SAN ANTONIO MEDICINE OCTOBER 2019

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The Corporate Practice of Medicine

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The Corporate Practice of Medicine (CPOM)

CPOM Legal Perspectives By George F. “Rick” Evans, Jr., Esq, BCMS General Counsel..................................................10 CPOM What is it? Well, in part it started with Fried Chicken By Rodolfo Molina, MD ..........................14 The State of CPOM and the Law in Texas

By Jeff Wurzburg, Esq. ...................................................16 Where Money & Physician Judgement Collide

By Mike Kreager, JD, LLM ..............................................19 Physician Independence vs. the Corporate Practice of Medicine By Manuel M. Quiñones, Jr., MD ................22 Remaining an Independent Physician by Adopting a Value-Based Care Model

By Alan Preston, MHA, ScD ...........................................................................................................24 Employer-Sponsored Healthcare Revisited By Roger Moczygemba, MD, MHA............................28

BCMS President’s Message ........................................................................................................................8 UTHSA: Whole Blood is a Trauma Game Changer

By William L. Henrich, MD, MACP, President and Professor of Medicine, UT Health San Antonio ........30 BCMS Legislative News ............................................................................................................................32 Medical Student Perspective: By Christian Jacobsen, MS2, UTHSA, LSOM ..............................................34 BCMS Circle of Friends Directory ..............................................................................................................36 Auto Dealers ..............................................................................................................................................43 Auto Review: 2019 BMW 850i Convertible By Steve Schutz, MD ..............................................................44 PUBLISHED BY: SmithPrint Inc. 333 Burnet San Antonio, TX 78202 Email: medicine@smithprint.net PUBLISHER Louis Doucette louis @smithprint.net ADVERTISING SALES: AUSTIN: Sandy Weatherford sandy@smithprint.net BUSINESS MANAGER: Vicki Schroder

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San Antonio Medicine • October 2019

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OCTOBER 2019

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VOLUME 72 NO. 10

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BCMS BOARD OF DIRECTORS ELECTED OFFICERS Adam V. Ratner, MD, President Rodolfo “Rudy’’ Molina, MD, Vice President John W. Hinchey, MD, Treasurer John J. Nava, MD, Secretary Gerald Q. Greenfield Jr., MD, PA, President-elect Sheldon G. Gross, MD, Immediate Past President

Corinne Elizabeth Jedynak-Bell, DO, Medical School Representative Robert Richard Leverence, MD, Medical School Representative Robyn Phillips-Madson, DO, MPH, Medical School Representative Ronald Rodriguez, MD, PhD, Medical School Representative Brent W. Sanderlin, DO,

DIRECTORS Michael A. Battista, MD, Member

Medical School Representative Alice Kim Gong, MD, Board of Ethics Chair

Vincent Paul Fonseca, MD, MPH, Member

BCMS SENIOR STAFF

Michael Joseph Guirl, MD, Member

Stephen C. Fitzer, CEO/Executive Director

David Anthony Hnatow, MD, Member

Melody Newsom, Chief Operating Officer

Gerardo Ortega, MD, Member

Alice Sutton, Controller

Manuel M. Quinones Jr., MD, Member

August Trevino, Development Director

David M. Siegel, MD, JD, Member

Mary Nava, Chief Government Affairs Officer

Rajeev Suri, MD, Member

Phil Hornbeak, Auto Program Director

Kelly King, Alliance Representative

Mary Jo Quinn, BCVI Director

George Rick Evans, Legal Counsel

Brissa Vela, Membership Director

Col. Charles Gregory Mahakian, MD,

Al Ortiz, Chief Information Officer

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San Antonio Medicine • October 2019

Kenneth C.Y. Yu, MD, Chair Kristi Kosub, MD, Vice Chair 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 John Seidenfeld, MD, Member

John D. Edwards, MD, Member

Military Representative

PUBLICATIONS COMMITTEE

J.J. Waller Jr., MD, Member

PRESIDENT’S MESSAGE

CPOM:

Are you a Physician or a Widget?

By Adam Ratner, MD, 2019 BCMS President The inherent conflict between nonphysician control of the practice of medicine was recognized in the state of Texas in the last century, resulting in the passage of the Texas Medical Practice Act, among other statutes. It has long been recognized that the incentive malalignment created by non-physician control of medical decision making is bad for patients. Over time, these protections for patients have been eroded by the lack of enforcement of current laws and growing asymmetrical power of corporate interests not controlled by practicing physicians.

We now know this incentive malalignment is also bad for physicians.

In 1964, dr. louis lasagna, dean of the Tufts University School of Medicine, wrote a wonderful modern version of the timeless Hippocratic Oath. In the intervening half century, radical changes in the practice of medicine have sadly created the need for an updated “corporate” version. With deepest apologies to dr. lasagna and modern physicians…

The “Oath” of the Corporate Physician

I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is 8

San Antonio Medicine • October 2019

mine with those who follow, so long as such knowledge and practice do not impair the

revenue cycle performance of my institution and its third-party payors.

I will apply, for the benefit of the sick, all measures which are approved by the benefit managers, administrators and regulators, avoiding those twin traps of spending too much time with a patient or customizing care for a patient if it reduces operational efficiency and net revenue.

I will remember that while there is art to medicine as well as science, that warmth, sympathy, and understanding have no CPT codes and are not reimbursed.

I will not be ashamed to say “I know not” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery unless such colleague is out of network.

I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know except for billing, collection, research and marketing purposes.

Most especially must I tread carefully with matters of life and death, particularly of our corporation.

While it may be within my power to take a life or perform a non-reimbursed procedure, this responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must never play God or

second guess benefit managers, administrators, regulators, and third-party payors.

I will remember that I do not treat a fever chart, a cancerous growth, or a sick human being who does not have insurance coverage or cash.

I will prevent disease whenever I can, for prevention is preferable to cure, as long as there is a reimbursable CPT code for such activity.

I will remember that I remain a member of a profession whose activities are now controlled by those who do not understand the needs of individual patients or do not care.

If I do not violate this oath, may I receive enough money to pay my student loans, my therapists and the army of administrators and practice consultants I must support before I die.

If this satirical “oath” too closely reflects your actual practice life, perhaps it’s time for you to act to change your circumstances.

You don’t have to settle. We at bCMS are here to help. let us know.

Dr. Adam Ratner is President of the Bexar County Medical Society and serves as Professor and Assistant Dean of the University of the Incarnate Word School of Osteopathic Medicine and Chair of The Patient Institute.

CORPORATE MEDICINE

The Corporate Practice of Medicine –

LEGAL PERSPECTIVES

By George F. “Rick” Evans, Jr., Evans, Rowe & Holbrook, BCMS General Counsel

et’s start with the very basics. From the law’s perspective, exactly what does it mean when lawyers and courts refer to the “corporate practice of medicine.” To a lay person, it sounds like some corporation providing health care, right? Just like General Motors makes and sells cars, why couldn’t some other corporation develop and sell health care. What’s wrong with that? Well, because it’s illegal when unlicensed persons or businesses do it.

To begin, the correct legal name is the “Corporate Practice of Medicine doctrine.” It’s an old doctrine and traces its roots back to 1847 in the AMA Principles of Ethics. What’s the doctrine?

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San Antonio Medicine • October 2019

very simple and one which you probably already know. It’s a series of statutes and court opinions which limits the extent to which non-physicians can become involved in practicing medicine. but the doctrine goes beyond the notion that one needs a medical license to provide care. The notion is to prevent any non-physician from influencing or controlling the independent and professional judgment of a doctor in his/her patient care. The laws were crafted to enable the physician to do that which is in the patient’s interest free of interference or control. The theory is that control by corporations could lead to discord between doctors trying to

CORPORATE MEDICINE care for their patients vs owners who are accountable to shareholders and trying to control health delivery in the interests of profits rather than health.

Critics claim these are antiquated laws not well suited to partnering physicians with health care delivery systems in a digital age.

That’s why we see so many “inventive” or “creative” arrangements intended to circumvent these laws. but, the fact remains that the doctrine remains very much alive and well today. believe it or not, most states have laws prohibiting this although, as usual, the devil is in the details (the details being all the exceptions to the doctrine).

It’s a common misconception that Texas is one of the last holdouts against the so-called corporate practice of medicine. virtually every state has legal prohibitions against controlling a physician’s exercise of professional judgment.

Most lay persons have too limited an understanding of these laws. The most common viewpoint is that they stop corporations owned/controlled by lay persons from hiring physicians as employees. That’s true in the sense that the laws don’t allow a layman owned company to hire a doctor and direct how the doctor can provide care. The company may tell a secretary how to answer phones, type letters or whatever, but they can’t tell the doctor not to remove a ruptured appendix because the patient must first try and fail conservative interventions. Simply put, these laws are crafted to stop an unlicensed lay person (whether it be a supervisor or corporate board) from telling the doctor how to diagnose and treat patients. but the doctrine goes well beyond that. It also looks to more subtle, more nuanced ways that can manipulate how a doctor exercises professional judgment. For example, suppose a company agreed to provide a doctor some office space, some medical staff, some equipment, etc. in exchange for a monthly fee. That’s okay. but suppose the company started to impose restrictions like mandating what hospital the doctor must send patients to, what medications could be used to treat various conditions, what conditions must be met before various interventions could be provided, etc.

Or suppose the company’s influence was financially driven such as taking a percentage of the doctor’s fees and requiring the doctor to generate so much money each month, refuse certain care to unfunded patients, etc.

In Texas, none of this is allowed. There are a series of statutes in the Texas Occupations Code that, collectively, accomplish three primary objectives. First, they stop any company or person without a license to practice medicine from directly employing doctors for the purpose of delivering health care. Second, these laws make unlawful any agreement or arrangement by which fees for a doctor’s services are somehow controlled or directly received by an unlicensed person or business. Finally, there are limitations on the extent to which a

physician and an unlicensed person or business can enter into agreements impacting a doctor’s practice (i.e. management and collection services are classic examples).

Here’s the bottom line or litmus test by which to judge the ever evolving and complicated business arrangements to which doctors may become a party. Any agreement or arrangement by which an unlicensed person or entity restricts or somehow limits the physician’s ability to truly exercise independent professional judgment in patient care is on very thin legal ice. You can try to disguise it, hide it or rename it, but a rose by any other name is still a rose. lay people and lay companies cannot control, direct or tell you how to care for your patients. Period.

Sounds simple and straight-forward... but then there are the exceptions to the rule.

One of the biggest exceptions is the “independent contractor” rule. In this scenario, the physician isn’t technically an employee, doesn’t get a W-2 form at year’s end, and doesn’t have the same benefits and legal rights that attach to a bona fide employer-employee relationship like when you hire a CPA or attorney to do some work for you.

They’re not your employee. You can control them to some extent (don’t spend more than X on this project, or I want you to draft my Will to give these people these things, etc.). but, at day’s end, you don’t dictate how they do their job. Just as your patient may say he wants you to fix his broken finger but that doesn’t mean he can tell you how to do it. lots of organizations hire doctors and identify all sorts of terms and conditions of employment but, to be legal, there has to be an overriding provision that gives the doctor the final say so on patient care. That’s how hospitals can legally hire a physician, pay a minimum guaranteed amount, collect fees, etc. but, rest assured those contracts have a provision guaranteeing the doctor’s independence when it comes to decisions on what care to provide a patient.

That said, calling a doctor an “independent contractor” doesn’t necessarily mean that’s true. The Court’s will look at form over substance to determine just how much liberty the doctor really has when it comes to matters of patient care (as distinguished from other matters like administrative, managerial and other functions unrelated to caring for a patient). The courts will look at the collective impact of all the limitations or controls an entity may exercise over a doctor. The litmus test remains whether the doctor can still exercise independent judgment, as to when that line has been crossed is decided on a case by case basis. It can be tricky and the line blurry. For example, in the landmark and oft cited case of Flynn brothers v. First Medical Associates, the corporate entity claiming the doctors were “independent contractors” was found to have too continued on page 12

visit us at www.bcms.org

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CORPORATE MEDICINE continued from page 11

much control over the doctor. Specifically, the corporation collected two thirds of the revenue, controlled the staff who worked with the doctors and commercialized the doctors’ license to obtain various health care contracts. The more strings and limits to the agreement, the greater the risk it will be illegal.

There are several other notable exceptions which allow an unlicensed entity to employ a physician. They include certain non-profit health care corporations, non-profit medical schools, various State and County institutions/organizations, including certain hospital districts and certain rural hospitals.

The penalties for violating this legal doctrine in Texas are pretty hefty. An offending party may get off with an administrative fine. but a doctor could also lose his license if the circumstances were sufficiently egregious. Worse yet, criminal penalties are at least a theoretical possibility even though the author has been unable to locate any imprisoned doctor for becoming a party to an unlawful agreement. However, that doesn’t mean it can’t or won’t happen.

What’s the take home message here?

Any time you’re asked to sign a contract or enter into some agreement involving lay people and your practice, you need to be on at least a low level alert. When it involves any form of compensation to you, or takes some percentage of your fee ostensibly for some service or product, the alert level goes from low to high. We’re not just talking about something that may look a little bit like an employment agreement. You need to take a hard look at things like practice management agreements, leases of real estate and equipment, franchise agreements or anything by which an unlicensed person may be entitled to a portion of your fee or may have some way, direct or indirect, to control your judgment.

Crafty lawyers get big bucks trying to imagine creative agreements to avoid the corporate practice of medicine doctrine.

At day’s end, the courts will always put substance over form. because your license could be at stake, don’t play lawyer in an effort to determine the legality of the proposal at hand. Find somebody who knows these laws and get a professional opinion first. Your job, and the purpose of this article, is simply to have enough knowledge to be aware of the warning signs and symptoms that should trigger an alert.

George F. “Rick” Evans Jr. is a founding partner of Evans, Rowe & Holbrook. A graduate of Marshall College of Law, his practice for 36 years has been exclusively dedicated to representation of physicians and other healthcare providers. Mr. Evans is the BCMS general counsel.

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CORPORATE MEDICINE

The Corporate Practice of Medicine –

What is it?

Well, in part it started with

FRIED CHICKEN

By Rodolfo Molina, MD Master ACR Fellowship ACP The year was 1968 and dr. Thomas Frist, Sr., a Nashville physician, and Jack C. Massey, the man who made Kentucky Fried Chicken into a national chain, formed the Hospital Corporation of America (HCA). This was done by using the capital in Frist’s private hospital, Park view, to acquire additional hospitals. HCA has since become the country’s largest investor-owned hospital chain in the United States.

At that time, few hospitals were for-profit. but by 1983, 13 percent were controlled by for-profit investors. Medicare/Medicaid (CMS) made this possible when it was established in 1965. This federally-funded insurance system created opportunities for profit seeking corporations that were not previously possible, allowing them to generate substantial wealth from healthcare. “Corporate Medicine” now includes all types of investor-owned corporations that seek to profit from healthcare; all are competing for a share of the healthcare marketplace and are firmly rooted.

The lack of a well-thought-out health delivery system has resulted in insurance giants such as Humana and Aetna buying up physician groups. Pharmacy benefit Managers (PbMs) have opened medical clinics in their pharmacies, supermarkets have created “retail medical clinics” in their stores, and free-standing medical clinics and surgical centers (physician or hospital owned) are part of the vista that we call healthcare. Mergers and acquisitions of medical practices by for-profit businesses have transformed healthcare into a commodity of convenience rather than a humanitarian and scientific effort.

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The rising costs of healthcare have put into question how healthcare is being delivered. Entering cost into the equation of how a patient is treated has led to the emergence of a new ethos that defines value in healthcare as “a patient’s outcome divided by the cost to achieve that outcome” (value = outcome/cost). If the cost of a patient’s illness is excessive in order to achieve a desired outcome, then the value of care to the payor is diminished, potentially delaying or rationing of care for said patient. Philosophical values driving a free market are woven into the financial platform of corporations that are difficult to deny. Physicians are referred to as “providers” and patients as “consumers”. If healthcare is to be considered a commodity we should ask: Are physicians the new proletariat?

The cost of doing business for private practitioners continues to rise and, if a physician is not part of a big entity that can absorb these costs, then the strategy for staying solvent is challenging.

Physicians must accept and understand how this system operates.

Insurers, their PbMs, pharmaceutical companies and all that can be considered corporate medicine are vying for the same dollar. They all have their guardrails to protect their profits. Yet, for small groups of physicians or solo practitioners who are battling the cost of EMRs, the costly bureaucratic time filling out prior authorizations, combined with increasing overhead costs, are traveling the path of extinction.

CORPORATE MEDICINE

What can we say then of the American corporate medicine experiment? Here are some examples of where it went very wrong.

Corporations have dominated dialysis units. The two largest, davita and Fresenius, have been cited as doing a poor job keeping patients alive. A 2011 study in Health Services Research found that for-profit chains had a 13% higher risk of mortality than not-forprofits. davita has paid out hundreds of millions to settle claims of overuse of potentially harmful drugs and of committing Medicare fraud. A 2002 meta-analysis found that patients in a forprofit hospital had a higher risk of death compared to not-for-profit hospitals.

So, looping back to the largest hospital system in America, how have they behaved? In 1993, the government launched what became a 10-year investigation of various allegations, one of which was overbilling Medicare. In 2003, the government received around $2 billion dollars from HCA in criminal fines and civil penalties. The Justice department called it the “largest healthcare fraud in US history”.

In 2016 in Texas, Austin hospitalists sued TeamHealth (a company St. david’s Healthcare uses) alleging they were being pressured to make medical decisions that make money for the hospital. Texas, like many other states, has created “corporate practice of medicine laws” that forbid a business from practicing medicine; hence, the lawsuit.

Although there are gaps in the literature, a 2014 study found that for-profit entities had inferior outcomes. Some physician practices are operating under a corporate roof, yet it’s unclear how it will affect patient outcomes. A 2016 study in Health Affairs of retail clinics found higher costs (by 21%) for “low acuity conditions“ such as colds. Also in this study, free standing ERs and retail clinics were

found to be disproportionately located in high income areas.

This is not intended to say all for-profit entities are flawed or corrupt. A recent case study examining Md Anderson (corporate entity) touts it to be an excellent example for others to follow. It is a non-profit hospital with some for-profit agreements. An example of a for-profit entity that has reported improved outcomes is the Pediatrix Medical Group, a subsidiary of MEdNAX Inc. Forprofit corporate medical groups keep a close eye on their finances while attempting to balance costs, patient well-being, and patient outcomes. This is not an easy task. We need updated outcome studies comparing the existing models that deliver care so that we can build a better delivery system; a system that strives to continually provide for a patient’s well-being.

Market forces drive for-profit organizations and corporate medicine is no exception. Corporate influences are reshaping reimbursement policies and competition, driving a shift from a solo practice to a group practice. Those who argue that market forces will solve the problems in healthcare, either fail to acknowledge or fail to understand that these same forces are devoted to a corporate ethic (loyalty to shareholders) and not to patients. At the same time, physicians also need to be financially able to provide services, but they are typically more focused on the well-being of the patient.

These divergent allegiances in healthcare are all-too-often ignored by our politicians. It is unfortunate that our destiny as practicing physicians is, and will continue to, be defined in political terms.

Therefore, we should all be involved in preserving the integrity of medicine, whether we champion the cause of the solo practitioner or that of “big medicine”.

Our patients have been defined as “consumers” by big business.

That is such a misuse of the word consumer. To be a consumer means you have a choice. Our patients often have no choice of who they see or what medicine they try first. We must defend those choices and we must incorporate the patient’s experience when developing policies. We have a moral obligation to reinsert ourselves into the discussion of how best to deliver care.

Bexar County Medical Society has a superb Legislative and Socioeconomic Committee that regularly meets with our local politicians and judges. As a member of BCMS, you can begin there; I know I did. The staff at our society is friendly, supportive and knowledgeable. Please reach out. visit us at www.bcms.org

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CORPORATE MEDICINE

The State of the CPOM and the Law in

TEXAS

By Jeff Wurzburg, Esq.

he Corporate Practice of Medicine (CPOM) doctrine faces renewed pressures in an era of delivery system reform and payors shifting reimbursement to value. In Texas and other states, legislative changes have loosened the prohibitions on corporate practice to align with current public policy goals of integration and collaboration.

In 2012, hospitals or health systems employed around 25% of U.S. physicians and by 2018 the percentage increased to 44%. between July 2016 and January 2018, hospitals acquired 8,000 medical practices and 14,000 physicians left private practice and entered into employment arrangements with hospitals. In 2018, close to 70% of physicians below 40 were employees. For many younger physicians, the promise of a set salary and the ability to focus on the

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practice of medicine, combined with the constraint of medical school debt, have made employment an attractive option.

However, this shift likely doesn’t spell the end to the principle underlying CPOM laws – that a physician’s medical judgment must remain free from corporate and financial pressures – just a realignment in philosophy. The dual trends of physician/hospital alignment and reimbursement based on value and clinical integration have put pressure on certain aspects of CPOM restrictions. However, Texas still maintains a robust CPOM law in comparison to many other states.

Texas Restrictions on CPOM Originally, the notion of corporate practice was defined and developed through case law. The prohibitions were later codi-

fied in the Texas Medical Practice Act, which is part of the Texas Occupations Code (TOC). In Texas, CPOM generally prohibits corporations, entities or individuals that are not physicians from the practice of medicine.

Section 155.001 Requires an individual to have a license issued by the TMb to practice medicine.

Section 155.003 Requires an individual to satisfy certain eligibility standards that a corporate entity would not be able to fulfill in order to receive a medical license, including with regard to age, professional character and education.

Section 157.001 Permits a physician to delegate certain

CORPORATE MEDICINE

medical acts to qualified individuals while prohibiting the delegated individual from representing to the public they are authorized to practice medicine.

Section 164.052(a)(13) Authorizes disciplinary action against any licensee for impersonation of a licensed practitioner or allowing another person to use their license to practice medicine.

Section 164.052(a)(17) Provides for disciplinary action against a practitioner that aides or abets, directly or indirectly, the practice of medicine by a non-licensed individual.

Section 164.156 Prohibits an individual, partnership, trust, association or corporation to represent they are entitled to practice medicine if they are not licensed to do so. despite this broad prohibition, over time, the Texas legislature has provided statutory exceptions to CPOM. However, while this could be interpreted as the erosion of CPOM, in each instance the legislation or implementing regulation makes clear that a physician’s independent medical judgment may not be directed or controlled by a nonphysician.

Certified Non-Profit Health Corporations The non-profit health corporation must be organized solely by licensed physicians.

The directors of the corporation are required to be licensed physicians that are actively engaged in the practice of medicine. The Corporation must be approved and certified by the Texas Medical board.

Policies regarding credentialing; quality assurance; utilization review; and peer review policies must be made exclusively by

the physician board of directors. The law remains clear that a “health organization may not interfere with, control, or otherwise direct a physicians’ professional judgment in violation of the Act, board rules, or any other provisions of law.”

Professional Associations (PA) doctors of medicine, osteopaths, and podiatrists may form and own a professional association. The practitioner’s authority is limited by the scope of their practice and a practitioner is prohibited from exercising control over the other’s clinical authority in any manner that would assert control over treatment decisions made by the practitioner.

Professional Limited Liability Company (PLLC) A PllC may be comprised of both professional individuals and professional entities. The PllC must be organized for the purpose of performing a specific type of professional service and ancillary services.

A PllC may not provide more than one kind of professional service. legislative changes in 2011 also provided for physicians and physician assistants to form a corporation or partnership to perform a professional service that falls within the scope of their practice. Additionally, critical access hospitals, sole community hospitals, federally qualified health centers, and certain hospital districts are permitted to employ physicians. This expanded upon prior exceptions for private, non-profit medical schools, school districts, certain state institutions, and rural health clinics.

It is also generally permissible for a physician to enter into an independent contractor relationship with a non-physician entity. Judicial scrutiny of CPOM in

Texas has evidenced the difficult balance in determining when a corporate entity has overstepped into the practice of medicine. A recent court, citing to other Texas cases regarding CPOM, noted the lack of “a finite or mandatory list of factors to determine whether a certain agreement or arrangement contravenes the [Medical Practice] Act.” Pressures on Traditional CPOM Restrictions The pressures on the CPOM in Texas are no different from other states. Trends in private and payor reimbursement and a general movement in policy towards valuebased reimbursement have put additional pressure on state legislatures to reduce barriers to clinical integration.

This policy shift has led to a rare and endangered form of governing historically known as “bipartisan” – the past three administrations in Washington have embraced the movement away from fee-for-service and towards a system that rewards value.

Starting with the George W. bush administration, the Centers for Medicare & Medicaid Services has moved towards increasing reimbursement mechanisms based on value. The current administration has endorsed and expanded the movement-tovalue implemented by the Obama administration through the Center for Medicare and Medicaid Innovation created under the Patient Protection and Affordable Care Act. Secretary of Health and Human Services Alex Azar has made the movement to value one of his top goals: “There is no turning back to an unsustainable system that pays for procedures rather than value. In fact, the only option is to charge forward – for HHS to take bolder action, and for providers and payers to join with us. This administration and this President are not interested in incontinued on page 18

visit us at www.bcms.org

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CORPORATE MEDICINE continued from page 17

cremental steps. We are unafraid of disrupting existing arrangements simply because they’re backed by powerful special interests. “despite earlier criticism of mandatory models implemented by the previous administration, in July the Trump administration proposed two mandatory models that would require certain providers to participate: End-Stage Renal disease Treatment

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San Antonio Medicine • October 2019

Choices and Radiation Oncology.

In addition, legislation such as the Medicare and CHIP Reauthorization Act of 2015 and its implementation through the Quality Payment Program in certain instances has increased practice costs and reporting requirements, creating additional incentives for physicians to align with larger systems.”

Conclusion In a 1934 JAMA article, the AMA warned that “the worst possible type of new methods in medical practice is in the incorporation by business men of organizations to engage in the practice of medicine, employing physicians on salaries and exploiting the services of these physicians unethically to the public.” Eighty-five years

later the practice of medicine faces the same forces of creative destruction as other professions. It is not only physicians facing changes regarding corporate involvement in their profession. The State bar of California recently requested comment on proposals that would permit nonlawyers to hold a financial interest in a law firm. However, even with the ever rapid changes in the way medicine is reimbursed and recent recalibrations to CPOM restrictions, the overarching principle remains firmly planted in the law: corporate decision-making must not interfere with the independent medical judgment of physicians.

Jeff Wurzburg is a Counsel in the San Antonio office of Norton Rose Fulbright US LLP. Previously he served in the United States Department of Health and Human Services Office of the General Counsel in Washington D.C.

CORPORATE MEDICINE

Where Money & Physician Judgement Collide

By Mike Kreager, JD, LLM

Ultimately it will be the resolve of

Texas physicians who sell their practices or

who go to work for management company-

controlled employers to appropriately push back

on the profit motive of management companies

to preserve the acknowledged priority in Texas

medical care – patients come first, before profit.

ny physician who has practiced medicine for any length of time has seen the line demarking management and the exercise of independent medical judgment clearly crossed.

In the 1990s, a new hospital business model was to acquire gatekeeper practices, primarily family medicine and internal medicine.

The premise of the model was to control, or perhaps better put, capture hospital admissions.

The 1990’s model was an utter failure, resulting in massive losses for the hospitals. Physicians soon reacquired their medical practices for virtually free. The financial flaw in the model was physician accountability. In over-simplified terms, the physician did not have to work – the base salary was guaranteed. Now twenty-five years later, the accountability issue has been solved by eliminating guaranteed

salaries and substituting productivity compensation based on work Relative value Units (wRvUs).

Similar waves of specialty practice acquisitions have since flourished, such as in orthopedics, oncology, ob/gyn, pathology and ophthalmology. These practice acquisitions fared better because the underlying business model was premised on, first, the payment to the physician being made up of cash, stock and longterm notes (deferred compensation); and, second, an assured payback to the buyer of a percentage of revenue or profit. In other words, the acquiring company was assured a payback of its purchase price over a five-year time frame because the physician’s base compensation was fixed for the next five years. Moreover, the employed physician was handcuffed to the practice through continued on page 20

visit us at www.bcms.org

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CORPORATE MEDICINE continued from page 19

onerous covenants not to compete.

The purchasers of the specialty practices at that time were primarily private-equity-backed management companies intending to aggregate sufficiently large footprints of practices across the country to allow the management company to go public. The shares of the management company would be offered to the public for purchase through an initial public offering. The IPO was the private equity firms’ “exit” strategy, allowing it to sell its shares in the management company through the stock exchanges. This spate of medical practice acquisitions has continued unabated since the 1990s, but through much more sophisticated business models. Most recently, dermatology practices have caught the eye of management companies.

The business model of medical practice acquisitions is simple and meets the needs of the dominant segment of private practice physicians, to wit, those baby boomer physicians looking to retire or cut back but having no ready “plan b” to sell to the next generation of physicians. Non-physician entities, such as hospital systems, insurance companies or management companies backed by private equity, acquire the assets of a medical practice and employ the physicians associated with the practice through an approved employer of physicians (commonly called 501a corporations). The acquiror has capital, meaning it has a ready source of money to buy the practice’s assets. Hospital systems and insurance companies are well-financed industries with positive cash flow, reserves and access to low cost capital. Privately-owned management companies rely on private equity.

Private equity funds are “alternate” investments for high net worth and institutional investors. Private equity creates a ‘fund’ which has as its investment purpose investment in management companies that manage medical practices. The fund attracts private investors who are willing to tie up their money for a relatively short term, usually five to seven years, to achieve a total annual return of 20 to 30 percent. The fund promoters are richly rewarded with a carried interest in the success of the fund. In other words, the fund promoters can receive 20 percent of the gain on the original investment in the management company. Thus, there is an overwhelming incentive to focus on achieving short-term profitability.

The private equity backed management company has a singular goal – to achieve positive earnings, that is total profit before interest, taxes, depreciation and amortization, the proverbial EbITdA; commonly called “cash flow”. Positive cash flow that consistently trends upward over the years has an exponential, positive impact on the value of the acquired enterprise. Similarly, for management companies, the increase in enterprise value justifies an exit through the sale 20

San Antonio Medicine • October 2019

to the public market because the equity markets will often value an enterprise at a multiple of its cash flow.

Stating the obvious – positive cash flow occurs only when revenues exceed operating costs.

Revenues in a medical practice are influenced by these variables: the number of patient encounters, payment rates for encounters, and opportunities to capture related income, i.e., ancillary income from referrals for diagnostic testing such as imaging and laboratory tests. If each of these components can be increased after the acquisition, cash flow goes up. Conversely, operating expenses are influenced by these variables: labor costs, occupancy costs, and the cost of goods, e.g., injectables, infusion pharmaceuticals, dME and the cost of ancillary services. As costs go down, cash flow goes up. basically, it is a very simple model – increase top line revenues and decrease operating costs to increase “free cash flow” then apply a valuation multiple to that number.

Knowing the motivation driving management companies to acquire medical practices, we come to the core question. When does the management company’s objective of increased cash flow encroach on the practice of medicine? The answer is readily apparent – when the control of the management company prevents the physician from doing what is best for the patient because it could negatively impact profitability. Control is the issue. Has the management company made its profit motive the ultimate priority, and has it tried to assure continuing profitability by directing patient care, either by mandate or more likely by subtle, nevertheless coer-

CORPORATE MEDICINE

cive, suggestions?

Texas ardently believes that physicians licensed to practice medicine should be the only individuals making patient care decisions, in concert with a wellinformed, consenting patient, without regard to profitability. Texas does not tolerate non-physicians controlling a physician’s determination of what is best for the patient. This intolerance dates to turn of the twentieth century company-towns that employed a physician to treat the workers and their families and to the days of ‘snake oil’ salesmen who promised many of the panaceas touted today by Cbd distributors. We call this policy the Texas prohibition against the ‘corporate practice of medicine’ or CPOM. Texas has a history of CPOM disputes in its legal lexicon. The current state of the law can be summarized as an issue of control.

When the management company has ultimate control of the medical practice, CPOM is violated and two consequences can ensue; the contractual arrangement can be negated or the Texas Medical board may take disciplinary action. However, a violation of CPOM does not entitle a physician to sue the management company for money. In legal jargon, there is no private cause of action for the physician or the physician group to pursue. The two solutions available are to abrogate the original contractual arrangement or to seek the TMb’s investigation. These are cumbersome, ill-suited dispute resolution paths that may linger years in the courts before the outcome is known.

Thus, it becomes an issue for the physician group to consider

when it sells its practice. How does the group shield itself from potentially intrusive incentives to put profit above patient care? The management company’s opportunity for abuse abounds. It is up to the physician to decide whether the paramount concern for the patient will prevail over the rationalized intrusions on medical care.

The rationalized intrusions into care focus on the cash flow variables, such as the volume of patient encounters, the rapidity of hospital discharges, required referrals for ancillary money-making diagnostics and the reduction in physician-patient coverage through physician extenders that are lightly or mostly unsupervised.

The studies of management company acquisitions are universally disappointing in their conclusions. Specifically, there is insufficient reported data to reach an empirical conclusion. Anecdotal conclusions of the impact of private equity ownership flow from logical extensions of the business model underlying the investment model.

The desire to increase revenue and decrease cost puts pressure on the physician to make medical decisions that align with the profit motivations of the management company. Management company acquisitions are abundant, but there are post-acquisition measures of impermissible physician control. Candidly, there are instances where non-physician control can be beneficial to patient care. Structured reliance on evidence-based medical protocols can reduce medical errors. Group purchasing power can reduce costs. It also remains to be seen, in this dawning age of artificial intelligence, whether physician control of medical care will give way to newer practice models that leverage the opportunity for earlier intervention or reduction in medical errors.

We have local success stories of hospital system-based practice groups that practice the highest level of medical care and reward physicians with appropriate levels of compensation. Similarly, Optum, a division of publicly traded United Healthcare Group, owns and operates WellMed, a multi-specialty physician group providing care to a large population of Medicare beneficiaries. On the other hand, there is the on-going legal battle between a hospitalist organization and a physician staffing contractor to the St. david’s hospital system in Austin, where the physicians’ allegations of unfair control over medical decision making are yet to be decided.

Ultimately it will be the resolve of Texas physicians who sell their practices or who go to work for management company-controlled employers to appropriately push back on the profit motive of management companies to preserve the acknowledged priority in Texas medical care – patients come first, before profit.

Mike Kreager is a senior member of Kreager Mitchell PLLC, a law firm dedicated to the unique legal matters confronted by physicians. visit us at www.bcms.org

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CORPORATE MEDICINE

PHYSICIAN vs. The Corporate Practice of Independence MEDICINE

By Manuel M. Quiñones, Jr., MD – Opinion/Editorial

This article is written strictly as an opinion piece by Dr. Manny Quiñones and is not to be interpreted in any way as the opinion of the Texas Medical Board.

“So why on earth is Manny writing an article again?” Well, I’ll tell you why. because for some time now, many things have gone unsaid, and if anybody would ever say them, it would have to be me. I know I may make some of you happy, thinking “Gosh I’m glad someone said something about that,” and others of you may say, “I can’t believe somebody said that!” So here goes.

In my book, there are a few rules you should never break and lines you should never step over. One of those is never bite the hand that feeds you. So what happens if you don’t work for yourself or for other physicians? Unfortunately, when you don’t 22

San Antonio Medicine • October 2019

work for yourself or for other physicians, having an opinion about how you take care of your patients can really be anxiogenic. So why would you ever want to work for an entity you have no control over, no hope of ever governing or leading, or worse yet, one that might have you in violation of the Corporate Practice of Medicine prohibition here in Texas? let me tell you a little about how I started my professional life and how it has evolved and maybe you will understand where I am coming from.

When I finished my residency in Family Practice in 1985, at the encouragement of a very dear friend, I went to work for another

Family Practice doctor. That didn’t work out very well because I thought I would become an equal partner as he had promised; but that was not on his priority list. Me not being shy about my concerns landed us in opposite corners. So, I was “released” and started my solo practice. I had the pleasure of working closely with three other FPs during my tenure of solo practice and they went off to do other things alone, which I respected.

Then about 10 years in to my solo life, my friend dr. Hugh Wolf, approached me and invited me to join one of the Santa Rosa groups. I was reluctant, but realized (25 years ago now) that the days of solo primary care

CORPORATE MEDICINE medicine were coming to a close in my lifetime. So I joined Solomon Anthony, and eventually we merged in to HealthTexas. A few years later, together with my very astute, well-informed and prophetic partners, HealthTexas decided to buy itself away from Santa Rosa. That divestiture process was very complicated, expensive and did not make us any friends. This was and remains the greatest metamorphosis of my professional practice life. We suddenly had wings.

Since that time, through sacrifice and hard work, we have managed to advance our practice to become a premier provider of healthcare in the greater San Antonio market; and we have managed to do so remaining totally physician governed and owned. We created a management company which manages HealthTexas. It is entirely owned and governed by its practicing physicians. Upon retirement, you cannot continue as an owner and must sell your shares back to enable younger partners to acquire them and therefore help lead the group in to the future. And therein lies the basis for this discussion.

There are only two types of people who embrace change – business consultants and wet babies. but you get to decide which one you will be. In any business, change is inevitable and unescapable. How you are able to manage that evolution is what divides satisfaction and success from discontent and failure. The Corporate Practice of Medicine, where physicians are controlled by nonphysician entities, does not end in satisfaction and success. No matter how the relationship starts off, when it comes to deciding on your personal success vs. the success of the corporate entity with its bricks and mortar, you will never win. Non-physician corporate entities do NOT have your best interest at heart. And, the Corporate Practice of Medicine is illegal.

Section 164.052 of the Texas Occupations Code specifically says “Physicians may not purchase or sell a medical degree, license, or

certification for application to TMb for a license to practice medicine. Physicians also may not permit another to use the physician’s license to practice medicine, nor can a physician assist another unlicensed person, or a partnership, association, or corporation in practicing medicine.” Case law has made it clear that physicians cannot be employees of corporate entities. The courts have held that allowing a non-physician entity/corporation to employee a physician has the potential to commercialize the practice of medicine and destroys the physician-patient relationship. I see this, and you see this, time and time again – something not getting approved because of cost. What did you think would happen when you went to work for that entity?

The Corporate Practice of Medicine prohibition is rooted in an unwavering desire to protect the public by prohibiting nonphysicians from practicing medicine. You became a physician to take care of patients and to heal. You probably trained at a time, as I did, when we were not taught to run our offices like a business. As a result, many of us fell victim to the ever-growing demands of insurance companies, government agencies and payers along with non-physician entrepreneurs who see the art of practicing medicine as a money cow. by creating more hoops to jump through, you have become so frustrated that the easy road always looks tempting; electronic medical records, star ratings, HEdIS scores, survey scores, Google Stars, Press-Gainey ratings, TPMP requirements – the list goes on and on. because of this, many of you have chosen to contract with entities which may or may not run afoul of the law and the Corporate Practice of Medicine. Please be careful if you choose this road. We as physicians are all subject to the Corporate Practice of Medicine prohibition and the Texas Medical Practice Act. You have to know the law and get good legal advice.

From my side of the fence, I can tell you

that life is great. The recent transition in leadership at my practice has been smooth and seamless. My partners have strongly embraced the idea that we should all get to chase our dreams by supporting one another. This has allowed me to stay involved in Organized Medicine, and to accept Gov. Gregg Abbott’s invitation to sit on the Texas Medical board, while continuing to pursue my ranching and hunting passions.

I am very happy doing what I do, and have been blessed with good health thus far. I have no desire to retire, and no plan on slowing down.

My practice is in growth mode, and the group has challenged me to open and establish our 16th area office in Helotes. I believe we have the best model for success we could hope for, established and governed by physicians, with the management company having only practicing physician leaders and owners.

This came with a lot of sacrifice and hard work, and the willingness of its physicians to buy in to the concept that only practicing physicians know what is best for their patients. Only physicians should be able to determine what is and is not needed to achieve the best possible outcome for those who rely on us for healthcare. We do not protect someone’s bricks and mortar, and we are not in the Practice of Medicine to protect stockholders in a corporation. We strive to practice efficient, evidence-based medicine with the goal of excellent outcomes – every patient, every time. We are the antithesis of the Corporate Practice of Medicine.

From the back porch, feet up, sun going down, I am Manny Quiñones.

Dr. Quiñones has a medical practice in San Antonio, was the 2008 President of the Bexar County Medical Society, currently serves on the BCMS Board of Directors and is on the Texas Medical Board. visit us at www.bcms.org

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CORPORATE MEDICINE

The Corporate Practice of Medicine: Remaining an Independent Physician

by Adopting a Value-Based Care Model

By Alan Preston, MHA, Sc.

The prohibition against the Corporate Practice of Medicine (CPOM) has been a medical doctrine for many years, dating back to the mid1800s. And like most doctrines, the root of this prohibition made sense.

The practice of medicine way back then was just getting organized, so it was necessary to differentiate between those who were schooled in medicine vs. those who were selling snake oil. The AMA was instrumental in passing a number of laws that restricted the CPOM in an effort to allow physicians the autonomy and authority to make patient medical decisions without the interference of corporations. Most would agree that the doctrine of placing the practice of medicine in the hands of physicians and not bureaucrats is sound judgment.

Fast forward to 2019; medicine is now big business. The estimates of the total cost for healthcare in the USA exceeds $3.5 trillion annually.

Many large companies, as well as mom and pop shops, are involved in managing various aspects of healthcare. The question is whether companies that control the many tangents of healthcare are practicing medicine? The short answer is some are (hospitals and physician offices), and some are not (call centers, billing companies, dME companies, etc.). Compelling arguments can be made either way as to whether a corporation is "practicing" medicine, examples being insurance carriers or Medicare or Medicaid. With the increasing number of laws dictating aspects of the regulation of medicine, one could argue legislators and members of Congress are buying into the CPOM. It is a challenge to define CPOM. For example, in the case where a physician has autonomy over medical decisions in his/her practice, but decides to grant payor contracting and other administrative functions to a Management Services Organization (MSO), or pays the MSO some percentage of their fees, some courts have ruled that model tantamount to the corporate practice of medicine and a violation of the Texas Administrative Code (TAC).

The tenets, according to the AMA of the corporate practice of medicine, have these characteristics attached:

1.

2.

3.

Commercialization of the practice of medicine, A corporation’s obligation to its shareholders which therefore may not align with a physician’s obligation to patients, and Employment of a physician by a corporation that may interfere with the physician’s independent medical judgment.

Many independent physicians feel the protections against the CPOM have been diminished and are eroding physician independence and autonomy. laws, lawsuits and regulations are all attempting to influence the physician. Some of it may be beneficial to physicians, and, much of it is not.

On another side, CMS is trying to influence the control of physicians with more money for better outcomes. It is called value-based Care (vbC). Is CMS in violation of the Corporate Practice of Medi-

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San Antonio Medicine • October 2019

CORPORATE MEDICINE cine? Maybe! Certainly, cutting physician pay when the physician community does not agree and adopt vbC, as well as other laws that interfere with the practice of medicine, is a more egregious example of diminishing physicians’ autonomy regarding their practice.

As almost every politician has come to realize (as they tinker with the healthcare system), healthcare is complicated. There may be a place for Corporate America to involve itself in the management of healthcare, but physicians need to be at the center of such changes. The beauty of the U.S. capitalistic system is that it provides choices; choices for physicians, payors, patients and employers. The market can accommodate an extensive variety of solutions by offering physicians options as to how to practice medicine, while at the same time allowing physicians to maintain autonomy over their practice. However, autonomy is the key for physicians. Physicians do not want bureaucrats telling them how to practice medicine.

The state of Texas has revised the prohibition of CPOM (Texas Administrative Code Title 22, Part 9, Chapter 177, Subchapter d, Rule §177.17) and has allowed physicians to be an employee of a hospital. Not every hospital in Texas can hire a physician, though the list is growing; and for many physicians, being employed is an appropriate strategy. For others, it is not. but there are choices! Providing options to physicians will be seen by some as essential, while for others it is viewed as a continual erosion of their independence.

The challenge for the remaining independent physicians is how they compete effectively with the corporate-owned provider community that controls more financial resources than do physicians.

Can the independent physician remain independent while Corporate America continues to provide a plethora of technology and resources to the physicians they employ? Following are some solutions for independent physicians in the area of value-based-Care. (vbC) There is a big push by CMS and the States to move value-based Care. The question is to whom the value inures. The vbC premise is that if physicians take on more risk for the outcomes of patients as opposed to obtaining a simple fee for service (FFS), physicians are more likely to improve the result of the patient. Presumably, this is done by monitoring the patient and ensuring the patient receives timely and appropriate care which produces better outcomes for the patient. Most physicians already strive to assure that patients receive the best care to deliver the best result. However, there has been quite a variety of outcomes from practice to practice. vbC provides financial incentives for physicians to adopt the best practices to achieve better outcomes. And often, independent physicians can work in concert with Accountable Care Organizations (ACOs) to achieve the necessary results without investing in the framework and structure it takes to achieve such improved patient outcomes.

How does vbC work? There are several levels of vbC where physicians can participate. The objective is the same regardless of

which model a physician decides to pursue. The objective is to improve the health outcomes of patients (demonstrated by objective outcomes such as lowering the HgbA1c below nine (9) as an example and identified by (HEdIS) and to reduce the overall cost of a population of patients assigned to a physician practice.

CMS has allowed physician practices to join an Accountable Care Organization (ACO) and to participate in a Medicare Shared Savings Program (MSSP). Much like the name suggests, CMS will share some of the savings of a Medicare population assigned to the practice if savings and improved patient outcomes are achieved. There are typically two components to this program; 1. Reduce the overall costs associated with the population of patients assigned to a physician, and 2. Improve the objective (HEdIS & NCQA) outcomes of the patients assigned to the practice in several defined metrics.

To the extent the practice can achieve such results, they will receive additional funding from CMS via the ACO (roughly 18 months after they start the program). To participate in the MSSP program, the practice MUST join an ACO. The ACO will often manage various aspects of the coordination of care for the benefit of the physician and the patient. depending upon which ACO the physician joins, the ACO will participate in a portion of the shared savings in order to help pay their administrative costs. And since the amount of money that CMS determines is earned depends on all of the physicians in an ACO, some due diligence is required by the individual physician. If a few physicians are not actively managing their population of patients and the costs are driven up, as a result, then every physician in the ACO will suffer financially.

The financial performance is based on both the individual physician, the performance of the group of physicians in the ACO, and the amount of money used by the ACO for administration. The financial upside or downside risk also plays a role and depends upon which model of the MSSP the physician practice engages. The model the physician practice is engaged in depends upon the contracting entity, which is usually the ACO. Thus, the first question to ask yourself is how much risk are you willing to accept? Once that question is answered, then the physician should find an ACO that participates in the level of risk sought by the physician practice.

The level of risk can range from shared savings with no downside risk, to full-risk being responsible for downside risk. If the physician is in an ACO that fails to lower costs, CMS may determine the ACO, and the contracting physicians, are accountable for the loss proportioned by the number of patients assigned to the practice. depending upon the size of the practice, the upside potential can be in the millions of dollars. Contrarily, the downside risk can be in the millions of dollars. Therefore, understandcontinued on page 26

visit us at www.bcms.org

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CORPORATE MEDICINE continued from page 25

ing all of the iterations of vbC is essential when aligning a practice to a level of risk.

Once CMS mandates that physicians will increasingly be paid on a vbC model, the physician practice will need to have the appropriate infrastructure in place to manage the risks and outcomes of their patient population. Some practices (smaller practices) will rely on "corporations" (such as ACOs, MSOs, and IPAs) to assist them in the infrastructure, while large practices may decide to develop the infrastructure internally. Either way, there should be tolerance for corporations who help physician practices prosper, and at the same time, not accuse them of practicing medicine for doing so.

For many physicians, an Accountable Care Organization (ACO) may be the answer. Independent physicians getting paid for doing what they desire, i.e. improved patient outcomes, seems like a nobrainer. However, as with most programs, hooking your existing practice to the right ACO is as important as deciding to participate in such a program from the time of its foundaton. And since the savings can depend upon the entire group of participating physicians, make sure you are in a network of like-minded physicians that want to achieve the same results and who pay attention to the details of how to accomplish the ultimate goal. Having an outside organ-

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San Antonio Medicine • October 2019

ization (like an ACO) can assist many physicians to remain independent and compete effectively with practices that were sold to a hospital or some other corporate type of entity.

At the end of the day, physicians want to practice medicine, and they want to be able to make a good living at it; but the environment is changing. Adaptation to enable competition in this complex environment is where the focus must be. Fighting the system is sometimes the answer, but you can be outspent and out-maneuvered. If your solution is to fight, band together with other physicians (that is what TMA and bCMS are all about). That will increase the volume of the voice. The other answer for physicians is to learn better business practices. bigger-is-better seems to be the current theme.

Adapt and innovate!

Dr. Alan Preston is an experienced Chief Executive Officer with a demonstrated history of working in the managed care and the healthcare industry. He has a Doctor of Science (Sc.D.) focused in Public Health, Health Services Research from Tulane University School of Public Health and Tropical Medicine.

He has been very involved in risk-sharing contracts, ACOs, Medicare Advantage including RAP scores, HEDIS, and STAR ratings which helps physicians and health plans alike in reducing MLR. Alan@Preston101.com.

CORPORATE MEDICINE

Employer-Sponsored Healthcare Revisited

By Roger Moczygemba, MD, MHA

“Corporate medicine has become one of those phrases that has no real definition, but still makes most physicians shudder”(Cook, 1999). Nearly a decade after the Affordable Care Act (ACA) mandated individuals to receive healthcare and subsidized insurance, the structure of the U.S. healthcare system remains unchanged and problematic.

As I have matured, I have come to appreciate the fact that if something is too difficult to achieve a good fit, maybe it is not meant to be, and there is a better way. let us consider some examples of a good fit and a problem solved from our healthcare history. In the 1920s, even wealthy Americans were unable to pay hospital fees, and many were facing bankruptcy. doctors were not receiving payment for their fee-forservices from patients, and dr. Justin F. Kimball of baylor University wanted to ensure hospitals were paid. He invented the method of prepayment during a time when hospitals were mostly nonprofit community institutions. dr. Kimball solved the university hospital's unpaid bill problems by discovering the delinquencies were coming from local schoolteachers who were unable to pay. Kimball resolved the issue by offering teachers covered hospital stays of up to three weeks for 50 cents per month. 1,250 dallas teachers enrolled in the 28

San Antonio Medicine • October 2019

first health plan of what would come to be known as blue Cross.

In this example, the employer (the school district) directly contracted with the provider (the hospital) to provide access to care.

Another example of a problem solved is when Henry Kaiser collaborated directly with Sidney Garfield, Md who had previously saved his own hospital from bankruptcy at the height of the Great depression by shifting away from fee-for-service to collecting a prepayment of a dime-per-day from aqueduct workers in exchange for his comprehensive services. This shift away from fee-for-service to prepayment and group practice gave rise to what would be known as health maintenance and wellness, emphasizing prevention and early detection or the “new economy of medicine.”

Another case of our American, employer-financed healthcare system is with the coal miners. After a life-risking career in mining, miners often developed occupational illnesses and diseases. In 1946, President Truman, Julius Krug and United Mine Workers of America President lewis made a deal that miners would have extended health care post-retirement, funded by their last employer known as The Promise of 1946 (Krug-lewis Agreement). For decades, contracts required this stipulation. Retirement health care was so critical to union miners that they were willing to strike and accept

CORPORATE MEDICINE lower salaries from coal operators to maintain it.

Thus, we can see some examples of the American ingenuity of employers solving their problems and achieving a “good fit” directly and on a local level. It has been said in healthcare that, “if you do what is right for the patient, everything else will fall into place.” After all, we as physicians went to school and got our training so we could serve our patients. We as physicians all know that the real value in what we do is doctor-to-patient, or in our employer-financed healthcare system, clinic-to-company.

As billions of dollars are spent on lobbying and as healthcare rises on the political agenda, I fear that it takes us further away from restoring what has been lost in healthcare.

Who Pays for Healthcare in the US?

Source: Congressional budget Office; staff of the Joint Committee on Taxation.

I operate a clinic in San Antonio called direct Med Clinic. In that capacity, I feel privileged to satisfy the needs of the community in ways I have described above. The direct Primary Care (dPC) model provides access to healthcare for those who might otherwise go without it because premiums or deductibles are too high. This is done by contracting directly with small employers who value their employees but who cannot afford insurance. This allows a physician to also see to the needs of large employers through onsite clinic services. For medium-sized employers, affordable access is provided through a “near-site” model.

Practicing this way allows the use of technology to care for our patients freely by whatever modality is a good fit. It has been said that “technology has far outgrown reimbursement systems”. Technology is a tool just as any surgical instrument. In the hands of an experienced physician, it can be used that way. Patients can use HIPAA compliant secure app-to-text, upload photos, videos or do video chat. despite the government subsidy of healthcare, it is still the employer that pays for the majority of healthcare in this country.

According to Mercer’s National Survey of Employer-Sponsored Health Plans 2018, the average per-employee cost tops $13,000 among employers with 500 or more employees. With all this cost, it is ironic that employers do not actually pay those who actually provide the care.

To the extent physicians can restore the direct relationship, we can align the incentives to what was the foundation of what our American free market and employer-based healthcare system was based upon. The development and growth of the Free Market Medical Association is an example of this principle. Through price transparency, providers and healthcare facilities demystify the cost of healthcare and create a free market where the purchasers of health-

care can shop for what they need and obtain it directly and on a local level.

As we look for solutions to healthcare problems, let’s be wise and not try too hard to make something fit if there is a better way.

References Cook, b. (1999, October 01). Redefining Corporate Medicine. Retrieved August 7, 2019, from https://www.aafp.org/ fpm/1999/1000/p9.html Field, M. J., & Shapiro, H. T. (1993). Origins and Evolution of Employment-based Health benefits. In Employment and health benefits: A connection at risk. Washington, d.C.: National Academy Press.

How it all started. Retrieved August 07, 2019, from https://about.kaiserpermanente.org/our-story/our-history/howit-all-started Crosson, J. (2006). dr. Garfield's Enduring legacy--Challenges and opportunities. The Permanente Journal, 10(2). doi:10.7812/tpp/05146 Coal Act. Retrieved August 7, 2019, from http://umwa.org/for-members/pensions-retiree-info/coal-act/ Schmidt, G. United Mine Workers of America welfare and retirement funds.

Retrieved August 07, 2019, from http://ir.lawnet.fordham.edu/flr/vol16/iss2/4 Joint Committee on Taxation. Retrieved August 10, 2019, from https://www.jct.gov/ Mercer National Survey. Retrieved August 9, 2019, from https://www.mercer.us/what-we-do/health-and-benefits/strategyand-transformation/mercer-national-survey-benefit-trends.html About FMMA. Retrieved August 9, 2019, from https://fmma.org/about-us/ Roger Moczygemba, MD, graduated from Texas A&M University Health Science Center - College Station in 1992, is specialized in General Family Medicine and Occupational Medicine, and is the owner of Direct Med Clinic in San Antonio, Texas. visit us at www.bcms.org

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UT HEALTH

Whole Blood is a Trauma Game Changer

By William L. Henrich, MD, MACP President, UT Health San Antonio Professor of Medicine

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San Antonio Medicine • October 2019

UT HEALTH

Many of us went through medical school

and deputy director of the Military Health

ners that include the San Antonio Medical

best way to give transfusions. This approach

turned to a wartime solution of years ago:

Center, University Health System, the San

always seems to be in short supply. Given

Using whole blood makes sense. Military

units and the U.S. Army Institute of Surgi-

learning that blood components were the

also helped stretch donated blood, which this has been the standard approach to

transfusions since the 1970s, it is not unex-

pected that many of us probably would

Institute at UT Health San Antonio, re-

whole blood.

Antonio Fire department, helicopter EMS

studies in the Middle East showed that a

cal Research at San Antonio Military Med-

nation of the three blood components or,

Also deserving of our thanks is C.J.

quick response – strengthened by a combi-

never think about using whole blood.

in essence, whole blood – provided the best

been giving whole blood a second look –

that cold-stored whole blood has more vol-

Our military colleagues, however, have

Foundation, South Texas blood and Tissue

ical Center.

Winckler, Md, who serves as assistant clin-

chance for survival. Science also showed

ical professor of emergency health sciences

and we all are the beneficiaries. The reality

ume lasting for 35 days and, as a result of

Antonio, and as deputy medical director of

patients in our region who would have

stantly to the exact temperature needed for

dr. Winckler conducted extensive research

is that more than 25 percent of trauma

new technology, can be warmed almost in-

died before making it to a hospital for a

transfusions.

military ingenuity that has been further

search into the civilian setting and are now

blood transfusion have been saved due to

drs. Eastridge and Jenkins took this re-

developed in the civilian sector by our

proving that whole blood is the best option

This ingenuity was born out of

lowing trauma from vehicular accidents, vi-

partners in the region.

desperate need. during the wars in Iraq and Afghanistan,

too many military personnel, injured from

improvised explosive devices, hemorrhaged

before they could be flown to a field hos-

pital. Military physicians, including Army Col. brian Eastridge, Md, now a professor

for patients who otherwise would bleed to

and emergency medicine at UT Health San

the San Antonio Fire department EMS.

using fire department data to produce the

protocol that makes donations of O-positive whole blood available when and where they are needed.

As word spreads about the value of

death before ever reaching a hospital fol-

whole blood, cities, hospitals, EMS sys-

olence or medical events such as maternal

United States are now approaching the

Today, South Texas patients are the first

Council and its members to learn how to

hemorrhage and pulmonary bleeding.

tems and regional systems throughout the

Southwest Texas Regional Advisory

in the nation to receive lifesaving O-posi-

implement this new model of care. To-

before they ever reach the hospital. In fact,

partners in medicine, I encourage you to

tive, cold-stored whole blood transfusions

whole blood transfusions are now available

on all medical transport helicopters

gether with the STRAC and all our other

take great pride in this unique and stellar

collaboration through which countless

and chief of the department of Trauma

throughout this 26,000-square-mile region.

Antonio, began researching what could be

made possible because of a partnership

The logistics of performing transfusions

sory Council (STRAC), which oversees

and professor of medicine, has

and programs in 22 counties in South Texas,

San Antonio since 2009.

Emergency response in South Texas has

research, healing and commu-

and Emergency Surgery at UT Health San done differently to improve survival.

on the battlefield with blood components

are complicated, because packed red blood

This lifesaving, game-changing protocol is

under the Southwest Texas Regional Advi-

trauma and emergency health care projects

lives are to be saved.

William L. Henrich,

MD, MACP, a nephrologist

been president of UT Health

cells, platelets and plasma all have different

including the entire San Antonio area.

ments. So dr. Eastridge, along with Air

been truly transformed, and that could not

nity engagement, UT Health San Antonio is one

fessor of trauma and emergency surgery

pertise of our military and dedicated part-

www.UTHealthSA.org.

storage, testing and temperature require-

Force Col. donald Jenkins, Md, now a pro-

have been accomplished without the ex-

With missions of teaching,

of the country’s leading health sciences universities.

visit us at www.bcms.org

31

BCMS LEGISLATIVE

Reception held in honor of State Representative Leo Pacheco

By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer On Thursday, Aug. 22, bCMS Alliance past president, Jenny Shepherd and her husband, John Shepherd, Md, hosted a TEXPAC-sponsored reception in their home in honor of State Representative leo Pacheco (district 118). Rep. Pacheco was honored for his work during the 86th legislative Session in support of medicine’s issues.

Many thanks to the Shepherds for hosting the event and to the physician members, Alliance members and medical students in attendance, including: Physicians - Carmen Garza, Md; david Henkes, Md; leah Jacobson, Md; Sanjiv Kumar, Md; bCMS President, Adam Ratner, Md; Gillian Schmitz, Md; Matthew Schmitz, Md; Jayesh Shah, Md; david Shulman, Md; Alliance members - lorie boies; James duerr; danielle Henkes; Neha Shah; Martha vijjeswarapu; and Medical Students - Marc Ghosn; Swetha Maddipudi; and Ryan Wealther.

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

Guests listen as Rep. Leo Pacheco (District 118) (in dark suit), provides remarks during a TEXPAC-sponsored reception held in his honor on Aug. 22 at the home of Jenny and John Shepherd, MD.

Enjoying the reception were (standing l-r): Swetha Maddipudi, UT Health medical student; Jayesh Shah, MD; Marc Ghosn, UIW School of Medicine medical student; and Ryan Wealther, UT Health medical student.

32

San Antonio Medicine • October 2019

From (l-r): Matthew Schmitz, MD and Gillian Schmitz, MD visit with event host, John Shepherd, MD.

Event hosts John Shepherd, MD (left) and his wife, Jenny Shepherd (right) pause for a photo with guest of honor, Rep. Leo Pacheco, center, and his wife, Melva Pacheco.

BCMS LEGISLATIVE

14th Annual Border Health Conference held in Laredo

By Mary E. Nava, MBA, BCMS Chief Government Affairs Officer On August 22, members of the Texas Medical Association (TMA) leadership and leaders of the border Health Caucus (bHC), of which bCMS is a member, hosted their 14th annual conference at la Posada Hotel in laredo. A pre-conference welcome reception was hosted on the evening of August 21 at the hotel and attendees heard remarks from luis benavides, Md, chair of the border Health Caucus and Congressman Henry Cuellar (TX-district 28) and honorary conference chairman, who welcomed attendees to laredo.

Approximately, 150 conference attendees participated in the day-long conference. Numerous topics were discussed during the conference in a 3-part panel discussion, covering the areas of Access to Care, Public Health on the border and Cross border Health Care Issues.

Among the many important topics discussed were: access to care concerns, women’s health, maternal and newborn care, preventative care, the uninsured, Medicaid, public health concerns and infectious disease threats. On the discussion of cross border issues, public health officials from both sides of the border stressed the importance of continued collaboration to improve surveillance and the timely reporting of infectious disease cases.

The border Health Conference was led by luis benavides, Md and luis Urrea, Md, chair and vice-chair, respectively, of the bHC. Mistress of ceremonies was TMA board of Trustees Chair, E. linda villarrreal, Md and remarks were provided by TMA President david Fleeger, Md and immediate past president, doug Curran, Md. Representing bCMS were: John Nava, Md and Mary Nava, bCMS chief government affairs officer.

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

On Aug. 21 during the Border Health Conference welcome reception held at La Posada Hotel in Laredo, Luis Benavides, MD (far left) introduces honorary conference chairman, Congressman Henry Cuellar (TX-District 28), (in dark suit), who provided welcome remarks to attendees.

TMA President, David Fleeger, MD provides welcome remarks to attendees of the Border Health Conference held on Aug. 22 at La Posada Hotel in Laredo. visit us at www.bcms.org

33

MEDICAL STUDENT PERSPECTIVE

A Bilateral Pleural Illusion

By Christian Jacobsen, MS2, UTHSCSA – LSOM

It's easy to forget our lungs and the type of air that we breath. After taking anatomy, seeing the lungs, and taking a class in pulmonology, it really struck me how important it is to breathe clean air. My grandfather passed away from lung cancer that metastasized to his brain; cancer that was originally caused by working with asbestos combined with a lifetime of smoking. His death was ultimately caused by breathing in toxins, polluting his lungs.

This drawing highlights the importance of keeping our lungs clean. The opposing sides of the image reflect the color of what a lung looks like in each given circumstance. On the polluted side, lungs turn black and dark. On the clean side, lungs retain a pink and healthy looking color.

In summary, it's easy to neglect things we can't see. "Out of sight, out of mind." Our lungs reflect what we breathe.

34

San Antonio Medicine • October 2019

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY

Please support our sponsors with your patronage; our sponsors support us.

ACCOUNTING FIRMS Sol Schwartz & Associates P.C. (HH Silver Sponsor) We specialize in areas that are most critical to a company’s fiscal well-being in today’s competitive markets.

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

ACCOUNTING SOFTWARE

Express Information Systems (HHH Gold Sponsor) With over 29 years’ experience, we understand that real-time visibility into your financial data is critical. Our browser-based healthcare accounting solutions provide accurate, multi-dimensional reporting that helps you accommodate further growth and drive your practice forward.

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

ATTORNEYS

Constangy, Brooks, Smith & Prophete (HHH Gold Sponsor) Constangy, Brooks, Smith & Prophete offers a wider lens on workplace law. With 190+ attorneys across 15 states, Constangy is one of the nation’s largest Labor and Employment practices and is nationally recognized for diversity and legal excellence.

Kathleen Barrow Partner 512-382-8796 kbarrow@constangy.com Ashlee Mann Ligarde 512-382-8800 aligarde@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

36

San Antonio Medicine • October 2019

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

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

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

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

Thornton, Biechlin, Reynolds, & Guerra (HHH Gold Sponsor) Worried about the TMB, government audit, or investigation? From how to avoid TMB complaints to navigating the complex regulations of government agencies like Medicare and Medicaid, we stand ready to guide and protect our clients.

Robert R. Biechlin, Jr., Partner (210) 581-0275

rbiechlin@thorntonfirm.com Michael H. Wallis Partner (210) 581-0294 mwallis@thorntonfirm.com Kevin Moczygemba, Associate 210-377-4580 kmoczygemba@thorntonfirm.com https://thorntonfirm.com “Protecting Physicians and Their Practices”

ASSETS ADVISORS/ PRIVATE BANKING

BB&T (HHH Gold Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services — BB&T offers solutions to help you reach your financial goals and plan for a sound financial future.

Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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.

Joseph Bieniek Vice President Small Business Specialist 210-247-2985 jbieniek@bbandt.com Ben Pressentin 210-762-3175 bpressentin@bbandt.com www.bbt.com

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”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

Broadway Bank (HHH Gold Sponsor) Healthcare banking experts with a

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY private banking team committed to supporting the medical community.

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

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) 750-8331 or info@synergyfcu.org www.synergyfcu.org “Once a member, always a member. Join today!”

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

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

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

COMMERCIAL PROPERTY MANAGMENT

Elizabeth.olney@edwardjones.com www.edwardjones.com/elizabetholney "Making Sense of Investing"

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com James Murry, Associate Realtor 210.314.7835 murry@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

DIAGNOSTIC IMAGING

Touchstone Medical Imaging (HHH Gold Sponsor) To offer patients and physicians the highest quality outpatient imaging services, and to support them with a deeply instilled work ethic of personal service and integrity.

Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

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

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

Elizabeth Olney, Financial Advisor (210) 493-0753

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Rene Farret Wealth Management Advisor 210-278-3806 rene_farret@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Jon M. Tober SWBC Mortgage—Sr. Loan Officer NMLS #212945 (210) 317-7431 jon.tober@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Tom Jordan SWBC Investment Services, Executive Benefits and Business Planning Advisor 210-376-3378 thomas.jordan@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

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!”

BankMD (HHH Gold Sponsor) We believe Physicians deserve specialized products and services to meet the challenging demands of their career and lifestyle.

Moses D. Luevano Market President 512-663-7743 mdl@bankmd.com www.bankmd.com “BankMD, "Specialized, Simple, Reliable" Banking for Doctors”

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

continued on page 38

visit us at www.bcms.org

37

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

rlgarcia@ft.newyorklife.com Efrain Mares, Agent 956-337-9143 emares@ft.newyorklife.com www.newyorklife.com/agent/ garciae “The Company You Keep”

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 Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth” Capital CDC (HH Silver Sponsor) For 25 years, Capital CDC has worked with hundreds of small 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.”

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

38

San Antonio Medicine • October 2019

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”

BBVA Compass (HHH Gold Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash management, lending, investments, insurance, and trust services.

Josh Collins SVP, Global Wealth Executive 210-370-6194 josh.collins@bbva.com Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities"

HEALTHCARE CONSULTING

CareAllies (HHHH 10K Platinum Sponsor) CareAllies works side-by-side with health care providers to accelerate the transition to valuebased care, helping improve the quality, value and experience of care for patients and make health care better for everyone.

Sabrina Moreno, Network Operations Senior Manager (713) 437-3088 X 523088 Sabrina.Moreno@careallies.com info@careallies.com https://www.careallies.com/ “For Better Health and Better Business”

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 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”

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 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

HOSPITALS/ HEALTHCARE SERVICES

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

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

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

Wendell England 512-370-1746 wengland@tmait.org James Prescott 512-370-1776 jprescott@tmait.org John Isgitt 512-370-1776 www.tmait.org “We offer BCMS members a free insurance portfolio review.”

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY OSMA Health (HHH Gold Sponsor) Health Benefits designed by Physicians for Physicians.

Bill Brooks Senior Vice President (214) 329-4584 BBrooks@abadmin.com www.osmahealth.com/ “People you know Coverage you can trust”

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 endorsed by the Texas Medical Association, the Texas Academy of Family Physicians, and the Dallas, Harris, Tarrant and Travis county medical societies.

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

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 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

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

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 Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BILLING AND COLLECTIONS SERVICES

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a checkup?

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

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

MEDICAL PRACTICE

UT Health Physicians (HHH Gold Sponsor) UT Health Physicians, the faculty practice of UT Health San Antonio, features the region's most

comprehensive array of specialists & sub-specialists. Now offering free, secure access to your patients’ records. Most health plans accepted.

For referrals or questions, contact: Jose Gamez, Director, Physician Relations (210) 450 8347 GamezJ4@uthscsa.edu www.UTHealthcare.org “Offering daily grand rounds with no-cost CME to local physicians since 1969.”

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.”

MORTGAGE

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

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

PRACTICE SUPPORT SERVICES

SWBC ( 10K Platinum Sponsor) SWBC for Personal and Practice: Physician programs for wealth management and homebuying; For Your Practice: HR administration, payroll, employee benefits, property insurance, and exist strategies Tom Jordan SWBC Investment Services, Executive Benefits and Business Plan-

continued on page 40

www.bcms.org 39 39 visitvisit us us at at www.bcms.org

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 39

ning Advisor 210-376-3378 thomas.jordan@swbc.com Maria Martinez SWBC Insurance Services, Commercial Lines Producer (210) 376-3478 maria.martinez@swbc.com Michael Gugliotti SWBC PEO, Sales Manager 830-980-1236 MGugliotti@swbc.com Debbie Marino SWBC Employee Benefits, SVP Corporate Relations (210) 210-525-1248 DMarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

Acumen Systems, LLC (HHH Gold Sponsor) Acumen Systems specializes in helping practices become more efficient and profitable, and aims to accelerate their growth with proven successes and systems William J. Trijullo Medical Services Representative 210-800-5500 wtrujillo@acumen.systems Christiane Escobar, CMRM Certified Medical Revenue Manager 210-687-5506 cescobar@acumen.systems Angeles Hubard Medical Revenue Representative 210-867-3834 ahubard@acumen.systems https://acumen.systems When was the last time your medical practice had a check-up?

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 non-

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San Antonio Medicine • October 2019

profit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

Tom Tidwell, President info4@samgma.org www.samgma.org

REAL ESTATE SERVICES COMMERCIAL

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

Connie P. Raub Executive V. Pres., Broker Associate Realtor 210.314.7838 cpraub@investmentrealty.com Joanne Vollmer Mirelez, CCIM, MHA, Broker Associate Realtor 210.314.7843 joanne@investmentrealty.com James Murry, Associate Realtor 210.314.7835 murry@investmentrealty.com www.InvestmentRealty.com Expect Extensive research, innovative solutions, value added services, unparalleled service."

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

RESIDENTIAL REAL ESTATE

Phyllis Browning Company (HHH Gold Sponsor) Our expertise is your advantage.

We have served the buyers and

sellers of premier Texas properties for over 29 years, earning our reputation as the very best independent residential real estate firm in San Antonio and the Hill Country.

Craig Browning MBA, GRI, ALHS, REALTOR® (210) 408-2500 x 1285 cbrowning@phyllisbrowning.com www.phyllisbrowning.com Robin Morris CRP, GDS, GRP, REALTOR® Director of Relocation & Business Development 210-408-4028 robinm@phyllisbrowning.com “Premier Properties, Singular Service, Exceptional Agents”

RETIREMENT PLANNING

Merrill Lynch ( 10K Platinum Sponsor) We are uniquely positioned to help physicians integrate and simplify their personal and professional financial lives. Our purpose is to help make financial lives better through the power of every connection.

Mike Bertuzzi Senior Financial Advisor 210-0278-3804 michael_bertuzzi@ml.com Tiffany Mock Briggs Wealth Management Advisor 210-278-3813 Tiffany_briggs@ml.com Ben Taylor Wealth Management Advisor 210-278-3802 ben_taylor@ml.com Ruth Torres Financial Advisor 210-278-3828 ruth.torres@ml.com https://www.local.ml.com/san_an tonio_0506ub/ “Life’s better when we’re connected®”

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.

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

TELECOMMUNICATIONS ANSWERING SERVICE

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

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

For questions regarding services, Circle of Friends sponsors or joining our program please contact August Trevino, Program Director at 210-301-4366, August.Trevino@bcms.org, 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

GUNN AUTO GROUP

11001 IH 10 W at Huebner San Antonio, TX

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Esther Luna 210-690-0700

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Ford 12300 San Pedro San Antonio, TX

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

Cavender Toyota 5730 NW Loop 410 San Antonio, TX

Marty Martinez 210-525-9800

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

David Espinoza 210-912-5087

Rick Cavender 210-681-3399

Gary Holdgraf 210-862-9769

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

North Park Subaru 9807 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

Mark Castello 210-308-0200

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

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

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

Sandy Small 210-341-8841

James Cole 800-611-0176

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

San Antonio, TX

Porsche Center 9455 IH-10 West San Antonio, TX

Ed Noriega 210-561-4900

Matt Hokenson 210-764-6945

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

AUTO REVIEW

2019 BMW M850i Convertible

By Stephen Schutz, MD

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San Antonio Medicine • October 2019

AUTO REVIEW The 2019 bMW M850i convertible is an impressive car that will get you where you’re going quickly and in style, but it’s not for everyone. While it’s an exaggeration to say that only well-heeled singles, dINKs, and empty nesters need apply, it’s not far from the truth.

For starters, bMW’s flagship car is a two-plus-two with a cabin that should really only be inhabited by one or two people. The rear seats are located extremely close to the front ones and therefore have very little leg room, so it’s not wrong to consider them bilateral briefcase holders (headroom back there is also poor, by the way.) Still, the rear seats are as sumptuous as the front ones, which means your briefcase or groceries get to sit on the same high quality leather as you do, a fact I find quite amusing, actually.

And the bMW M850i is as over-engined as it is under-passenger spaced. Using a 523HP version of the 4.4l twin turbo v8 that propels the portly X7 SUv, the M850i can zip from 0–60 MPH in just 3.6 seconds. This is a fast car.

The M850i’s exterior design is well done and should appeal to its target demographic. Substantial and very “Grand Touring” is how I’d describe the styling. The profile flows nicely, the rear looks contemporary and chic, and the front has visual heft. I’ve criticized various bMW designs in the past as having too many trees and not enough forest, and I’ve given demerits to the 7-series for lacking gravitas. but none of those negatives apply to the M850i, which manages to look cohesive, sporty, and expensive all at the same time. Thankfully, adding a cloth convertible top doesn’t subtract from the appeal of the M850i’s styling. In fact, you could argue that the convertible looks better than the coupe.

As alluded to above, the interior of the M850i, while being almost impossibly tight for rear passengers, is a very nice place to be. All of the materials look and feel rich, and, despite my best efforts, I didn’t find any sub-par plasticky areas.

Still, it’s the tech you notice most when driving the M850i. bMW gauges used to have white numbers and needles over a black background with orange backlighting. No more. Now everything’s virtual and configurable, and located on a screen right in front of the driver.

The curmudgeon in me wants to not like this change, but I do. visibility and, critically, the imparting of important information, are significantly enhanced, which is really all that matters. driving the M850i is a treat, mostly because of the muscular engine described above, but also because of a very well sorted chassis. The ride is a little rougher than I’d like, but the handling is first rate, especially on high speed b-roads and open highways.

Nevertheless, the overwhelming sense you get when driving this car is that it’s fast. like very fast in all conditions at all times.

All 850is come with the excellent and ubiquitous 8-speed automatic transmission sourced from German supplier ZF. If you drive a fairly new car, SUv, or crossover, and it has an 8-speed transmission, it’s very likely to be from ZF. be grateful that you have it.

One qualm I have with the driving experience is common to many modern cars, though not most SUvs and crossovers: relatively poor visibility. I blame high door sills that make you feel as though you’re sitting in a bathtub as well as a relatively tall hood that makes the road seem far away. both of those realities are due to more stringent safety regulations: high sills protect passengers in case of a collision, while the tall hood mitigates injuries to pedestrians in case you hit them. Safety is a good thing, of course, and these particular changes are common to all manufacturers not just bMW, but they subtract from the joy of driving.

In case you’re curious – and I can’t imagine many M850i buyers will be – fuel economy for bMW’s nicest grand tourer comes in at 16 MPG City and 25 Highway. The price is just over $122,000 to start, and there are many option packages and other extras, which can increase that number significantly. As always, call Phil Hornbeak at bCMS headquarters to get your best deal on a bMW M850i or any other vehicle you’re interested in.

The 2019 bMW M850i convertible is a wonderful grand tourer designed to carry one or two individuals quickly and comfortably either over vast distances or just out to dinner. It’s not a car for everybody, but if you’re fortunate enough to be able to afford it, and you don’t need to transport kids to soccer practice or wherever, this is a bMW you’ll be happy to own.

To get your best deal on a new bMW, call Phil Hornbeak at bCMS 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 45 45 visit us us at at www.bcms.org

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

MEDNAX

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Peripheral Vascular Associates, PA

Dermatology Associates of San Antonio, PA

San Antonio Eye Center, PA

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ENT Clinics of San Antonio, PA

San Antonio Infectious Diseases Consultants

Gastroenterology Consultants of San Antonio

San Antonio Kidney Disease Center

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Alamo Medical Group

Institute for Women's Health

South Texas Radiology Group, PA

Lone Star OB-GYN Associates, PA

The San Antonio Orthopaedic Group

M & S Radiology Associates, PA

Urology San Antonio, PA

MacGregor Medical Center San Antonio

Contact BCMS today to join the 100% Membership Program! *100% member practice participation as of September 19, 2019.

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San Antonio Medicine • October 2019