy.org 9. Shlafer, R., Hardeman, R., & Carlson, E. (2019).

• Ban the Box Campaign https://bantheboxcampaign.org Reproductive Justice for incarcerated mothers and advocacy for their infants and young children. Infant Maternal Health Journal, 40: 725-741 A Call- to-Action 10. Shlafer, Gerrity, Ruhland, & Wheeler (2013). Children with InInadequate health services plaguing system-impacted mothers, carcerated parents-considering children’s outcomes in the contheir children and families is a multifaceted problem that will require text of Family experiences. Children’s Mental Health Review a multifaceted solution. Healthcare providers can have a unique role 11. Sufrin, C & Kuhlik, L. (2020). During Covid-19 Crisis, We must with advocacy and public health initiatives to alleviate disparities in prioritize the release of pregnant and postpartum people. Amerincarcerated populations (Table 1). Together, by spreading awareican Civil Liberties Union.

Retrieved from: ness and alleviating barriers, we can assist in enhancing the qualityhttps://www.aclu.org/news/prisoners-rights/during-covid-19of-life and health equity for this underserved population of mothers crisis-we-must-prioritize-the-release-of-pregnant-people/ and children.

12. Texas Department of State & Human Services (2018). Maternal Mortality and Morbidity Task Force & Department of State and Allison Crawford RN, BSN is a PhD Candidate and obstetrical nurse in Human Services Joint Biennial Report; Texas DSHS San Antonio, Texas. She specializes in researching systemic racial inequities 13. Ross, L. (2017) Reproductive Justice as Intersectional Feminist in mothering social groups impacted by the institutions of incarceration.

Activism, Souls, 19:3, 286-314 doi: 10.1080/ 10999949.2017.1389634 Sources: 1. Alleyne, V. (2007) Locked Up Means Locked Out, Women & Therapy, 29:3-4, 181-194, DOI: 10.1300/J015v29n03_10

visit us at www.bcms.org

23

EQUALITY IN HEALTHCARE

White Coats for Black Lives

June 7, 2020

By William L. Henrich, MD, MACP President, UTHSA and Professor of Medicine Universities aspire to have, at their cores, a central compass that invariably points to qualities we admire: fairness, respect, inclusivity, civility and diversity. As citadels of learning, they aspire to have receptivity to new ideas as they seek to lead society to higher achievements, to a more noble standing for all of us. Universities are tasked with teaching us lessons from the past, so that those who follow will enjoy better futures void of past mistakes. Universities, when at their best, are about seeking the truth about the human condition and then teaching us the truths about what is necessary to live lives unburdened by injustice, fear and pain.

The murder of Mr. George Floyd last week is a vivid reminder that there is a wide gap between these lofty sentiments and our current reality. Mr. Floyd’s death (and the deaths of many, many others) tells us that the central lessons that universities in a democracy wish to impart — lessons of decency and tolerance — are conspicuously absent from many institutions in our country today.

My sense is that one defining ingredient that allows the seeds of animus to grow is the notion by some that lives have unequal value.

In a health science university like ours, we are reminded daily of the inequalities in our systems of care, from access to providers to procurement of medicines to adequate counseling. Thus, we strive, as professionals, to level the playing field because we regard human life as so precious, so dear. The death of Mr. Floyd is an anathema to us because it is so antithetical to the very calling of our vocation: to make lives better.

As we consider solutions to achieve the aspirations we have for healing and progress in our country, there are many elements now being thoughtfully suggested as essential. I urge us not to overlook the one proffered by former Texas Governor Dolph Briscoe who said, “No matter what the problem, the solution, in part, is always 24

San Antonio Medicine • August 2020

education.” Education shines the bright light of scrutiny on hateful ideologies like racism and xenophobia, and, in the process, teaches us that there is healing power in simple human kindness; that empathy, when sincere, is a priceless gift embedded in love. I am reminded in saying this that the great theologian, Thomas Merton, defined hate as the absence of love, and, in so doing, pointed us to what is ultimately a helpful solution which we must practice daily.

This moment is a challenge for us as it is deeply painful and arrives in the midst of a pandemic which, by necessity, constrains our ability to touch each other, to even see each other, as our faces are half obscured by masks. But irrespective of the constraints, as trying as these times are, we should take solace in the fact that the ideals our university holds dear and teaches — inclusivity, diversity, respect, integrity, honesty, selflessness and love — are what we seek to reflect in our personal behaviors to everyone, and, by our examples, lift our friends, patients and everyone who we know to better tomorrows. UT Health San Antonio offers its sincere condolences to Mr. Floyd’s family as we affirm our rejection of violence, hate and discrimination.

The Vice Dean of Inclusion and Diversity in the Long School of Medicine, Dr. Chiquita Collins, has arranged for a “Collective Healing Virtual Roundtable” for all members of our campus. This Roundtable is designed to provide our students, residents, fellows, faculty and staff a way to process their feelings and experiences in relation to the loss of Mr. Floyd and so many others.

With great respect, William L. Henrich, MD, MACP President UTHSA and Professor of Medicine Bexar County Medical Society Member

EQUALITY IN HEALTHCARE

COMMUNICATION INTERRUPTED:

The Spread of Misinformation and How Do We Do Better?

By Kalli R. Davis and Maria Batchinsky Communication is always crucial, therefore we must learn to communicate effectively. During this pandemic we have watched what could be termed, “healthcare communication INTERRUPTED.” It’s like we are an FM radio station between counties and we’re constantly being cut off by static or another station’s broadcast. The amount of information regarding COVID-19 is overwhelming and social media has become an outlet for opinions and misguided information leaving healthcare workers, infectious disease specialists and community leaders to do damage control. While healthcare workers have done their best to communicate with the general public regarding the virus, they are often overshadowed by blog posts, viral Facebook posts, memes and more, that have infiltrated social media. Media reporters with no healthcare education or experience take it upon themselves to discuss the virus, further spreading misinformation. All of these interrupted modes of communication put us exactly where we are today – at the center of a public health crisis.

Through observation, the main conclusion we have come to is that we can’t fault the general public for not understanding. The misconception and assumption that people who do not understand viruses and their biology are “uneducated” is unfair. Many people who lack an understanding of viruses, their spread, and the severity of this pandemic are highly educated in business and other fields.

Their educational paths were simply different and they have not 26

San Antonio Medicine • August 2020

studied science the way researchers and healthcare professionals have. The slander, name calling, and other mockeries of these individuals has only led to further distrust of recommendations from healthcare professionals.

So how do we solve this problem? While there is no way to prevent social platforms and the media from covering a pandemic, we can and must prevent the share of misinformation to the greatest extent possible before it becomes appropriated as fact. A perspective piece published in 2018 by Raina provides strong recommendations for problems we are facing today. He stresses the importance of media involvement in outreach efforts by recommending that: the health department schedule regular press releases and conferences with the media allowing them to disseminate information while simultaneously limiting misinterpretation of information. He also notes the benefit of utilizing all available platforms from which people receive their information and proactively front-loading them with facts to limit the amount of irrational fear or extreme complacency that surrounds opinion-fueled social media posts.

Incorporation and successful adaptation of these strategies is the challenge. There are many factors that play into the public’s response to the information received. It is important to keep in mind that people fear what they do not understand. Without question a pandemic is scary, and the fear and anxiety associated with uncer-

EQUALITY IN HEALTHCARE

tainty leads individuals to seek out information on their own rather than waiting for the next press release or televised briefing.

This hunger for information may lead people to accept information from sources that we as professionals consider unreliable. This is why it is important during crisis management to communicate with everyone involved, including the community, as their participation and compliance is vital for the success of all activities. (du Pre, 2014) It is important for healthcare providers to remember that “communication should be an ongoing process, that involves not just one message, but many diverse messages about risk factors,” with special attention given to the audience’s reception and interpretation of the intended message. (du Pre, 2014). Similarly, the CDC discusses in the Field Epidemiology manual “how persons affected by the disease outbreak or health threat perceive the risk differently from the experts who mitigate or prevent the risks.” We must remain mindful that each individual plays a factor in the overall outcome of our interventions, and that one’s past experiences [ourselves included] influence perspective and interpretation of the information provided.

So then, what we must ask ourselves is “How?” How can we do better?

According to the American Public Health Association, four factors affect the acceptance of public health messages by the community: 1. Environmental – How can we equalize the gap between gender, income status or gentrification?

2. Social and cultural – How can we better understand and better affect populations with differing societal norms?

3. Language preferences – cultural predomination in specific areas. How can we reach our Spanish-speaking population better here in Bexar County?

4. Attitudes towards public health interventions – How can we increase trust and build relationships necessary to promote community adherence to recommendations?

Pandemics are often spread out over time like a “rising tide”; pandemics pose a risk that continues to develop (Vaughn and Tinker, 2009). Sometimes the key to prevention is early interception; however, plans made early-on in a pandemic will likely require adjustment. Inconsistency in recommendations can contribute to distrust from community members. Therefore, full disclosure is important,

and it is recommended that messages be up front from the beginning to accommodate for the dynamic nature of a pandemic.

Most pandemic guides discuss media relations but do not address recommendations for communication between providers and patients. What if every provider sent a generic message to their patient list just like retailers send out “deals of the day”? PCPs could implement pamphlets in their office, on websites, and in remote office locations. In areas where internet access is not as prominent, could we encourage county public health officials to post billboard messages or signs in town squares? With such a vast amplitude for communicating- are we really doing enough? Are we only thinking big when we should think small too?

As communication evolves, the healthcare profession must evolve with it. A large part of social media is unregulated by healthcare professionals because they are handling real-time issues. The times are changing, and we must too as we continue to move forward in a generation where social media activity is on a steady rise.

We must consider the potential benefits and limitations of each communication platform and learn to utilize them to the fullest of their potential. Maybe the COVID-19 pandemic can help us process these issues. Food for thought, as always, is important to medical advancement.

Kalli R. Davis is a student at UIWSOM in San Antonio, Texas and is a member of the Bexar County Medical Society.

Maria Batchinsky is a student at TTUHSC in Lubbock, Texas.

Works Cited: Crouse Quinn S. Crisis and emergency risk communication in a pandemic: a model for building capacity and resilience of minority communities. Health Promot Pract. 2008;9(suppl 4):18S–25S. Pre, A. D. (2014). Communicating about health: Current issues and perspectives. New York, NY: Oxford University Press.

Raina SK. State of the globe: Ensuring effective communication in public health emergencies. J Global Infect Dis 2018; 10:173-4 Tumpey, A., Daigle, D., & Nowak, G. (2018, December 13). Communicating During an Outbreak or Public Health Investigation. Retrieved July 01, 2020, from https://www.cdc.gov/eis/ field-epi-manual/chapters/Communicating-Investigation.html Vaughan E, Tinker T. Effective health risk communication about pandemic influenza for vulnerable populations. Am J Public Health.

2009;99 Suppl 2(Suppl 2):S324-S332. doi:10.2105/AJPH.2009.

162537

visit us at www.bcms.org

27

EQUALITY IN HEALTHCARE

Stress Management & Resiliency

By Ajeya P. Joshi, MD

28

San Antonio Medicine â&#x20AC;¢ August 2020

EQUALITY IN HEALTHCARE Stressors, big and small, come at us regularly in distinctive but relatable ways. It might be the worry on any given day about whether we will succeed in leaving the office with no loose ends to make an evening commitment on time. In medicine specifically, it might be the upcoming contract negotiation with an insurance entity, a patient who is not faring well in spite of our care or an HR issue that we feel ill-equipped to deal with.

‘Micro’ level daily stressors include a trying patient interaction, running clinic as the wi-fi goes down, interruptions like the spam call from a roofing company and an attention-getting email. This is ‘the daily grind’; getting through it smoothly without feeling bruised is one kind of challenge. Examples of ‘macro’ stressors include concerns about the direction one’s practice is taking, about an aging parent, about a medical group’s culture and about rising overhead. Another example would certainly be this ongoing public health crisis with no seeming end in sight.

Potential endpoints from ongoing stressors and our responses to them include physical, mental, and emotional damage. The dreaded burnout status lays at the end of this path. Some think about burnout, recognizing it may exist and seeking to alleviate it, while others exhibit signs (substance abuse, isolation, impaired relationships) yet cannot come to acknowledge this state of being. Burnout does not have a universal definition, but the core attributes include (Maslach): • Fatigue symptoms: either mental, physical or emotional exhaustion, or in combination • Depersonalization: a sense of callousness towards others • Reduced personal accomplishment: feeling worthless, ineffective and having a sense of failure I bring this up to acknowledge this important issue, which is often hard to do in terms of self-reflection, but more importantly to point constructively to solutions. There is great value in focusing on stress management and resiliency as self-care tools. We have immense intrinsic power to build resiliency. Whatever stage of grappling with stress we’re at, we can contribute enormously to healing ourselves.

We just have to build the skills, which comes with time, practice, and intention, just like better cardiovascular conditioning, or flexibility in a yoga pose, or an improved motor skill such as in surgery.

The skill-building in resiliency and self-care, including mindfulness

practices, was referenced as ‘Swimming Lessons’ in the May issue of this publication (1).

The world of Mind-Body Medicine provides guidance in this area; self-care, mindfulness, and resiliency-building are not standard offerings in medical school and post-graduate training and support that many of us have received in the last few decades. The powerful linkage between the mind and body is illustrated in profound ways, from the understanding that meditation decreases chronic inflammation and improves gut health (including the state of our internal microbiome), to the recognition that among the subgroups of myocardial infarction survivors least likely to have a secondary cardiac event are those who feel a sense of purpose, and who feel supported by and connected to others. Positive thinking could literally be the difference between life and death in this scenario.

We recall homeostasis from undergraduate biology and medical school, which is obviously the process of maintaining a regulated, nearly constant internal environment. I was not familiar with the term allostasis, until taking the Stress Management and Resiliency Training (SMART) course from the Benson-Henry Institute for Mind-Body Medicine at Massachusetts General Hospital. Allostasis means staying the same (or thriving), but in the face of a changing environment. In a changing environment (change here meaning various stressors coming at us), the adaptive response to one condition may not make sense later in time, and if left on, it represents a harmful, maladaptive response.

Allostatic load means the cumulative wear or damage we experience in the ongoing effort to achieve allostasis. Allostasis is always the goal, and the stressors are never-ending. So how do we lessen, or minimize, cumulative allostatic load over time, and continue to not just survive, but thrive? One central answer is to practice the Relaxation Response and other forms of mindfulness.

The Relaxation Response was described by Harvard cardiologist Herbert Benson, and colleagues, in the 1970s. They first studied practitioners of Transcendental Meditation and found that this practice effectively lowered blood pressure in those individuals. Metabolic activity is lowered in general, reflecting a broad parasympathetic activation during the Relaxation Response. Eliciting this response involves using a simple, secular version of Transcendental Meditation technique. The technique involves a mental tool (a word, phrase or image to keep the mind from wandering) and a passive attitude.

Ironically, the Relaxation Response was studied in the same lab at Harvard Medical School where Walter Cannon described the ‘fight or flight’ response several decades earlier. This stress response, necessary for survival and in certain situations, is a sympathetic nervous system activation, including HPA (hypopituitarypituitary-adrenal) stimulation, and norepinephrine and epinephrine release. Sustained activation of these systems can have harmful effects on numerous organ systems, including immune function, cardiovascular health, and pre-cancerous activity. All in addition to headaches, other chronic pain, GI disequilibrium and insomnia, continued on page 30

visit us at www.bcms.org

29

EQUALITY IN HEALTHCARE continued from page 29

common consequences of prolonged responses to stress.

This is all, in short, allostatic load.

Eliciting the Relaxation Response is an example of a mindfulness practice. Other examples include exercise, volunteering, singing, gardening – in short, any activity that can promote being fully present, and not distracted by potential concerns or stressors that could hover and enter our awareness if we allowed our mind to wander. This is very individual and we should explore what we truly love as an outlet. In my house, since we rescued and adopted our dog three years ago, the parenting has been much calmer, and rubbing that dog’s belly is one mindfulness practice that truly works for me to release from a day that had mental and psychological bumps and bruises.

In the middle of the work day, ‘dog meditation’ may not be accessible, so breathing exercises, as a way of invoking the Relaxation Response during a short midday break, or in between patient encounters, are realistic and rewarding.

Meditation, again a secular activity intended to evoke the Relaxation Response, has immense benefits, including physical changes (thickening) of parts of the cerebral cortex, improved insulin sensitivity, and improved HRV – heartrate variability. It can be learned and progression is possible for anyone. It can defuse and erase harmful stress responses, like ‘awfulizing’: assuming the worst, when likely there is not a major problem. In my world, an inpatient nurse calling about a post-op spinal patient experiencing significant pain might make me worry about fracture or spinal hardware shifting.

These are typically irrational worries, and the pain usually subsides with medication adjustments. I have learned not to fixate on the worst-case scenarios and this has helped my well-being immeasurably. The Relaxation Response similarly helps me to stop worrying about factors in delivering patient care that are not in my control.

Other times that I have benefitted from mindfulness practices include the night before or right after a long operative day. The key the night before is to rest, and not be revved up thinking about the next day’s work. The key after a long day of surgeries is to relax on time, to be ready for the next day. In both situations earlier on, left to my own devices, I might channel surf, browse on my phone, plan out online chess moves, or snack late at night. Now I am better able to help myself wind down. Certain Apps are helpful in this regard: Insight Timer and Calm, to name two, and the Boho Beautiful 30

San Antonio Medicine • August 2020

YouTube channel, among many others. Remember, your mindfulness practice works best in a quiet environment, and for breathing or meditating especially, a dark one as well. This is a work in progress, and regular practice has benefits for the short-term and long-term.

Tips for Microresilience, a specific approach to ‘being present’ during a busy day in medical practice, include creating ‘flow states’, dedicating specific times for email (like the end of the day or a lunch break, and not having email spill into other core activity like patient encounters). In addition, consider handing your phone to a trusted assistant during clinic so it is not a distraction or interruption during patient encounters. These and other very helpful strategies are found in ‘Micro-Resilience: Minor Shifts for Major Boosts in Focus, Drive, and Energy.’ (2) In summary, resiliency amounts to getting better at maintaining allostasis without getting worn down. Mindfulness practices are essential in this self-care effort, and they take different forms for different people. It is never too late to start, and the payoff is immense.

Ajeya P. Joshi, MD is board certified in Orthopedic Surgery and Orthopedic Spine Surgery and is a member of the Bexar County Medical Society.

Notes/References: (1) ‘Swimming Lessons For the Greater Good’, San Antonio Medicine May 2020 (2) ‘Micro-Resilience: Minor Shifts for Major Boosts in Focus, Drive, and Energy.’ by Bonnie St. John and Allen Haines

SAN ANTONIO MEDICINE

Do Your Part

By Nichol C. Henkes

visit us at www.bcms.org

31

THE BUSINESS OF MEDICINE

Updates Make PPP Easier for Physicians

By Jim Rice, CPA

There continues to be a constant stream of new updates to the Paycheck Protection Program (PPP) loan. We expect to see even more updates and modifications in the coming months as Congress continues to try to assist medical practices with this pandemic. With each update and modification there are increasingly favorable rules that make it easier for physicians to work with the PPP loan program and to obtain forgiveness of the PPP loan received.

Covered period and payroll costs Key highlights on the Paycheck Protection Program Flexibility 32

San Antonio Medicine â&#x20AC;˘ August 2020

Act of 2020, passed on June 5, include the extension of the covered period for loan forgiveness from eight weeks to 24 weeks. Borrowers who received their loan before June 5 may elect to use the original eight-week period for determination of the loan forgiveness amount. However, it is probable that the 24-week period will allow for a greater amount of loan forgiveness. The 24-week period begins with the date of receipt of the loan proceeds.

Another change from the PPP Flexibility Act is that only 60 percent of the loan proceeds must be used for payroll costs, which is defined as salaries, employer health insurance premiums, retirement

THE BUSINESS OF MEDICINE plan contributions and state unemployment insurance payroll taxes.

The remaining 40 percent of the loan may be used for rent, utilities and mortgage interest. This is a change from the prior requirement that 75 percent of the loan had to be used for payroll costs.

There is also the suggestion from the guidance being given by the SBA (Small Business Administration) that a partial forgiveness of the loan is possible with even a less than 60-percent usage of the loan for payroll costs.

For loans not forgiven, the loan repayment period is extended to 5 years for loans issued after June 5. For loans issued before June 5, borrowers and lenders can mutually agree to modify the maturity date. Borrowers may defer payment of principal and interest on a PPP loan until the forgiven amount from the SBA is determined.

For borrowers who fail to apply for forgiveness within 10 months from the end of the 24-week period, this deferral of payment on the loan will end at the 10-month period after the 24-week period expires. It must be mentioned here that the amount of loan forgiveness should be very high if there is any attempt to comply with the spirit of the purpose of the PPP loan – payment of salaries to staff and the other allowed expenses.

Favorable FTE changes A very important provision of the Act is the allowance of more time to restore pre-COVID-19 full-time equivalent (FTE) staffing and wages. To avoid any reduction of the PPP loan forgiveness, borrowers now have until December 31, 2020 to restore any reductions in the FTE staffing and salary levels that were in place on February 15, 2020. There are exceptions for certain ex-employees to not be counted toward the FTE reduction. This is important, favorable news. Borrowers must document for these ex-employees: 1. The borrower tried but was unable to rehire the employee who had been employed on February 15, 2020.

2. The borrower could not find a similarly qualified employee for the open position by December 31, 2020.

3. The borrower could not restore medical practice activity to a level comparable to February 15, 2020 because of the COVID-19 guidelines issued by Secretary of Health and Human Services, the director of the Centers for Disease Control and Prevention or the Occupational Safety and Health Administration.

forgiven. This is a deferral, only. The first 50 percent of the deferred amount is payable on December 31, 2021 and the other 50 percent is due on December 31, 2022. This deferral may help substantially with maintaining cash flow in the medical practice, so it should be considered.

Simpler forms Two revised PPP loan forgiveness application forms (Form 3508 and Form 3508 EZ) were recently released. One form is now only five pages versus the earlier 11-page form. A new EZ loan forgiveness application is only three pages. There are certain requirements for use of the EZ form. I will not go into the details other than the EZ form is mainly designed for employers who did not reduce salaries below 25 percent during the loan period.

With the ability to use a 24-week period for determination of the PPP loan amount to be forgiven, the payroll limit for an employee earning more than $100,000 annually is now capped at $46,154 versus the eight-week limit of $15,385. For an owner employee, selfemployed individual and general partner, the compensation cap for forgiveness during the 24-week period is the lesser of two-and-ahalf months’ worth of 2019 compensation, or $20,833. This is before consideration of other qualified payroll expenses including employer health insurance premiums, retirement plan contributions and state unemployment insurance payroll taxes.

Additional legislation was recently passed that extends the date to apply for a PPP loan to August 8. However, existing loan recipients may not apply for a new loan or request an increase in their current PPP loan amount.

This article is a brief summary of several complex laws and guidance issued by SBA and Congress. It is not an all-inclusive discussion of the PPP loan provisions. More detailed guidance should be obtained from your tax advisor and your lending institution.

There are still questions that need additional guidance from the SBA and Congress on the final calculation of the amount to be forgiven on the PPP loan. In the interim, the new Form 3508 should be reviewed now in order to begin to prepare for maximizing forgiveness of physicians’ PPP loans.

Jim Rice, CPA is a shareholder at Sol Schwartz & Associates and leads the firm’s healthcare practice. The firm is a Gold-level Circle of Friends sponsor of the Bexar County Medical Society and is observing its 40th anniversary this year. Jim Rice may be reached at 210.384-8000, ext. 112 or jpr@ssacpa.com.

Employers may now defer deposit of the employer’s share of payroll taxes through December 31, 2020 even if the PPP loan is visit us at www.bcms.org

33

PHYSICIANS PURCHASING DIRECTORY Brought to you by the BCMS Circle of Friends

By supporting these sponsors with your patronage, you are supporting the BCMS. ACCOUNTING FIRMS

Sol Schwartz & Associates P.C. (HHH Gold Sponsor) Celebrating our 40th anniversary, our detailed knowledge of medical practices helps our clients achieve a healthy balance of financial, operational, clinical and personal well-being.

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

ACCOUNTING SOFTWARE

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”

ARCHITECTURE LK Design Group, Inc. (HH Silver Sponsor) LK Design Group has over 24 years of experience designing various medical and hospital buildings. We have experience in both ground up developments and re-design of interior spaces for medical professionals.

Lynn Kuckelman Peters President 210-824-8825 Lynn.p@lkdesigngroup.com Kristin Savage Director of Business Development 210-824-8825 Kristin.s@Lkdesigngroup.com www.lkdesigngroup.com

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor)

34

San Antonio Medicine • August 2020

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

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

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

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

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres 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 Michael_bertuzzi@ml.com Ruth Torres Financial Advisor 210-278-3828 Ruth.torres@ml.com http://fa.ml.com/bertuzzi-torres

Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BANKING

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

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

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

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

Ken Herring 210-283-4026 kherring@broadwaybank.com Daniel Ganoe Mortgage Loan Originator 210-283-5349 www.broadwaybank.com “We’re here for good.”

Synergy Federal Credit Union (HHH Gold 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.

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 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.

Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

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

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

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

COMMERCIAL PROPERTY MANAGMENT

Investment Realty Company, L.C. (HHH Gold Sponsor)

We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

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

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

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

FINANCIAL SERVICES

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!”

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

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

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

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.

Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@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 (512)226-0208 www.Regions.com

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society.

Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

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

HEALTHCARE BANKING

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

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

HEALTHCARE 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 SERVICES Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based

continued on page 36

visit us at www.bcms.org

35

PHYSICIANS PURCHASING DIRECTORY continued from page 35 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 John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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

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

OSMA Health (HHH Gold 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”

36

San Antonio Medicine • August 2020

INSURANCE/MEDICAL MALPRACTICE

INTERNET TELECOMMUNICATIONS

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) Texas Medical Liability Trust is a not-for-profit health care liability claim trust providing malpractice insurance products to the physicians of Texas. Currently, we protect more than 18,000 physicians in all specialties who practice in all areas of the state. TMLT is a recommended partner of the Bexar County Medical Society and is endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

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

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 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 512-375-3972 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

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

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.”

furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

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 SUPPLIES AND EQUIPMENT

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

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

MEDICAL FURNITURE

MOLECULAR DIAGNOSTICS LABORATORY

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio provid-

ing 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”

MORTGAGE

PrimeLending (HHH Gold Sponsor) Doctor Loans, Construction Loans, VA Loans, Conventional and FHA Loans.

Cleo Garza Sr. Loan Officer NMLS#218858 210-483-4907 cleo.garza@primelending.com www.lo.primelending.com/cleo.garza Home Loans Made Simple

OFFICE FURNITURE

CBI Group (HHH Gold Sponsor) From reception to waiting rooms to workstations, CBI Group is your trusted partner for turnkey office furnishing solutions. Our culturedriven approach and unique access to factory-direct pricing allow us to work within any budget/timeline.

Brent Warrilow 210-504-3740 brent.warrilow@cbi-office.com Brody Whitley 210-741-0438 brody.whitley@cbi-office.com Craig Hewines 210-941-1257 craig.hewines@cbi-office.com www.cbi-office.com

PRACTICE SUPPORT SERVICES

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard

Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exit strategies. SWBC family of services supporting Physicians and the Medical Society.

Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Raymond Frueboes SWBC Wealth Management, Licensed Client Associate (210) 376-3730 raymond.frueboes@swbc.com Jon Tober SWBC Mortgage, Sr. Loan Officer NMLS# 212945 (210) 317-7431 jon.tober@swbc.com Deborah Marino SWBC Employee Benefits Consulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com

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

STAFFING SERVICES

CARR Healthcare (HHH Gold Sponsor) CARR Healthcare is the nation’s leading provider of commercial real estate services for tenants and buyers.Our team of healthcare real estate experts assist with start-ups, lease renewals, expansions, relocations, additional offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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.

Donna Bakeman Office Manager 210-301-4362 dbakeman@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELECOMMUNICATIONS ANSWERING SERVICE Investment Realty Company, L.C. (HHH Gold Sponsor) We act as Trusted Advisors leveraging our expertise as we assist Physicians in making the best commercial real estate decisions for their practices whether it's leasing, purchase or asset acquisiton.

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com Miranda Rihn, Associate Realtor 210.642.5429 mrihn@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

KW Commercial (HHH Gold Sponsor) We specialize in advising Medical Professionals on the viability of buying & selling real estate, medical practices or land for development Marcelino Garcia, CRE Broker Assciate 210-381-3722 Marcelino.kwcommercial@gmail.com Leslie Y. Ayala Business Analyst/ CRE Associate 210-493-3030 x1084 Leslie.kwcommercial@gmail.com www.GAI-Advisors.com “Invaluable Commercial Real Estate Advice for The Healthcare Professional”

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

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

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 visit us at www.bcms.org

37

AUTO REVIEW

FUTURE CARS WORTH WAITING FOR

By Stephen Schutz, MD

38

San Antonio Medicine â&#x20AC;¢ August 2020

AUTO REVIEW It’s still very difficult to get press cars, so I’m going to write another non-review, this time about some vehicles due to be launched in the next year or so that I think may be worth waiting for. Here’s my list, as always in no particular order.

Audi A3 – While it still rides on Volkswagen’s ubiquitous MQB platform, the new A3 is slightly bigger and roomier than before and features an updated design with a lot more lines and creases.

Inside, the latest Audi tech does away with the rotary MMI knob we’ve grown accustomed to and replaces it with a touchscreen.

And a new app allows owners to lock and unlock their Audis with their phones rather than a fob. OMG! why isn’t this already a thing in all cars?

Ford Mach-E – A cool electric car that looks like a Mustang was a stroke of brilliance in 2019, but now that post-COVID gas prices are as low as low can get, I can’t imagine this car selling very well. If you want a high performance electric car that’s more affordable than a Tesla, take a look at this Ford. Otherwise maybe buy an F-150 Raptor pickup.

Mercedes SL – In an effort to stay relevant, the next gen SL will move to the AMG GT platform and adopt a 2+2 seating configuration, presumably to better compete with the Porsche 911.

Adding two seats is not unprecedented for the SL – the SLC from the mid 1970s was also a 2+2 – but it is a big change. And while the SL will still be a convertible, its body will inevitably grow to incorporate the extra passenger space. We’ll have to wait for the final design, but the renderings I’ve seen look like a mashup between the AMG GT coupe and Lexus LC. Subaru WRX/WRX STI – My favorite Subies survive with their bad attitudes largely intact, despite moving to a new platform.

Thankfully, both offer manual transmissions — in fact, the STI’s only gearbox is a 6-speed manual — and new turbocharged engines bring more power, in the case of the STI, a brawny 400HP. Thank you Subaru for not giving up on these wonderfully fun cars.

Ram Dakota – Given strong sales of the Ford Ranger, Chevrolet Colorado, and Toyota Tacoma, it should be no surprise that Ram is introducing a smaller pickup. It will look like a 3/4 scale Ram 1500, and, assuming it has a similarly good interior, will do well in the marketplace.

Lexus LQ – Lexus’ answer to the Audi Q8, Range Rover, and Lamborghini Urus ultra-luxury SUVs is an attempt by the Japanese brand to compete in the luxury automotive big leagues. Will it work? If it loses the Remote Touch user interface and includes an

interior to rival Audi I’d say maybe. Lexus needs to create products that luxury buyers want to buy and give those buyers an experience that they enjoy, otherwise they’ll follow Infiniti into irrelevance.

Jeep Wagoneer/Grand Wagoneer – Finally Jeep introduces a full-size, three-row SUV. Based on the Ram 1500 pickup platform, the Wagoneer’s job is to compete with the Chevrolet Tahoe/Ford Expedition, while the Grand Wagoneer will take on the Cadillac Escalade, BMW X7, and Mercedes GLS. They will need to successfully combine legitimate off road chops with true luxury look for this Jeep duo to sell well.

BMW M3/M4 – Most of the advance press for these high performance cars has been focused on the controversial front end of the M4, which is a shame since both cars promise to be true gentlemen's (and women’s), expressed with big power and understated exteriors. Thanks to an enthusiastic fan base, both inside and outside the company, a “Pure” version of both models will be available with a manual transmission. New for 2021 is standard AWD to put all that power on the ground without ruining your tires — over 500HP is rumored — but, alas, the Pure versions with manual gearboxes will have to make do with less horsepower and RWD. That’s ok, order the manual anyway.

Chevrolet Tahoe/Suburban/etc – GM’s second most profitable vehicle models (after their full-size pickups) get bigger and more luxurious this year. Extra wheelbase adds additional space for rear passengers, and enhanced features and better materials give occupants a nicer experience once they’re inside, even in the “way back”. As you’d expect, GMC Yukon Denali and Cadillac Escalade buyers get the best stuff, but even BCMS members who buy a base Tahoe can expect a pretty nice truck. I expect this whole family of trucks to succeed.

Genesis GV80 – A luxury SUV with three rows of seats from Genesis has been eagerly awaited, and now it’s here (or will be very soon). It looks exactly like you’d expect a Genesis SUV would, which I think is good, and it incorporates every luxury doo-dad you’d expect inside. Is it unique and mid-blowing? No, but if you’re looking for a BMW X7 or Mercedes GLS for about 75% of the price, this may be your next car.

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. visit us at www.bcms.org

39

RECOMMENDED AUTO DEALERS • • • •

Bluebonnet Chrysler Dodge Ram 547 S. Seguin Ave New Braunfels, TX 78130 Matthew C. Fraser 830-606-3463

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

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

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

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

11001 IH 10 W at Huebner San Antonio, TX Esther Luna 210-690-0700

Northside Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Marty Martinez 210-525-9800

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Honda 9100 San Pedro San Antonio, TX 78216

Cavender Audi Dominion 15447 IH 10 W San Antonio, TX 78249

Sean Beardsley 210-988-9644

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

Cavender Toyota 5730 NW Loop 410 San Antonio, TX Gary Holdgraf 210-862-9769

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

San Antonio, TX Ed Noriega 210-561-4900

Porsche Center 9455 IH-10 West San Antonio, TX

www.bcms.org

Matt Hokenson 210-764-6945

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

THANK YOU to the large group practices with 100% MEMBERSHIP in BCMS and TMA ABCD Pediatrics, PA

MEDNAX

Dermatology Associates of San Antonio, PA

Peripheral Vascular Associates, PA

Diabetes & Glandular Disease Clinic, PA

San Antonio Eye Center, PA

ENT Clinics of San Antonio, PA

San Antonio Gastroenterology Associates, PA

Gastroenterology Consultants of San Antonio

San Antonio Infectious Diseases Consultants

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Alamo Medical Group

Institute for Women's Health

South Texas Radiology Group, PA

Little Spurs Pediatric Urgent Care, PLLC

South Texas Renal Care Group

Lone Star OB-GYN Associates, PA

Star Anesthesia (USAP Texas-South)

M & S Radiology Associates, PA

The San Antonio Orthopaedic Group

MacGregor Medical Center San Antonio

Urology San Antonio, PA

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of July 24, 2020.

42

San Antonio Medicine â&#x20AC;¢ August 2020