San Antonio Medicine October 2018

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OCTOBER 2018

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VOLUME 71 NO. 10

MEDICINE SAN ANTONIO

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

Asthma & Allergies

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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By Mike W. Thomas .......................................................12

By Juan Jose Ferreris, MD, MHA, FAAP.........................15

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

Asthma in Children & Management

By Meena Chintapalli, MD, FAAP ..................................16

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

5 Steps to an Allergy-Free Home Life

By Cleo Garza ...............................................................20

A Medical Student’s call to action to support Tobacco 21 By Sanmar Ghannam ..............................22 BCMS President’s Message........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 BCMS News ............................................................................................................................................11 TMA Feature: 75 Ways Big Medicare Changes are Very Bad for Physicians and Patients

By Steve Levine .....................................................................................................................................24 Business: Creating a System Where Health Outcomes are Paramount By Jorge Arango...........................26 Feature: The Swarm, Part 2 of 4, By Allen Cosnow, DVM..........................................................................28 Feature: A Floral Fiasco By Fred H. Olin, MD ............................................................................................29 BCMS Circle of Friends Directory ..............................................................................................................30 In the Driver’s Seat ....................................................................................................................................35 Auto Review: 2018 Mazda 6 By Steve Schutz, MD .................................................................................36

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San Antonio Medicine • October 2018

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VOLUME 71 NO. 10

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

San Antonio area growth and progress comes with increased pollution that can trigger and worsen asthma in children

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

UT Health researchers finding new ways to treat asthma

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Sheldon G. Gross, MD, President Gerald Q. Greenfield Jr., MD, PA, Vice President Adam V. Ratner, MD, President-elect Leah H. Jacobson, MD, Immediate Past President Kristi G. Clark, MD, Secretary John Robert Holcomb, MD, Treasurer

DIRECTORS Rajaram Bala, MD, Member Jenny Shepherd, BCMS Alliance President Josie Ann Cigarroa, MD, Member Kristi G. Clark, MD, Member George F. "Rick" Evans Jr., General Counsel Vincent Paul Fonseca, MD, Member Michael Joseph Guirl, MD, Member John W. Hinchey, MD, Member Col. Charles Mahakian, MD, Military Representative Gerardo Ortega, MD, Member Robyn Phillips-Madson, DO, MPH, Medical School Representative Manuel Quinones, MD, Member Ronald Rodriguez, MD, Medical School Representative Carlos Alberto Rosende, MD, Medical School Representative David M. Siegel, MD, JD, Member Bernard T. Swift, Jr., DO, MPH, Member

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications 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

COMMUNICATIONS/ PUBLICATIONS COMMITTEE Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair Pavela Bambekova, Medical Student Darren Donahue, Medical Student Carmen Garza, MD, Member Leah Jacobson, MD, Member Fred H. Olin, MD, Member Jaime Pankowsky, MD, Member Alan Preston, Community Member Rajam S. Ramamurthy, MD, Member Adam Ratner, MD, Member David Schulz, Community Member Austin Sweat, Medical Student J.J. Waller Jr., MD, Member

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San Antonio Medicine • October 2018

PRESIDENT’S MESSAGE

LEADERSHIP SYMPOSIUM

By Sheldon Gross, MD, 2018 BCMS President

Dear Colleagues,

One of the main goals of my year as president has been to design and implement a leadership training program for physicians who seemed interested and willing to step forward as leaders in the years and decades to come. I am very pleased to announce that we had our inaugural Symposium on Leadership on Sept. 8, 2018 at the Bexar County Medical Society building. There were approximately 21 participants. They represented a broad spectrum of specialties and practice models. They also shared one major characteristic.

They understood the important role that physician leadership will play in years to come.

We were very fortunate to have a world-class faculty teaching our four-hour symposium. These are faculty from Trinity University. We started off with a one-hour lecture giving a brief synopsis of Medical Economics. We were told how the United States compares to other countries with regards to medical expenditures and with regards to medical outcomes. This was then followed by two professors giving an additional three-hour introductory course on Fundamentals of Leadership. What ensued was a very lively debate about the characteristics of a good leader and the characteristics of any organization that is well-led. I was impressed not only with the sophistication of our faculty but also with the level of sophistication of the participants. Their questions and comments were thoughtful, provoking, and very much on target. The seminar was over at noon.

We requested that all participants fill out an evaluation form and offer comments on how to improve programming in the future.

One hundred percent of the participating physicians filled out an evaluation form. This is almost unheard of. There was unanimous agreement that the faculty were indeed world class. Several physicians lamented the fact that the seminar could not have been longer than four hours. This initial symposium exceeded my expectations greatly, and my expectations were high to begin with.

This initial class of 21 individuals will continue to meet and attend lectures approximately every six weeks over the following year. I have no doubt that they will finish much further along in their development as leaders. I regret that I was unable to attend a similar seminar 30 years ago. There are two fundamental questions that remain to be answered.

The first question pertains to how these individuals will utilize their newly honed leadership skills. I am obviously hopeful that they will see Bexar County Medical Society and the Texas Medical Asso8

San Antonio Medicine • October 2018

ciation as important and essential organizations to become actively involved in.

As I looked across the room, I saw an abundance of human potential. I saw future members of our Board of Directors and future Presidents. I saw future Chiefs of Staff of their Hospitals and future activists within their specialty societies. I saw future leaders within multispecialty groups. I felt personally challenged as the current President of Bexar County Medical Society to find the best ways of funneling this group of talented individuals into activist roles.

The second question that I had to deal with is what happens after this inaugural class is finished. Will this be a one-time experience never to be repeated? After what I saw in that room on that Saturday morning, I can only hope that this will be an experience to be repeated year after year. I am hopeful that in September of 2019, there will be another group of 25 individuals who are equally eager to develop their leadership skills and put them to work.

We are living in a time that sitting by passively is not an option.

In many ways, our political and legislative strength is directly related to the strength of our medical societies and organizations. A single individual has little hope of negotiating with insurance giants or the state or federal government. However, a strong medical association at the state and national level can be extremely effective. I have seen tort reform pass the Texas Legislature. I have seen state and federal officials come to the Texas Medical Association and American Medical Association seeking advice and expert opinion. These organizations require great physician leaders to continue to be dynamic and effective into the future.

If anyone reading this column feels that they would be interested in participating in the next round of leadership seminars starting in September 2019, please consider attending future Medical Society functions and letting our present leadership know of your interest.

The classes will remain small and focused. To my knowledge, Bexar County Medical Society is the only county medical society in Texas offering this type of program to its membership. Your thoughts and comments are always welcome.

Sincerely, SHELDON GROSS, MD President, Bexar County Medical Society

BCMS LEGISLATIVE NEWS

With Midterm Elections just around the corner, BCMS members work to complete visits with candidates and elected officials

By Mary E. Nava, MBA, Chief Government Affairs Officer, BCMS It has been a busy year for members of the BCMS Legislative and Socioeconomics Committee – from the start of the year, leading up to the March 6 election primaries and May 22 primary run-offs, to the July 31 special emergency election to fill the Senate District 19 seat held by former Senator Carlos Uresti, which at the time of this writing, early voting is in progress for the runoff election coming September 18 – committee members have worked tirelessly to meet with numerous candidates to discuss medicine’s issues.

Committee members met with candidates vying for the Senate District 19 seat: Republican candidate, Pete Flores and Democrat candidate, Pete Gallego. In addition, the committee met with several candidates running for the seats being vacated

by Texas House Speaker Joe Straus, House District 121, including: Mark Whyte, Carlton Soules and Steve Allison, who won the runoff in May on the Republican ticket. Committee members also met with Republican candidate, Chip Roy and Democrat candidate, Joseph Kopser, both vying for the seat being vacated by Congressman Lamar Smith, U.S. House District 21. Additionally, the committee also met with the Democratic candidate for Texas House District 118, Leo Pacheco. The group also visited with two Fourth Court of Appeals judges, who are both up for re-election in November: Marialyn Barnard and Rebeca Martinez. Committee members discussed numerous topics of importance to medicine with the candidates, including: scope of practice, insurance networks, Medicaid, access to care, the Affordable Care Act, the State budget and taxes.

From the top, left to right: On January 24, Committee members greeted Steve Allison, now the Republican candidate for House District 121. BCMS member, David Shulman, MD (left) with Congressman Henry Cuellar, U.S. House District 28, at a reception in honor of Congressman Cuellar held on June 29 in San Antonio.

On August 15, Committee members welcomed Justice Marialyn Barnard, who is up for re-election to the Fourth Court of Appeals, Place 2. Legislative and Socioeconomics Committee members visit with Republican congressional candidate for U.S. House District 21, Chip Roy on August 22. On August 22, committee members visited with Joseph Kopser, the Democratic congressional candidate for U.S. House District 21. Committee members met with Justice Rebeca Martinez on August 22, who is up for re-election to the Fourth Court of Appeals, Place 7.

For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

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San Antonio Medicine • October 2018

BCMS NEWS

2nd Annual BCMS Writers’ Workshop Saturday, Oct. 13 from 8:30 a.m. to Noon

Course Description: Found Objects: A Microprose Workshop

Life is full of objects, full of people, full of things to do, full of things that are lost and things that are found. In this generative workshop for busy people, participants will explore the idea of misplaced or recovered things; examine how to shape an effective prose piece, regardless of length; and learn how to write in small, complete bursts. Participants will leave with several short pieces and a deeper understanding of microprose.

The Teachers:

JESSICA WRIGHT: Jessica Wright is an Assistant Professor of Classics and Medical Humanities at UTSA. She hails originally from England, but she lived in Los Angeles, New Jersey, and China before arriving in San Antonio. Her poetry has been published in anthologies such as Circe's Lament, in online journals such as Lines + Stars and Alliterati, on broadsides, and her non-fiction has appeared in Eidolon and Cloelia. She has taught writing in colleges and in prisons. Her day job is as historian of the brain.

PATRICK STOCKWELL: Stockwell is a native of Houston, Texas and holds an MFA in Creative Writing-Fiction from New Mexico State University where he served as an assistant editor for Puerto del Sol and a coordinator with La Sociedad para Las Artes and the Distinguished Visiting Writers Series. He is the co-founder of the Lone Star Salon reading series, The Short Fiction Soundtrack literary performance series, and has worked to organize other events for Southern New Mexico and Southeast Texas arts communities. As an undergraduate at the University of Houston, he served as editor for Glass Mountain and helped to establish Boldface, an annual conference for emerging writers.

BCMS Building, 2nd Floor, 4334 N. Loop 1604 W. Call 210-582-6399 for information and to register. visit us at www.bcms.org

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ASTHMA & ALLERGIES

UT HEALTH RESEARCHERS finding new ways to treat asthma

By Mike W. Thomas

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San Antonio Medicine • October 2018

Sandra Adams loves solving mysteries.

That is one of the things that made her want to go into medicine, the challenge of solving medical mysteries.

“A new mystery reveals itself in the form of a patient every day in the ICU,” said Adams, now a Distinguished Professor of Medicine at UT Health San Antonio. “Patients come in and you are faced with the challenge of learning about their past medical history, recent state of health, stress levels, family history, and then you factor in their social behaviors and currently prescribed and non-prescribed medications to build your case. It’s a bit Sherlock Holmes-like if you think about it, but if it is all done correctly, you can set your patient on the path to healing.”

One of the biggest mysteries facing Adams upon graduating from medical school was the plight of patients suffering from chronic obstructive pulmonary disease or COPD. These patients seemed to be sentenced to die a miserable death with many believing their fate was deserved as a result of poor lifestyle choices (i.e. smoking). Adams was dismayed by this prospect and refused to accept that conclusion.

Dr.

ASTHMA & ALLERGIES “We as health care professionals don’t tend to blame patients who have had a myocardial infarction or a stroke for leading a sedentary lifestyle, etc.,” she said.

“In my experience, this type of blaming is not DR. SANDRA ADAMS productive and may result in a toxic/adversarial atmosphere.”

Adams said that while she consistently maintained empathy and support for these patients, she was frustrated for many years when trying to manage patients with COPD because she didn’t feel that she could really do anything to help them.

“Fast forward to my second year of residency when I just happened to “fall into” a research study in COPD,” Adams recalls. “I was amazed to learn about so much misinformation regarding COPD and that there were strategies, truly proven, to help patients with obstructive lung diseases such as COPD and asthma. I was excited to discover that with proper management, these patients could live long and productive lives.”

Adams said she wanted to let everyone know what she was discovering and she was sure that research was going to be the area where she was going to make the biggest difference.

“That was until I realized I could reach even more lives by becoming the “Johnny Appleseed” of COPD and asthma education by translating complex topics into practical and simple strategies through teaching,” she said.

Adams said her approach to education is the same whether she is teaching medical or nursing students, practicing primary care clinicians or academic pulmonary/critical care specialists.

“My bottom line messages may be different, but in all situations, I provide information in a clear, concise and understandable manner

that makes it easy to learn, adopt and utilize,” she said. “I realized one day that a visiting physician used a maneuver that to my knowledge I had crafted and taught to a few students and colleagues. After watching him use the maneuver and in essence, teach it to other health care professionals in the room, I began wondering if it was mine. Maybe I was wrong and had seen it somewhere else and buried it in my subconscious until I needed it.

“After the crisis was over, I talked to him, and he told me he had learned it from someone who happened to have been a person I originally taught. I began to realize that the ripple effect of good education travels far beyond those who are directly taught. I love treating my individual patients and supporting their caregivers and family members. However, I’ve discovered I am able to impact exponentially more lives by educating others, which provides me with personal satisfaction and motivates me to continue to improve.”

Using this same approach, Adams said she founded the WipeDiseases Foundation (https://wipediseases.org), a not-for-profit, resource used by many health care professionals to better serve their patients with COPD and asthma.

For Dr. Jay Peters, an early interest in pulmonary/critical care in medical school led to a career-long focus on research and investigation.

“I have always been very interested in pulmonary infections and how they affect the body,” Peters said.

“When I first came to San Antonio, we ran a NIH (National Institute of Health) study in the University Hospital ICUs and developed a primate ICU to evaluate the role of pulmonary infections in ARDS (acute respiratory distress syndrome) and its role DR. JAY PETERS

continued on page 14 visit us at www.bcms.org

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ASTHMA & ALLERGIES continued from page 13

in multi-organ failure.”

Dr. Peters is currently a Professor and Chief of Pulmonary and Critical Care at UT Health San Antonio.

“Over the past 10 years, I worked with the Department of Microbiology studying the role of Mycoplasma pneumoniae in chronic asthma,” Peters said. “Our NIH grant allowed us to study patients with difficult to control asthma and the potential effect of Mycoplasma CARDS toxin (Community-Acquired Respiratory Distress Syndrome) in the initiation and persistence of asthma. For many years, I have been interested in patients with severe asthma and trying to improve the medical care of these patients.”

Both Peters and Adams say there is a benefit to researching asthma treatments in San Antonio and at UT Health.

“Having practiced in other communities, I was surprised by the close sense of family ties that we see in Bexar County,” Peters said.

“When a patient is ill, there is tremendous support by both the direct and extended family.”

There is also a sense of caring and collaboration at UT Health that you cannot find at many other institutions, he adds. The faculty and staff at UT Health are unique and special individuals.

Adams said that UT Health has many forward-thinking physicians and other health care professionals who work as a team to provide advice, guidance and healing.

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San Antonio Medicine • October 2018

“I am proud to be a part of the UT Health healing community,” Adams said. “In my experience, a white coat sometimes adds another layer of apprehension and intimidation that may take months or years to gain the confidence of a patient. Removing them from the white coat scenario brings down barriers and confidence is gained.

“You’d be surprised how much information I’m able to discover when a patient feels comfortable talking with me. Not wearing a white coat and not having my patients call me Doctor does not negate the fact that I am a pulmonologist,” she adds. “They quickly learn that I believe I earn respect by how I treat others, rather than simply by how many years I’ve spent in training. I’m here to heal and to care.”

ASTHMA & ALLERGIES

San Antonio area growth and progress comes with increased pollution that can trigger and worsen asthma in children

By Juan Jose Ferreris, MD, MHA, FAAP

ast month, the Environmental Protection Agency designated that San Antonio will be in non-attainment because of persistently elevated levels of ozone pollution.

Ozone is a well-recognized trigger for asthma symptoms in asthmatics.

Most patients with asthma are not aware of environmental triggers that can significantly lower their threshold for loss of asthma control or worse yet an unexpected serious asthma flare that may result in an emergency room visit.

Most patients are aware of their allergic triggers such as pet dander and the dreaded Ragweed, Mountain Cedar and Oak pollen seasons. However, many pediatric patients and their families are not as aware of the outdoor environmental pollutant triggers such as ozone and especially particulate matter.

Ozone action days are increasing in frequency in our San Antonio area because of increasing frequency of ideal conditions for ozone: more vehicles and more sunny and hot weather. Schools are aware of ozone as a trigger for asthma. They receive alerts of “orange” ozone action days that identify “ideal” conditions for high ozone levels that triggers asthma flares in asthma patients. During these days, asthmatics should remain indoors during periods of high ozone to reduce the risk of an asthma event.

Particulate matter or “dust” of all types is also increasingly a problem in the San Antonio area with increased construction and more vehicle traffic. Sources of particulate matter comes from unpaved roads, vehicle traffic and even power plants. AirNOW.gov is a great

L

resource for an APP that focuses on your zip code to provide realtime data on ozone and particulate matter, and provides predictions for the next 24 hours. This real-time information can help asthma patients plan to minimize their outdoor exposure during the peak ozone and particulate matter hours of the afternoon and early evening.

Other commonly overlooked sources of irritants and pollutants that can trigger allergies and asthma are also found indoors. Sources of particulate and chemical triggers such as fireplaces, new paint and carpet can also trigger asthma and allergy symptoms in sensitive individuals.

Patients can reduce their exposure by avoiding outdoor activity during high ozone and particulate matter days and especially in the afternoon when levels are usually at their highest. They can ensure that a/c filters are clean, consider a HEPA room filtration unit, avoid use of fans and reduce surfaces that hold dust such as carpet, drapes and stuffed animals. This could be the “clean air room”.

As our city grows in population and vehicular traffic, the inevitable consequence is increased ozone and particulate matter pollution. As clinicians, we need to educate our patients and families on these two very important and sometimes not so obvious triggers for asthma flares.

Dr. Juan Jose Ferreris is an Adjunct Assistant Clinical Professor at UT Med San Antonio and Baylor College of Medicine and Medical Director for Children’s Hospital of San Antonio Pediatric Group. visit us at www.bcms.org

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ASTHMA & ALLERGIES

Asthma in Children

& Management

By Meena Chintapalli, MD, FAAP

Asthma is a chronic medical condition that can be

easily managed when patients are educated on the

need for daily controllers to have active lives and pre-

vent long-term impact on heart, lungs and general

wellness. Out of 25 million asthmatics in the U.S., 9 million are children. There are about 5,000 fatalities per year from asthma, according to the World Health

Organization (WHO). Globally 150 million people suffer with asthma and there are 180,000 deaths per year attributed to the condition.

Asthma is a chronic swelling of airways, triggered

by many causes and starting in early childhood. Inflammation is reversible when controlled well under 6-7 years, leaving permanent reorganization of narrowed airways if not well controlled by 7 years.

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San Antonio Medicine • October 2018

ASTHMA & ALLERGIES

CAUSES:

It is extrinsic and intrinsic in children, triggered by many factors.

1. Mostly viral infections trigger attacks in young infants and children.

2. Irritants like tobacco smoke, perfumes, sprays, fumes, cotton linters, paints, detergents.

3. Drugs like Aspirin, Beta blockers, NSAIDS. 4. Emotional stress and child trauma from Adverse Childhood Experiences (ACE).

5. Viral infections.

6. Pollen, house dust, mites, roach dust, pet dander, certain foods, molds.

7. Hot and cold weather fluctuations, barometric pressure differences like heat and humidity, mouth breathing.

8. In 75-80 percent of reoccurring wheezing after RSV, there will be a family history of allergy or atopy of some kind.

SYMPTOMS:

A whistling sound during expiration is the 4th stage of asthma and when airways are at 50 percent of their normal diameter. Air flow in and out is compromised.

1. Chronic cough: Nocturnal, Exertion induced, Post viral 2. Chest tightness with or without exertion.

3. Wheezing after exertion, unable to cope with physical activities.

4. Chest retractions, active neck muscles movement to respiratory distress. This stage is an emergent situation and needs an ER visit.

5. Children without cough, with compromised airways can collapse during physical exertion.

DIAGNOSIS:

A good history and clinical exam can pick up wheezing associated respiratory disorders till 5.5 years. Not everything that wheezes is asthma and foreign body aspiration needs to be kept in mind (crushed beans, particles, nuts).

By 5.5 years of age an asthma challenge test can be performed in the physician’s office through spirometry. There is about 12 percent improvement of FVC, FEV1 and the FEV /FEV1 ratio after albuterol treatment. It is safe and can be done in a physician’s office or by a pulmonologist. Allergy testing helps patients to understand and to avoid triggers in older children. Intrinsic asthma is individual sensitivity and manifests as coughing or wheezing with multiple triggers.

MANAGEMENT: GOALS:

1. To have quality of life and be active in sports and physical activities.

2. Minimize ER visits, prevent school absenteeism.

3. Avoid chronic coughing, nocturnal and post viral.

4. Avoid permanent reorganization of the airways with inflammation by 6-7 years of age, that leads to Chronic Obstructive airway disease (COPD).

5. Compliance on using medicines by patient and the family through self-education is important.

PATHOGENESIS:

Infants and young children have small airways, become very narrow with slightest inflammation from a viral infection and wheezing follows immediately. RSV infection usually triggers the first wheezing episode in infants 6 months to 3 years. In vulnerable children with family history of allergies, 75-85 percent of infants have reoccurring wheezing after every viral URI. Maternal antibody protection is lost by 6 months. Therefore, persistent post viral cough and reoccurring wheezing is common 6 -48 months. Airways grow by 6 years of age, instead of wheezing cough is a symptom of asthma. continued on page 18 visit us at www.bcms.org

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ASTHMA & ALLERGIES continued from page 17

PREVENTION:

Controllers of airway inflammation are the main stay and yard stick for asthma management.

1. Inhaled Corticosteroids (ICS) are the first line of defense. If they do not help, Long Acting Beta Agonists are added with ICS (LABA +ICS like Advair, Symbicort). Usually done after 6 years of age.

2. Immunomodulatory drugs like Singulair or Montelukast are not the first line for asthma management. Antihistamines to control coughing from “Post Nasal Drip” can exacerbate asthma and be harmful as it dries up the sticky phlegm that causes symptoms of asthma. Avoid antihistamines.

3. Dust control measures and avoiding exposure to indoor irritants.

Avoid indoor smoking and get smoke free ash trays. Room air purifiers help. Steam vacuum cleaning prevents kick back of dust. Avoid stuffed animals in bed. Have blinds and maybe tiled bed room floors. Vinyl covers on mattresses and pillows with weekly changing of linen.

4. Start preventive Montelukast and steroid nasal sprays during seasonal allergic rhinitis to open up nostrils as mouth breathing is a trigger for asthma. Normal saline irrigation of nose helps open passages.

5. Understand that thick green secretions do not mean infection but need cleansing of mucous that is thick.

6. Monitor airway obstruction with peak flow meter readings and have Spirometry quarterly at your doctor’s office.

7. Breathing exercises with Yoga and mindfulness is very helpful as a preventive measure.

8. Understand how to use an Asthma Action Plan and must have a copy at school and at home.

9. Avoid inhaled indoor irritants to help your child.

ACUTE PHASE:

1. During an acute attack use a Rescue inhaler, short acting albuterol is very important, used as directed by ASMA plan.

2. The dosing is guided by the Asthma Action Plan. Usually 2-3 puffs, every 3-4 hours through a spacer with valve is important.

If not relieved, call a doctor or go to the ER. For very young children a Nebulizer may be more helpful than a spacer, although literature supports use of spacers and Metered Dose Inhalers.

3. In very severe asthma from allergens, Oxalizumab is available but has serious side effects also. It should be given and monitored by a pulmonologist.

Asthma can kill if it is not monitored and treated well. It can be easily treated with compliance and prevent long-term morbidity when diagnosed early and treated preventively. Normal, physically fitness and an active lifestyle can be assured.

Dr. Meena Chintapalli can be reached by calling : 210-490-8888 or 6147500 or by email at mkchintapalli@yahoo.com.

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San Antonio Medicine • October 2018

ASTHMA & ALLERGIES

Hypoallergenic Homes: STEPS TO AN ALLERGY-FREE HOME LIFE

By Cleo Garza, Sr. Loan Officer, SWBC Mortgage Corporation

Whether you have asthma, allergies, or a com-

bination of both, you aren’t suffering alone! Ac-

cording to the American College of Allergies,

Asthma & Immunology, over 50 million Ameri-

cans suffer from allergies each year! And while we can’t give you the cure to that lingering cough

or the non-stop sneezing, we can help you find ways to make your home a sneeze-free sanctuary.

After all, home should be your happy place right?

Transforming your home into a hypoaller-

genic paradise can seem like an overwhelming

task. So we’ve broken down the basics into five easy and maintainable rules that you can start practicing today!

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San Antonio Medicine • October 2018

ASTHMA & ALLERGIES Upgrade Your Cleaning Schedule.

The first step to an allergy-proof home is to keep it as clean as possible, as often as possible. If you struggle with maintaining a regular cleaning schedule, it’s time to hire help! A housekeeper will remember to do the little things like dust, vacuum, and sweep when you’re busy running a household.

Switch to All Natural— Everything.

If you aren’t already using all natural, non-toxic cleaning and household products, it’s time to make the switch! For some individuals, even toilet paper can be an irritant!

The chemicals and irritants in standard household products could be provoking already sensitive sinuses. It’s easy to find allnatural, chemical free, and even organic household products just about anywhere these days. These products are designed to make cleaning or everyday tasks easy, and irritant free for allergy sufferers.

If you want to try making your own cleaning products you can stock up on staples like vinegar, baking soda, and lemon juice. There are many resources online about how to make your own cleaning products that work just as good as store bought brands, without having to sacrifice irritating your allergies.

Make Your Bedroom a Sanitized Sanctuary.

Bedrooms can be the household hub of indoor irritants. Mattresses, sheets, and pillows are magnets for invisible allergens, such as dust mites. Consider covering your pillows, mattress and box spring in dustmite proof covers. You’ll also want to remember to wash all bedding weekly, in hot water. To get a deeper clean, you can use a HEPA (high-efficiency particulate air)

vacuum on your mattress and pillows while the linens are in the wash.

Prevent Pet Dander.

We all love and treat our pets just like family, but when it comes to your allergies, you may want to set a regular grooming schedule and boundaries on the bedroom.

Keep pets out of the bed, or the entire bedroom, to ensure you’re able to get a good night’s sleep. Also, preventing pet dander in the air is easy when you stick to a regular grooming schedule.

Keep the Air Clean.

It seems obvious, but keeping the air clean in your home is a must-do for the allergy and asthma prone. Using HEPA filters within your home is a must-do to trap and filter out invisible dander in the air.

You’ll also want to keep your windows sealed and closed to prevent outdoor pollens from blowing inside on a windy day!

You can also invest in a good quality (and HEPA friendly) air purifier to filter allergens out, and a dehumidifier to prevent mold.

Although we know it’s impossible to entirely erase allergens from our everyday life, coming home can be a relief if you follow a strict cleaning schedule to ensure your home is a dust, dirt, and allergy-free zone. This extra time and dedication to reducing allergens from your home can help you wake up refreshed, breathing easier, and ready to take on a new day!

Cleo Garza has been active in the mortgage industry since 2003.

Whether you are looking to purchase your first home, refinance you existing home, or purchase investment properties, Cleo would be honored to help you through each stage of the home financing process. Contact Cleo today at CleoGarza@swbc.com or apply online at swbcmortgage.com/cleogarza.

visit us at www.bcms.org

21

ASTHMA & ALLERGIES

A Medical Student’s Call to Action to Support Tobacco 21

By Sammar Ghannam

San Antonio is the only city in Texas leading an effort towards protecting its residents from the single largest cause of preventable death and disease.1 What’s the issue?

The issue is that even though smoking may seem like a harmless way to decrease stress, it is extremely harmful to one’s health. According to the Centers for Disease Control and Prevention, smoking causes disease, increases the risk for certain cancers, and negatively effects almost every organ system.1 Smoking is causing much damage: 16 million Americans suffer from a disease associated with smoking.1 480,000 deaths annually in the United States are linked to smoking.1 Smoking does not only affect us at an individual level but also affects the nation’s economy. Bunn et al. found that smokers missed more days of work and were more unproductive than nonsmokers or former smokers.2 A loss of 2623 dollars/year was observed for nonsmokers, 3246 for former smokers, and 4430 for current smokers was reported.2 22

San Antonio Medicine • October 2018

Why is Tobacco 21 important?

In October 2017, the San Antonio Metropolitan Health District formally requested that the City Council raise the legal age to purchase tobacco products from 18 to 21 years.3 This approach makes sense since 9 out of 10 smokers (90%) start smoking by age 18.4 Since 90% of smokers begin smoking by age 18, raising the legal tobacco purchasing age will interrupt this pattern. This ordinance will reduce the prevalence of smoking in future generations and decrease morbidity and mortality.5 On January 11, 2018, the San Antonio city council voted to approve the ordinance to raise the legal tobacco purchasing age from 18 to 21 years.6 More than 270 localities nationwide have already passed a Tobacco 21 law.6 The ordinance will be put in effect October 1, 2018.

ASTHMA & ALLERGIES Why should we support Tobacco 21?

In a 2015 report published by the Institute of Medicine, experts concluded that raising the minimum tobacco purchasing age to 21 would decrease the amount of people initiating tobacco use by 25% in 15- to 17-year-olds and by 15% in 18- to 20-yearolds nationwide. 7 Raising the minimum tobacco purchasing age to 21 would be an effective way to decrease the initiation of tobacco use in adolescents. 7 Tobacco 21 is addressing the smoking rate from the correct angle. Young adults have a higher probability of getting addicted compared to someone that smokes later in life.8 Damaging health effects are seen in youth that smoke: early cardiovascular injury, reduction of lung function, retardation of lung growth, and premature death. 8 Tobacco contains harmful substances such as benzo[a]prene, nitrosamine, and polycyclic aromatic hydrocarbons which are considered carcinogens associated with the development of bronchogenic carcinoma.9 Therefore, is imperative that we enact policy to decrease tobacco use in young adults specifically.

If we are successful at preventing young adults from using tobacco, the negative health effects can be avoided. The anticipated outcome is that the amount of tobacco users will decrease by 12% and tobacco related deaths by 10%. 8

Any opposing opinions?

Even though the ordinance is very promising and will benefit the city immensely, there are arguments against the ordinance. San Antonio grocers fear customers will choose to buy groceries at stores that can legally sell them tobacco, decreasing their own personal sales.6 In August, Dr. Bridger encouraged other local municipalities to pass similar ordinances in order to create a level playing field with other local businesses. This has created much contention between the two groups for and against the ordinance.6 While discussions are ongoing, no other municipalities have signed on to the effort at this time.

Some people worry that the state will suffer a decrease in tax revenue due to the lack of tobacco sales to customers between the ages of 18 and 20.10 This perspective fails to realize the impact of the new law in the context of the overall effects of reducing tobacco usage. Winickoff et al. found that the number of cigarettes purchased by 18 to 20-year-old smokers is only about 2% of total cigarette sales in the United States.11 Since it may take years before we see the effects of the new law, there should be adequate time for businesses to adjust to the new market conditions. Also, since the law may be adopted by other cities in Texas in the future, the concern about competition or unfair trade practices should decrease.11

A call to action.

As a medical student, I think that this ordinance is definitely something that San Antonio should be proud of. This ordinance has the potential to improve and save many lives. The problem of smoking prevention is complex but there are simple steps we can all take to help prevent one of the most common killers. There is no better time than now to join the movement, but how?

We must act locally, very locally. Raise awareness about the ordinance and educate yourself about it. Learn about the harmful effects of smoking and inform your family and friends. Smoking is a widely studied subject and there are many resources to use to learn more about the general Tobacco 21 movement. This website is a good place to start: https://tobacco21.org/t21-toolkit/ We must make our voice heard and advocate. Talk with your Federal representatives. Write to your Federal representatives. Write a resolution or testimony in support of Tobacco 21. There are many opportunities for you to be a part of this movement and advocate for a healthier Texas.

For every person who dies because of smoking, at least 30 people live with a serious smoking-related illness.1 Smoking has a strong influence and causes a significant amount of damage but it does have one particular weakness: the deaths it causes are 100% preventable. Join the movement and be a part of the effort to halt useless suffering.

References: 1.

CDC Fast Facts and Fact Sheets. (2017, February 09). Retrieved March 1, 2018, from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm 2. Bunn, W. B., Stave, G. M., Downs, K. E., Alvir, J. M., & Dirani, R. (2006). Effect of Smoking Status on Productivity Loss. Journal of Occupational and Environmental Medicine, 48(10), 1099-1108. doi:10.1097/01.jom.0000243406.08419.74 3. Johnson, K. (n.d.). Should San Antonio Raise The Minimum Age To Buy Tobacco Products? Retrieved March 1, 2018, from http://tpr.org/post/shouldsan-antonio-raise-minimum-age-buy-tobacco-products 4. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults. Retrieved March 1, 2018, from https://www.surgeongeneral.gov/library/reports/preventing-youth-tobaccouse/factsheet.html 5. Steinberg, M. B., & Delnevo, C. D. (2013, October 15). Increasing the "Smoking Age": The Right Thing to Do. Annals of Internal Medicine. Retrieved March 1, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726390/ 6. Zielinski, A. Legal Age to Buy Tobacco in San Antonio Raised to 21. Retrieved March 1, 2018, from https://www.sacurrent.com/thedaily/archives/2018/01/11/legal-age-to-buy-tobacco-in-san-antonio-raised-to-21 7. Institute of Medicine. 2015. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington, DC: The National Academies Press. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2015/TobaccoMinAge/tobacco_minimum_age_report_brief.pd f 8. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults. Retrieved March 1, 2018, from https://www.surgeongeneral.gov/library/reports/preventing-youth-tobaccouse/factsheet.html 9. Harmful Chemicals in Tobacco Products. (n.d.). Retrieved March 03, 2018, from https://www.cancer.org/cancer/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html 10. Steinberg, M. B., & Delnevo, C. D. (2013, October 15). Increasing the "Smoking Age": The Right Thing to Do. Annals of Internal Medicine. Retrieved March 3, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5726390/ 11. Winickoff, J. P., Hartman, L., Chen, M. L., Gottlieb, M., Nabi-Burza, E., & DiFranza, J. R. (2014). Retail Impact of Raising Tobacco Sales Age to 21 Years.

American Journal of Public Health, 104(11), e18–e21. http://doi.org/10.2105/AJPH.2014.302174 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202948/

TMA FEATURE

75 WAYS the Big Medicare Changes Are

VERY BAD for Physicians and Patients

By Steve Levine he Texas Medical Association cried foul on that claim with a painstakingly detailed comment letter it delivered to CMS. “We fear that the rule will significantly increase Medicare’s administrative burden, will reduce Medicare payments to many physician practices, will do little to improve quality of care or reduce the cost of care, and will further reduce Medicare beneficiaries’ access to care,” John G. Flores, MD, chair of TMA’s Council on Socioeconomics, and Jeffrey B. Kahn, MD, chair of the Council on Health Care Quality, wrote in their introduction to the 58-page letter.

This year, the agency combined two historically complex and controversial Medicare rule proposals into a single 1,453-page document covering the annual Physician Fee Schedule update and revisions to the Quality Payment Program (QPP).

TMA’s analysis found extensive problems in both parts of the proposed rule. The association offered 75 distinct recommendations for improvement.

TMA welcomed CMS’ proposal to simplify the “outdated, excessive, and overwhelming” documentation requirements associated with evaluation and management (E&M) services.

But the association rejected the agency’s plan to collapse the five levels of E&M office-visit payments to two levels, with one payment rate for level 1 visits and another covering levels 2-5. The rule projects the higher payment level to fall between the payment for levels 3 and 4 in the current structure — meaning physicians who typically handle level 4 and 5 visits for more complex patients would see their payments take a hit.

“While CMS is proposing to reduce the E&M documentation requirements, the amount of time, expertise, and skill used with the patient will not change,” Drs. Flores and Kahn wrote. “This is a significant devaluation of the physician’s work.”

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San Antonio Medicine • October 2018

Since its inception, physicians have complained that the QPP — with its multiple, rapidly changing data elements, measures, objectives, activities, thresholds, deadlines, reporting periods, and submission mechanisms — is a bureaucratic nightmare.

“As we move into the third year of the QPP, TMA continues to be concerned that the compliance, documentation, and data submission requirements required by law and regulation are costly and wasteful with no proven evidence of benefit,” Drs. Flores and Kahn wrote.

“We remind CMS that with each measure, objective, and improvement activity it subjects physicians to under the QPP, physicians must spend more time on paperwork to document every aspect of clinical care delivery that corresponds to the data elements that support each metric.”

Failure to comply, TMA pointed out repeatedly, exposes practices to Medicare payment cuts and costly audits.

“While we acknowledge that many physician practices are in a position to engage in full participation, we continue to hear from even more physicians who are neither ready nor have the time and resources to take on and manage the additional administrative, technological, and financial challenges associated with the QPP while being subject to annual Medicare payment penalties due to nonparticipation,” the association noted.

TMA proposed delays, or major changes, to CMS’ plans to, among many other things: •

•

Pay for physician consultations with patients by telephone or telehealth; Not change the payment localities used in calculating the Geographic Pricing Cost Index ;

TMA FEATURE • • •

• •

• •

Ask physicians to provide extensive price and charge data that has little or no applicability to the Medicare program;

Reduce payments for E&M services provided at standalone office visits on the same day as a procedure;

Continue to judge physicians’ cost and quality performance without appropriately risk-adjusting their scores based on patients’ demographic or socioeconomic characteristics that have been proven to correlate with poor health outcomes; Double the number of points a physician must earn to avoid a Medicare payment penalty;

Neither expand the number of quality measures a practice may choose from nor reduce the minimum number (six) of measures on which a practice may report — all while planning to further reduce the number of available measures over the next few years;

Continue to rate physicians based on costs of services that are completely unrelated to any medical care that the physician may have provided, ordered, or recommended; Completely replace the terms it uses to describe its quality

• • •

measures, data submission mechanisms, and submission processes; Reduce the bonus points available for small practices;

Refuse to hold physicians harmless for data collection and submission errors made by outside vendors; and

Force practices to accept more risk than they can financially manage if they wish to earn bonus payments under an Advanced Alternative Payment Model (APM).

Finally, because of “the overall program complexity of the QPP and annual changes to data requirements, terminology, and policies that are not finalized until two months before each performance period,” TMA said CMS should simplify and improve the educational materials it provides to help physicians and groups succeed under the QPP. “Physicians report that learning about and navigating the MIPS and APM pathways is very challenging, confusing, or simply not feasible,” Drs. Flores and Kahn wrote.

Steve Levine is vice president of communications for the Texas Medical Association.

visit us at www.bcms.org

25

BUSINESS

AT THE HELM:

CREATING A SYSTEM WHERE HEALTH OUTCOMES ARE PARAMOUNT

By Jorge Arango Healthcare in the United States is no longer focused primarily on care provided at the point-of-service. It now requires a broader perspective such as a focus on health promotion, population health, and individualized approaches. The main goal is to achieve the Triple Aim: Patient Satisfaction, Better Health Outcomes, and Reduced Costs.

The Triple Aim is of course an oversimplified objective – a goal.

To get there one must come to the realization that our healthcare system has to be first radically transformed. In her new book, An American Sickness: How Healthcare Became Big Business and How You Can Take it Back, Elizabeth Rosenthal, MD., examines the current state of our health care system and concludes that it is in a state of disrepair.

Due to third party involvement and the takeover of finances (insurance/health plans), we have failed miserably in controlling the cost of administered healthcare services across the country. We spent $10,000 per person in America in 2016, which is almost twice the average cost in most developed countries. Today, we are at a staggering $3 trillion according to data from the federal government and the Robert Wood Johnson Foundation.

Although they are at the core of the system and the reason for the existence of the medical universe, doctors and patients are not being served well. Often times, they are left out of the decision making process and have to beg their way to either provide a service or receive the clinical services they want. Because of concepts like “out 26

San Antonio Medicine • October 2018

of network”, patients pay more and/or cannot access the doctors of their choosing. Meanwhile, doctors have to deal with a myriad of obstacles unrelated to the doctor/patient relationship.

Furthermore, doctors spend an inordinate amount of time filling out questionnaires or as scribes typing endlessly on keyboards. At great expense, they hire personnel that sit all day calling insurers or health plans and asking for pre-authorizations for diagnostic procedures, labs, or prescription medications.

One must recognize that the American healthcare system is one of the best ones in the world. We have prestigious training institutions, some of the best doctors and hospitals in the world, as well as some of the most advanced and ingenious technology. However, due to administrative costs and third party meddling, we have miserably failed in controlling the costs on healthcare services across the country. In 2018 we have approximately 55 million Medicare beneficiaries, and by 2030 we will have close to 80 million. If nothing is done about this, our healthcare system will only get worse.

Dr. Robert Pearl, CEO of Kaiser Permanente’s medial group in California and an authority on our health care system, says that Americans are dying unnecessarily from failure of prevention or complications of chronic illness. “We value intervention over prevention: we value the newest advance over the things that are tried and true. To achieve improved outcomes we would need not only better coordinated care but also the use of technology.” Dr. Pearl is an advocate of virtual visits, telemedicine, and other technologies

BUSINESS that improve communication between doctors and their patients.

Dr. Pearl writes in his book, “Mistreated, Why We Think We’re Getting Good Healthcare – And Why We’re Usually Wrong”, that about 50% of medical care costs go to 5% of the people. He explains that these individuals have multiple chronic conditions, have severe disease, and that our healthcare system missed the opportunity 20 or 30 years before to actually prevent them from developing those kind of diseases.

Going from an industry in the business of providing care to one that’s geared entirely toward maximizing profits is particularly troublesome for our senior Medicare/Medicaid beneficiaries. Not only do they have to deal with an excessively expensive and complicated system but also one that is splintered and scattered. It is no secret: our healthcare system is fragmented, suffering from what George Halvorson, CEO of the Institute for InterGroup Understanding, calls “clinical linkage deficiencies, evidenced by conflicting incentives and lack of coordination, cost lives and fuel the unsustainable spiral of US healthcare expenditures.”

Recognizing the problem of our healthcare industry, the government has introduced in the last few years a series of laws/programs to better serve doctors and patient care. In keeping with the triple aim, the government is transitioning from volume based to value base care. They instituted such things as MACRA, MIPS, bundle payments, and more. As we all know many doctors are not happy with these ideas. Recognizing this, the government recently passed the (C.H.R.O.N.I.C) Care Act, paving a way for greater access to technology and care while reducing costs. This bipartisan act signals an important shift in the government’s recognition of the value of telehealth services, like Chronic Care Management or Remote Patient Monitoring. As the Act offers easier access and flexibility to choose these services, providers offering Medicare services can now take full advantage of the new law’s ability to allow for timelier, convenient, and continuous care. By offering continuous RPM and CCM, a provider is better able to monitor a person’s health and trends or changes in the management of his or her condition. In addition, these Telehealth services offer more timely care to help patients with more urgent issues as Dr. Pearl suggests.

As the number of patients with chronic conditions continues to rise, it’s crucial that clinicians be proactive in providing more effective and appropriate care for each individual, in order to improve outcomes and ultimately reduce costs.

As a result, Digital Telehealth Solutions was created in an effort to keep patients healthy and out of the hospitals. We believe that keeping Doctors informed by connecting their patients to our platform, we can help them in achieving better outcomes.

When it comes to judging the currents of the healthcare industry,

there is an old journalism expression that serves to be a pretty reliable guide: once is a fluke, twice is coincidence, and three times is a trend. Based on the truism, we at DTS feel confident in writing that technology is here to stay for providers and patients.

By utilizing this technology, and integrating this kind of value in healthcare, Digital Telehealth Solutions can help optimize practice revenues while also providing Chronic Care Management to patients and increasing care coordination.

Chronic Care Management is our specialty and our Health Care Coordinators are trained to do all the necessary work to get a practice started with no initial investment. Digital Telehealth Solutions provides the work involved in motivating patients to persist with the necessary therapies, interventions, and then helping them to achieve an ongoing, reasonable quality of life. The ongoing care is provided month to month and the time is documented within our platform. The process starts with identifying the patients that have two or more chronic conditions that will last at least a year, then inviting the patients to participate. Our Healthcare Coordinators then build a care plan for each patient that includes and assessment of the patients’ medical, functional, and psychosocial needs, consistent with the patients’ choices and values. This documentation spans from a minimum of 20 minutes to 60 minutes of care coordination in which it is then provided to those Physicians enrolled with our company at the end of the month. Chronic Care Management helps patients systematically monitor their progress and coordinate with experts to identify and solve any problems they may encounter in their plan of care treatment. As an effort to help Doctors take better care of their patients a series of different CPT codes and G-codes are used by CMS for reimbursement purposes. This Chronic Care Model can be applied to a variety of different chronic conditions, health care settings, target populations and specific DRG’s.

Integration of resources and coordination of care play crucial roles in reaching goals for enhancing community health and reducing the overall cost of care. It is to the interest of health care providers to avail themselves of newer reimbursement models stemming from the Medicare Shared Savings Program, Quality Payment Program, Bundle Payments, and Valued-Base Care.

To learn more about DTS, and the other services we have to offer, contact us! Or visit our website at: www.digitaltelehealthsolutions.com.

Jorge Arango is CEO and founder of Digital Telehealth Solutions. Contact him at 210-332-5455.

visit us at www.bcms.org

27

FEATURE

The Swarm

Part 2 of 4

By Allen Cosnow, DVM

ere I should explain that from the point of view of the beekeeper, this natural way of reproduction for colonies of honey bees (no other kinds of bees) is undesirable.

The beekeeper would much prefer to have all of the workers in the colony continue to live in his hive and make honey, rather than fly off in a swarm to who knows where, to set up on their own, leaving behind a skeleton crew. In fact, there are measures, beyond the scope of these paragraphs, which the beekeeper employs in the spring in an effort to discourage swarming; sometimes these measures work, sometimes they don't. (We say swarm "control," not swarm "prevention.") But let's see what happens in a colony when there is no human intervention, or in spite of it: Once the colony has become intent on swarming it starts to reduce its activity. Within 48 hours it completely suspends the collection of nectar and pollen. In the meantime, the queen is fed less and less by the workers and as a consequence loses weight; this prepares her to be able to fly soon.

The workers have already prepared to raise one or several new queens. They began by constructing "queen cells," into each of which the queen deposited an egg. A queen cell starts as an ordinary small hexagonal worker cell in a wax comb, and the egg is also an ordinary worker egg. The differences are that the workers greatly enlarge the cell until it is the size of an unshelled peanut, and then when the egg develops into a larva three days later, they supply it with royal jelly, a highly nutritious substance that they themselves secrete. These two things--the abundance of space and the special nutrition--make an egg that would have produced an ordinary shortlived worker like all the thousands of others, to develop into that

H

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San Antonio Medicine • October 2018

rarest of bees, a queen.

For six days the larva of the new queen-to-be gorges, literally submerged in the royal jelly with which the workers continue to replenish her cell. At the end of nine days (three days until the egg hatched and six days while she ate and grew), the larva, still inside her cell, spins a cocoon, and the workers seal the opening of the cell with new wax. Now she is a pupa. Inside her cocoon in the sealed cell she will undergo her metamorphosis, to emerge in another nine days (eighteen days altogether) as a virgin queen.

But as soon as the queen cell is sealed, the workers, having done everything possible to insure the future of the colony, have no further obligations and are now free and eager to find a new home. At this point there is little that can be done to stop them. Swarming is imminent.

Who will take part in the swarm? Almost all of the more mature workers (from forty to sixty percent of the total population that by now has grown to about fifty thousand), plus a hundred or so drones, and the old queen. Remaining behind will be the newlyemerged workers, some other drones, the thousands of worker larvae and pupae that have not yet emerged from their cells, and one or several sealed queen cells.

The bees wait for the first warm day, not too windy or wet, and they swarm.

To be continued‌ Allen Cosnow, D.V.M. is a retired small animal veterinarian who keeps his several bee colonies on a city lot in Glencoe, Il, a lake-shore suburb of Chicago. He is a veterinary school classmate of Fred H. Olin, D.V.M., M.D.

FEATURE

By Fred H. Olin, MD

My wife, Sondra, died earlier this year. This is not a search for sympathy nor a paean to her…although I have had lots of the former and I could do the latter. Rather, it is a narrative about an occurrence at her funeral. Everything below is true. I have anonymized it as much as I can. None of the initials are accurate, but all of the narrative is. Here we go…

Ten or 15 minutes before the ceremony at the funeral home was to start, my family and I were allowed into the chapel to see the setup, look at the flowers, read the cards, be told where we would sit, etc. As we looked at the flower arrangements, several of which had been supplied by the mortuary, it was evident that, although we had requested that no flowers be sent, there were quite a few sent by friends, organizations we supported, etc. After a short while, one of my daughters said “Daddy, look at this!” She was holding the card attached to one of the rather large, tall and very beautiful arrangements sitting on the floor near the head of the casket.

I bent over to look at the card. The part facing outwards said:

“DEAR FEMALE FIRST NAME, LAST NAME, OUR THOGHTS AND PRAYERS ARE WITH YOU. LOVE, W.X.Y.Z.” The facing part of the quarter-folded card had my wife’s name and the name of the funeral home on it. When we unfolded it, there was the name of the florist on one of the quadrants and the name and phone number of a physician on the other. The doctor’s name was vaguely familiar to me, however none of us knew anyone by the woman’s name to whom it was addressed.

We asked our funeral director if perhaps it belonged to another family who also had a funeral that day? She said that there were no pending services for anyone with that last name, but she volunteered

to go call the florist. Later in the afternoon she approached us and said she had followed up as we requested. She told us the florist had said they only had written what the customer ordered. A bit later she was back again and prefaced her story with, “I have never heard of anything like this happening before.”

The florist had called whomever had ordered the arrangement and was told the person named on the card as one of the bereaved had told her supervisor at W.X.Y.Z (which proved to be a very subspecialized clinic in the Medical Center area) that her grandmother, Sondra Olin, had died, and she needed to be off to grieve for Grandma. This was news to all of us, since neither of my daughters have children, and Sondra and I had no knowledge any grandchildren.

My older daughter looked at her younger sister and said, “Are you holding something back from us?” That actually got a laugh because of her severe expression and tone of voice.

Like our funeral director, we didn’t quite know what to make of this…so we kept the flowers. The next day I carried three or four of the donated arrangements to Methodist Hospital, where Sondra had died, and asked the pastoral care people to use them as they saw fit.

As we had time to think about the whole event, my family and I had to give the perpetrator of this floral fiasco some points for originality. However, we all pretty much agreed we hoped that the lady’s employer had some strong words to say to her for lying and causing them to spend a considerable sum for a really big, beautiful flower arrangement. We also wondered if she returned to work with a tan after grieving in Port Aransas. Finally, as one of my daughters pondered the situation aloud as we left the funeral she said, “Things we do always seem to end with a joke.” I think my wife would have laughed.

Dr. Fred Olin is a retired orthopedist and a member of the BCMS Publications Committee. visit us at www.bcms.org

29

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San Antonio Medicine • October 2018

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U.S. Trust ( Gold Sponsor) At U.S. Trust, we have a long and rich history of helping clients achieve their own unique objectives. Since 1853, we've been committed to listening, building long-term relationships, and helping individuals and their families realize the opportunities they create for themselves, their children, busi-

nesses, communities and future generations.

SVP, Private Client Advisor, Certified Wealth Strategist® Christian R. Escamilla 210.865.0287 christian.escamilla@ustrust.com “Life’s better when we’re connected®”

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”

BB&T (HHH Gold Sponsor) Checking, savings, investments, insurance — BB&T offers banking services to help you reach your financial goals and plan for a sound financial future.

Stephanie Dick, Vice PresidentCommercial Banking 210-247-2979 sdick@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

BBVA Compass (HHH Gold Sponsor) Our healthcare financial team provides customized solutions for

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY you, your business and employees.

Mary Mahlie Global Wealth Management 210-370-6029 mary.mahlie@bbvacompass.com www.bbvacompass.com “Working for a better future”

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 www.broadwaybank.com “We’re here for good.”

The Bank of San Antonio (HHH Gold Sponsor) We specialize in insurance and banking products for physician groups and individual physicians.

Our local insurance professionals are some of the few agents in the state who specialize in medical malpractice and all lines of insurance for the medical community.

Brandi Vitier, 210-807-5581 brandi.vitier@ thebankofsa.com www.thebankofsa.com

RBFCU (HHH Gold Sponsor) RBFCU provides special financing options for Physicians, including loans for commercial and residential real estate, construction, vehicle, equipment and more.

Novie Allen Business Solutions 210-650-1738 nallen@rbfcu.org www.rbfcu.org

Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

Synergy FCU Member Service (210) 345-2222 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

First National 1870, a division of Sunflower Bank, N.A. (HH Silver Sponsor) First National 1870 is a regional community bank dedicated to building long-term relationships founded on sound principles and trust.

Jamie Gutierrez Business Banking Officer 210-961-7107 (Direct) Jamie.Gutierrez@firstnational1870 .com www.FirstNational1870.com “Creating Possibility For Your Medical Practice”

your people anytime, anywhere.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Beginning relationships honorably with a clear understanding of what you can expect from us"

FINANCIAL ADVISOR

BUSINESS CONSULTING Alto Vista Enterprises, LLC (HH Silver Sponsor) We specialize in helping physicians grow their business according to the goals and timeline of the practice. Customized business development strategies are executed by an experienced and dedicated team of consultants.

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

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/elizabetholney "Making Sense of Investing"

FINANCIAL SERVICES DIAGNOSTIC IMAGING Touchstone Medical Imaging (HH Silver Sponsor) Touchstone Medical Imaging provides a wide range of imaging services in a comfortable, service oriented outpatient environment while utilizing state of the art equipment, the most qualified radiologists and superior customer service.

Patrick Kocurek Area Marketing Manager 210-614-0600 x5047 patrick.kocurek@touchstoneimaging.com www.touchstoneimaging.com/ locations " We provide peace of mind, giving compassionate care to our community with integrity"

EMPLOYEE MANAGEMENT

Beyond (HHH Gold Sponsor) Beyond helps you take care of your people with a single-source, cloud-based human resources system that is simple yet powerful enough to manage the entire employee life cycle. From online onboarding to certification tracking to payroll processing, manage

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com

SWBC family of services supporting Physicians and the Medical Society

Avid Wealth Partners ( Gold Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's ommitted 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”

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!”

Beyond ( Gold Sponsor) Beyond is a financial technology company offering a suite of business tools including payment processing, employee management (payroll, HR, compliance), lending, and point-of-sale. Beyond demonstrates business ethos with unwavering commitment and delivers results that make a difference.

Founding Member Division Sales Director San Antonio and Austin Jeromé Vidlock 972.839.2423 jerome.vidlock@getbeyond.com www.getbeyond.com "Good enough is not nearly enough. We go Beyond!"

continued on page 32

visit us at www.bcms.org

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 31

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

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

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

New York Life Insurance Company (HHH Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

businesses and partnered with multiple financial institutions, to assist with financing of building acquisitions, construction projects, and machinery and equipment loans.

Cheryl Pyle Business Development Officer – San Antonio & South Texas 830-708-2445 CherylPyle@CapitalCDC.com www.capitalcdc.com “Long-term, fixed-rate financing for owner-occupied commercial real estate.”

Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small

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San Antonio Medicine • October 2018

HOSPITALS/ HEALTHCARE SERVICES

the Medical industry.

David Stich Senior VP of Strategic Partnerships 210-569-3328, David.stich@ylconsulting.com Marisu Frausto Account Executive 210-363-4139, Marisu.frausto@ylconsulting.com www.ylconsulting.com/ “Your success is our success.”

INSURANCE

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 CONSULTING

RBFCU (HHH Gold Sponsor) RBFCU Investments Group provides guidance and assistance to help you plan for the future and ensure your finances are ready for each stage of life, (college planning, general investing, retirement or estate planning).

Shelly H. Rolf Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org

r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

Digital Telehealth Solutions (HHH Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031

Warm Springs Medical Center Thousand Oaks Westover Hills (HHH Gold Sponsor) Our mission is to serve people with disabilities by providing compassionate, expert care during the rehabilitation process, and support recovery through education and research.

Central referral line 210-592-5350 “Joint Commission COE.” Methodist Healthcare System (HH Silver Sponsor) Palmire Arellano 210-575-0172 palmira.arellano@mhshealth.com http://sahealth.com

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.”

INFORMATION AND TECHNOLOGIES

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based 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” Y&L Consulting (HH Silver Sponsor) We are an IT Consulting company that specializes in Software Managed Delivery, Business Process Outsourcing Managed Services, IT Staff Augmentation, Digital and Social Media with experience in

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

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

INSURANCE/MEDICAL MALPRACTICE

Texas Medical Liability Trust (HHHH 10K Platinum Sponsor) 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 en-

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY dorsed 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

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) Medical Protective is the nation's oldest and only AAA-rated provider of healthcare malpractice insurance.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance (HH Silver Sponsor) Group (rated A+ (Superior) by A.M. Best) helps you protect your important identity and navigate today’s medical environment with greater ease—that’s only fair.

Keith Askew, Market Manager kaskew@proassurance.com Mark Keeney, Director, Sales mkeeney@proassurance.com 800.282.6242 www.proassurance.com

INTERNET TELECOMMUNICATIONS

Digital Telehealth Solutions ( Gold Sponsor) Physicians are reimbursed for providing none face-to-face care coordination services to eligible Medicare patients with multiple chronic conditions. We Provide Chronic Care Management and Remote Patient Monitoring within our Home Telemonitoring Program.

Dr. Jorge Arango, CEO 956-227-8787 Dr.jorgearango@gmail.com Rosalinda Solis Business Development Director 361-522-0031 r.solis@digitaltelehealthsolutions.com Eduardo Rodriguez Marketing Director 210-294-2069 eddie.r@digitaltelehealthsolutions.com www.digitaltelehealthsolutions.com “Improving Patient outcomes and lower unnecessary 30-day readmissions”

LUXURY REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Realty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

MARKETING ADVERTISING SEO

Veerspace (HHH Gold Sponsor) We're a nationwide digital advertising agency that specialize in growing aesthetics practices through videography and social media. Office contact number is 210-969-7850.

Michael Hernandez President/ Founder 210-842-3146 Michael@veerspace.com Genevieve Pineda Business Development Director 210-386-7853 Genevieve@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BUSINESS CONSULTING

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

MEDICAL BILLING AND COLLECTIONS SERVICES

Progressive Billing (HHH Gold Sponsor) The medical billing professionals at Progressive Billing realize the importance of conducting business with integrity, honesty, and compassion while remaining in compliance with the laws and regulations that govern our operations.

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com www.progressivebilling.com "We provide quality, professionalism and results for your practice."

Commercial & Medical Credit Services (HH Silver Sponsor) A bonded and fully insured San Antonio-based collection agency.

Henry Miranda 210-340-9515 hcmiranda@sbcglobal.net www.cmcs-sa.com “Make us the solution for your account receivables.”

MEDICAL 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.”

PHYSICIAN SERVICES

SWBC ( 10K Platinum Sponsor) SWBC helps physicians keep order in both their personal and business financial matters. For individuals, we stand ready to assist with wealth management and homebuying services. For your practice, we can help with HR administrative tasks, from payroll services to securing employee benefits and P&C Insurance.

Leslie Barnett, SWBC Mortgage lbarnett@swbc.com Gil Castillo, SWBC Wealth Management, 210-321-7258 gcastillo@swbc.com Kristine Edge, SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza, SWBC Mortgage 210-386-0732 cleogarza@swbc.com Debbie Marino, SWBC Insurance & Benefits, 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

continued on page 34

www.bcms.org 33 33 visitvisit us us at at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 33

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.

Tina Turnipseed, President Tom Tidwell, President-Elect info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

Rastegar Equity Partners (HHHH 10K Platinum Sponsor) Rastegar Equity Partners is a Private Equity Commercial Real Estate Investment Firm. Rastegar focuses on building portfolios to generate above market current income along with long-term capital appreciation.

Kellie Rastegar 818-800-4901 kellie@rastegarep.com Ari Rastegar 917-703-5027 ari@rastegarep.com Sandy Fliderman 646-854-9996 sandy@rastegarep.com www.rastegarep.com

RESIDENTIAL REAL ESTATE

Kuper Sotheby’s International Realty (HHH Gold Sponsor) As real estate associates with Kuper Sotheby’s International Re-

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San Antonio Medicine • October 2018

alty, we pride ourselves in providing exceptional customer service, industry-leading marketing, and expertise from beginning to end, while establishing long-lasting relationships with our valued clients.

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations"

RETIREMENT PLANNING

New York Life Insurance Company ( Gold Sponsor) We specialize in helping small business owners increase personal wealth by offering tax deferred options and providing employee benefits that enhance the welfare of employees to create a more productive workplace.

Eddie L. Garcia, MBA, CLU Financial Services Professional Ofc 361-854-4500 Cell 210-920-0695 garciae@ft.newyorklife.com Becky L. Garcia Financial Services Professional Ofc 361-854-4500 Cell 210-355-8332 rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

STAFFING SERVICES

Favorite Healthcare Staffing (HHHH 10K Platinum Sponsor) Serving the Texas healthcare community since 1981, Favorite Healthcare Staffing is proud to be the exclusive provider of staffing services for the BCMS. In addition to traditional staffing solutions, Favorite offers a comprehensive range of staffing services to help members improve cost control, increase efficiency and protect their revenue cycle.

Brody Whitley, Branch Director 210-301-4362 bwhitley@favoritestaffing.com www.favoritestaffing.com “Favorite Healthcare Staffing offers preferred pricing for BCMS members.”

United States Air Force (HH Silver Sponsor) As a doctor in the USAF you can practice medicine without the red tape of managing your own practice. Our doctors are free from bureaucracy and paperwork and can focus on treating their patients MSgt Robert Isarraraz, Physician Recruiter Robert.isarraraz@us.af.mil 210-727-5677 www.airforce.com/careers/ "Caring For Those Protecting The Nation"

TOXICOLOGY LABORATORY TESTING

Diagnostic Solutions, LLC (HHH Gold Sponsor) Partnering with Diagnostic Solutions allows providers to incorporate the industry’s best practices into drug compliance testing and clinical decision-making with accurate and timely results for UDT quantitation and identification.

Jana Raschbaum, MBA, BSN, RN 210-478-6633 janelleraschbaum@gmail.com Donald Nelson, MD 928-529-5110 dhnelson@citilink.net www.trustedtox.com

For questions regarding services, Circle of Friends sponsors or Joining our program.

Please contact August Trevino program director: Phone: 210-301-4366, email August.Trevino@bcms.org, www.bcms.org/COf.html

RECOMMENDED AUTO DEALERS AUTO PROGRAM

• • • •

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. GUNN AUTO GROUP

Ancira Chrysler 10807 IH 10 West San Antonio, TX 78230 Rudy Solis 210-558-1500

Ancira Buick, GMC San Antonio, TX Jude Fowler 210-681-4900

Ancira Chevrolet 6111 Bandera Road San Antonio, TX

Batchelor Cadillac 11001 IH 10 W at Huebner San Antonio, TX

GUNN Chevrolet GMC Buick 16550 IH 35 N Selma, TX 78154

Jude Fowler 210-681-4900

Esther Luna 210-690-0700

Bill Boyd 210-859-2719

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Honda 14610 IH 10 W San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Nissan 750 NE Loop 410 San Antonio, TX 78209

Eric Schwartz 210-680-3371

Coby Allen 210-625-4988

Abe Novy 210-496-0806

Alamo City Chevrolet 9400 San Pedro Ave. San Antonio, TX 78216

Cavender Audi 15447 IH 10 W San Antonio, TX 78249

David Espinoza 210-912-5087

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Northside Ford 12300 San Pedro San Antonio, TX

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Subaru 9807 San Pedro San Antonio, TX 78216

Gary Holdgraf 210-862-9769

Marty Martinez 210-525-9800

William Taylor 210-366-9600

James Godkin 830-981-6000

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Mazda 9333 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 Toyota 10703 SW Loop 410 San Antonio, TX 78211

Scott Brothers 210-253-3300

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

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

Justin Boone 210-635-5000

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lincoln 9207 San Pedro San Antonio, TX

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

13660 IH-10 West (@UTSA Blvd.)

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Barrett Jaguar 15423 IH-10 West San Antonio, TX

Sandy Small 210-341-8841

James Cole 800-611-0176

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

Victor Zapata 210-341-2800

15423 IH-10 West San Antonio, TX Dale Haines 210-341-2800

Land Rover of San Antonio

AUTO PROGRAM

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

AUTO REVIEW

2018 Mazda 6

By Stephen Schutz, MD Like Subaru, Mazda has lived in the shadow of Toyota and Honda when it comes to sales in the U.S market. They’ve always done okay, but huge success has eluded them. While Subaru has focused on utility and all-wheel drive to sell their vehicles, Mazda has been Japan’s BMW, producing sporty cars like the RX7, Mazdaspeed3, and Miata supported by the tagline “Zoom-Zoom.”

Interestingly, with no fanfare and little notice, Mazda has pivoted away from sportiness recently to become more of a Japanese answer to Audi. It’s probably a smart move as Audi is currently doing very well with a knack for creating cool vehicles that appeal to intelligent and accomplished customers.

If you doubt my assertion that Mazda is “Audi-ifying” itself, I’d invite you to look inside the 2018 Mazda6, the subject of this review, where you’ll find a newly luxurious interior with a focus on rich materials and advanced tech. Then check out their current advertising — no more Zoom Zoom — and earlier this year Mazda terminated their sponsorship of the iconic Laguna Seca Raceway.

Anyway, on to the Mazda6. Still a FWD midsize sedan, the Mazda6’s exterior design is — hello Audi — understated but attrac36

San Antonio Medicine • October 2018

tive. Subtle styling elements are visible everywhere and complement each other. My favorites are the connection areas between the grille and headlights, the slightly tapered rear end, and the gentle flame surfacing on the rear doors, but there are many other thoughtful touches. As is the case with modern Audis, Mazda’s designers strove to create a carefully integrated whole rather than gesture wildly for our attention with visual gimmicks (I’m looking at you Lexus). And yet the Mazda6 retains a clear connection to other Mazdas.

As alluded to above, the interior is noticeably better than it used to be. The plastics are softer and nicer to look at, and the seats are more plush. I especially enjoyed the stitching on the seats, which is usually meh in moderately-priced cars, but in the Mazda6 is terrific.

For the record, that stitching and some of the best interior bits in my Mazda6 test car came with the top-level Signature trim, which gets you rich leather, real wood trim, and a host of other desirable features (more about that later).

For 2018, every Mazda6 has a larger 8.0-inch infotainment screen in place of the old 7.0-inch unit. Operated by an upscale control knob on the center console similar to those used by the Germans

AUTO REVIEW

— note to Mazda: Audi, your interior benchmark, is moving from knobs to touchscreens in their newest vehicles — Mazda’s infotainment system is easy to use and visually modern. While Apple CarPlay and Android Auto are expected to be added to the Mazda Connect system soon, they aren’t here yet.

Base model Mazda6s come with a 2.5 liter 4-cylinder engine that makes an uninspiring 187 HP but sips fuel to the tune of 26 MPG city/35 highway. So what? The engine you want is the turbocharged version of that powerplant that pumps out 227 HP and enables the Mazda6 to scoot from 0 to 60 MPH in 6.4 seconds.

There’s a fuel consumption price to be paid, of course, but not much of one — the turbo gets 23 MPG city/31 highway. Both engine choices feature SkyActiv technology, which is basically direct injection coupled with a high-compression ratio and other technology to optimize combustion.

So how does the Mazda6 drive? Very well, and definitely better than the big selling Honda Accord and Toyota Camry (or even the Audi A4, for that matter). Twisty B-roads are where the Mazda6 feels most comfortable thanks to neutral handling and good weight balance (and obviously enthusiastic engineers), but it’s fine on the interstate or in town as well. I’m surprised a FWD car can drive this well.

The base Mazda6 is the Sport, which is pretty unadorned but only costs about $23,000. The good news is that you can get a Sport with a six-speed manual transmission, but the bad news is that’s the only

trim level that offers my favorite gearbox. That means no manual with the turbo. (I’m going to take a moment of silence now... Ok, I’m back.) The Sport also comes with blind-spot monitoring, rear cross-traffic alert, low-speed forward-collision warning, and automated emergency braking.

The $26,595 Touring model adds 19-inch wheels, heated front seats, a power-adjustable driver’s seat, and additional safety features.

If you’d like your 6 with an interior that even Car and Driver compares favorably with the Audi A4, order the Signature edition. It comes with upholstery trimmed in leather and alcantara, Japanese Sen wood trim, and more — all for an affordable $35,645.

The 2018 Mazda6 is growing up with a sophisticated design, more upscale interior, and improved tech to go with driving excellence. In fact, I’d say they’re emulating Audi, which seems smart given that company’s recent sales success. It may not sell like an Accord or Camry, but it should. In many ways it’s a better car.

If you’re in the market for this kind of vehicle, call Phil Hornbeak at 210-301-4367.

Stephen Schutz, MD, is a board-certified gastroenterologist who lived in San Antonio in the 1990s when he was stationed here in the U.S. Air Force. He has been writing auto reviews for San Antonio Medicine since 1995. visit www.bcms.org 37 37 visit usus atatwww.bcms.org

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San Antonio Medicine • October 2018