Conclusions Drawn from the 87th Legislative Session By Leah H. Jacobson, MD, FAAP

from San Antonio Medicine August 2021

Medicaid Expansion By Cameron Holguin and Ida Vaziri

Conclusions Drawn from the 87th Legislative Session

By Leah H. Jacobson, MD, FAAP

In today’s hyper-political environment, summarizing the outcome of an inherently political process can be difficult. Do I focus on how important it is to participate in First Tuesdays and how to get involved at a local or state level? Or what BCMS and the Legislative Committee have been doing to advocate for its members and patients? Or, a wrap-up of what we know so far from the 87th Legislative Session?

Many Texans believe the Legislature was disappointing, as evidenced by the most recent University of Texas/Texas Tribune polls regarding the legislative session and what Texans thought of the issues dominating it. I was once again struck by how many topics directly or indirectly relate to health care and public health. Some issues were directly related to health care, such as the coronavirus pandemic and Medicaid issues. Others focused on more indirect issues, such as public education, immigration, electric reliability, public safety and homelessness, to name a few.

The majority of Texans voted on an expansion of Medicaid (sixty-seven percent support it (50% Republicans and 90% Democrats)). There was significant bi-partisan support for this issue, but GOP leaders did not share the same perspective. House Bill 3871 and Senate Bill 117 for the expansion of Medicaid did not make it out of the committee. Two related bills that did pass and were signed involve the Healthy Texas Women Program and expanded benefits (HB 133), and HB 290. The latter was incorporated into HB 2658, which makes it easier for children eligible for Medicaid to receive and keep their coverage.

Texans were in favor of the legalization (or at least partial legalization) of marijuana (only 13% of those polled were against any circumstance being made legal). Almost 60 bills related to marijuana were introduced this Session. Ultimately, only two bills regarding marijuana use were adopted. (House Bill 1535 expands the Compassionate Use Program, and HB 567 protects parental rights regarding the administration of low-THC cannabis to their child for approved medical reasons.)

With regards to our state infrastructure and electric system, 52 percent of Texans polled were not satisfied with the Legislature’s work on the reliability of the state’s electricity grid, and even more were less confident that the Legislature had passed laws to prevent future issues in utility services like those that had occurred in February.

This is just a small look at some of the issues that are being discussed. With the Legislature returning to Austin in July for the first, though likely not the only Special Session, there will be more topics discussed. We will have to wait and see how these issues affect us and our patients.

As The Texas Tribune poll shows, the Legislature does not always represent every single view of their constituents. It is up to us as health care providers to help continue to advocate for our patients and the population at large. I urge you to get involved. You can join the BCMS Legislative and Socioeconomics Committee and meet or contact your state Senator or Representative about a topic you are passionate about. You can also learn about TEXPAC (Texas Medicine’s Political Action Committee) and the TMA’s Political Action Committee and learn how you can get involved in advocacy. Lastly, you can talk to your patients about these important issues and find out what is important to them. These things can all make a big impact!

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.” - Margaret Mead

Reference: https://www.texastribune.org/2021/06/25 /texas-permitless-carry-medicaid-transgenderstudents-poll/

Leah H. Jacobson, MD, FAAP is the Chair of the BCMS Legislative Committee and was the 2017 President of the Bexar County Medical Society.

Benzene in Sunscreen

By Ryan Wealther, Jane Margaret Anderson and Caroline Zhu

If you feel like you’re having deja vu because sunscreen is in the news again, you’re not alone. In 2019, the United States Food and Drug Administration (FDA) proposed a rule that called for the further study of 12 active sunscreen ingredients before definitively declaring these ingredients GRASE (generally recognized as safe and effective).6 These ingredients were found to be systemically absorbed at much higher concentrations than previously recognized.3 The FDA has placed these ingredients into a separate category, Category III, while research is ongoing. However, they have not called for the discontinuation of Category III ingredients because no harmful effects have been linked to date. Sunscreen is once again receiving attention because a recent study found benzene in sunscreen.

Valisure, a company whose core mission is to bring transparency and increased quality to the pharmaceutical industry, released a report in May 2021 indicating that it found benzene in sunscreen products.2 Benzene is an organic solvent and a known human carcinogen—exposures to even low doses of benzene have been linked to hematologic malignancy.5 The Valisure report found that 78 out of 294 batches from 69 brands of sunscreen contained detectable levels of benzene.

Valisure is petitioning the FDA Commissioner to initiate a recall of the sunscreen batches containing benzene and also requested the FDA define limits for benzene in drug and cosmetic products. The American Academy of Dermatology (AAD) released a statement regarding the detection of benzene in sunscreen products.4 It explains that the AAD looks forward to the FDA’s review of Valisure’s report and discusses how it plans to address the findings. The statement also acknowledges that unprotected exposure to the sun’s ultraviolet (UV) rays is a risk factor for skin cancer, and sunscreen is one way to protect your skin and reduce your risk of getting skin cancer.

It is important to remember that there are other components of a comprehensive sun protection plan besides sunscreen. Dr. Allison Pye, MD, FAAD, a board-certified dermatologist at Audie L. Murphy Memorial Veterans' Hospital and Adjunct Assistant Professor of Dermatology at UT Health San Antonio, has some advice for patients who are uncomfortable wearing sunscreen for the time being. “I still encourage these patients to wear sunscreens that are known to be safe, but I also encourage them to use other forms of sun protection by seeking shade and wearing SPF clothing and wide-brim hats.” However, there are some important details to consider regarding Valisure’s recent report, which only represents one study and still needs to be validated. Only a minority (27%) of sunscreen batches were found to contain benzene. Even among batches of the same product, some batches were found to contain benzene while others did not. Furthermore, benzene is not supposed to be in any sunscreens. While it needs to be definitively determined how benzene got into these sunscreen batches, Valisure suggests that benzene is most likely a production contaminant. The full list of affected batches can be found in Valisure’s report.2

While we await the FDA’s review of the Valisure report, uncertainty remains regarding sunscreen, and patients must weigh the risks of potential benzene exposure against the benefits of sunscreen. It is important to remind patients that sunscreen has multiple benefits, including protection against sunburns and the prevention of skin cancer. “UV damage also plays a role in accelerated aging, so in addition to keeping you safe and reducing the risk of skin cancer, sunscreen has the added benefit of maintaining more youthful looking skin,” says Dr. Pye. The AAD and dermatologists recommend using sunscreen that is SPF 30 or greater and broad-spectrum, meaning it protects against both UVA and UVB rays.1

Acknowledgements:

Thank you for the expertise and guidance provided by Dr. Allison Pye, without whom we could not have written this article, and for the assistance provided by Dr. Robert Gilson.

References:

1. American Academy of Dermatology Association. (n.d.). SUNSCREEN: QUES-

TIONS PATIENTS ASK. aad.org. https://www.aad.org/public/everyday-care/sunprotection/sunscreen-patients 2. Light, D., Kucera, K., & Wu, Q. (2021, May 24). Valisure Citizen Petition on Benzene in Sunscreen and After-sun Care Products. Valisure. https://www.valisure.com/wpcontent/uploads/Valisure-Citizen-Petition-on-Benzene-in-Sunscreen-and-After-sun-

Care-Products-v9.7.pdf. 3. Matta, M. K., Florian, J., Zusterzeel, R., Pilli, N. R., Patel, V., Volpe, D. A., Yang, Y.,

Oh, L., Bashaw, E., Zineh, I., Sanabria, C., Kemp, S., Godfrey, A., Adah, S., Coelho,

S., Wang, J., Furlong, L. A., Ganley, C., Michele, T., & Strauss, D. G. (2020). Effect of Sunscreen Application on Plasma Concentration of Sunscreen Active Ingredients:

A Randomized Clinical Trial. JAMA, 323(3), 256–267. https://doi.org/10.1001/jama.2019.20747 4. Petronelli, M. (2021, May 27). Detectable Levels of Benzene Noted in Some Sunscreen Batches. DermatologyTimes. https://www.dermatologytimes.com/view/carcinogen-found-in-multiple-sunscreens 5. Smith, M. T. (2010). Advances in understanding benzene health effects and susceptibility. Annual review of public health, 31, 133–148. https://doi.org/10.1146/annurev.publhealth.012809.103646 6. United States Food and Drug Administration. (2019, February 21). FDA Advances

New Proposed Regulation to Make Sure That Sunscreens Are Safe and Effective.

Fda.gov. https://www.fda.gov/news-events/press-announcements/fda-advances-newproposed-regulation-make-sure-sunscreens-are-safe-and-effective

Ryan Wealther, Jane Margaret Anderson and Caroline Zhu are medical students at the UT Health San Antonio Long School of Medicine. All three have served as leaders for the school’s Dermatology Interest Group.

The Health Care House of Cards

By David Alex Schulz, CHP

If American health care were its own patient, "code blue" might be a generous call. It has never been closer to flatlining, according to Brian Alexander’s “The Hospital: Life, Death, and Dollars in a Small American Town.” His exam of natural and artificial forces acting on a typical health care facility leaves the reader shaken and disturbed – particularly as the content largely precedes COVID-19.

Alexander’s analysis of a system gone awry focuses on the Community Hospitals and Wellness Centers (CHWC) of Bryan, Ohio: a microcosm through which to see the whole. The author is a storyteller. “The Hospital” is a narrative history, not a chronologic recounting. Through the eyes of patients, physicians, staff and governance, we see generosity, greed and the effects of happenstance and planned malfeasance.

In Bryan as elsewhere, public service health care only gained momentum after the Spanish Flu, but relations between private and public medicine, both competitive and cooperative, created an immediate, persistent tension. Alexander says that as early as 1929, “The AMA and local medical societies acted like cartels to block experiments in medical payment that sought to make care affordable.” When Los Angeles doctors formed the country’s first group care plan, the Ross-Loos Medical Group, the Los Angeles Medical Association expelled them.

Such tension left physicians uncertain and patients confused. Spotlighting the decade between the Great Recession and Pandemic allows Alexander to contrast access to insurance with the availability of services. Many small-town hospitals “went bankrupt, or were absorbed (and sometimes gutted) by bigger regional health systems, or the towns themselves had slowly become more memory than living reality until there was no point in having a hospital there at all.”

CHWC was falling prey to the same travails: “CHWC lost money every month of 2018 … dogged by big hospital chains in Toledo and Fort Wayne … Both had been gobbling up small independents like CHWC for over a decade in a crazed rush to consolidate before they could be targeted themselves by even bigger predators.”

Phil Ennen, our protagonist and hospital CEO, faces these trials as a Bryan native and community leader. The author reminds us the title is from business, whereas hospitals once had ‘administrators.’ “Performing like a business while simultaneously taking on a mission nobody fully understood meant that one goal would always be in tension with the other,” reflects Ennen.

Detailing patients’ struggles displays that the forces acting on American health could correlate closely with social and economic disparities. Although the 36,000 county clients of CHWC were “preternaturally homogenous, there could be as much as eight year’s difference in life expectancy from one part of the county to the next, and even from one part of tiny Bryan to the next.”

In Keith* (surnames redacted), we see the relationship between marginal income and mordant diabetes. Keith discovers his blood sugar level was more than twice the 400 mg/dL at which his reader topped. The Medicaid expansion Ohio’s governor accepted provided insulin support. However, when amputation made mobility an issue and only a Dollar Store (accepting SNAP) is reachable, a healthful diet is harder to access.

In Marc*, we see a good-hearted person (kidney donor, community volunteer, model family) suffer a cardiac arrest. Hypertension, arrhythmia, arterial blockage; America was a heartsick nation at this time, and performing cardiac catheterizations were a necessary attribute of even

a small facility like CHWC.

In Valerie*, we have an incredibly hard worker – three jobs! — who one day heaved and strained too far, blowing two discs in her lower back. “Workers’ compensation covered her vertebrae-fusion surgery and physical therapy afterward. But then the recession hit.” Her job disappeared.

In the book, we see obesity, over-work, hypertension and cardiac issues as plaguing suburbs and cities alike. Alexander then discusses addiction as a public health issue. As Alexander points out, “Sociologists had tried for years to tell politicians that drug abuse was a symptom, not a cause. The kind of drug was irrelevant … alcohol might be more immediately dangerous than obesity, lousy dental care, poverty and low wages, crummy housing, depression, trauma and anxiety. They were all part of the same pathology, though, and arguing about which was worse obscured the underlying causes of the abuse.”

Herein we find Alexander’s primary thesis: the isolating of health care as a separate, biologic-only function fouls our approach from the beginning. To distinguish addiction, depression, or suicidal tendencies as separate from obesity, coronary-disease or cancer is to look only at the manifestations of a deeper, underlying and more widespread epidemic.

“Over years — over two generations — they’d become part of a culture of defeat, what doctors liked to call noncompliant … but noncompliant in a bigger sense. They no longer complied with society’s prescriptions. They were either unable or unwilling to obey. Maybe some of them had tried to obey, once, but obeying didn’t lead anywhere better, or obeying was just too difficult because everything cost so much, or was so hard to achieve, and so they said to hell with it.”

Such attitudes, whipsawing people with contradictory messages and magnified by a media alarming the public, leads to a suspicious, dogmatic polarization that COVID-19 lay bare. “The Hospital,” while initiated years before the current crisis, deals with the pandemic as its fitting epilogue, a capstone that provides fitting validation for Alexander’s insights.

All quotes from “The Hospital: Life, Death, and Dollars in a Small American Town” by Brian Alexander, St. Martin's Publishing Group March 2021, Kindle Edition.

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

INTEGRATIVE MEDICINE

By Neal S. Mertiz, MD

Alternative medicine describes medical treatments and products that are utilized in place of traditional mainstream therapies. This is also known as complementary medicine, and when used along with accepted Western medicine, it is now called integrative medicine. More than half of adults in the United States use some form of alternative or integrative medicine. Patients report they are more readily able to cope with stress and feel better by concentrating on relaxation. Integrative therapies allow for a more active role in treatment and recovery as well as a partnership with the health care provider. Many people like the idea that these therapies seem natural and nontoxic. The search for a potentially elusive cure for symptoms and attempts to boost the immune system are also motivations, although less well-accepted. Patients may receive a great deal of comfort and satisfaction from the touch, talk and time offered by an integrative medicine therapist.

Acupuncture is a traditional Chinese medicine technique that utilizes needles to trigger specific body points, thus allowing for stimulation of the natural healing processes of the body. Homeopathy involves treating disease with minute amounts of natural substances, like plants and animals, with the belief that this will encourage healing. Herbal medicine employs the parts of the plant, such as its roots, leaves, berries and flowers to heal the body. Although this is often the basis for traditional medicine, there is limited evidence for the safety and efficacy of most of these products, with dosage and purity standards that are poorly regulated. Magnetic field therapy uses magnets or electrical currents to treat certain musculoskeletal problems. Proponents of Reiki believe the body’s natural energy can be utilized to speed healing. This is similar to Healing Touch in which a therapist employs an approach which identifies and repairs imbalances in the patient’s energy field. Chiropractic medicine focuses on spinal adjustments that create proper alignment, thus easing pain, improving body function and aiding natural healing. Integrative therapies also include behavioral care, nutrition recommendations, breathing and meditation regimens, and all are well-regarded in most areas of medical practice.

Integrative medicine involves the use of both conventional and alternative methods to facilitate the innate healing response of the body. It includes a consideration of all factors that influence health, such as mind, spirit and community. This philosophy neither rejects conventional medicine nor accepts alternative medicine absolutely. Integrative medicine is open to new concepts, though there is a preference for the use of natural, less invasive interventions whenever possible. Multiple

studies are currently in progress to determine the safety and efficacy of many integrative medicine practices. Obtaining adequate funding is invariably difficult, with studies typically attached to a blockbuster drug.

Much misinformation exists, especially on the Internet, regarding integrative health approaches. There are many charlatans, and red flags abound. For example, conventional medicine bashers should be avoided, and preference is often given to integrative providers who coordinate care with conventional proponents. Providers whose promises are too good to be true should also be shunned. Some practitioners are product, test and technology happy and some who sell their own supplements are less than trustworthy. Occasionally, the provider will demand a monetary commitment for an extended period of time. Additionally, hazy credentials are often a sign of troublesome intentions. The greatest danger of integrative medicine is that patients who see alternative practitioners will often discontinue receiving mainstream care altogether.

When false and unproven health schemes are promoted for profit, it is called quackery. This term is most often used to denote the peddling of “cure-alls,” as well as the merchandising of fraudulent or ignorant medical practices. Integrative medicine often appropriates several science-based medical modalities, such as nutrition and lifestyle changes. These accepted concepts are then described as complementary or holistic, rather than simply good medicine. Advocates of non-evidencebased medicine are masters of marketing, with integrative medicine being promoted as the best of both worlds, that is, science-based and alternative. If alternative claims are fraudulent and promoted for financial profit, then a caring, holistic provider must avoid embracing them.

Despite a mostly proven lack of effectiveness, several reasons for patient acceptance of integrative medicine have been suggested. Proponents take advantage of ignorance regarding conventional treatments. Substances and products known to have no pharmacologic effect on a disease can still affect perception, and this belief may often cause a therapeutic response, leading to improvement. This is known as the “placebo effect” and is now recognized to have a proven neurological basis. Many people have a strong distrust of conventional medicine, of regulating organizations such as the FDA and of major drug corporations. Conspiracy theories are prevalent among many who are anti-science, with the established medical care system suspected of attempting to preserve their power and increase their profits. Many people fear side effects from conventional medications and treatments, or are concerned with cost. Desperation is often a strong motivation. Some practitioners, aware of the ineffectiveness of a product, still intentionally produce fraudulent scientific studies and test results, thus further deceiving potential consumers.

Medical universities now struggle with the problem of how to present integrative medicine in their curricula. Some practices have compelling evidence but aren’t science-based. A survey by the Association of American Medical Colleges revealed that 126 of the 132 schools that responded are now offering classes in these disciplines. Integrative medicine must be taught dispassionately on the basis of the existing evidence. This evidence is positive in a few cases, especially when diet, behavioral therapy, meditation and breathing techniques are included, but negative in the overwhelming majority of studies. It is problematic that most medical schools delegate this task to enthusiasts of the respective therapies.

Evidence-based medicine applies the scientific method to medical practice, and it advocates the use of current best data. Advocates of integrative medicine acknowledge the placebo effect may provide significant benefit, but that this fact does not diminish its validity. Many people obtain compelling improvement from alternative types of therapies and they should not be discouraged from pursuing nonmainstream modalities as an enhancement to their conventional medical treatment. There exists a reasonable argument that there is no integrative medicine, only scientifically proven, evidence-based medicine. People who choose integrative medicine think that they are utilizing a safe, effective treatment, but they are often deceived. Integrative medicine may be a strategy to make pseudoscience acceptable, but there are also undeniable benefits for many.

References 1. Philosophy of Integrative Medicine by David Rakel MD and Andrew

Weil MD. 4th Edition Elsevier 4/2017 2. Modern Medicine vs. Alternative Medicine: Different Levels of Evidence. By Thomas Sullivan Policy & Medicine 5/6/2018 3. What Exactly is Alternative Medicine? By Melinda Ratini MD

WebMD 3/20/2021 4. Complementary and Alternative Health Care, Is It Evidence-Based?

By Sved Amin Tabish Int J Health Sci 1/2008 5. Medical Schools Embrace Alternative Medicine by Meryl Davids

Landau. US News and World Report 4/12/2021 6. Most Medical Schools Offer Courses in Alternative Medicine.

Here’s How to Avoid Quackery By Julie Belluz Vox 7/8/2015 7. 5 Red Flags Your Non-Conventional Medicine Provider is Doing

Harm. By Anna Medaris Miller US News and World Report 5/1/2018

Neal S. Meritz, MD is a retired Family Practice physician and a member of the BCMS Publications Committee.

Please ask your practice manager to use the Physicians Purchasing Directory as a reference when services or products are needed.

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”

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor) At Kreager Mitchell, our healthcare practice works with physicians to offer the best representation possible in providing industry specific solutions. From business transactions to physician contracts, our team can help you in making the right decision for your practice. Michael L. Kreager 210-283-6227 mkreager@kreagermitchell.com Bruce M. Mitchell 210-283-6228 bmitchell@kreagermitchell.com www.kreagermitchell.com “Client-centered legal counsel with integrity and inspired solutions” 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

BANKING

BankMD (HHH Gold Sponsor) Our Mission is your Success. We are the ONLY Physician-Focused Bank in the Country Moses Luevano, President 512.547.6065 mdl@bankmd.com Chris McCorkle Director of Healthcare Banking 210.253.0550 cm@bankmd.com www.BankMD.com “Specialized, Simple, Reliable”

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a private banking team committed to supporting the medical community. Shawn P. Hughes, JD Senior Vice President, Private Banking (210) 283-5759 shughes@broadway.bank www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians. Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community. Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com

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

Synergy Federal Credit Union (HH Silver Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need. Synergy FCU Member Services (210) 750-8333 info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

BUSINESS CONSULTING

Medical Financial Group (★★★ Gold Sponsor) Healthcare & Financial Professionals providing core solutions to Physicians from one proven source. CEO is Jesse Gonzales, CPA, MBA Controller & past CFO of (2) Fortune 500 companies, Past Board President of Communicare Health Systems. Jesse Gonzales, CEO CPA, MBA 210.846.9415 information@medicalfgtx.com Linda Noltemeier-Jones Director of Operations 210.557.9044 lindanj@medicalfgtx.com www.medicalfgtx.com “Let’s start with Free Evaluation and Consultation from our Team of Professionals”

FINANCIAL ADVISOR

Elizabeth Olney with Edward Jones (HH Silver Sponsor) We learn your individual needs so we can develop a strategy to help you achieve your financial goals. Join the nearly 7 million investors who know. Contact me to develop an investment strategy that makes sense for you. Elizabeth Olney, Financial Advisor 210-858-5880 Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabeth-olney "Making Sense of Investing"

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!”

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services. Mary P. Mahlie Vice President Wealth Advisor (512)787.2488 Mary.Mahlie@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (210)385.9326 Fred.Kelley@Regions.com www.Regions.com

SWBC (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Michael Leos Community Relations Manager Cell: 201-279-2442 Office: 210-376-3318 mleos@swbc.com swbc.com

HEALTHCARE BANKING

First Citizens Bank (★★★ Gold Sponsor) We’re a family bank — led for three generations by the same family-but first and foremost a relationship bank. We get to know you. We want to understand you and help you with your banking. Stephanie Dick Commercial Banker 210-744-4396 stephanie.dick@firstcitizens.com Danette Castaneda Business Banking Specialist 512.797.5129 Danette.castaneda@firstcitizens.com https://commercial.firstcitizens.co m/tx/austin/stephanie-dick “People Bank with People” “Your Practice, Our Promise”

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

Nitric Oxide innovations LLC, (★★★ Gold Sponsor) (NOi) develops nitric oxide-based therapeutics that prevent & treat human disease. Our patented nitric oxide delivery platform includes drug therapies for COVID 19, heart disease, Pulmonary hypertension & topical wound care. info@NitricOxideInnovations.com (512) 773-9097 www.NitricOxideInnovations.com

HOSPITALS/ HEALTHCARE FACILITIES

UT Health San Antonio MD Anderson Cancer Center, (HHH Gold Sponsor) UT Health San Antonio MD Anderson Cancer Center, is the only NCI-designated Cancer Center in South Texas. Our physicians and scientists are dedicated to finding better ways to prevent, diagnose and treat cancer through lifechanging discoveries that lead to more treatment options. Laura Kouba Manager, Physician Relations 210-265-7662 NorrisKouba@uthscsa.edu Lauren Smith, Manager, Marketing & Communications 210-450-0026 SmithL9@uthscsa.edu Cancer.uthscsa.edu Appointments: 210-450-1000 UT Health San Antonio MD Anderson Cancer Center 7979 Wurzbach Road San Antonio, TX 78229

INFORMATION AND TECHNOLOGIES

INSURANCE

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

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) With more than 20,000 health care professionals in its care, Texas Medical Liability Trust (TMLT) provides malpractice insurance and related products to physicians. Our purpose is to make a positive impact on the quality of health care for patients by educating, protecting, and defending physicians. Patty Spann 512-425-5932 patty-spann@tmlt.org www.tmlt.org Recommended partner of the Bexar County Medical Society

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

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more. Kirsten Baze 512-658-0262 Kirsten.Baze@medpro.com www.medpro.com

ProAssurance (HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior). Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

INTERNET TELECOMMUNICATIONS

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

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

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

MEDICAL PHYSICS

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

MEDICAL SUPPLIES AND EQUIPMENT

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

Henry Schein Medical (HH Silver Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere. Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases. Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

MORTGAGES

SWBC MORTGAGE - THE TOBER TEAM (HHH Gold Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying. For You Practice: HR administration, payroll, employee benefits, insurance, and exit strategies. SWBC’s services supporting Physicians and the Medical Society. Jon Tober Sr. Loan Officer Office: 210-317-7431 NMLS# 212945 Jon.tober@swbc.com https://www.swbcmortgage.com /jon-tober

PRACTICE SUPPORT SERVICES

PROFESSIONAL ORGANIZATIONS

The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who

propel the healthcare and bioscience industry in San Antonio. Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more! President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet”

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

REAL ESTATE SERVICES COMMERCIAL

CARR Healthcare (HH Silver Sponsor) CARR is a leading provider of commercial real estate for tenants and buyers. Our team of healthcare real estate experts assist with start-ups, renewals, , relocations, additional offices, purchases and practice transitions. Brad Wilson Agent 201-573-6146 Brad.Wilson@carr.us Jeremy Burroughs Agent 405.410.8923 Jeremy.Burroughs@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

Foresite Real Estate, Inc. (HH Silver Sponsor) Foresite is a full-service commercial real estate firm that assists with site selection, acquisitions, lease negotiations, landlord representation, and property management. Bill Coats 210-816-2734 bcoats@foresitecre.com https://foresitecre.com “Contact us today for a free evaluation of your current lease”

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

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle. Cindy M. Vidrine Director of Operations- Texas 210-918-8737 cvidrine@favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

TELEHEALTH TECHNOLOGY

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, please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366

2021 GENESIS G80

By Stephen Schutz, MD

Genesis, the upmarket sister brand of Hyundai, has been in business in the country since 2016. While they have been gradually ramping up their sales of cars and SUVs since then, they had garnered very little attention in the press until last February when Tiger Woods famously crashed a loaner GV80 SUV at high speed in Southern California during a PGA golf tournament.

It’s said that there’s no such thing as bad publicity, and given the fact that Tiger’s crash markedly heightened awareness of the Genesis brand, it would seem that this old saw is true. Genesis is selling every vehicle they can manufacture these days—to be fair, so are most automakers— and they finally seem to be getting attention from customers who, before now, would only consider Lexus and the big three German brands (Mercedes, BMW and Audi).

Lexus is a good brand to mention, actually. When Genesis launched, it seemed like every article about it referenced Lexus as though Genesis was to Hyundai as Lexus was to Toyota.

I think a better analogy is Audi. While Lexus became a legitimate luxury brand on day one of its existence, Audi struggled for many years before finally breaking through. It was during the 1970s that Volkswagen first tried to position Audi as a car for upscale buyers who liked VW but wanted something more luxurious, but the effort mostly failed. It wasn’t until the early 1980s that Audi became a legitimate luxury automotive contender thanks to Quattro all-wheel drive, many successes in World Rally Racing, and, oh by the way, much better cars. I doubt it will take Genesis as long to make it as it took Audi, but it’s already clear that they're not Lexus.

I recently drove a 2021 Genesis G80 in an effort to gauge the company’s progress in what can only be described as a frantic luxury automotive market. I think Genesis is in good shape.

A quick aside: what is the current luxury automotive market? It’s a mixture of newbies (imagine a radiologist who has just paid off her student loans), postponers (an older family practice physician who recently sold his building to a real estate investor), regulars (a dermatologist who’s been leasing a new Mercedes every three years since 1998) and enthusiasts (a surgeon who perpetually “needs” the latest special Porsche as soon as it’s been introduced to the media).

It’s more complex than that, of course, but this breakdown gives you an idea of how difficult it is to break into this market. Genesis has a shot at the newbies and postponers, but it has an uphill fight to get to the regulars and enthusiasts. Which means that Genesis has to make excellent vehicles to be a player. The G80 is definitely that.

First of all, the G80 looks like an expensive luxury sedan. Tightly designed with a large can’t-miss-this grille, Genesis’ best sedan looks handsome and contemporary. Numerous creases accentuate the flowing sedan-ish profile, and the stance says, “sporty sedan,” but it’s the grille that grabs your eyes. It’s huge.

By the way, when Audi started their successful climb up the sales charts about 15 years ago, they began by putting big grilles on their vehicles.

Driving the G80 isn’t as great as its sporty looks would make you think. This is a rear-wheel drive platform (AWD is optional), but the engineers went for comfort over athleticism. The default during spirited driving is understeer, and steering effort has been minimized so you feel less involved on a winding road.

The interior is as good as anything you’ll find from the above-mentioned competition. Genesis has borrowed Audi’s terrific diamond stitching to accent their seats, and everything you see and touch looks and feels good. The round controller on the console, which takes you through the various menus on the prominent central screen, is different from the user interfaces other manufacturers use, but you get accustomed to it in time.

The entry-level G80 comes with a standard turbocharged 2.5-liter inline four-cylinder engine that makes 300 horsepower, but a more potent twin-turbo 3.5-liter V6 with 375 horsepower is available. Both engines connect with an eight-speed automatic transmission and either rear- or all-wheel drive. My test car came with the larger engine, which I think is the way to go.

Pricing starts at around $48,000 for a base four-cylinder G80 with rear wheel drive, but I expect most of these models, like any luxury vehicle, will get optioned up and sell for close to $60,000. That’s not cheap, but compared to a similarly equipped E-class Mercedes or 5-series BMW, it represents a $10,000 to $15,000 savings.

Genesis is producing some impressive products like the G80 these days, and according to sales figures, customers are buying them. It’s surreal that a celebrity road accident led to increased awareness, but that’s the way it goes sometimes.

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.