San Antonio Medicine November 2020

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Telemedicine

Telemedicine in COPD and Other Vulnerable Patients

By John J. Seidenfeld, MD, MSHA, FACP and Alexandra G. Bailey .......................................................12 Telemedicine Under COVID-19

By Alan Preston, MHA, ScD ..........................................14 TMA Telemedicine Visit Checklist

By Texas Medical Association........................................16 Telemedicine Incorporation into a PCP During the Pandemic By Joyce Yuen, DO, and Ramon Cancino, MD, MS, FAAFP .................................18 Texas Medical Board Telemedicine FAQs

By Texas Medical Board ................................................21 TMA Telemedicine: Getting Started

By TMA COVID-19 Taskforce .......................................22

BCMS President’s Message .....................................................................................................................................8 BCMS Alliance .......................................................................................................................................................10

NOVEMBER 2020

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VOLUME 73 NO. 11

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San Antonio Medicine • November 2020

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

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

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San Antonio Medicine • November 2020

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

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

PRESIDENT’S MESSAGE

Telemedicine: Will it Survive the Pandemic?

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

The current COVID-19 pandemic has led to changes in the practice of medicine all over the world. Beginning in March 2020, many practices in Bexar County and in Texas began a transition to telemedicine. Aside from clinical concerns regarding the adequate delivery of medical care, economic and technology constraints initially limited this practice. The initial days of telemedicine forced physicians to either shut down their practice for an indefinite period-of-time with zero revenue or adapt to the new system.

The practice of medical care delivery by what is now called telemedicine began in the military. In order to provide adequate care to deployed forces with a limited number of physicians, a new technique of communication and care-delivery was developed.

Often through the use of cameras and secure communication techniques, medical care in austere environments was provided at a highly sophisticated level. In the original telemedicine scenarios, communication from frontline providers was often with some of the most highly trained clinicians in the military, located at medical teaching facilities. This enabled those frontline providers, such as combat medics and physician assistants, to provide medical care at higher levels of sophistication in a combat environment. While this did not allow the performance of surgical procedures, it did enable appropriate decision-making for the individual patient. This insured that those patients who needed to be evacuated from frontline medical treatment facilities could be identified.

Efforts by the Texas Medical Association in the 2017 legislative session achieved coverage parity for telemedicine visits for a covered service. However, the new law did not mandate payment parity. This meant that healthcare plans were not required to pay physicians the same for a telemedicine visit as was paid for a similar in-person visit. The onset of the current COVID-19 pandemic

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forced state and federal government agencies to drop the payment barriers to delivering medical care by telemedicine. Beginning in March and into April 2020, due to the public health emergency, the Centers for Medicare and Medicaid Services (CMS) relaxed certain regulations. This enabled "all beneficiaries across the country (to) receive Medicare telehealth and other communications technology-based services wherever they are located." Medicare also greatly expanded payment for these telehealth services; and this is to continue for the duration of the public emergency. The Texas Department of Insurance (TDI), as well as many of the largest commercial health plans, have followed the lead of CMS in providing reimbursement for telemedicine services.

Due to the ongoing pandemic, many patients have welcomed the opportunity to continue their medical care from the safety of their homes, offices, or even vehicles through the use of telemedicine. While this was initially a challenge to some physician offices, as time has passed it has become more and more efficient. This was initially literally a telephone medicine consultation. Now the use of smart phones and computers has added a video component.

This has allowed patients to reduce the risk of exposure to the virus and to save time and money involved in visits to a physician office. For physicians it has often made medication adjustments easier and more rapidly accomplished. The increased flexibility will hopefully allow physicians to provide the highest level of medical care during and even after the current healthcare emergency.

In a recent survey of Texas physicians, over 80% of respondents do or plan to offer telemedicine services to their patients. This includes a majority of both surgical and nonsurgical specialists. There are, however, limitations to the use of telemedicine. It is much more useful in the treatment of established patients or for follow-

PRESIDENT’S MESSAGE

up visits. Treatment of patients who require laboratory or radiographic studies or where physical examination is required in order to establish a diagnosis may not be candidates for telemedicine. The use of video components to telemedicine such as with smart phones may allow the expansion in the types of patients who can be adequately treated.

Another impediment to the delivery of care by telemedicine is the lack of adequate broadband access, especially prevalent in rural areas. This does not exclude the limitations of many urban neighborhoods as has been shown with the current problems for virtual education in the school system. Current fixes which are being applied in the face of educational requirements may allow wider use of telemedicine in all communities. This is especially helpful in disadvantaged communities where patients must use public transportation and often have limited funds. The expanded use of telemedicine has also allowed a reduction in the number of visits to emergency centers for acute care. This has resulted in a decreased cost for providing this emergency care. It is hoped that with cost shifting these savings can be applied elsewhere in the medical care delivery system.

Currently, the future of telemedicine is somewhat unclear. Once the COVID-19 crisis has been averted, the continued use of telemedicine will be based on data showing how well it actually

works. There is already data showing that it drives down the costs of emergency care. The question remains whether a year from now those practices which currently use telemedicine will continue to offer it as an option. Certainly, decisions by CMS will have a role in whether telemedicine continues to be a viable option or not. If the billing and coding for telemedicine does not work and, if reimbursement is not adequate, many practices may resort to conventional medicine. However, if we as physicians continue to provide the same amount of problem-solving care as we would otherwise give, we will hopefully preserve this option for ourselves and for our patients.

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

BCMS ALLIANCE

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TELEMEDICINE

Telemedicine in COPD and Other Vulnerable Patients

By John J. Seidenfeld, MD, MSHA, FACP & Alexandra G. Bailey Consideration of best practices for the vulnerable patient, or those at greatest risk of death and disability, is imperative. COPD patients are a cohort vulnerable to infections, pollutants, and other toxic inhalants such as streptococcus pneumoniae, ozone and toxic gases, and pollens, respectively.

Previous evidence has pointed out that these patients receive a high degree of low value services without improvement1. These patients value and prioritize convenient, high quality, and inexpensive aspects of medical care. Telemedicine may be used for many applications from health care provider (HCP) to HCP consultation, HCP to patient visit, patient management and monitoring of disease, resource sharing, and communication for alerts, advice, and education.

Since the widespread use of the “smart” phone in 2010, this mode of eHealth has been explored and discussed with journals solely devoted to it. While some may have been skeptical of telemedicine in the past, it has allowed practitioners to continue to treat their patients in these demanding times2.

Consider problems with the waiting room before 2020: confined space and air rebreathing, other vulnerable patients and their caregivers, no screening prior to entry of health care personnel or patients and family members, rare PPE use and a high likelihood of contagion spread. Conversely, telemedicine promises greater convenience and reduced exposures for all vulnerable patients, including those with COPD, improved access for close and distant patients, enhanced immunization education and prompts, environmental hazard warnings, and fewer ED visits. Improved screening, diagnosis, triage, and prioritization may be done with algorithms and mid-level provider interactions3,4.

Telemedicine, both in the time of this COVID-19 pandemic and what was once considered “normal” life, provides many benefits for the entire healthcare system5. Organized medicine has long fought to provide adequate medical care to rural America, supplying incentives to young doctors to work there even if only for a few years. Urban America, as well, poses a challenge. The same areas that have become known as “food deserts”, are also known to be short on medical staff and supplies. Telemedicine brings exceptional care to these underserved areas. Telehealth opens the doors for specialists to treat patients without requiring a trek cross country for a 12

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single consultation. Even in emergency departments which have a high burden of behavioral health patients, staff can work directly with a telehealth behavioral provider, for example, to determine the best course of action and enable staff to treat other critical patients6.

Another daunting task the health care system faces is monitoring adherence to treatment and treatment success. Telemedicine and the incorporation of biomedical devices that fit into our hands or lay on our wrists allow for a more quantitative assessment in determining the success of a treatment plan. From rings that monitor your oxygen saturation, displaying data on your phone, to watches that can detect if you have an irregular heartbeat, patients may play an active part in their treatment and providers gain tools for management and treatment.

Like the current healthcare system, an efficient telemedicine system is complex and will not be built overnight. In a time of crisis, we make do with what we have. However, if we hope to incorporate the use of telemedicine after this pandemic, we must conquer a few barriers. These include CPT coding broad acceptance, inter-operability of eHealth record systems, licensing acceptance nationwide and HIPAA compliance. Other concerns or fears are the threat of “Bot” replacement of health care workers, the lack of “hands on” perception of impersonal care, “best” site of care decisions for providers and patients, and inertia of “overcoming the way it has always been done”.

In addition, some vulnerable patients and communities that could most benefit from telemedicine lack the infrastructure capable to support telehealth7. Governmental action is necessary to provide these communities, that often have the greatest health disparities, with adequate infrastructure. At the very least, we could provide regions most affected by COVID-19 with low cost or free broadband internet access which might accompany rural electrification.

Technology itself is a substantial hurdle for telemedicine. Older individuals should be directed toward telemedicine, especially during pandemics or epidemics, and helped to understand the technology.

In this case, technological literacy may be a matter of life and death; so improving access to technological education or creating an intuitive user interface is imperative to the use of telemedicine for older populations.

TELEMEDICINE

Finally, with this pandemic, many health insurers have begun covering telehealth services3. This coverage is critical now and afterwards. Geographic areas, vulnerable patients, veterans, and the disadvantaged that have often felt betrayed or left out will greatly benefit by access to telehealth care services. The actual benefit of telehealth has just scratched the surface of its full potential. There is much hard thought and work to be done.

John J. Seidenfeld, MD, MSHA, FACP is a member of the Bexar County Medical Society and its Publications Committee; Alexandra G. Bailey is a Biomedical Engineering Student at The University of Texas at Austin.

References 1) https://www.choosingwisely.org/ 2) Duffy S, Lee TH. In-person health care as option B. N Engl J Med 2018;378:104-106.

3) Joshi AU, Randolph FT, Chang AM, et al. Impact of emergency department tele-intake on left without being seen and through-

put metrics. Acad Emerg Med 2020;27:139-147.

4) Langabeer JR II, Gonzalez M, Alqusairi D, et al. Telehealth-enabled emergency medical services program reduces ambulance transport to urban emergency departments. West J Emerg Med 2016;17:713-720.

5) Goodfellow A, Ulloa JG, Dowling PT, et al. Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review. Acad Med. 2016;91(9):1313-1321. doi:10.1097/ ACM.0000000000001203 6) Douglas MD, Xu J, Heggs A, Wrenn G, Mack DH, Rust G. Assessing Telemedicine Utilization by Using Medicaid Claims Data.

Psychiatric Serv. 2017;68(2):173-178. doi: 10.1176/ appi.ps.201500518 7) Jain KM, Bhat P, Maulsby C, et al. Extending access to care across the rural US south: Preliminary results from the Alabama eHealth program. J Telemed Telecare. 2019;25(5):301-309. doi:10.1177/1357633X18755227

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Telemedicine Under COVID-19

By Alan Preston, MHA, ScD COVID-19 has forced all types of participants in the marketplace to innovate in an effort to stay in business. Unfortunately, many companies were unable to pivot quickly enough, and as a result, they have gone out of business. Well-known companies such as Neiman Marcus, JC Penny, J. Crew, Diamond Offshore Drilling, Gold's Gym, Sur la Table, Hertz, and Bravo restaurants, to name a few, have filed for bankruptcy protection. There is a tendency to dismiss the failure of some of these companies. Some reasons are due to the popularity of Amazon for online shopping and energy companies for the glut of oil in the market, causing the price of a barrel of oil to plummet.

And all too often, business owners think it cannot happen to them. Unfortunately, when the government decides to shut one business down over another, often there is little the business can do. Take Gold's Gym as an example. On a recent trip to California, 14

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I was unable to go to the gym because that State closed gyms to protect residents. Had the gym sold food, maybe the government would allow a few people to enter the premises. Likewise, the government decided that certain medical services were banned, placing enormous financial strains on hospitals and healthcare providers that perform elective surgeries and procedures.

Two fundamental problems face business during the "management" of COVID-19: 1. The demand for services drops off precipitously for most services

2. The supply is restricted due to social distancing constraints (such as only allowing 25% of customers entering into a location) imposed on businesses by local governments.

TELEMEDICINE

For a physician practice, the demand for services may exist; however, much of the public is frightened to visit a doctor's office out of fear they may become infected with COVID-19. Therefore, the demand is reduced. Furthermore, the supply (i.e., healthcare providers, including MAs, NPs, PAs, and doctors, as well as the back office to manage the demand) is diminished for many practices.

Whether shutting down businesses is an effective strategy to mitigate COVID-19 remains to be seen.

How can a physician mitigate the lower demand for services during this pandemic? Telemedicine is one way for patients to seek medical advice while at their home. And conversely, not having a patient come into the office helps the physician manage their supply and capacity issues at a physical location. Telemedicine is not a panacea by any stretch; however, it can help mitigate some of the issues mentioned supra. Patients can seek needed advice, and the physician can decide who should be involved in managing a patient's medical concern (i.e., the triage approach).

Prior to COVID-19, physicians were reluctant to adopt Telemedicine for a variety of reasons. Two of the biggest reasons had to do with compliance with the Federal Government and the payment associated with such visits. CMS has relaxed the rules and Texas has also followed suit. The Texas Medical Association (TMA) surveyed Texas doctors and asked them in April 2020 if they would use Telemedicine. 80% indicated they would.

Payment parity is a very important issue for physicians. Many physicians believe that as long as a contracted physician performs a covered service that meets the standard of care for a particular episode of care, then what a Managed Care Organization (MCO) pays for such service shouldn't be conditioned on the location, meaning office, video, or telephonic visit. The good news is that CMS has created payment parity. Medicare pays the same amount for Telehealth services as it would if the service were furnished in person. Not all MCOs have adopted payment parity; thus, physicians should seek advice when seeing a non-Medicare or Medicaid patient.

The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) define Telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration. Technologies include videoconferencing, the internet, imaging, streaming media, and landline and wireless communications.

The Telemedicine services a physician can provide under the Public Health Emergency (PHE) section 1135 waiver is quite extensive.

All services that a covered health care provider, in their professional judgment, believe that can be provided through Telehealth in the given circumstances of the current emergency are covered. This includes diagnosis or treatment of COVID-19 related conditions, such as taking a patient's temperature or other vitals remotely, and diagnosis or treatment of non-COVID-19 related conditions, such as a review of physical therapy practices, mental health counseling, or adjustment of prescriptions, among many other services.

As more physicians and patients adopt Telehealth platforms, it is likely that Telehealth will remain a terrific alternative to an in-person office visit for many patients. This is particularly true for patients that have a long drive to a physician's office. Adopting new technologies to meet the demand of existing patient services is a terrific way to accommodate the marketplace. Additionally, many patients would rather have a video conference in the comfort of their home as opposed to driving to a doctor's office waiting for their name to be called. Not that Amazon is a fair comparison per se; however, creating a great customer experience at the convenience of the patient will create an ongoing demand for physician services via Telemedicine. The world is changing, and organizations must decide whether they will and can adapt to the changing environment or potentially face bankruptcy for failing to innovate.

Alan Preston works in the area of Population Health Management and has a doctorate in Science in Epidemiology and Biostatistics from Tulane University and has spent his entire career in the healthcare space. visit us at www.bcms.org

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TELEMEDICINE

Telemedicine Incorporation into a PCP During the Pandemic

By Joyce Yuen, DO, and Ramon Cancino, MD, MS, FAAFP

With the emergence of SARS-CoV2, the novel coronavirus that causes COVID-19, the medical community had to quickly adapt from traditional face-to-face healthcare delivery to one that utilizes more telemedicine due to concerns about potential risk of exposure to clinicians, staff, patients and the community. While the concept of telemedicine is not new, multiple barriers constricted physicians from fully embracing this technology, including compliance and reimbursement concerns.1,2 However, recent policy changes have reduced the barriers to provide telemedicine to patients.3 During this public health emergency, in order to maintain the ability to care for its patients, UT Health San Antonio implemented telemedicine. UT Health Physicians primary care was one of the first UT Health Physicians practices to implement video visits, and was the first to implement On-Demand Urgent Care video visits to meet the acute medical needs of its patient population.

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TELEMEDICINE

Multiple lessons were learned during UT Health San Antonio’s telemedicine implementation that are relevant for any organization, small or large.

Start with a small pilot, then implement iteratively. This first primary care practice to implement video visits, with the support of IT and clinical operations, included only 2 scheduled visits in its first day of operations. With a fail-fast mentality and an eye towards continuous improvement, the lead physician and team assessed the clinician and patient experiences after each visit. The first few visits went smoothly, and lessons learned from this pilot phase were quickly integrated into the implementation process at other primary care practices as well as the rest of the UT Health San Antonio. Utilizing a constant feedback loop between physicians, staff, patients, operations, and Health IT, the team was able to continue to improve multiple processes, including virtual patient “rooming,” adjusting templates for both in-person and telemedicine appointments, and identification of inappropriate telemedicine visit chief complaints which would require in-person appointments instead.

Educate all stakeholders so the focus can remain on delivering medical care to patients. While the entire organization was learning how to effectively utilize telemedicine, the expectation to deliver the best care possible to patients remained. Physicians enhanced history-taking workflows and adjusted reliance on physical exams. Staff helped contribute to new scheduling, follow-up, and communication workflows. Patients acclimated to speaking with their primary care physician from their phone or computer. We were all learning. The Health IT team developed telemedicine training materials to teach physicians, staff, and patients. At the same time, marketing updated patient-facing education on current and new websites. This education was important because, while technological concerns and barriers were certainly front-and-center, the focus needed to be on the medical needs of our patients. An educated workforce and patient-base ensured that, when virtual visits occurred between patients and clinicians, the technology did not overshadow the medicine.

Do not forget to communicate regularly. During times of volatility, uncertainty, complexity, and ambiguity, as physician leaders we should respond with agility, information, restructuring, and experimentation.4 The implementation of telemedicine required clinical, operational, and technological adjustments, which meant communication needed to be constant. UT Health Physicians primary care leadership implemented nightly “debrief ” meetings to assess the constantly changing environment in order to make proactive decisions for the following day. During these meetings, input from physician and operations leaders were aggregated and processes were updated for the next day. Morning clinical team huddles ensured the changes agreed upon the evening before were

clearly communicated to all faculty and staff. Updated process maps were sent out if needed. These meetings ensured all stakeholders were able to not only give input to developing telemedicine workflows but ensured questions and feedback were funneled to the appropriate decision-makers.

COVID-19 continues to require us to innovate. In a normal environment, ensuring timely access to care is extremely crucial to high-value care. Challenging this is the fact that the COVID-19 public health emergency has made patients more hesitant to leave home for medical concerns.5,6 To improve patients’ access to medical care, we started offering On-Demand Urgent Care video visits in June 2020. Patients access this service through the UT Health San Antonio Epic patient portal; the service is staffed by primary care clinicians.

The lessons learned from our telemedicine implementation helped inform the implementation of On-Demand Urgent Care video visits. We utilized a “soft opening” without any marketing to pilot the new care delivery process. We utilized feedback from our Primary Care Patient and Family Advisory Council to help inform our marketing team about On-Demand Urgent Care video visits.

After seeking further input from our primary care team, we trained all primary care clinicians on the new processes and workflows, including how to utilize a “virtual” On-Demand clinical supervisor to assist with patient communication and IT issues. Lastly, we implemented weekly debrief meetings to collect clinician feedback on and update workflows. We also personally outreach to every patient who utilizes On-Demand Urgent Care video visits in order seek feedback so that we can constantly improve.

On-Demand Urgent Care video visits are primary care focused, continued on page 20

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continued from page 19

because continuity of care matters.7 Different from urgent care business models which solely focus on acute concerns, current UT Health Physicians patients who utilize On-Demand care will find that On-Demand clinicians can ensure communication of the visit to their own UT Health Physicians primary care physician. On-Demand team members can connect primary care patients to their specific medical home even before the appointment begins. A team lead and a clinical supervisor help facilitate communication between the On-Demand provider and the patient’s primary care physician so that there is seamless care for patients. Importantly, if a chief complaint is determined to be inappropriate for an On-Demand visit, our team helps facilitate the scheduling of an in-person appointment at their medical home. Patients even receive follow-up calls one or two days after their On-Demand visit to ensure the patients acute issues are improving and to further help maintain continuity of care with the patient’s primary care physician.

Overall, the response from patients has been extremely positive.

Patients repeatedly tell us that the service is high-quality, accessible, and convenient. They appreciate the ability to receive medical care rapidly, on their schedule, and often from home. Over the past few months, patients aged 20 to 50 years old have utilized the service the most. However, we have had patients as old as 90 years old successfully complete a visit. Patients have been logging into On-Demand Urgent Care for upper respiratory symptoms, COVID concerns, urinary tract infections as well as other minor illnesses.

There are limitations and challenges to telemedicine.

The physical exam is limited. While some patients have thermometers, pulse oximeters, and blood pressure monitors at home to take their own vitals, others do not, potentially making the telemedicine visit less effective. We anticipate that there will soon be a proliferation of cost-effective telemedicine vitals collection equipment, such as interactive digital stethoscopes, which will help clinicians conduct more in-depth physical exams via virtual care.

The future of reimbursement is still open-ended. It is uncertain whether telemedicine visits will continue to be reimbursed at similar rates as compared to in-person visits. If current policies expire, then it will be difficult to continue providing patient’s care through telemedicine.

Disparities may still exist. Telemedicine using video visits certainly increases access to those with video visit-capable technologies, such as smartphones with data plan and home computer with camera, microphone and internet connection, at their disposable, but we worry that those who do not have access to these technologies may not benefit. Reimbursement limitations for “audio-only” (telephone) visits may further widen gaps in access to care.

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Although telemedicine is not a new care delivery option, COVID19 has sped-up its implementation and utilization. Facilitated by advances in technology and a receptive patient population, telemedicine is currently meeting the needs of the community while catering to the wants of patients. It will be interesting to see how clinical medicine and telemedicine will continue to change and adapt into the future.

Joyce Yuen, DO, is a Lead Physician with UT Health Primary Care On-Demand Urgent Care.

Ramon Cancino, MD, MS, FAAFP, is Director, UT Health Physicians Primary Care and is a member of the Bexar County Medical Society.

References: 1. Lurie N, Carr BG. The Role of Telehealth in the Medical Response to Disasters. JAMA Intern Med. 2018;178(6):745-746. doi:10.1001/jamainternmed.2018.1314 2. Duffy S, Lee TH. In-Person Health Care as Option B. N Engl J Med. 2018;378(2):104-106. doi:10.1056/NEJMp1710735 3. Centers for Medicare and Medicaid Services. Medicare telemedicine health care provider fact sheet. Accessed September 26, 2020. https://www.cms.gov/newsroom/fact-sheets/medicaretelemedicine-health-care-provider-fact-sheet 4. Bennett N, Lemoine GJ. What a difference a word makes: Understanding threats to performance in a VUCA world. Bus Horiz. 2014;57(3):311-317. doi:10.1016/j.bushor.2014.01.001 5. Acute Hospitalizations Decrease During the COVID-19 Pandemic | Cigna. Accessed September 27, 2020. https://www.cigna.com/about-us/newsroom/studies-and-reports/deferring-care-during-covid-19 6. Solomon MD, McNulty EJ, Rana JS, Leong TK, Lee C, Sung SH, Ambrosy AP, Sidney S, Go AS. The Covid-19 Pandemic and the Incidence of Acute Myocardial Infarction. N Engl J Med. 2020;383(7):691-693. doi:10.1056/NEJMc2015630 7. Cabana MD, Jee SH. Does continuity of care improve patient outcomes? J Fam Pract. 2004;53(12):974-980.

TELEMEDICINE

Telemedicine FAQs What are the primary requirements for telemedicine in the state of Texas?

In Texas, telemedicine involves a health care provider’s medical care delivered to patients physically located

at sites other than where the provider is located. The primary requirements are:

The same standard of care that applies to an in-person setting applies to health care services or procedures

provided by telemedicine.

Telemedicine services can be provided by:

(A) synchronous audiovisual interaction between the practitioner and the patient in another location; (B) asynchronous store and forward technology, including asynchronous store and forward technology

in conjunction with synchronous audio interaction between the practitioner and the patient in another location, as long as the practitioner uses clinical information from:

(i) clinically relevant photographic or video images, including diagnostic images; or

(ii) the patient's relevant medical records, such as the relevant medical history, laboratory and pathology results, and prescriptive histories; or

(C) another form of audiovisual telecommunication technology that allows the practitioner to comply

with the standard of care described in Section 111.007, Texas Occupations Code.

See statute and rules: TMB Rule, Chapter 174 - Telemedicine Texas Occupations Code, Chapter 111 - Telemedicine and Telehealth

visit us at www.bcms.org

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TELEMEDICINE

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San Antonio Medicine • November 2020

TELEMEDICINE

visit us at www.bcms.org

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SAN ANTONIO MEDICINE

New Strategy for COVID-19 Hospitalization Discharge Patient Care

By Jairo Melo, MD

When COVID-19 hit its second peak in San Antonio, during the late June 2020, it became evident that this wave of the pandemic was different. Patients were younger, sicker, and less likely to have longstanding relationships with primary care physicians, endangering their recovery. It was clear that a different approach was needed when discharging patients back to their homes after a COVID-19related hospitalization.

Our practice chose to set up a COVID-19 post-discharge followup clinic, managed by Wellvana, which builds clinically integrated networks. This clinic would be similar to what is done for chronic disease management or recovery from major procedures. In addition, this kind of care could be a vital source for capturing clinical data with remote patient monitoring and patient surveys for much needed insight on how patients are recovering from the virus once their inpatient stays are done.

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San Antonio Medicine • November 2020

The care management team uses remote patient monitoring technology to watch for changes in temperature, pulse oximetry, and blood pressure for higher-risk patients and sends text messagebased symptoms surveys to discharged patients to ensure no patient falls through the cracks. Most patients are seen by a physician within three days of discharge, whether for in-person follow-up appointments or by using one of several telemedicine platforms present throughout the network. Not only does the specialized care management team provide up-to-date patient education based on the latest CDC guidance, but they elevate patient concerns to the appropriate physician and encourage recovered patients to donate convalescent plasma. The clinic also partners with several lab providers for a COVID-19 curbside swab clinic to give physicians clinical data about discharged patients.

CASE Study: COVID-19 Post-Discharge Patient Care Coordination Success July 1, 2020 was not a good day for a local retired physician, who exemplifies the challenges of this second wave of infections. He was hospitalized after four days of fatigue, body aches, poor appetite, and a climbing temperature. Medical training was not necessary to decipher that his symptoms were inevitably linked to COVID-19. Arriving at the hospital, he was quickly diagnosed with COVID-19 pneumonia and acute hypoxic respiratory failure. During a hospital stay managed by doctors from Texas Intensivists, Pulmonary and Sleep Medicine (TIPS), he made notable improvements after the administration of convalescent plasma and initiation of Remdesivir. The inpatient team determined he was well enough to go home, but being discharged on a holiday weekend made follow-up care even more critical.

The continued rampant nature of the virus combined with the patient’s history of sleep apnea, along with multiple other cardiopulmonary issues, complicated his discharge. Once home, an assigned care coordination nurse became concerned about the patient’s continued severe shortness of breath with hypoxia and confusion; however, the patient refused to return to the ER. After the patient was unable to be seen by his pulmonologist due to his COVID status, his daughter called and requested help, fearing her father was going to “pass away in his sleep.” Following his initial visit, the patient was seen for a curbside COVID swab on July 15 and is now utilizing remote monitoring devices for daily monitoring of BP, pulse, oxygen levels and temperature. He is now asymptomatic and stable on home oxygen.

The patient and his family have expressed their gratitude and believe that rapid access to care enabled the patient to continue to improve at home. His caregiving daughter could now return to her own home and work with peace-of-mind knowing that her father was being monitored and supported.

The COVID-19 discharge clinic has received more than 1000 referrals and successfully navigated the majority of these patients from discharge to recovery. The program has worked so well that it will be handling additional diagnoses in the near future. Even more important than this possible expansion, the clinical data gathered through monitoring programs and survey data is a source of growing insight into COVID-19 and how it affects patients once they have passed the acute stage of the virus.

Jairo Melo, MD is the Chief Medical Officer of Wellvana and is a member of the Bexar County Medical Society.

Thank You, San Antonio Area Foundation!

The Bexar County Medical Library Association (BCMLA) wants to thank the San Antonio Area Foundation COVID-19 Response Fund for providing a grant to help fund the ongoing Personal Protective Equipment (PPE) Project.

The COVID-19 Response Fund is a community fund jointly managed by the San Antonio Area Foundation and the United Way of San Antonio. The fund is comprised of nearly 30 caring businesses, donor advised funds, philanthropic foundations, and government entities. For a complete list of the donors to the COVID-19 Response Fund visit the San Antonio Area Foundation website https://saafdn.org/nonprofits/grants/covid19-response-fund/.

With the assistance of SAFER Texas (Strategic Alliance for Emergency Response), the BCMLA PPE Project has been able to serve over 15,000 medical professionals with upwards of 300,000 pieces of PPE from March through September. The project is ongoing and continues to fulfill orders from medical practices every day.

If a medical practice is having trouble acquiring PPE, visit the BCMS COVID-19 Resources page on the BCMS website www.bcms.org and click on the Request PPE button on the left-hand side of the COVID-19 Resources page. visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Risky Substance

By Arti Thangudu, MD

The coronavirus pandemic has turned our world upside down. More time at home has had positive effects, like more time with our family and perhaps more sleep. However, the stress of the pandemic along with finding ways to unwind at home have led many people to reach for increasing amounts of alcohol. Nielson reports increased alcohol purchasing in-store and online during the pandemic and in a poll done on 2,200 adults; 19% reported drinking more during the pandemic.

In my practice, I’ve had several patients report drinking much more than usual early in the pandemic and now finding themselves trying to cut back, realizing that their drinking was going to extremes and also realizing that this quarantine is going to last much longer than any of us expected.

Many people may be drinking in excess without realizing it. That gives us a great opportunity to educate ourselves and our patients and screen for risky behaviors related to alcohol.

Per the National Institutes of Health (NIH), a standard drink is 12 fluid ounces of regular beer, 8-9 fluid ounces of malt liquor, 5 fluid ounces of table wine or 1.5 fluid ounces of distilled spirits.

As defined by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), low-risk drinking for women is no more than 3 drinks on any single day and no more than 7 drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. However, even within these limits, people can have problems if they drink too quickly or if they have other health issues.

NIAAA defines binge drinking as drinking that brings blood alcohol concentration to 0.08 grams per deciliter (0.08%) or higher, which typically occurs after a woman consumes 4 drinks or a man consumes 5 drinks in a 2-hour time frame. At risk drinking includes drinking that exceeds the number of drinks per day any day of the week, binge drinking at least once per month or drinking that increases the risk for problems even if no current problems exist.

Alcohol Use Disorder Identification Tests (AUDIT) exist to help providers with screening. There are multiple in-office behavioral interventions and anti-relapse medications to help you and your patients in managing alcohol abuse.

COVID-19 has put a magnifying lens on our healthcare system’s need for increased dedication to preventative healthcare. Targeting risky behaviors with regard to substances and mental health are areas we all can work on in our practices to improve the health of our community.

Arti Thangudu, MD, is the Founder of Complete Medicine and is a member of the Bexar County Medical Society.

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San Antonio Medicine • November 2020

SAN ANTONIO MEDICINE

Understanding Patient Healing

By Edward Visnaw

Everyone is going through something and has a story, whether it is externally apparent or not.

My first research project as a medical student explored the relationship between social determinants of health and the subjective and objective outcomes of diabetic patients. The subjects were patients seen by providers within the Resident Research Network of Texas (RRNeT), a collaboration of twelve different Texas family medicine residency programs. As a starting second-year medical student, this project provided my first real exposure to a clinical environment. I had not yet taken endocrinology and was eager to learn through speaking with patients at the primary care clinic.

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San Antonio Medicine • November 2020

My role in the project was to interview patients and collect data from their charts. However, my experience went beyond survey answers and numbers and became very intimate and personal. When a memorable patient opened up to me, I realized how truly honored I was to be in this position and for her to share a very personal story with me. I was humbled, and having completed only my first year of medical school at that time, I did not anticipate that a patient could leave such a lasting mark on my career.

I met her on a typical summer day in San Antonio. I was excited

SAN ANTONIO MEDICINE to find another patient to interview for my project. I walked into the room and saw a healthy-appearing, middle-aged female who pleasantly greeted me. She had radiant skin, a calm, soft smile, and an air of confidence about her. She expressed how very excited she was to help me and to be a part of my project. This encounter seemed like it would be routine. Towards the end of my survey, the questions became sensitive. They were adverse childhood experiences (ACEs) questions. Halfway through the ACEs, her attitude shifted from an enthusiastic patient to a tearful patient right in front of me. I was nervous but kept my composure, set down my clipboard, and comforted her through a moment of silence and sobbing. I questioned myself: "Did I break her? What did I do wrong?" She said through the tears: "Growing up, I was gravely abused. I am still too affected by my past and sad, and I feel like I just eat my feelings. I do not tell anyone this. I am sorry." In her most vulnerable moment, I replied, "Please do not be sorry. I want to help you."

After explaining to the patient that it is okay to feel these emotions and that she is not alone, she expressed a willingness to seek counseling and mental health services. I then sought out and printed some resources for her. At that moment, whether either of us realized it or not, she instilled in me the value of empathetic understanding.

Years later, I still think of her. Our encounter marked the beginning of my journey to appreciating and understanding the patient perspective. I often think about how composed and externally healthy she appeared. However, she truly felt distraught and was affected by many different social factors that impacted her diabetes outcomes. Our interaction was a reality check for me. Since I saw how an outwardly healthy person struggled with illness and abuse, I continue to rethink what I observe in an exam room today. Everyone is going through something and has a story, whether it is externally apparent or not.

In today's world, effective treatment requires more than addressing a simple disease or applying an algorithm. It requires understanding the intricate relationships among various social circumstances that affect health outcomes. Throughout my clinical rotations training, I find this to be relevant and applicable to ef-

Developing an efficient yet genuinely empathetic relationship with patients is vital. fective illness management. Food insecurities, mental health, transportation issues and numerous other factors affect our community's health outcomes. I firmly believe that future health care teams and physicians must acknowledge this complex relationship for the sake of our patients. Social determinants of health are critical, and I will strive to incorporate these into my future treatment plans as a physician.

I reflect on how my research, clinical experiences and the social challenges that affect patients today have shaped me as a future physician. I wonder about the issues facing the world today and feel a renewed inspiration to act as an unbiased advocate for patients, who are at their most vulnerable during medical visits. I realize that developing an efficient yet genuinely empathetic relationship with patients is vital. Every patient has individual needs, especially those who are coping with a chronic disease. We must address their social needs to manage illnesses, such as diabetes, and to optimize health.

My experiences have set the stage for my clinical rotations and my future career as a physician.

Edward Visnaw is a fourth-year medical student at the Long School of Medicine, UT Health Science Center San Antonio and is a member of the Bexar County Medical Society. visit us at www.bcms.org

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SAN ANTONIO MEDICINE

Diabetes, PAD and Preventing Lower Leg Amputations

By Jeffrey Martinez, MD November is Diabetes Month. Kin to diabetes is Peripheral Artery Disease (PAD), and as a vascular surgeon who treats diabetes patients from the San Antonio area daily, I welcome the opportunity to spread an understanding of diabetes and PAD. PAD is a circulatory ailment; it is the narrowing of peripheral arteries due to atherosclerosis (plaque buildup on arterial walls), decreasing blood flow to legs, feet and toes. Complications from untreated PAD include pain, nonhealing ulcers, gangrene and amputation.

Who gets PAD? Pad affects as many as 12 million Americans, and major risk factors include type 2 diabetes, age, obesity, high blood pressure, high cholesterol and smoking. In South Texas, PAD is particularly evident in the diabetic Hispanic American population.

A relatively new outpatient procedure is becoming a standard option for diabetics, PAD sufferers and their physicians to consider.

Endovascular procedures are minimally invasive, fluoroscopicguided radiologic procedures. They pose minimal risk to the patient, are typically quicker and offer reduced recovery time. Endovascular procedures are real options for PAD sufferers, and treat vascular disease down to the toe. These procedures give patients options that prevent amputations and keeps them whole. Patients are often discharged the same day and use moderate sedation or local anesthesia rather than general anesthesia like more invasive procedures.

The best way to understand the effect PAD (and endovascular procedures) can have on lives is to hear about the procedure from the patients themselves. For example: - Patricia, whose podiatrist had treated her for neuropathy pain for years complained that at night her chronic pain would get worse when she sat and elevated her legs. Severe pain in her toes would keep her awake at night. Her doctor finally referred her for evaluation and an endovascular procedure. It restored her circulation – down to the toe – and she felt immediate relief from pain.

- George, a diabetic for 30 years, who had long-standing problems with his legs, reported he felt tingling and burning, and discol30

San Antonio Medicine • November 2020

oration of his foot. The day after his surgery, he walked a full mile with no pain.

- Trinidad, who suffered from plaque buildup in his legs, proudly announced after undergoing the procedure for his left leg, that he could lift the leg properly and no longer dragged his foot.

What can at-risk patients do to save their limbs? The first step is awareness – of the risk factors, symptoms, and new therapies like endovascular procedures. Also: - For at-risk populations, (particularly those with diabetes), proactive screening tests, such as a pulse check or ultrasound, will find problems early.

- Annual (or more frequent) foot care can detect or prevent ulcer development. Often, people with PAD will be unaware of ulcers and other lower leg injuries for days or weeks because they don’t feel them. Regular care ensures detection before it’s too late.

- If PAD symptoms worsen to where amputation is recommended, patients should ask their doctors about alternatives.

That’s where an endovascular procedure often comes in.

Over the last year, more than a thousand patients in the San Antonio area alone have had their toes, feet and lower legs saved by endovascular procedure. Our hope is that greater awareness of this option will save even more limbs from amputation.

Dr. Jeffrey Martinez, MD, is managing physician at Modern Vascular’s new second clinic in San Antonio. A native of San Antonio and a board-certified vascular surgeon with additional training in endovascular surgery, he attended Texas A&M University and received his medical degree from the University of Texas Health Science Center at San Antonio.

He completed his residency in general surgery in San Antonio as well as his vascular fellowship at the University of Tennessee Medical School in Memphis, TN. After serving eight years on active duty in the U. S. Navy, Dr. Martinez has been practicing in San Antonio since 2001. Dr. Martinez is a member of the Bexar County Medical Society. https://modernvascular.com/modern-vascular-of-san-antonio-lexington/.

BCMS AUTO SHOW

BCMS 34th ANNUAL AUTO SHOW

On October 15, 2020, the Bexar County Medical Society held its 34th Annual Auto Show in the Society parking lot on 1604. Even with COVID-19 restrictions, guests enjoyed great food and drink, music, cars and trucks and some social interaction, for a change; it was a marvelous affair! Special thanks to the dealer members of the BCMS Auto Program, Dominion Country Club and Wellvana for the food, Circle of Friends members for their continued support, The Rick Cavender Band for the tunes, and great physician members with their families and staff for attending and celebrating what turned out to be the only in-person, social get-together for the Society since COVID changed our lives!

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San Antonio Medicine • November 2020

BCMS AUTO SHOW

visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY Support the BCMS by supporting the following sponsors.

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

ACCOUNTING FIRMS

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

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

ACCOUNTING SOFTWARE

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

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

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

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

ATTORNEYS

Kreager Mitchell (HHH Gold Sponsor)

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San Antonio Medicine • November 2020

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

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

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

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

ASSETT WEALTH MANAGEMENT

Bertuzzi-Torres Wealth Management Group (HHH Gold Sponsor) We specialize in simplifying your personal and professional life.

We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending and estate planning.

Mike Bertuzzi First Vice President Senior Financial Advisor

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

BANKING

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

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

Synergy Federal Credit Union (HHH Gold Sponsor) Looking for low loan rates for mortgages and vehicles? We've got them for you. We provide a full suite of digital and traditional financial products, designed to help Physicians get the banking services they need.

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

ment, lending, investments, insurance, and trust services.

Mary Mahlie SVP, Private Banking 210-370-6029 mary.mahlie@bbva.com Mark Menendez SVP, Wealth Financial Advisor 210-370-6134 mark.menendez@bbva.com www.bbvacompass.com "Creating Opportunities" BB&T (HH Silver Sponsor) Banking Services, Strategic Credit, Financial Planning Services, Risk Management Services, Investment Services, Trust & Estate Services -- BB&T offers solutions to help you reach your financial goals and plan for a sound financial future Claudia E. Hinojosa Wealth Advisor 210-248-1583 CHinojosa@BBandT.com https://www.bbt.com/wealth/star t.page "All we see is you"

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

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

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

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

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

Brandi Vitier, 210-807-5581 brandi.vitier@thebankofsa.com www.thebankofsa.com BBVA Compass (HH Silver Sponsor) We are committed to fostering our clients’ confidence in their financial future through exceptional service, proactive advice, and customized solutions in cash manage-

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

Caleb Ross Area Marketing Manager 972-989-2238 caleb.ross@touchstoneimaging.com Angela Shutt Area Operations Manager 512-915-5129 angela.shutt@touchstoneimaging.com

www.touchstoneimaging.com "Touchstone Imaging provides outpatient radiology services to the San Antonio community."

FINANCIAL ADVISOR

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

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

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

FINANCIAL SERVICES

Bertuzzi-Torres Wealth Management Group ( Gold Sponsor) We specialize in simplifying your personal and professional life. We are dedicated wealth managers who offer diverse financial solutions for discerning healthcare professionals, including asset protection, lending & estate planning.

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

Aspect Wealth Management (HHH Gold Sponsor) We believe wealth is more than money, which is why we improve and simplify the lives of our clients, granting them greater satisfaction, confidence and freedom to achieve more in life.

Jeffrey Allison 210-268-1530 jallison@aspectwealth.com www.aspectwealth.com “Get what you deserve … maximize your Social Security benefit!”

Elizabeth Olney with Edward Jones ( Gold Sponsor)

We learn your individual needs so we can develop a strategy to help you achieve your financial goals.

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

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

Regions Bank (HHH Gold Sponsor) Regions Financial Corporation is a member of the S&P 500 Index and is one of the nation’s largest full-service providers of consumer and commercial banking, wealth management and mortgage products and services.

Jake Pustejovsky Commercial Relationship Manager (830)302.6336 Jake.Pustejovsky@Regions.com Blake M. Pullin Vice President - Mortgage Banking Regions Mortgage NMLS#1031149 (512)766.LOAN(5626) blake.pullin@regions.com Fred R. Kelley Business Banking Relationship Manager (512)226-0208 www.Regions.com

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

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

sulting Group and SWBC PEO, SVP Corporate Relations (210) 525-1241 DMarino@swbc.com Avid Wealth Partners (HH Silver Sponsor) The only financial firm that works like physicians, for physicians, to bring clarity and confidence in an age of clutter and chaos. You deserve to be understood and wellserved by a team that's committed to helping you avidly pursue the future you want, and that's our difference.

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® CEO | Wealth Advisor 210.864.3350 eric@avidwp.com avidwp.com “Plan it. Do it. Avid Wealth”

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

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

HEALTHCARE TECHNOLOGY SOLUTIONS SUPPLIER GHA TECHNOLOGIES, INC (HH Silver Sponsor) Focus on lifelong relationships with Medical IT Professionals as a mission critical, healthcare solutions & technology hardware & software supplier. Access to over 3000 different medical technology & IT vendors.

Pedro Ledezma Technical Sales Representative 210-807-9234 pedro.ledezma@gha-associates.com www.gha-associates.com “When Service & Delivery Count!”

INFORMATION AND TECHNOLOGIES

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

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

INSURANCE

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

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

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

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

continued on page 36

visit us at www.bcms.org

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PHYSICIANS PURCHASING DIRECTORY continued from page 35 OSMA Health (HH Silver Sponsor) Health Benefits designed by Physicians for Physicians.

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

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

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

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

Katy Brooks, CIC 210-807-5593 katy.brooks@bosainsurance.com www.thebankofsa.com “Serving the medical community.”

MedPro Group (HH Silver Sponsor) Rated A++ by A.M. Best, MedPro Group has been offering customized insurance, claims and risk solutions to the healthcare community since 1899. Visit MedPro to learn more.

Kirsten Baze 512-375-3972 Kirsten.Baze@medpro.com www.medpro.com ProAssurance

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San Antonio Medicine • November 2020

(HH Silver Sponsor) ProAssurance professional liability insurance defends healthcare providers facing malpractice claims and provides fair treatment for our insureds. ProAssurance Group is A.M. Best A+ (Superior).

Delano McGregor Senior Market Manager 800.282.6242 ext 367343 DelanoMcGregor@ProAssurance.com www.ProAssurance.com/Texas

Margaret S. Matamoros Executive Director, San Antonio 210-792-2478 mmatamoros@integranethealth.com Nora O. Garza, MD Medical Director, San Antonio 210-705-3137 ngarza@garzamedicalgroup.com www.integranethealth.com “We encourage you to learn more about how IntegraNet Health can help you “

MEDICAL PHYSICS

Dr. Niti Vanee Co-founder & CEO 210-257-6973 nvanee@iGenomeDx.com Dr. Pramod Mishra Co-founder, COO & CSO 210-381-3829 pmishra@iGenomeDx.com www.iGenomeDx.com “My DNA My Medicine, Pharmacogenomics”

PRACTICE SUPPORT SERVICES

INTERNET TELECOMMUNICATIONS

Unite Private Networks (HHH Gold Sponsor) Unite Private Networks (UPN) has offered fiber optic networks since 1998. Lit services or dark fiber – our expertise allows us to deliver customized solutions and a rewarding customer experience.

Clayton Brown - Regional Sales Director 210-693-8025 clayton.brown@upnfiber.com David Bones – Account Director 210 788-9515 david.bones@upnfiber.com Jim Dorman – Account Director 210 428-1206 jim.dorman@upnfiber.com www.uniteprivatenetworks.com “UPN is very proud of our 98% customer retention rate”

MEDICAL BILLING AND COLLECTIONS SERVICES 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

IntegraNet Health (HHHH 10K Platinum Sponsor) Valued added resources and enhanced compensations. An Independent Network of Physicians with a clinical and financial integrated delivery network, IntegraNet Health serves as your advocate and partner.

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

Medical & Radiation Physics, Inc. (HHH Gold Sponsor) Medical physics and radiation safety support covering all of South Texas for over 40 years. Diagnostic imaging, radiation therapy, nuclear medicine and shielding design. Licensed, Board Certified, Experienced and Friendly!

Alicia Smith, Administrator 210-227-1460 asmith@marpinc.com David Lloyd Goff, President 210-227-1460 dgoff@marpinc.com www.marpinc.com Keeping our clients safe and informed since 1979.

MEDICAL SUPPLIES AND EQUIPMENT

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.”

MOLECULAR DIAGNOSTICS LABORATORY

iGenomeDx ( Gold Sponsor) Most trusted molecular testing laboratory in San Antonio providing FAST, ACCURATE and COMPREHENSIVE precision diagnostics for Genetics and Infectious Diseases.

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

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

PROFESSIONAL ORGANIZATIONS The Health Cell (HH Silver Sponsor) “Our Focus is People” Our mission is to support the people who propel the healthcare and bioscience industry in San Antonio.

Industry, academia, military, nonprofit, R&D, healthcare delivery, professional services and more!

President, Kevin Barber 210-308-7907 (Direct) kbarber@bdo.com Valerie Rogler, Program Coordinator 210-904-5404 Valerie@thehealthcell.org www.thehealthcell.org “Where San Antonio’s Healthcare Leaders Meet” San Antonio Group Managers (SAMGMA) (HH Silver Sponsor) SAMGMA is a professional nonprofit association with a mission to provide educational programs and networking opportunities to medical practice managers and support charitable fundraising.

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

REAL ESTATE SERVICES COMMERCIAL

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

“Invaluable Commercial Real Estate Advice for The Healthcare Professional”

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

Join our Circle of Friends Program The sooner you start, the sooner you can engage with our 5700 plus membership in Bexar and all contiguous counties.

For questions regarding Circle of Friends Sponsorship or, sponsor member services please contact: Development Director, August Trevino august.trevino@bcms.org or 210-301-4366 www.bexarcv.com/secure/ bcms/cofjoin.htm

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!"

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

visit us at www.bcms.org

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AUTO REVIEW

Worth Waiting For

By Stephen Schutz, MD

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San Antonio Medicine • November 2020

AUTO REVIEW

It’s still difficult to get press cars, so I’m going to highlight some more upcoming vehicles that I think will be exciting and (maybe) worth waiting for.

Ford Bronco: the last time I saw this much excitement for an upcoming vehicle was in 1990 when the Lexus LS400 and Mazda Miata launched. And the Bronco seems to be generating more energy than both of them put together. This new Ford off-roader, which is nothing less than a dagger aimed at the Jeep Wrangler’s heart, is going to be a gigantic home run. How much does Ford want it to succeed? Despite the fact that pre-orders are off the charts, the company recently announced that the most extreme Sasquatch version will be available with a manual transmission after all (it was originally announced as automatic only). Why? Because they want every single Wrangler buyer they can get.

An aside: during the original Bronco’s heyday in the late 1960s, its nemesis wasn’t the Jeep Wrangler; it was the similarly iconic Chevy Blazer. If a new Bronco is being created to compete with the popular Wrangler, why not a new Blazer? Good question.

Chevy actually sells a Blazer right now, but it’s a completely anonymous small crossover SUV that looks as though it were designed for Enterprise Rent a Car rather than actual retail customers. Supposedly after the highly successful Bronco reveal earlier this summer, GM’s CEO Mary Barra sent a “WTF?” email to her company’s product planners asking why they had missed this (very profitable) boat. My answer: because GM has been too focused on electric cars to think much about mainstream products.

Ford F-150: the 2021 F-150 is heavily facelifted rather than all new, but there are many changes for America’s perennial best selling vehicle. The PowerBoost hybrid’s eco credentials are meant to turn Greta Thunberg’s frown upside down, but the Pro Power Onboard system that the hybrid enables is the feature that will excite buyers. Providing either 20 or 30 amps of 110 volt electrical power, Pro Power Onboard can provide electricity for your work (or campsite) so you can leave your generator at home (the system automatically turns the engine on and off as needed to keep the electricity flowing). The F-150’s interior has been enhanced to better compete with the increasingly popular Ram 1500, but my favorite change is the new grille, which pays homage to F-series pickups from the 1970s.

Ram TRX: just as the V6 Ford Raptor heads to the dressing room to take a breather, Ram is launching the TRX to show Ford how it’s done. A 702 HP supercharged V8 (yes, you read that right, Seven-Hundred-and-Two horsepower) means that this new full size Ram pickup comes with a serious attitude problem right out of the box, which customers will no doubt appreciate. And in case you don’t understand why Ram is introducing the TRX now, under the hood there’s a rendering of a Tyrannosaurus Rex devouring a Raptor. Subtle? No, but it does make a point. Note to Ford: don’t give the next Raptor a V6.

Audi E-tron GT: essentially an Audi version of the Porsche

Taycan, the E-tron GT looks like a sleeker A5 Fastback that happens to be electric. Less expensive than the Taycan, Audi hopes the E-tron GT will steal sales from Tesla, now inexplicably the most valuable car maker on the planet. Will it succeed? Probably, but with gas prices remaining stubbornly low, expect most luxury sports sedan buyers to stick with the BMW M5 and Porsche Panamera.

Audi Q4 E-tron: smaller than the already-on-sale E-tron SUV, the Q4 E-tron is aimed at Q5 buyers who are interested in an allelectric crossover with similar capability as a Q5. It won’t be the big hit the Q5 has been, but it will likely attract some new buyers to the BEV fold.

Aston Martin DBX: James Bond’s favorite automaker bet the farm on the DBX SUV, and early indications are that the company created an excellent product. Will it find enough buyers to save the company and fund future DB sports cars? Probably. It looks good and will give buyers a tasty combination of aggressive Mercedes AMG V8 goodness and understated Olde English leather and wood. I hope it succeeds.

Mercedes S-Class: many customers who can afford an S-Class are turning instead to luxury SUVs like the Range Rover (and Mercedes GLS), but enough are staying in the sedan market to make it worth Mercedes’ while to keep producing their flagship car. An all new “S” debuts soon, and it’s expected to bring lots of tech including screens with 3D-ish graphics, four-wheel steering, and flush door handles that pop out as you approach. The last S-Class was achingly good to experience, and I’d be surprised if the new one were anything short of brilliant.

As always, call Phil Hornbeak, the Auto Program Manager at BCMS (210-301-4367), for your best deal on any new car or truck brand. Phil can also connect you to preferred financing and lease rates.

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

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RECOMMENDED AUTO DEALERS • • • •

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

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

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

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

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

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

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

Northside Ford 12300 San Pedro San Antonio, TX

David Espinoza 210-912-5087

Marty Martinez 210-525-9800

GUNN AUTO GROUP

GUNN AUTO GROUP

GUNN Acura 11911 IH 10 W San Antonio, TX

GUNN Honda 14610 IH 10 W San Antonio, TX

Coby Allen 210-625-4988

Eric Schwartz 210-680-3371

Northside Honda 9100 San Pedro San Antonio, TX 78216

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

Sean Beardsley 210-988-9644

Rick Cavender 210-681-3399 KAHLIG AUTO GROUP

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

Mercedes Benz of Boerne 31445 IH 10 W Boerne, TX

North Park Mazda 9333 San Pedro San Antonio, TX 78216

William Taylor 210-366-9600

James Godkin 830-981-6000

Scott Brothers 210-253-3300

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

North Park Subaru 9807 San Pedro San Antonio, TX 78216

North Park Lexus 611 Lockhill Selma San Antonio, TX

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

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

Mark Castello 210-308-0200

Tripp Bridges 210-308-8900

Justin Blake 888-341-2182

Stephen Markham 877-356-0476

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

KAHLIG AUTO GROUP

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

North Park Lincoln 9207 San Pedro San Antonio, TX

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

Justin Boone 210-635-5000

Sandy Small 210-341-8841

James Cole 800-611-0176

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

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

San Antonio, TX Ed Noriega 210-561-4900

Porsche Center 9455 IH-10 West San Antonio, TX Matt Hokenson 210-764-6945

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

Jenny Shepherd, Alliance past president and John Shepherd, BCMS board member, educate other physician couples on grassroots medical advocacy during a Party of Medicine event. The brainchild of Jenny, the program garnered 2020 advocacy awards from American Medical Association Alliance and Texas Medical Association Alliance.

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

MEDNAX

Dermatology Associates of San Antonio, PA

Peripheral Vascular Associates, PA

Diabetes & Glandular Disease Clinic, PA

San Antonio Eye Center, PA

ENT Clinics of San Antonio, PA

San Antonio Gastroenterology Associates, PA

Gastroenterology Consultants of San Antonio

San Antonio Infectious Diseases Consultants

General Surgical Associates

San Antonio Pediatric Surgery Associates, PA

Greater San Antonio Emergency Physicians, PA

South Texas Radiology Group, PA

Institute for Women's Health

South Texas Renal Care Group

Little Spurs Pediatric Urgent Care, PLLC

Star Anesthesia (USAP Texas-South)

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 October 23, 2020.

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San Antonio Medicine • November 2020