San Antonio Medicine September 2020

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Employed Physicians

The Employed Physician Trend

By Carlos A. Rosende, MD, FACS ...................................12 Working to the End of the Rainbow

By Wendy B. Kang, MD, JD.............................................15 “To Be or Not to Be” Employed, That is the Question!

By J.D. Martinez, MD, FACC............................................20 Selling a Practice – Becoming an Employed Physician

By Anton J. Jirka, Jr., MD ................................................22 The Only Job I Have Stayed Loyal to is Being a Doctor

By John J. Seidenfeld, MD...............................................24 Physicians – Read Your Employment Contract Before Signing It: Here’s Why

By Mike Kreager ..............................................................26

BCMS President’s Message .....................................................................................................................................8

SEPTEMBER 2020

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VOLUME 73 NO. 9

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San Antonio Medicine • September 2020

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.

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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

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San Antonio Medicine • September 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

Leadership – Physicians as Employers or Employees

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

Traditionally, new graduates of training programs seek to either set up their own practices or join a previously established practice. These practice opportunities were populated by from one to over 100 physicians. Each of these practices was guided by physicians who define and provide the product, which is medical care.

Management of the practice or the day-to-day running of the practice was typically by a practice manager or CEO who has training in business and business administration, often an MBA. More recently, graduates are opting to be employed physicians. In this practice mode the physicians work FOR the organization, but do not guide it. Newer physicians want to “do medicine” and to leave “the other stuff ” to someone else. The “someone else” has the responsibility of managing the office personnel, the supplies and the contracts of the practice.

The managed physician model is in fact similar to the private practice model. In both, the physician chooses to do that for which he or she is trained – provide medical care. Both seek to have the management aspect of providing care performed by someone else with a different skill set. Just as these two backgrounds operate differently, their goals may also differ. The business aspects of contracting, personnel management and supply chain usually seek the least expensive option. However, as we have seen in medicine, “cheap” and “better” don’t necessarily equate.

With physician leadership, the most appropriate equipment and compensation for medical care can be better even if they are not the least expensive. The innuendo associated with personnel management, however, is often outside of even the most accomplished physician’s skill 8

San Antonio Medicine • September 2020

set. They can provide a vision and a goal. The selection of support personnel to reach that goal may be better done by someone skilled in business management.

In the private practice model, physicians set the tone and course of the practice. They determine what and how services are provided.

The medical risks and opportunities can often only be identified by a physician. Management skills, much like other skills, can be learned if given the proper instruction. In fact, today’s physicians who obtain a post baccalaureate degree will frequently obtain an MBA rather than an MS or an MPH. With these skills, they are better equipped to judge the fiscal opportunities available and balance them with the requirements of the employed physician. In this way, with appropriate physician input and leadership, the care provided in an employed-physician model can be equal to that provided by a private practice.

In the brave new world of medicine there will be an ongoing comparison between private practice and employed physician opportunities.

Only time will tell which option, if either, provides the best care for patients. In both cases, leadership by physicians will be necessary to assure that the practice of medicine does not become mercenary.

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

BCMS ALLIANCE

Meet our 2020 Scholarship Awardees Each year, the BCMS Alliance provides scholarships to students in Bexar County who are academically excellent and pursuing a career in Allied Health (nursing, physical therapy, audiology, physician assistant, speech-language pathology, occupational therapy, etc.). Special thanks to our 2020 Scholarship Committee who met virtually this year: Chair Lori Boies, Jennifer Lewis, Elisa Vasconcellos, Nichole Eckmann, Carol Growney, Aleida Colen, Danielle Henkes and Jenny Shepherd.

Mattie Price was chosen for our highest scholarship – the Sandra Vela Memorial Scholarship which honors our Centennial Board member Sandra Vela who passed in 2017. It carries a $1,500 award.

Described as a “shining star” who excelled at both knowledge-based and clinical learning, Mattie’s “kind, compassionate personality” was appreciated by patients and professors alike.

Mattie graduated this summer from UTHSCSA School of Nursing’s Accelerated BSN Track. Inspired by her personal experiences with juvenile diabetes, Mattie plans to work as a diabetes educator at diabetes camps before pursuing a doctorate in family nursing.

I would like to say ‘thank you’ to you all for providing me a way to one day serve my community. This scholarship lifts some stress off of my shoulders and allows me to focus on what really matters, which is learning all I can in order to be the best nurse I can be.

Our $1,000 scholarship recipient was Anoosha Momin. A UTSA student completing her B.S. of nursing at UTHSCSA, Anoosha plans to continue her studies following graduation and become a nurse practitioner. She is passionate about reaching out to underserved populations and working in the NICU, pediatrics and emergency departments. Child health, cancer in children, diabetes, cardiovascular issues and Alzheimer’s disease are areas of research she hopes to continue.

Receiving a scholarship from the Bexar County Medical Society Alliance means so much to me as it will allow me to fully focus on my studies without having to worry about finances. I can also be more selective with my time and maximize my college experience through volunteer opportunities, internships and community service. I am extremely grateful and honored to have received this scholarship and the support by BCMSA will surely go a long way in helping me achieve my educational and career goals.

St. Mary’s University student Cydney Stephens received a $500 scholarship. Accepted to the University of Incarnate Word Feik School of Pharmacy as a junior, Cydney will begin her pharmacology studies there this fall. An Honors Program biology student, Cydney was lauded for her ability to quickly grasp “com-

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San Antonio Medicine • September 2020

plex, technical science problems” while demonstrating “a perseverant and mature demeanor” which earned her respect from both peers and faculty. In addition to her studies, she works as a Certified Pharmacy Technician.

I am incredibly grateful for the opportunity to receive this scholarship from the Bexar County Medical Society Alliance because it not only shows support from my community for me to pursue my future career in pharmacy, but it also will take some of the stress off my current and future self so I can maneuver my way through my next level of schooling before I graduate and begin the loan repayment process.

Ruby Jaimes was a recipient of our $500 award.

A graduate of UT Austin with a B.S. in Nursing and a certificate of Social Entrepreneurship and Nonprofits in Healthcare, Ruby worked full-time for 2.5 years as an intensive care unit nurse at Seton Main Medical Center in Austin. She continued her educational journey on acceptance to UTHSCSA’s Master of Science in Nursing program - Family Nurse Practitioner track. Ruby currently provides care to our military service men and women in SAMMC’s ICU. Thank you for continuing to support my goal in becoming a family nurse practitioner. I hope to touch the lives of many and positively impact the outcome of our community. This scholarship grants me further financial stability and more importantly gives me hope to know that my work and efforts are not overlooked and truly supported. Thank you and God bless.

UTHSCSA nursing student Maria Wallace was given a $500 scholarship. Following graduation from UT-Arlington with a B.S. in Nursing, Maria began pursuing her Doctorate of Nursing Practice in Mental Health here in San Antonio. Working in ICUs during her training, she was struck by the prevalence of mental illness combined with acute medical conditions and felt an immediate calling to this field.

Upon graduation I became an ICU nurse helping take care some of the sickest patients in South Texas. After a few years I realized many patients had underlying issues, such as mental illness that contributed to their overall medical illness. This scholarship is important to me as it helps me to reach my goal of becoming a mental health nurse practitioner.

EMPLOYED PHYSICIANS

The Employed Physician Trend

By Carlos A. Rosende, MD, FACS In 1981 when I graduated from medical school, almost all my classmates anticipated going into private practice after their residencies and ultimately owning his or her practice. A handful contemplated pursuing academic medicine and almost an equally small number would be going into the military to pay back obligations (but all expected to enter private practice after their service commitments). As we get closer to our fortieth anniversary, almost all the members of that class achieved their career expectations. That is not surprising, as an American Medical Association (AMA) survey in 1983 revealed that 76.1% of physicians owned their practices.1 This situation, however, would begin changing: another AMA study conducted over a decade later showed that between 1988-1994 there was a 14% decline in physicians who were “self-employed”2, i.e., were solo owners, were part-owners or were buying into an ownership arrangement. By 2012, the percent of self-employed physicians was 53.2%. In a press release by the AMA in May 2019, they announced that for the first time “employed physicians outnumbered self-employed” physicians. Their study conducted in 2018 noted that “47.4% of all patient care physicians” were employed compared to 45.9% who described themselves as “self-employed”.

Although most (54%) physicians worked for a physician-owned practice (as owner, employee or contractor), 34.7% worked either directly for a hospital (8%) or for a practice that was at least partly owned by a hospital.3 It is easy to understand the trend toward physician employment.

It is becoming more difficult for physicians to manage a “small business” while also providing patient-centered care. There is the growing volume and complexity of laws and requirements pertaining to dealing with employees and those associated with accounting and business practices. These contribute to greater costs of running a business. Combine those challenges with the ever-increasing number of complicated Medicare rules and payment and penalty schemes (MIPS, MACRA, ACOs, etc.)—not to mention the demands of private insurance carriers—and the young physician entering practice for the first time (and likely heavily in debt) is bewildered. Now add the uncertainties of what healthcare delivery

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EMPLOYED PHYSICIANS and reimbursements will look like in a few years, and the young physician is completely overwhelmed. Employment, particularly with a guaranteed base salary and a chance for an incentive payment, appears very attractive. Employed physicians are willing to let someone else deal with those issues plus the hassles of revenue cycle, contracting, liability and electronic medical record management. Medical school and residency have not prepared the young physician for the “real world” of practice ownership. Furthermore, the current rate of change will not give them an opportunity to catch up.

Indeed, in 2018, 70% of physicians less than 40 years of age were employed, and more women than men were employees.4 More “seasoned” physicians, many who have invested years and dollars into developing their private practices, have been able to adapt to the changes over time and expect to ride out their careers as self-employed. However, at or near retirement, they are likely to sell their practices to larger groups or hospitals, as it is becoming more difficult to find younger physicians who wish to take on additional debt and ownership burdens.

For the price of the perceived autonomy found in self-employment, some physicians find that employment not only relieves them of the business headaches, but more importantly, frees them to concentrate exclusively on taking care of patients.

In employment models, some physicians find flexibility of work hours, guaranteed income, incentive potential, generous fringe benefits and even the opportunity to assume leadership positions in clinical care areas. Moreover, without being “anchored” to a practice in which they have significant capital invested, a physician may have the comfort of knowing that they could readily move to another town or state if a better opportunity presents.

Employment contracts can vary widely, and the physician considering this path should carefully review the contract and feel comfortable with the terms. In addition to such issues as working hours, on-call coverage, work location, base compensation and fringe benefits, the offer of an incentive or bonus payment and how it is calculated needs to be understood. Incentive amounts also can vary significantly, either as a percentage of base salary and/or calculated on achievement of productivity metrics (RVU or revenue generation) and quality performance (meeting certain HEDIS measures, utilization management, patient satisfaction scores, etc.). In an increasing “value-based care” world, employers (both hospitals and large physician groups) are placing these criteria in the contracts.5 Other terms to consider are the presence of “restrictive covenants” and “liquidated damages” for an early departure.

Who are the employers of physicians? Of course, hospitals are the first that come to mind. The number of hospital-employed physicians rose from 95,000 in 2012 to 169,000 in 2018; hospital owned practices went from 36,000 in 2012 to 80,000 in 2018.6 Of the various specialties, family physicians have the highest percentage of hospital employment: 57.4%.7 In the value-based care world we are entering, primary care physicians are the key to coordinating care, referring to other specialties and ensuring that quality elements are met. Though a recent study by the Kentucky Hospital Association revealed that 58% of hospitals reported a loss of $100,000 per employed physician, another study showed that “family physicians generate an average of more than $2 million per year on behalf of their affiliated hospitals through admissions, prescriptions, tests and procedures.”8 Hospital employment of physicians has a rarely discussed significant impact on the cost of care. When physicians practice in hospital-owned facilities, Medicare charges for clinical care are subject to HOPD (hospital outpatient department) rates, which can be considerably higher than standard outpatient rates (e.g., 80% more for cardiac imaging, 35% more for colonoscopy, 30% more for many standard E&M services). A study conducted between 2012-2015 showed that the shift to HOPD rates cost Medicare $2.7 billion more in payments and to the Medicare beneficiaries their costs went up $411 million (27% more)!9 It is no wonder that hospitals invest in employing physicians!

Though periodically the concept of HOPD rates has been the target of Congress, it has not eliminated the practice, though it did take recent steps to limit its spread. We can hope that with greater emphasis on value-based care there will be incentives for hospitals to participate in controlling costs.

Large, multispecialty physician groups (which are often physicianled) are also employers of physicians. Their goal is typically to provide vertically and horizontally integrated medical and surgical care so that they can succeed in controlling costs while achieving high quality outcomes. In this manner, they can capitalize on value-based care reimbursements.

Other physician employers include urgent care centers (which often offer great flexibility in working hours), retail clinics, surgery centers, Federally Qualified Health Centers (FQHCs), large employers, insurance companies, and academic health centers.10 But all may not be rosy for employed physicians. A Physicians Foundation survey found no significant difference between employed and non-employed physicians in the hours spent per week performing nonclinical paperwork (9.8 hours and 10.6 hours, respectively).11 There is also increased physician turnover among employed physicians, a situation that could harm continuity of care.12 On the other hand, employed physicians did see fewer patients per day: 19.5 versus 23.4, which if among primary care physicians continued on page 14

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EMPLOYED PHYSICIANS continued from page 13

can exacerbate the primary care shortage.13 However, if done in a value-based care model, the patients seen may require less expensive care and in the long run save healthcare dollars and, more importantly, improve the health status of patients.

There is always the concern among employed physicians that their autonomy to practice “the best medicine” may be impeded by a “corporate” approach to healthcare delivery which prioritizes the financial “bottom line” instead of quality of care or clinical outcomes.

Although this may have been a realistic issue in the 1990s with capitation and the focus strictly on costs, the current trend which emphasizes outcomes, evidence-based medicine, and utilization management (with ease of obtaining data given our IT advances) reduces these concerns.

Finally, will physician employment have a negative impact on the nature or culture of the medical profession? Will the transactional atmosphere of the employer-employee relation side-line the patient?

Will physicians be less engaged in the patients’ health and will they lose their advocacy for the patient? Will the medical profession become a trade?14 Personally, I have not seen or experienced “disengagement” by employed physicians. Furthermore, nurses have long been employed by hospitals and they are highly respected for their caring attitudes, professionalism and dedication to their patients. I cannot imagine physicians would be any different.

In the growing confusion surrounding the future of healthcare delivery (even IT companies want to get into the act!) and reimbursements, many physicians want to simply focus on the reason they pursued medicine: to take care of patients, one at a time. Many see “employment” as offering that safe harbor where they can concentrate on their craft, and let others deal with the headaches and uncertainties of the business of medicine. It does certainly sound attractive! But employment is not a panacea; like everything in life, there is no perfect situation, but rather, one must seek his or her own source of fulfillment and balance.

Carlos A. Rosende, MD, FACS, Professor/Clinical of Ophthalmology, Executive Director of UT Health Physicians, Executive Vice Dean for Clinical Affairs, Long School of Medicine, UT Health San Antonio.

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References 1 Murphy, Brendan, American Medical Association: Practice Management—Economics: For first time, physician practice owners are not the majority, May, 31, 2017, https://www.amaassn.org/practice-management/economics/first-time-physicianpractice-owners-are-not-majority (Accessed February 13, 2020).

2 Mills, Robert J, American Medical Association: Press Releases: Employed physicians outnumber self-employed, May 6, 2019, https://www.ama-assn.org/press-center/press-releases/employed-physicians-outnumber-self-employed (Accessed February 13, 2020).

3 Murphy.

4 Mills.

5 Darves, Bonnie, NEJM Career Center: For Employers: Understanding the Physician Employment “Movement”, July 23, 2014, https://www.nejmcareercenter.org/article/understanding-thephysician-employment-movement-/ (Accessed February 7, 2020).

6 Physician Advocacy Institute, PAI: Updated Physician Practice Acquisition Study: National and Regional Changes in Physician Employment 2012-2018, February, 2019, http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/021919Avalere-PAI-Physician-Employment-Trends-Study-2018-Update .pdf?ver=2019-02-19-162735-117 (Accessed February 7, 2020).

7 Mills.

8 Singleton, Travis and Phillip Miller, “The Physician Employment Trend: What You Need to Know”, Fam Pract Manag. 2015 JulAug;22(4):11-15.

9 Physician Advocacy Institute.

10 Singleton and Miller.

11 Ibid.

12 Ibid.

13 Ibid.

14 Ibid.

EMPLOYED PHYSICIANS

By Wendy B. Kang, MD, JD

I often wonder if I took the right path through the dense

woods of life. The poet could only take one, the one less travelled.

I tried them all. Indulge me in guiding your virtual walk through private practice and academics by sharing some of my lessons learned while looking for the right road.

I started with a group on the highly travelled Dallas road, detoured into academic medicine employment, went off-roading in a solo rural practice and packed up to an out-of-state academic institution. Realizing my wrong turn of having left Texas, I whooped at re-crossing the Red River to rest for a spell. Too young to retire, I contemplated again which path to take: as my own boss with myself as employee, or employed by an academic institution?

Group private practice can work very well given the right mix of factors. After interviewing with the “associates” (not legalese partners) in a small group, a verbal agreement sealed our deal.

There was NO written employment contract. My word to join was as good as the oral promise of the group. Since I received a salary, I was technically an employee. However, we functioned as an interdependent group where the corporation’s receipts paid for expenses and salaries. I decided what my monthly salary would be, knowing that I had to work hard enough to pull enough revenues to pay for my share of expenses. If I didn’t hit my profit metrics, my colleagues essentially floated me a loan (especially for the first three months of starting practice) until my receipts flowed. Though I entered as the newest associate, I had equal voting rights as the three who founded the group. The work load was distributed as fairly as possible while allowing for each associate’s preferences and skills. (The men handed this thankless task to the women.) Squabbling occurred only behind closed doors. Once

the doors reopened, we presented a solid front of collegiality and mutually agreed upon practice parameters. When one senior associate became president of the county medical society, the other seven picked up the additional workload. His revenues went down that year, but he did not waive his seniority as entitlement to the corporate coffers. Most of my colleagues acted very responsibly, honorably and ethically. We took care of patients, regardless of insurance status—unlike a few groups who developed a notoriety for trying to pawn off the uninsured.

Does this type of physician-only and physician-run group practice still exist? Did my group click because we were a small group, all with inherent beliefs that every person must work hard and honorably in order to succeed as a collective entity? Have employment contracts become necessary because someone reneged on their verbal promise to join—at the last moment—forcing the group to scramble frantically for replacements from an empty barrel? Conversely, I have heard horror stories of new associates being terminated right before they reached partnership status because of unscrupulous behavior of entrenched seniors. Do physician employees working in regional centers have much say at the national headquarters of the holding company? I wonder. Some people accuse me of being pessimistic; I prefer “realistic”, thank you.

Private practice entails incredibly hard work and long hours.

When patients need care, the physician must be the three A’s: Able, Affable and Available. If a surgeon called and my on-call partners were all working, then my 12 hour work day got extended and my personal plans were cancelled. No eighty-hour work period restrictions. Medicine is a business made much harder when you are the owner and employee, even in a group. continued on page 16

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EMPLOYED PHYSICIANS continued from page 15

“Surely there is more to life than making money” crossed my mind with increasing frequency as I would arrive home in the dark and leave the following morning in the dark. I could easily understand why physicians suffer from high divorce rates or depression from sunlight deprivation. The thought of being a workaholic mushroom for the next four or five decades was unpalatable. I did not feel myself to be contributing anything of significance to humanity. The federal government had frozen the Medicare reimbursement rate. Trial lawyers and frivolous medical malpractice lawsuits squeezed physicians dry while medical insurance underwriters fled the state. (Bad news is not a recent invention). I needed to understand how law intersects and interferes with medicine. As a result, I decided to study for a doctorate of jurisprudence. After all, “Knowledge is Power”. Physicians have always been adding alphabets behind their names with fellowship subspecialties, doctorates of philosophy, or masters degrees in public health, and nowadays in business and hospital administration.

My path towards law school doubled back to my alma mater across town. Because I had Board Certification (an optional rarity back then), had instructed residents gratis on my post call days, and had private practice experience when the medical school was feeling its way into operating its own ambulatory surgery center, I received an offer to join the academic faculty. In exchange for acceptance, I got flexible work hours to pursue legal studies. I became an academic, workaholic mushroom, for less salary, but fulfilling my desires to be a legal scholar. I learned that legal briefs are anything but brief. There are honorable and ethical lawyers, thank goodness.

I studied medical ethics during law school; medical schools did not teach ethics. As a sleep-deprived physician with a law degree, I reaffirmed my desire to take care of patients rather than clients.

Having straddled both sides of academia and private practice, I see turf battles intensifying over slicing the economic pie. Academicians who have never left the ivory tower cannot comprehend the mentality nor work habits of the private practitioners who need to provide their own livelihoods. Pure academicians want to be able to think the theoretical, analyze the abstract, plan the probabilities and write research grants; the paycheck is not a top priority. Private practice physicians want to get the work done as safely and quickly as possible. But with vastly diminished state funding, academic institutions seek revenues to fund its research, teach future healthcare providers, treat indigent populations and pay a growing employee base. Group and solo private practices work harder to find and keep patients. Fading are the good reimbursements as insurance companies ratchet tighter, downward. Will the clash of titans cease when physicians are all in the same sardine can as employees of hospital systems vertically integrating its referral bases, or dispensed 16

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out of vending machines by national chains of specialty stores or academia?

Is life better in academics? Increasingly, the academic physician gets to work at private practice warp speed at a low academic salary while fulfilling criteria for promotion. The naïve type thinks s/he has landed into a 7-3 or 8-5 shift type of employment, get guaranteed morning/lunch/afternoon breaks and goes home punctually, being paid regardless of work productivity and getting promoted every x number of years for a higher salary. The realistic type knows that work actually will begin around 6 AM with teaching medical students and residents, taking care of patients and double checking on the underlings to prevent adverse events. If s/he is lucky to be relieved after 8 to 10 hours of clinical work, s/he will need to attend committee meetings, prepare teaching sessions, submit articles for publication, possibly do research at a lab and be fortunate if the day has only been 12 to 14 hours—similar to the private practice physician. This academic, employed physician understands that clinical productivity must generate enough money to cover salary and “benefits” such as malpractice premiums, health/life/disability insurances. Additionally, the academic physician must generate scholarly activities worthy of promotion from Assistant to Associate, and ultimately to Full Professorship. Working only to collect a paycheck does not entitle one to promotions up the academic ladder.

I left my first academic post for reasons similar to other academic positions. There were 5 changes in the chairmanship in the 6.5 years I was there. The department marched right, left, over, under and through the foggy leadership. Yes, I had an employment contract which I, despite my legal training, did not read. Nor was I informed to read the Handbook on Policies about faculty responsibilities or reasons for terminations. My teaching contract was one year, renewable at the discretion of the employer; no reasons need be given if contract was not renewed. I was an “at-will” employee: if I gave a minimum of 2 weeks-notice, I could walk out.

Doom and gloom warnings followed my first exit from the ivory towers. I wanted to escape the frenzied metropolis congestion for a simpler, rural East Texas. Colleagues told me I would starve in the lower reimbursement climate and medical malpractice prone region, especially being solo. I learned this during my brief stint: a good competent physician following the 3 A’s rule will have plenty of sick patients; whether they could pay is another issue. Board certification greased the credentialing process. Banks bent backwards for me. I set up an S corporation. I controlled all aspects of my practice, paid quarterly Workman’s compensation fees on behalf of myself as sole employee, worked closely with a tax accountant and someone to cajole patients to pay. There were months of financial droughts followed by unpredictable flash floods of payments. Sum-

EMPLOYED PHYSICIANS mary: I earned as much in solo, rural practice as I did while Assistant Professor, with half the time commitment. I had more time to sip coffee in my gazebo while gazing upon bluebirds gliding through the lush green foliage.

Some people regard the paths in their neck of the woods as exclusively theirs. An extremely qualified internist asked me why the heck I was out there: “You’re female, Asian, and Board Certified!

That’s three strikes against you. And, you don’t have three or four generations of folks buried in the local cemetery.” He was male, Caucasian and Board Certified, with four layers of relatives buried in the rural cemetery. He was right. He would have referred patients to me were I back in the big megapolis, but small town, USA, was not ready for the likes of me. The general counsel of our state medical association assured me that he knew Caucasian female physicians in small rural towns who told him similar stories as mine.

I learned that nice-and-mean people exist all over. Meanness is easier to find in small towns. Racism and sexism are still rampant.

When the door closes on happiness, one opens a window. I took the interstate. Accepting an invitation from a prestigious private academic institution to practice what I had been accumulating in actual experiences, I was soon in charge of birthing a pain fellowship program. I had been promoted to Associate Professor, once again a workaholic mushroom.

The quality of life’s path determines the feasibility of traversing it.

Up in the northeast, alone with no family support despite very friendly church friends and professional colleagues, a postage stamp house lot covered by icky cold white stuff as conveyed through the eyes of my prissy, Texas-born golden retriever, and taxes in everything (federal, state, county, city, even my garbage disposal installation cost $10 tax quarterly!), I worked. I dictated complex patient consultations until 2 AM and was back at the clinic to teach the 6 AM conferences. A rudderless department and a researcher/supervisor who knew nothing about running a viable practice eventually took a toll on my health. My blood pressure was higher than the skyscapers (e.g. 165/135). I left that path before any heart attacks or strokes ambushed me. I went home.

Texas is a glorious state! It has plenty of big cities and small towns.

It even has culture! Texas has wide open blue skies, plenty of sunshine, friendly Texans and no state income tax! (My Associate Professor salary in the frigid northeast, after taxes, was equal to my Assistant Professor salary in Texas.) For those who want icky snow, head up to the Panhandle. Having worked nonstop since a teenager, I decided to stop spinning the hamster wheel and rest a spell.

A midlife sabbatical is sublime. Even mushrooms need sunshine now and then. I read voraciously all the books I had deferred. I took walks with my golden retriever who was thrilled to have enough land to run full throttle. I napped. I reminded myself why I became a physician by resuming my medical missions work.

Doing locums tenens during this break was not bad at all. The stereotype was that physicians who did temporary work assignments couldn’t hold on to steady jobs. As in all aspects of life, I found people of varying levels of competence. Many physicians, especially the younger ones, enjoy the flexibility and freedom of working only when they want. They combine love of travelling, adventures, and newness of hospital people and facilities. They avoid being stuck in rutted paths of obligations to pay for the big practices, houses, fancy cars, private schools and social standing. They can work as hard or as laid-back as they want. They are independent contractors paid by the middle-man locums company. Medical malpractice coverage is usually occurrence rather than the less attractive claims made. Living arrangements in a hotel or rental apartment, with use of rental car, permits a sense of vacation when one’s work shift is finished. Many physicians self-incorporate to provide themselves with their own health insurance and retirement saving options.

Locums docs are hybrids: working for themselves while employed by other entities for temporary durations. Some physicians do locums as their full-time career.

Using my legal training and actually reading my locums employment contract, I found a very interesting finder’s fee clause. If I decided to stay on permanently after a locums assignment, somebody had to pay the locums company a $25,000 fee for “finding” me. Would the local group of physicians or the hospital pay? Or would I? I avoided places which interested me for permanent positions to duck the expensive penalty.

That’s why it took me a while to get to San Antonio. When large private or academic corporations are employing physicians, the distinctions blur. The scholar in me won out: the academic road. I enjoy working with bright young minds who, despite adverse economic conditions, are still dedicated to become future physicians.

My employment by a state institution meant opportunities to be significant in the lives of medical students and resident physicians through my teaching and being an experienced role model. I had the thrill and headaches of setting up new curriculum, running workshops and still tackle the clinical arena of patient care. Mushroom moments. I muttered repeatedly why I left real world practice for academic pay, though I knew my answers.

Being employed in a state institution conveys advantages to offset the lower salary differential. The state offers matching money for those employees willing to save retirement money. It also includes continued on page 18

visit us at www.bcms.org

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EMPLOYED PHYSICIANS continued from page 17

medical malpractice self-insurance, health insurance, accident and disability protection. Employees can defer pre- and post-taxed money into state approved investment programs. Sick time and vacation time are part of the employment package. Seniority as to duration of employment and academic rank are tied to increases in pay and vacation time. Salaries can be augmented by additional skills, training and productivity, at the discretion of the management. Perhaps someday there will be those physicians who are only clinical specialists, minus the obligations and rank of being academic faculty.

Whether large corporations, academic institutions, hospitals or small groups, there are plenty of rough spots. Employed physicians must meet productivity metrics which are defined by employers. Pay disparity exists along gender lines. Men still hold the vast majority of leadership positions. Covert discrimination as to color, creed, sex, gender, race, age, and whatever adverse “isms” continue because we are flawed human beings. Fortunately, such negative bumps are being smoothed out, albeit at sloth’s speed.

Ask yourself if you are on the path you like. Physicians change jobs, practice locations, specialties. More physicians are employed and they should read their employment contracts. If an attorney is 18

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needed to decipher the English legalese so you can understand, then hire an attorney. The likelihood of being able to change terms of employment are slim, unless you come equipped with a hefty research grant or lots of alphabets behind your name. Read policies which delineate expected employee and employer behavior. Pay particular attention to what actions can result in job termination.

Avoid those actions. Know what avenues exist to fix inadequate work performances. Take time-off and vacations to rebalance life.

Above all, expect more than an eighty-hour work week for a forty hour weekly salary. That’s the general direction in Medicine.

Dense woods through life obscure paths. Whether you take the highly or less travelled road, seeing beyond the bend remains difficult. Keep walking, maybe doubling back to try again. The best part of traveling one or multiple paths over forty years of practicing Medicine is finding the end of the rainbow: retirement.

Wendy B. Kang, MD, JD, recently retired as Professor/Clinical. She maintains Adjunct Professor status in the Department of Anesthesiology at the UT Long School of Medicine in order to help younger colleagues explore the paths towards the rainbow. Dr. Kang is a member of the Bexar County Medical Society.

EMPLOYED PHYSICIANS

“To Be or Not To Be” Employed, That Is The Question!

By J.D. Martinez, MD FACC

After graduating from the hard-fought years in training, most doctors just want to do the right thing. “Was my progress note done correctly? Did I apply the right therapy for the diagnosis? Was my diagnosis even accurate? Did I miss something? Should I call for a consult?” The thoughts of becoming an employed physician, or building your own practice, seem like distant ones. When this decision does arrive, it can be complicated.

Having your own independent practice comes with its own hardships. This can include obtaining your own malpractice insurance, credentialing with insurance payers and hospitals, finding the right staff, and making sure overhead does not overwhelm your bottom line. Despite its many headaches, being an independent physician allows you to still practice medicine with a genuine focus on patient care. It is difficult to imagine developing a clinical practice out of nothing, however, cost-conscious small business minded management companies do exist.

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Independent physicians are not alone. Here in San Antonio, physician management companies (not related to hospitals or insurance products) ease opening doors for clinicians. The management companies will assist in quick mass credentialing, keep up your licensing, hire staff and assist with decisions as to where to invest for clinical space without hurting your pocketbook. These management companies will also help access better products for health benefits for staff as well as the physician and family, and can develop plans for practice growth. Many physicians in San Antonio have had successful growth with these types of practices. For those interested in managing their own business and want some exposure to opening a practice, these management companies can also be a step towards learning the business side of medicine.

Initially, many of us are not sure what we want. When we are finishing training, we have financial deadlines in mind. We worry about medical school loans, and growing families. In addition, we are easily

allured by sign-on bonuses. These factors affect our decision about becoming employed vs being in independent practice. Some of us cannot, or prefer not, to deal with the stress related to burdensome administrative work associated with managing our own practice in addition to practicing medicine. That is why it is so very important for us to understand ourselves, our needs, and our comfort levels.

In my own trek to find the right fit, I developed an understanding of the various practice breeds. Through trial and error, I figured out what practice choices fit my needs as well as those of my family.

Many models of practice exist and can include hospital, clinic, and administrative work. Much will depend on who owns the practice, because this is who leads the practice agenda. For hospital employed primaries, this can include direct facility employment or indirect employment through a hospitalist corporate company.

There is negligible difference between them. These types of practices will encompass mostly shift work and being a default-admitting physician for hospitals.

Employed hospitalist positions may seem more attractive for many at the onset. This type of practice may appear more lucrative and less stressful. But, keep in mind federal allowances for small business owners may bridge the financial differences between being self-employed and employed-by-facility.

Corporate employment for physicians can relieve much of the pressure related to some administrative tasks but only to supplant for others. While hiring, firing, signing leases and paying for utilities may not be a problems as a corporate employed physician, pressure related to rapid discharges, shortened hospital stays, and “cost-conscious” clinical decisions can provide for soul-crushing stress, particularly if you are a new incoming physician attempting to bring recent medical understanding to groups of employed, aged, “oldtime” physicians.

For physicians, depending on the point of their career or their own social dynamics, employed practice types are practical and can potentially be fruitful. Although, new physicians should be cautious in reviewing contracts and practice details before entering into any model. Income is an important factor, but details like vacation days, call frequency, number of admissions during call, rounding during call, presence of nocturnist and expectation of administrative (unpaid) tasks. It is important that we delve deep into ourselves and seek to understand our individual needs, both in clinical practice and socially. If scales are tipped, this can produce burnout and poor clinical decisions affecting not just the physician’s life, but the lives of those who we are asked to help.

J.D. Martinez, MD FACC is an internal medicine physician and a member of the Bexar County Medical Society. visit us at www.bcms.org

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EMPLOYED PHYSICIANS

SELLING A PRACTICE

Becoming an Employed Physician

By Anton J. Jirka, Jr., MD My first work arrangement after graduation from medical school was an easy decision. Since the US Air Force had paid for my education, I went to work for them. Everything was simple and structured. There was only one payer, one formulary, the referral network was clearly defined, and my salary and benefits did not change because of utilization, quality measures, or any other metric besides promotions and time in grade. When my military commitment was up, I worked for an urgent care company at an hourly wage while trying to convince my wife that we should stay in Alaska. That was also a very straightforward arrangement and I enjoyed it at the time, but the dark and the cold did not agree with my spouse, so we moved back to Texas where she got a job with a hospital affiliated group and I went back to finish my training at UT. I left residency in 1999 during the heyday of the HMOs, when capitation and being “at risk” in primary care was big and even doctors with well-established, successful practices were being squeezed and were selling their practices to join groups in order to survive.

When the major employers in town who provide the insurance for large chunks of the patient population decide to go with the HMOs, one is left with the option of losing a lot of patients who have been with you for years or signing onto their contracts. If it were just for primary care capitation, that would probably still be doable for solo or small groups (assuming the monthly payments were high enough), but when they throw in being “at risk”, it is like playing Russian roulette. Just one or two really sick patients could easily bankrupt a small practice, especially with a physician that is just starting out. For this reason, as well as the fact that my wife already worked there, I joined a hospital affiliated group.

At first, I liked my work arrangement there. I was making way more money than I had in the military or as an hourly employee in urgent care, but I soon came to dislike the system where my pay was determined by how many patients I had in my panel and how 22

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little I spent caring for them. It seemed, at times, like an adversarial relationship between my patients and me, especially when I was seeing someone who knew how the system worked and accused me of denying them appropriate care because it would cost me too much. The situation was made worse when our group merged with another, the leadership changed, and the methods advocated by the new leadership were not good fits for me. They also dictated how our schedules would be structured and made us attend countless meetings about utilization and other things that drove me crazy.

I was starting to regret being a doctor. Fortunately, my wife came up with a brilliant idea that had not even occurred to me: what if we went out into private practice? By this time, enough people had become so fed up with the system that it was possible to sign contracts with insurance companies, even the big HMOs, without capitation or risk. We would be paid fee for service, even if their insurance card said HMO. Patients would still need referrals and restricted formularies and networks, but we wouldn’t face financial disaster if we had one or two of our patients suffer from catastrophic illnesses, and no one would be able to tell us how we had to structure and operate our clinic. This worked out great for over 15 years and we built a successful and rewarding practice in the medical center; but then the government decided that they needed to fix the medical system in the United States. Since they knew that they were the best and the brightest, they proceeded to tell all of us what we were doing wrong and what we needed to do to fix it. They created MACRA, MIPS, and all kinds of boxes we had to check in the EMR to meet the quality measure du jour. It didn’t matter that we had always done these things and even that we documented them in the notes. If the boxes weren’t checked it didn’t count, and they kept adding more boxes. It got to the point that one needed a

EMPLOYED PHYSICIANS full-time employee just to keep up with the latest Medicare rule changes. As a small office, we couldn’t afford that but we didn’t have the time to keep up with it ourselves. On top of this they started touting the concept of ACOs, which sounded a lot like HMOs to those of us who had been there (it even rhymed), which made us once again consider the advantages of joining a group for the economy of scale. So, we started making some inquiries.

We reached out to the three major hospital systems in town that were not run by the government. One was focusing on acquiring specialty practices and we are primary care; one didn’t seem sure what they wanted to do; and the other one seemed enthusiastic so we started to talk. We told them that the most important things to us were keeping our autonomy, practicing medicine the way we thought was best, being able to keep all of our patients (which meant accepting all the same insurance plans), keeping all of our staff (some of whom had been with us for years) and receive atleast the same salaries. We also wanted to maintain ownership of our building and rent it to them so we would be in the same clinic that was familiar to us and our patients and not lose a key piece of our retirement strategy. Much to my surprise the recruiter said, “Fine.” Just to be clear I went over all of the points again and he said, “Yes.” So, we agreed to sell and started the process.

I had been in the military and I have seen the movie “Private Benjamin,” so I must admit I was carrying a bit of skepticism about promises from recruiters, but I have to say that everything he said would happen did. The hardest part was selling our equipment and practice assets at what seemed like pennies on the dollar. Equipment items we had paid thousands for were worth a couple of hundred, according to the appraiser; but we were, after all, essentially selling used office furniture, computers, TVs, and refrigerators. I thought that the medical records and “intangibles” of an established practice were worth something, but the records were all electronic and they said once we neared retirement we would be glad that we wouldn’t have the responsibility of dealing with them; we would be able to just walk away into the sunset. We would still own the building even after exiting the practice, which we could continue to rent out to other doctors.

It has been over two years now since we sold our practice, and a lot has changed in our lives. Nearly all of my stress is gone. I no longer have to worry about hiring and firing, making payroll, or keeping up with the latest Medicare changes. I have paid vacation, better benefits including vision, dental, disability and life insurance, 401K with a match, and pay about $30 a month for a great health insurance plan. If I use our owners’ doctors and our hospitals, most of my care is essentially free. My wife and I are able to go on vacation at the same time without our income dropping to zero 2 weeks later while our bills stayed the same. We are making substantially more money for the same work, largely because the hospital has better contracts with the insurance companies (we were always so busy we

never thought to renegotiate our contracts). The hospital has economy of scale and the negotiating power of a large organization.

We get paid based on RVUs, with substantial bonus incentives for productivity. This means that I don’t care who the payer is, I get paid the same for the same amount of work, and the harder I work the more I make, regardless or things like utilization. I am able to order the tests I want and do the referrals I see fit without having to worry about someone trying to second guess me from inside my own organization. My patients know and appreciate that. I of course still have to do prior auths, follow formularies, insurance networks, and do the occasional peer-to-peer with the insurance companies, but that’s on them. Neither I nor my group are the enemy. I have been able to keep my long established referral patterns, but I have also developed new relationships with people within our organization and have been happily sending many of my patients to them with great results. That is because that’s where I wanted to send them, not because someone dictated that I send them there.

There have been a few downsides to joining this group, the biggest of which are not being able to meet with drug reps at lunch and not being able to offer private pay patients the kind of discounts that we were able to when it was just us. We do have a sliding scale for private pay patients, but it is still substantially higher than the basic Medicare rates we used to offer them. We also used to have a deal with a lab to offer substantial discounts on lab tests for our patients without insurance, but we had to stop that. Not seeing drug reps at lunch amounts to a fairly substantial pay cut for our staff, and we feel somewhat isolated in that we don’t have anyone to talk to who goes around to the other clinics in town and tells us what’s new outside of ours. Although I get the Prescriber’s Letter, it also seems like we are no longer as familiar with newer medications and the developments with older ones.

For anyone out there who is contemplating taking the plunge as we did, or even those who hadn’t been thinking about it, I will say that for us, at least, selling our practice has worked out great. None of the things that I hated about being an employed physician 20 years ago seem to apply anymore. Our experience has been that as long as we work hard, meet the quality measures (which they provide extra staff to help us with), and get the kinds of reviews that we get from our patients, we are left to practice medicine as we see fit with the support and economy of scale that comes with being part of a larger organization. I have experienced a wide variety of practice situations, from military, to hourly wage, to managed care groups, to private practice, and now back to a hospital affiliated group; and I can say that for me this is the best it has ever been.

Anton J. Jirka, Jr, MD is a Family Medicine specialist with MedFirst Primary Care, Medical Center, and is a long-time member of the Bexar County Medical Society. visit us at www.bcms.org

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EMPLOYED PHYSICIANS

The Only Job I Have Stayed Loyal to is

Being a Doctor

By John J. Seidenfeld, MD

My passion for medicine has never changed, and I have always “owned” the care I delivered. Sometimes it meant leaving one job for another because of a disagreement about best practices or because my interests or priorities changed. At times I have been employed and other times I was the employer. That is OK with me. I love practicing medicine either way. There are differences and tradeoffs. The only job I have stayed loyal to is being a physician.

After completing Internal Medicine and Pulmonary Disease training at the University of Iowa, the United States Army collected on their Berry Plan offer to make me a medical officer. Vietnam had wound down, but it seemed G.I. doctors were still needed to care for active duty and retired troops. Uncle Sam gave me gainful employment for two years at Ft. Ord (now a junior college campus) on the Monterey Bay in California. There I cared for military members and dependents who had need of pulmonary or intensive care.

The time went quickly with staff teaching, patient care, and being part of a young family. When my time was up, I was offered a wonderful array of other assignments to stay in the military but chose to pursue teaching, research, and patient care at the University of Arizona in Tucson.

In Arizona I was able to study under a great pulmonologist, Dr. Ben Burrows who did most of the epidemiologic work in COPD. Dr. Burrows helped me get grant funding to pursue an interest in bench research in lung injury and development of fibrosis in small mammals. There I worked with excellent people and began to become a lab researcher once again after work in fellowship with Dr. Hal Richerson in Iowa. We were just beginning to understand how injury progressed to fibrosis in the lung of ARDS patients. I continued to teach 24

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medical students and residents and help raise a young family.

At that time, Dr. W.G. Johanson (Buzz) was the head of pulmonary at UTSAHSC who invited me to speak on research in progress. He then asked if I would join his group in San Antonio studying lung injury in large mammals at the Southwest Foundation and participate in a large NIH grant he led. The offer was exciting as the team in San Antonio was very good and the work complimentary to what I had been doing. My young family and I moved to San Antonio and I continued to teach and research, but also care for pulmonary patients at UTSAHSC. We had a very productive few years before the group began going in different directions, as Dr. Johanson left for greener pastures (but less delectable TexMex food).

Whether it was that I had decided I would never attain the Nobel Prize or would not be able to afford the colleges my children wanted to attend is unclear. Eventually, I left the hallowed halls of teaching and research for solo practice and call sharing with a wonderful San Antonio pulmonologist, Dr. Carlos Orozco. Solo practice was challenging and rewarding. Most of the loans I received were paid back in the first few years and the practice thrived. I worked twelve of fourteen days, most holidays, and ten-to-twelve hours most days with many long nights and calls out in the wee hours. At one time, Carlos and I were seeing patients in almost all the hospitals in San Antonio (there were fewer hospitals in the 1980’s, but we still made a circle similar to loop 410 around the city once or twice a day). I loved patient care and the people I worked with at the office and at intensive care units. Work in intensive care, respiratory therapy leadership, hospital and BCMS committees, as well as so many other

EMPLOYED PHYSICIANS community areas was fulfilling and kept me “off the streets”.

When Dr. Norman Jacobson invited me to be medical director of a new group he was forming, the Solomon Anthony Clinic, and continue to practice pulmonology, I joined that effort. Soon we had multiple primary care groups serving outpatients and Santa Rosa (now Christus) inpatients. Eventually, Norm left and I became the group’s lead. That group later merged with Health Texas and the rest is, as they say, history.

During this time, I found administration challenging in a world dominated by health insurers who knew more about contracting than most doctors. As a result, I began a course of study at Trinity University in Health Care Administration to better understand the economic, legal, epidemiologic and general direction of U.S. health care. Journal readings which had included the Annals of Internal Medicine, the New England Journal of Medicine and the American Review of Respiratory Diseases to Health Affairs, changed to the Wall Street Journal and other health policy materials.

The next step on this career and life train was working for what some call the “enemy”, i.e. health insurers. As we all aspire to have health coverage for the unforeseen, I saw an opportunity to learn more about benefits, coverage decisions and health policies that affect all of us. Some of my peers saw this as a defection and others have continued to be friends, but I was interested in trends in practice ownership, quality of medicine standards, new forms of health care delivery and incentives for providing excellent health care. In this capacity, I was able to help pass state legislation on surgical infection reporting, develop a method of price sharing with consumers, serve on the National Committee for Quality Assurance and try to help improve care provided in the mid United States.

After leaving Anthem Healthcare, I retired to care for elderly parents; a move which I will never regret. We got to know each other as adults and they were fine people from the greatest generation.

Grandchildren were part of the joy as well, particularly as their parents picked them up at the end of the day. I missed clinical medicine and worked with an Internal Medicine group at the Nix. Eventually, I left the group to practice three half-days a week near home. This led to another retirement and more interaction with children and grandchildren. It also gave me a chance to grow to love the Texas Hill country east of Blanco and walk among the flora and fauna.

When a colleague, Dr. Adam Ratner, called to ask me to discuss the UIW School of Osteopathic Medicine at Brooke City Base, I went down and heard about his interests in the project and the school’s focus on social justice, diversity, and health equity. His enthusiasm led to me applying for work with the new school. Here I have been able to catch up on years of wonderful work in teaching and research as well as spending time with amazing and enthusiastic young people and faculty.

So, on the whole issue of employer or employee, whether you work for yourself or someone pays for your services, see yourself as the responsible party for delivering the best care possible and always serve the patient.

What’s it all about in the end? For me, it has been love of family, passionate interests in medical literature and of health care delivery, teachers, colleagues, patients, and students. My guiding principles are these: 1) care for people like they are family

2) use ethical principles to shape your decisions

3) have well trained clinicians deliver the best care possible

4) prevent disease if you are able

5) focus on the patient and community, and

6) consider care in the light of social justice and equity John J. Seidenfeld, MD is board certified in pulmonary diseases and internal medicine, an associate professor at UIWTX SOM, and is vice chair of the Bexar County Medical Society Publications Committee.

visit us at www.bcms.org

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EMPLOYED PHYSICIANS

PHYSICIANS

Read Your Employment Contract Before Signing It: Here’s Why

By Mike Kreager

Corporate Employment.

The siren’s song of corporate employment is tantalizing … and effective. Survey after survey of employed physicians confirms corporations are gaining physician employment over private practices.

As a corporate law attorney, I have read hundreds of corporate employment agreements. This article will share the positives and negatives of corporate employment that might not be immediately apparent, which will hopefully enable you to make an informed choice if the opportunity presents. I caution you: if you do not read the employment agreement before signing, it is tantamount to giving an injection to a patient without reading the label first.

Corporate Motives.

Increased corporate employment of physicians is directly tied to the corporation’s profit motives. Hospitals want to capture in-patient referrals. Insurance companies want to increase profit by controlling the cost of physician providers to its insureds. Private equity seeks to profit from a business model that controls costs and maximizes clinician revenue. So, what are the positives and negatives of corporate employment?

Money.

The initial minimum salary will be attractive. This positive is one of the hooks to entice you to join their team. But the guaranteed minimum compensation evaporates after the first year. Thereafter, the salary will shift to pay for production. That is, you will be paid only for the wRVUs you generate. This model discretely shifts the burden to you to maximize patient encounters. If there is not enough work or if you are not efficient, you will make less in subsequent years. A sign-on bonus is often an added inducement, but more on that later. Look down the road. Is it possible that too many providers will be employed, resulting in fewer encounter opportunities?

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For the positive, wRVU-based compensation is not necessarily bad.

You are not penalized if the payor does not pay or is slow to pay.

The employer assumes the risk of non-payment. Of course, the employer will be looking to favorably hedge the amount of the payor reimbursement against the employer’s projected payments to you.

In other words, if priced right, the employer’s collections will exceed your pay. You are a corporate profit center to the employer! Your employment has an added benefit to the corporation, as you will be required to refer to its other providers absent narrow exceptions.

Conversion Rate and Cap. Your pay is the product of your wRVUs times their assigned conversion rate, e.g., $36 per wRVU. To understand if you are being treated fairly, compare the assigned conversion rate to the current Medical Group Management Association (MGMA) survey. But be careful. All too often the corporation pegs dollar conversion at the median of the MGMA survey. That means your worth/cost is the midpoint between the highest and lowest conversion rates. If that is the case, when negotiating point out reasons that distinguish yourself, such as quality outcomes and experience or specialty training, and argue for a higher percentile, e.g., 90th percentile. Often, a cap is placed on the compensation, notwithstanding that you are a high producer. You should object to any cap. If the conversion rate is fair market value (FMV), there should be no cap if quality bears out.

Ancillary Earnings.

You will not be paid for ancillary referrals, e.g., imaging, or midlevel providers. Private practices can arrange Stark-compliant arrangements that allow the providers to share in ancillary profits; but corporate employers do not credit you for ancillary referrals.

Another point of divergence concerns investments. In private practice you can make investments in associated, profitable businesses,

EMPLOYED PHYSICIANS such as in a surgery center. These investments are strictly prohibited by corporate employers, and are treated as prohibited, competitive investments with the employer’s owned centers.

Duration of Employment.

The duration of employment is the term or length of the contract. The usual term is three-to-five years. But that is purely an illusion. The employer can dismiss you on short notice, usually 90 days. You will find this dismissal in the paragraph that uses the words “termination without cause.” Thus, your employment security is only 90 days. However, it is not uncommon for the contract to be silent on your right to terminate without cause. This is a very unbalanced portion of physician employment contracts. Unless you are able to negotiate the right to terminate your employment under reasonable terms, you must keep working the full three or five years or face being responsible for the employer’s costs in finding your replacement, e.g., locums coverage and recruiting expenses.

Culture.

The corporate setting is far different than private practice—where you can be an equal co-owner. Face it, your boss in a corporation will most likely not be a physician. Moreover, the corporation will be almost exclusively focused on profit. Without profit, it has no reason to employ you. Get used to the reality—you are a functionary—a highly trained and skilled functionary, but a utility, nonetheless. The executives of your employer are rewarded handsomely in bonuses and stock options for profitability. That incentive becomes apparent in the culture of the practice. All variables, save possibly medical judgment, are in the hands of non-physicians. This extends to your schedule, time off and the assignment of staff.

Non-Compete.

Without fail, if your employment ends, even if you are fired without cause, you will be banned from working for one to two years anywhere from ten to thirty miles from your former clinic. Noncompetes are enforceable if reasonable. Even if unreasonable, you will spend tens of thousands of dollars contesting the scope of the restrictions, only to find that the court can repair unreasonable restrictions to what the court considers reasonable. In the presence of a noncompete, you may have no choice but to relocate your family to earn a living. In one obscene use of a noncompete, UT’s orthopedic surgery department imposed a geographic restriction of 200 miles! Try limiting the restrictions so that you can relocate elsewhere in the community, e.g., five to ten miles. Ask the employer to waive the noncompete if your employment is ended without cause or if you do not associate with a competing employer. It is a fair request, as the employer apparently decided that you have no continuing value and the logical extension is that you are not a competitive threat.

Repayment of Incentives.

Recall the mention of your receiving a sign-on bonus. If your employment ends early, you will be required to pay the unamortized portion of the bonus. Usually sign-on bonuses, and similar incentives, burn off monthly over two years. For example, if your employment ends at the end of the first year, you must repay the employer half of the bonus within thirty days. The amortization acts as a short-term pair of handcuffs. Also, recall your employer’s right to end your employment on short notice without cause. As a practice tip, ask the employer to modify its contract to clarify that your obligation to repay the incentives are waived if the employer chooses to end your employment without cause.

Professional Liability Insurance.

In private practice, the employed physician must pay the premium to extend liability coverage after the end of employment—called a “tail policy”. An incentive of corporate employment is a fully-paid tail at the end of employment. Beware of contract exceptions to this benefit. If you terminate employment without cause, you can be responsible for paying for that tail policy. Always ask about the form of insurance. Is the tail real insurance or is it self-insurance, where the corporation sets aside accounting reserves for future losses. If the latter, the corporation will assign a premium cost for the tail insurance.

Disputes.

Contract disputes are resolved by lawsuits. Lawsuits are typically very expensive (for both sides), so corporate employers favor binding arbitration instead. The arbitration may follow nationally recognized neutral rules, e.g., the American Arbitration Association or the American Health Lawyers Dispute Resolution Rules, or the corporation’s own set of rules. Often the contract will require the arbitration to take place in the corporation’s home city, as opposed to where you work. While arbitration can be an effective alternate to a lawsuit, insist that it take place in your home city. It will save you money.

Corporate employment contracts can be a mixed bag—offering both positive and negative benefits. But BEFORE YOU SIGN, read your employment contract closely and consult with your attorney.

Mike Kreager, the founder of the firm KreagerMitchell, is a business attorney and is board certified in tax law, having practiced in San Antonio for more than 40 years.

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DIET AS A LIFESTYLE

Diet as a Lifestyle

By Simone Norris, MD

Virtually every patient that I encounter asks me, “What should I eat?” The options are endless and often overwhelming.

Paleo. Primal. Vegan. Vegetarian. Keto. Atkins. South Beach.

Whole 30. Detox. Mediterranean. DASH diet. Low-fat. Low-carb.

Intermittent Fasting. Elimination diets. Blood type diet. The 10 best foods for your _____. Non-GMO. Organic.

Is there a right answer? My answer usually is... keep it simple.

Food is life. Food is comfort. Food is celebration. What, how, why, where and when we eat is influenced by our culture, upbring28

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ing, lifestyle, philosophy, politics, finances, and time constraints.

Health conditions, food allergies and individual preferences add to the mix. We are bombarded by information about what is “healthy” by both our medical training and the food industry. How are we to determine what is best? What is the goal of healthy eating?

Longevity Rich cultural traditions abound in our eating lives. Methods of food preparation and consumption, including the practice of fasting, form part of many cultures and religious traditions as a means of self-care and promoting health and longevity. The Blue Zones – areas with the highest proportion of Centenarians – have been

DIET AS A LIFESTYLE well-studied regarding food choices and lifestyle. The people of Okinawa, Japan are included in this group, with 50 Centenarians per 100,000 people. Many follow a practice called “Hara Hachi Bun Me” – intentional caloric restriction by stopping eating when they feel 80% full. On average, they consume 1800-1900 kcal/day. As a result, elders’ typical BMI is 18-22. In contrast, the typical BMI of Americans over 60 years of age is 26-27.

The practice of caloric restriction is not new; similar philosophies/practices have a long tradition in other Asian countries. In 5th century BCE China, according to TCM (Traditional Chinese Medicine), the practice was to eat until 70% full. In 4th century BCE India, traditional Indian/Ayurvedic medicine philosophy was “Fill one third of the stomach with liquid, another third with food, and leave the rest empty.”

Physiologically, when we eat less, the gastric stretch receptors that signal satiety become used to a smaller amount. It is then possible to become used to eating less food. This caloric restriction is the basis of most modern-day, weight-loss programs such as Weight Watchers and the newer Noom app. Cultivating the mindset to eat less can improve longevity. It is important to note, however, that the citizens of the Blue Zones have some other characteristics in common: no smoking, eating a plant heavy diet, strong family connections, constant moderate physical activity, social engagement, and consumption of legumes.

Inflammation Cardiovascular disease and cancer still rank as the top two leading causes of death in the United States. Increased morbidity from diabetes, autoimmune disease, allergy, asthma, respiratory diseases like COPD, GI-related illnesses, and mental health issues not only rob people of a vibrant life, they are responsible for hundreds of billions of dollars of cost burden in the United States. What is at the root of these issues? Many believe it is inflammation gone awry.

There is much evidence to support inflammation as the common thread that drives all of these problems. An elegant defense mechanism of the body mediated by the immune system, the inflammatory response is vital to our health. Acutely, the process works to heal and restore homeostasis from physical, environmental or psychological injury. When dysfunctional or chronic, however, the inflammatory process can increase morbidity and decrease mortality.

Is it possible to impact this phenomenon with our food? I believe that it is. How does this work? Enter the Microbiome and Anti-Inflammatory eating.

Microbiome Established in 2008, the NIH Human Microbiome Project describes the microbiome in this way:

The Human Microbiome is the collection of all the microorganisms living in association with the human body. These communities consist of a variety of microorganisms including eukaryotes, archaea, bacteria and viruses. Bacteria in an average human body number ten times more than human cells, for a total of about 1000 more genes than are present in the human genome. Because of their small size, however, microorganisms make up only about 1 to 3 percent of our body mass (that's 2 to 6 pounds of bacteria in a 200-pound adult). These microbes are generally not harmful to us, in fact they are essential for maintaining health. For example, they produce some vitamins that we do not have the genes to make, break down our food to extract nutrients we need to survive, teach our immune systems how to recognize dangerous invaders, and even produce helpful anti-inflammatory compounds that fight off other diseasecausing microbes. An ever-growing number of studies have demonstrated that changes in the composition of our microbiomes correlate with numerous disease states, raising the possibility that manipulation of these communities could be used to treat disease.

Each of us has a unique makeup of gut microbiota, based on our route of birth, use of antibiotics, steroids, and other prescription meds, environment, and the food we put in our bodies every day.

At the most basic level, we are what we eat.

The Western-Pattern or Standard American Diet (SAD), with its calorie-dense, nutrient-poor refined foods, sugar, fat, conventionally-raised animal products, and artificial sweeteners, dyes and additives has been demonstrated to contribute to chronic disease – via alteration of the gut microbiota.

It is well-established that modification of diet can help lower blood sugar, reduce blood pressure, and lower cholesterol and cancer risk. There is more evidence now that it will also improve autoimmune disease, obesity, and mood disorders. Food can and should be our first line of defense for achieving and maintaining optimal health.

Anti-inflammatory Eating/What to Eat In 2006, I was teaching in a family medicine residency program for Christus Santa Rosa. In this busy outpatient clinic treating San Antonio’s downtown urban, largely Medicaid population, we encountered much obesity, diabetes, and cardiovascular disease. Access to quality food was (and is) limited, and the average 7 minutes spent in a patient visit didn’t allow for much nutritional evaluation, much less counseling. I chanced upon a CME opportunity through the University of New Mexico – SIMPLE – Symposium of Integrative Medicine Professionals in the Land of Enchantment. It was there I first heard Dr. Andrew Weil speak, and then started a 2year course of study with his Integrative Medicine Fellowship through the University of Arizona. A pioneer in the field of Intecontinued on page 30

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DIET AS A LIFESTYLE continued from page 29

grative Medicine, Dr. Weil’s outside-the-box approach to taking care of the whole patient nicely dovetailed with my family medicine training, and I became more knowledgeable in the tools I could offer my patients for health and healing. One of these tools is Dr. Weil’s Anti-Inflammatory Diet. Based on the Mediterranean Diet, this plan adds more fresh fruits and vegetables and reduces processed foods and unhealthy animal products. Quality of food is important. Organic foods are emphasized to avoid pesticide contamination. This is not a diet per se, but an overall approach to eating that intends to provide steady energy and ample vitamins, minerals, essential fatty acids, dietary fiber, and protective phytonutrients. The Anti-Inflammatory Food Pyramid is a revised model of the food pyramid we were taught; I like that it emphasizes foods to eat instead of to eliminate.

General guidelines include: • Eat a variety of foods • Include as much fresh food as possible

How to Eat How do many of us eat? On the run, standing up, in our cars, or while we are working? Making the time to sit and enjoy our meals, mindfully focused on our food, can lead to more satisfaction and better assimilation of the nutrients. It is likely that eating this way will also promote healthier food choices and consuming less.

We are charged as physicians to “First do no harm.” How might we achieve this? For ourselves, our families, friends, and patients?

Start where you are. Reflect on what you are putting in your body every day and if it serves you. Enjoy your food. Eat it mindfully.

Strive for consistency, not for perfection. Encourage your patients to do the same.

The goals of healthy eating are to reinforce a healthy gut and reduce inflammation, thereby improving quality of life and longevity.

To answer the question “Doc, what should I eat?” The American author Michael Pollan, who writes “about the places where nature and culture intersect: on our plates, in our farms and gardens, and in our minds,” says it best in his book In Defense of Food, An Eater’s Manifesto:

“Eat food. Not too much. Mostly plants”

• Minimize processed or fast foods

Dr. Simone Norris is the creator and sole proprietor of Integrative Family Medicine, a local medical practice that strives to treat the whole patient and is a member of the Bexar County Medical Society.

• Eat an abundance of fruits/vegetables • Try to include carbohydrates, fat, and protein at each meal • Eat more whole grains, legumes, winter squash and sweet potatoes • Reduce intake of saturated fat, and avoid all products made with partially hydrogenated oils of any kind • Use extra virgin olive oil as a main cooking oil. Expellerpressed organic canola, sunflower, and safflower oil are also recommended.

• Include avocados and nuts, especially walnuts, cashews, almonds, and nut butters • Include omega 3 fatty acids in the form of cold water oily fish, ground flax, chia, or hemp • Decrease animal protein consumption except for fish and high quality natural cheese and yogurt • Eat more vegetable protein, especially from beans and whole-soy foods • Aim for 40 grams of fiber per day • Include herbs and spices such as garlic, ginger, turmeric, and cinnamon • Choose brightly colored fruits and vegetables, cruciferous vegetables, and organic produce when possible (See the Dirty Dozen and the Clean 15) • Consider drinking tea instead of coffee • Drink red wine preferentially, if you drink alcohol • Enjoy plain dark chocolate in moderation

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References 1.

Sears, B. Anti-inflammatory Diets. J Am Coll Nutr. 2015;34 Suppl 1:1421. doi: 10.1080/07315724.2015.1080105. https://pubmed.ncbi.nlm.nih.gov/26400429/ 2. Levine, A., El-Matary, W., Van Limbergen, J. A Case-Based Approach to New Directions in Dietary Therapy of Crohn’s Disease: Food for Thought. Nutrients. 2020 Mar; 12(3): 880. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146196/ 3. Bennett, J., Reeves, G., Billman, G. Sturmberg, J. Inflammation—Nature’s Way to Efficiently Respond to All Types of Challenges: Implications for Understanding and Managing “the Epidemic” of Chronic Diseases. Front Med (Lausanne). 2018; 5: 316. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277637/ 4. Grotto, D., Zied, E. The Standard American Diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010 Dec;25(6):603-12. doi: 10.1177/0884533610386234. https://pubmed.ncbi.nlm.nih.gov/21139124/ 5. Nelson, JB. Mindful Eating: The Art of Presence While You Eat. Diabetes Spectr. 2017 Aug; 30(3): 171–174. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556586/ 6. NIH Human Microbiome Project: www.hmpdacc.org/overview/ 7. Pollan, Michael. In Defense of Food: An Eater's Manifesto. New York, New York: Penguin Books, 2009.

8. Buettner, D. The Blue Zones: 9 Lessons for Living Longer from the People Who've Lived the Longest. , 2012 9. Andrew Weil Center for Integrative Medicine: https://integrativemedicine.arizona.edu/about/definition.html 10. Andrew Weil Anti-Inflammatory Diet and Food Pyramid: https://www.drweil.com/diet-nutrition/anti-inflammatory-diet-pyramid/dr-weils-anti-inflammatory-food-pyramid/

FIND A BCMS PHYSICIAN

Finding a BCMS Physician Five Ways!

One of the important services of the Bexar County Medical Society (BCMS) is enabling physician members to find each other, as well as enabling patients to find physicians. Just take a sort moment to review how many ways BCMS has made this possible.

Ways to Find A Doctor

BCMS Physician Directory – Printed (Every BCMS Member gets a copy)

BCMS Physician Directory – Online Version bcms.org/directory/ mobile/index.html

Find-A-Doctor Search Tool BCMS Website bcms.org/ findadoc3/php

Find-A-Doctor Search Tool BCMS Mobile App Search App Store for Bexar County Medical Society

Live BCMS Staff Person by calling 210-301-4391

The BCMS Physician Directory is a black-and-white printed directory used as a BCMS member referral tool. Beginning in 2019, the same printed directory is made available on the BCMS.org website in pdf format. This enables the public to search the directory and find BCMS member physicians. The information includes a professional picture (when provided by the physician), the physician’s specialty as reflected on the physicians’ medical license, insurance options, office location and office contact information.

The BCMS Find-A-Doctor search tool, used on the BCMS website as well as the Bexar County Medical Society phone app, is a BCMS member referral tool used by both physician colleagues and the general public. The information includes a color professional picture (when provided by the physician), the physician’s specialty as reflected on the physicians’ medical license, languages spoken by the physician, insurance options, office location and office contact information.

The general public as well as physicians and their staff often use these tools to find physicians. BCMS sees about 1,000 searches per month on the search tools, but also receives hundreds of telephone inquiries per month by patients looking for physicians. This telephone help is available in both English and Spanish. Please note that whenever possible, the BCMS referral service will provide inquiring patients with 3 names of physicians that meet their requested needs. It will then be up to the patient to verify with their insurance provider that those three referrals are covered under their plan.

To update your physician profiles, please visit www.bcms.org and click the Find A Doc tab, Check out your profile and if anything needs to be updated, please follow these simple steps: • Visit www.bcms.org • Click on the Membership Tab • Click on Update your Information • Enter any information that needs to updated • Click Submit in the top left corner

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BCMS COVID-19 TASK FORCE

The Pandemic is Still Here…

What the BCMS COVID-19 Task Force is Doing Now

By Mary E. Nava, MBA

In the May edition of San Antonio Medicine, I informed you of what BCMS and TMA were doing for our members since the start of the pandemic. Both organizations worked together and with local and state agencies to get the groundwork started for implementing communication and collaboration on numerous fronts. A lot has happened since then and as the pandemic has taken hold of our community, days have turned into weeks and weeks have turned into months of this long battle to contain the coronavirus. Daily reports in the news about our city and county numbers in terms of new COVID-19 cases, number of deaths, number of people hospitalized, along with hospital capacity numbers, including the number of staffed beds and ventilators available, continue to dominate news wires everywhere. The BCMS COVID-19 Task Force (herein the Task Force) remains in contact with Mayor Ron Nirenberg, County Judge Nelson Wolff, along with Metro Health leadership, to keep our city and county officials informed of any comments, concerns, recommendations or official statements by BCMS leadership and also the Task Force.

Almost from the start of the pandemic, several actions began to take shape and it became readily apparent that developing some public service announcements (PSAs), along with news releases and op-eds or opinion pieces, might be where BCMS could focus

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its energy to help educate the community on the importance of following the science of proper handwashing, maintaining social distance and wearing a mask. As time went on, a Communication Plan subcommittee was established, led by Dr. Lubna Naeem, and eventually, more ideas for PSA messages started to percolate and more Task Force members became interested in recording a PSA. The PSAs are posted on the BCMS website, Facebook page and Twitter page, once completed and approved. If you have not yet seen the new PSAs, go to bcms.org and click on the new “Wear a Mask” Campaign banner to see all the video PSAs that have been released to date.

On the news media front, we have had several media inquiries and, on occasion, we work with the Texas Medical Association (TMA) media relations team to address any inquiries that can benefit from both a local and statewide message. In late May, for example, Dr. Leah Jacobson was interviewed on KSAT-TV 12 for a story that also featured TMA President, Dr. Diana Fite, on the impact of the pandemic on the medical practice and what physicians were doing to deal with these issues. Additionally, as our Task Force also monitors news stories in general about COVID-19, the Task Force stands ready to respond to any misinformation or inaccuracies that may be presented to our community. Our president, Dr. Gerald

Greenfield, was able to do just that and prepared an op-ed piece that ran in the San Antonio Express-News in mid-June. His op-ed informed our community about the other side of the coin when it comes to wearing masks; that if some people say wearing a mask is an infringement on a person’s rights, then perhaps not wearing a mask is an infringement on the rights of physicians, other medical personnel and their families. Most recently, BCMS released a Statement on School Reopenings, in late July, which subsequently received several media inquiries. Once again, Dr. Leah Jacobson, who, as chair of the BCMS Task Force Subcommittee on Pediatrics and Schools, was interviewed by news outlets regarding our statement. To keep our members informed, we have taken steps to capture the publicity BCMS has garnered since the start of the pandemic, by categorizing our media stories and mentions chronologically under “BCMS in the News”, found by clicking on the BCMS COVID-19 Resource page banner on our website.

By the end of June, the work of the Task Force began a shift to begin a more defined focus on several key areas. As a result, the Task Force created four subcommittees: Communications Plan, chaired by Dr. Lubna

BCMS COVID-19 TASK FORCE

Naeem, which develops, reviews and schedules PSAs for release and other forms of communication as necessary in coordination with the other subcommittees, Task Force and BCMS leadership; Disease Investigation, Contact Tracing and Community Mitigation, chaired by Dr. Diane Simpson, which works to educate the community on what steps to take if exposed to an infected individual or if a person tests positive for the virus; Hospitals and Workforce, chaired by Dr. Zeke Silva, which maintains a close watch on hospital capacity and workforce issues; and Pediatrics and Schools, chaired by Dr. Leah Jacobson, which looks at policy, procedure and recommendations for getting children back to school safely. Each subcommittee meets independently and at times finds they need to collaborate with other subcommittees on some items, such as topics for PSAs, so as to minimize duplication of effort. The subcommittee chairs are dedicated to the cause and their input and support is greatly appreciated.

At the time of this writing, there has been significant discussion about how children will return to school safely for in-person instruction after Labor Day. Members of the Pediatrics and Schools Subcommittee have

been poring through tons of articles, reports and data sets in the hopes of crafting messaging and information charts for parents, in an effort to help them monitor their children’s health as they go back to school. The ball is in the court of school boards to make the determination for when and how to return to school safely. Our public health authority, Metro Health, may advise schools, but they cannot, however, dictate any directives for schools to follow on this matter.

Likewise, the issue of helping educate people on what to do if they test positive or are exposed to an infected individual, along with concerns for adequate contact tracing have been high on the radar for members of the Disease Investigation, Contact Tracing and Community Mitigation Subcommittee and also the Task Force. There is a great need for further education on what the responsibilities are of an individual who has been exposed, may have been exposed, or who has tested positive for COVID-19. To reduce any confusion, it is important to clearly state what steps need to take place to properly self-quarantine, inform contacts of a possible exposure and provide accurate information to Metro Health for follow up with respective parties so that everyone can receive proper care and guidance from their physician. A key message this Subcommittee is working on is to educate and inform everyone on the importance of answering

the phone call from the health department, should they be contacted, so they can protect their families and other persons with whom they may come in contact.

Rest assured, members of the Task Force, along with the various subcommittees and BCMS leadership, are actively engaged and are keeping a close eye on these situations as they continue to develop amid the on-going presence of this pandemic.

Mary Nava is the Chief Government Affairs Officer and lobbyist for BCMS. She is the staff liaison to the BCMS COVID-19 Task Force and Subcommittees, in addition to the Legislative and Socioeconomics Committee and Public Health and Patient Advocacy Committee. She has been with BCMS since February 2000.

visit us at www.bcms.org

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PEDIATRIC COVID-19 IN THE US

Pediatric COVID-19 in the US Data Based, Back-to-School Recommendations and Considerations

By Kalli R. Davis, BCMS COVID-19 Task Force, Pediatrics and Education Subcommittee Based on current available data, pediatric COVID-19 seems to follow a bimodal distribution pattern for infection rates in the US, with infants < 1 years old and children > 12 years old accounting for the majority of hospitalized cases among pediatric patients. This finding was consistent across 3 of the 4 Cohort studies conducted in the US thus far. For the study that did not explicitly support these findings, only children requiring admission to the pediatric intensive care unit were included, with ages ranging from 1 month old to 21 years old, with a median age of 15 years old.

In the other 3 studies, infants typically did not require that level of hospital care; therefore, the findings from this study support the theory that children > 12 years old are at increased risk for severe COVID-19 infection. With that being said, cohort studies encourage us to shift our focus to the older children, 12 years and up, as being the potential high-risk pediatric population when discussing COVID-19 infection. Aside from the cohort studies, the morbidity and mortality weekly report from the CDC also includes data from March 21 â&#x20AC;&#x201C; July 25, 2020 that further supports the notion that children 12-17 contract the virus at higher rates with 241/576 (41.8%) of the cases reported in this study attributable to children 12-17 years old. Once again, similar to data from the cohort studies, infants < 3 months old had the second highest number of cases totaling 108/576 (18.8 %) of the total cases.

Children < 1 years old accounted for 157/576 (27.3%) of the total cases. In total infants < 1 year old and children 12-17 years old accounted for 69.1% of the pediatric cases reported in the MMWR. Compared to other countries, the US 34

San Antonio Medicine â&#x20AC;˘ September 2020

studies have shown a higher incidence of ICU level care among pediatric patient populations, while the mortality rate has remained consistently low in both foreign and domestic studies. Hospitalizations of infants tend to be associated with a mild clinical presentation and fever of unknown etiology. This admission is usually based on sepsis protocol/evaluation for a serious bacterial infection per hospital guidelines.

The majority of infants experience a noncomplicated hospital stay and are discharged following a mildly symptomatic case of COVID-19. Infants tend to have a mild clinical course most of the time; severe cases in infants have been documented in other studies. Based on the MMWR report from the CDC, infantile clinical manifestations of COVID-19 seem to align well with reports from the Cohort study and support the idea that infants and children alike can have a distinctly different clinical presentation of COVID-19 compared to adults.

The chart with the breakdown for clinical presentation based on age ranges can be found at: https://www.cdc.gov/mmwr/ volumes/69/wr/mm6932e3.htm The MMWR report from the CDC pointed toward a higher incidence of hospitalization among Hispanic (8x higher) and black (5x higher) children compared to white children. The report also found an increased prevalence of underlying health conditions in Hispanic (45.7%) and black (29.8%) children, compared to white children (14.9%). The increase in underlying health conditions supports the idea that pre-existing conditions in children increases their risk for hospitalization. Overall, children seem to fare well when contracting the virus even with preexisting health condi-

tions, with only 4 deaths reported across the cohort studies and 1 death reported in the MMWR from the CDC. The most common underlying conditions among the cohort studies were respiratory/lung diseases (asthma, chronic lung disease) which were also found to be the most common causes in the MMWR report, second only to obesity. In specific regards to asthma, studies seem to conclude that asthma does not significantly influence the severity of infection or increase the risk for hospitalization. Based on the results from one study, neurologic, cardiac, hematologic and oncologic underlying conditions seem to have a higher risk for hospitalization; still, they did not have a higher incidence of severe infection necessitating critical care interventions.

Obesity is a potential co-morbidity and was the most common underlying condition reported in the MMWR report (42/111, 37.8 %). However, data from studies seem to suggest that it doesnâ&#x20AC;&#x2122;t increase the risk for severe infection. One study did note that obesity may increase the need for mechanical ventilation if the child develops a severe case of COVID-19, but their risk to develop severe infection would be similar to the risk of other healthy children. Obesity is extremely prevalent in the US, with 1 in 5 children meeting the criteria to be classified as obese. This factor warrants urgent consideration and research. More data is required to elucidate the absolute risk of COVID-19 and the severity of the illness in obese pediatric patients.

The study focused on critically ill children in New York and showed that 74% of the critically ill children in their study had a least one underlying co-morbidity. While co-

PEDIATRIC COVID-19 IN THE US morbidities were consistently present in all studies, healthy children were still susceptible to COVID-19 infection in all three forms: mild, moderate, and severe. In the study by DeBiasi et. al., data was included for hospitalized and non-hospitalized patients who tested positive for COVID-19: 96/177 (55%) of COVID-19 positive individuals did not have any underlying co-morbidities, 16/44 (37%) of hospitalized patients had no co-morbidities and 2/9 (22%) of critically ill patients had no comorbidities. In the MMWR report, 222/576 (38.5%) of children had at least one underlying condition, with 94 (42.3%) having more than one underlying condition.

The data collected in the study indicates that co-morbidities may play a role in contracting the virus, and even increase the risk for severe illness and hospitalization, but mostly highlight the fact that healthy children are still at risk for hospitalization and potentially severe COVID-19 infection.

With regards to back to school, recommendations for consideration based upon this data are: • Junior high/high school age students should take online classes, since they overwhelmingly know how to use the technology. They can meet with teachers/peers 1-2x per week as needed for peer review and tutoring.

– Aspects of having jr high/high school students stay at home: • They do not require childcare.

• Ability to spread out Pre-K – 5th grade students utilizing jr high/high school facilities.

• Special learning needs children and students with preexisting health conditions should be identified for potential risk for severe illness. Special precautions should be used to ensure they are getting the appropriate educational support they need to succeed, while ensuring their safety.

– Ways to protect these children:

• Teachers should wear an N-95 and Face Shield.

• Social distance (6ft minimum) between student workstations.

• Separate supplies for all students.

• Provide masks or face shields for students.

• Designate frequently cleaned bathrooms for only these children.

The recommendations above are closely aligned to recommendations released by the Harvard Global Health Institute and Center for Ethics Convergence group. The figure below is from the document they released on July 21 titled Path to Zero & Schools: Achieving Pandemic Resilient Teaching and Learning Spaces.

Further recommendations on how to implement pandemic resilient teaching and learning spaces are included in that document and grouped based on recommendations for district, state and federal levels.

District level recommendations from the Harvard document state that the top priorities for districts at this time should be to achieve maximal physical distancing and healthy ventilation and filtration. They also encourage districts to begin “inventory” of spaces (indoor and outdoor) available for them to use when schools reopen. This inventory should include creative problem solving to foster the inclusion of “pandemic resilient” teaching spaces, which may be classrooms at local colleges, empty buildings/businesses and even outdoor spaces.

Moving forward with these recommendations may be useful in providing community leaders and physicians a basis for developing a system to help regulate a successful and safe back to school plan.

Kalli R. Davis is a medical student at the Long School of Medicine at the UTHSCSA, and is on the BCMS COVID-19 Task Force and Pediatrics and Education Subcommittee.

Works Cited:

Agha, R., Kojaoghlanian, T., & Avner, J. R. (2020). Initial Observations of COVID-19 in US Children. Hospital pediatrics, hpeds.2020000257.

Advance online publication. https://doi.org/10.1542/hpeds.2020-000257 DeBiasi, R. L., Song, X., Delaney, M., Bell, M., Smith, K., Pershad, J., Ansusinha, E., Hahn, A., Hamdy, R., Harik, N., Hanisch, B., Jantausch, B., Koay, A., Steinhorn, R., Newman, K., & Wessel, D. (2020). Severe COVID-19 in Children and Young Adults in the Washington, DC Metropolitan Region. The Journal of pediatrics, 223, 199– 203.e1.

Advance online publication. https://doi.org/10.1016/j.jpeds.2020.05.007 Derespina KR, Kaushik S, Plichta A, Conway Jr. EE, Bercow A, Choi J, Eisenberg R, Gillen J, Sen AI, Hennigan CM, Zerihun LM, Doymaz S, Keenaghan MA, Jarrin S, Oulds F, Gupta M, Pierre L, Grageda M, Ushay HM, Nadkarni VM, Agus MSD, Medar SS, Clinical Manifestations and Outcomes of Critically Ill Children and Adolescents with COVID-19 in New York City, The Journal of Pediatrics (2020), doi: https://doi.org/10.1016/j.jpeds.2020.07.039.

Kainth MK, Goenka PK, Williamson KA, et al. Early experience of COVID-19 in a US children’s hospital. Pediatrics. 2020; doi: 10.1542/peds.2020-003186 Kim L, Whitaker M, O’Halloran A, et al. Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 — COVID-NET, 14 States, March 1–July 25, 2020. MMWR Morb Mortal Wkly Rep. ePub: 7 August 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6932e3e xternal icon The Path to Zero: Key Metrics for COVID Suppression. (2020, July 1). Retrieved August 05, 2020, from https://ethics.harvard.edu/path-tozero Path to Zero & Schools: Achieving Pandemic Resilient Teaching and Learning Spaces. (2020, July 21). Retrieved August 05, 2020, from https://globalhealth.harvard.edu/path-to-zeroschools-achieving-pandemic-resilient-teachingand-learning-spaces/

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36

San Antonio Medicine â&#x20AC;˘ November 2019

Care for Your Child Based on Symptom Severity

For additional information regarding children with COVID-19 visit these websites: • https://riseandshine.childrensnational.org/coronavirus/?_ga=2.240209859.1369509836.1594923301-620827878.1594923301 • https://healthychildren.org/English/health-issues/conditions/COVID-19/Pages/2019-Novel-Coronavirus.aspx • https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/how-covidspreads.

• html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fabout%2Findex.html Resources used to create this chart: • https://www.cdc.gov/coronavirus/2019-ncov/phone-guide/phone-guide-H.pdf • 2019 Novel Coronavirus (COVID-19). (2020, June 26). Retrieved July 15, 2020, from https://healthychildren.org/English/health-issues/conditions/COVID19/Pages/2019-Novel-Coronavirus.aspx • Fever in Children - Stanford Children's Health. (n.d.). Retrieved July 15, 2020, fromhttps://www.stanfordchildrens.org/en/topic/default?id=fever-in-children-90-P02512 Shu, J. (2020, May 30).

• Is it OK to call my pediatrician during COVID-19? Retrieved July 15, 2020, from https://healthychildren.org/English/tips-tools/ask-the-pediatrician/Pages/Is-it-OKto-call-the-pediatrician-during-COVID-19-even-if-Im-not-sure-my-child-is-sick.aspx • When to Call Emergency Medical Services (EMS). (2019, September 30). Retrieved July 15, 2020, from https://healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx • Villines, Z., & Goodwin, M. (2020, June 7). COVID-19 symptoms in kids: What do children experience? Retrieved July 15, 2020, from https://www.medicalnewstoday.com/articles/covid-19-symptoms-in-kids

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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)

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San Antonio Medicine • September 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" 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"

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

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 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)

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/eliza-

beth-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 well-

served 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!”

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor)

continued on page 40

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PHYSICIANS PURCHASING DIRECTORY continued from page 39 With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

Rana Camargo Senior Account Manager 210-771-7903 ranac@expressinfo.com www.expressinfo.com “Leaders in Healthcare Software & Consulting”

INSURANCE

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

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org 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 (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians.

Fred Cartier Vice President Sales (214) 540-1511 fcartier@abadmin.com www.osmahealth.com “People you know Coverage you can trust”

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San Antonio Medicine • September 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”

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 administra-

tion, 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

offices, Purchases and practice transitions Matt Evans Agent 210-560-1443 matt.evans@carr.us www.carr.us “Maximize Your Profitability Through Real Estate”

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”

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

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

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

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Happy Birthday BCMS! Since 1853

TEXASâ&#x20AC;&#x2122; OLDEST COUNTY MEDICAL SOCIETY Supporting the honored practice of medicine through legislative representation and local involvement with elected leaders.

Supporting practice management efforts to ensure a successful and productive business environment for Bexar County physicians.

Orienting future generations of physicians through leadership opportunities, committee involvement, information and training.

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 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 August 23, 2020.

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San Antonio Medicine â&#x20AC;¢ September 2020