San Antonio Medicine December 2018

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VOLUME 71 NO. 12

MEDICINE SAN ANTONIO

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

Diabetes & Obesity

THE OFFICIAL PUBLICATION OF THE BEXAR COUNTY MEDICAL SOCIETY

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Nicole Sanders, FNP-C..................................................12

By Sherryl D. Mitchell Hernandez, MD............................16

Fertility Issues in Women with Diabetes

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

By Jaye Adams, MD .....................................................18

Addressing Food & Mood for Improved Outcomes in Obesity and Diabetic Control

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

By Edward Dick, MD......................................................22

How Managed Care Companies are Managing Care: The Type 2 Diabetes Case

By Alan Preston, MHA, ScD...........................................................................................................24

Diabetes in Veterans – Detecting Frailty in Time By Patricia S. Machado, MS2 ......................30 BCMS President’s Message........................................................................................................................8 BCMS Legislative News ............................................................................................................................10 Practice Groups: Pediatrix Medical Group By Mike W. Thomas .................................................................32 BCMS Auto Show.....................................................................................................................................34 BCMS Circle of Friends Directory ..............................................................................................................36 The Swarm, Part 4 of 4 By Allen Cosnow, DVM ........................................................................................41 In the Driver’s Seat ....................................................................................................................................43 Auto Review: 2019 Lincoln Navigator By Steve Schutz, MD ....................................................................44

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San Antonio Medicine • December 2018

VOLUME 71 NO. 12

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

Diabetes and Obesity: How are they related and how we can prevent them

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

The Continuing War on a Metabolic Crisis in Bexar County By Jacob Vadakekalam, MD and

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DECEMBER 2018

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

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

BCMS SENIOR STAFF Stephen C. Fitzer, CEO/Executive Director Melody Newsom, Chief Operating Officer Alice Sutton, Controller Mike W. Thomas, Director of Communications August Trevino, Development Director Mary Nava, Chief Government Affairs Officer Phil Hornbeak, Auto Program Director Mary Jo Quinn, BCVI Director Brissa Vela, Membership Director Al Ortiz, Chief Information Officer

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

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San Antonio Medicine • December 2018

PRESIDENT’S MESSAGE

Thank you for a very successful year

By Sheldon Gross, MD, 2018 BCMS President

dear Colleagues,

My year as President of bexar County Medical Society has gone by very quickly. As it is coming to a conclusion, it seems appropriate to reflect on what has transpired over the past year.

Firstly, I must comment on a group of individuals that have been marvelous to work with. Our Executive director, Stephen Fitzer, is one of a kind. Not only has he shown tremendous leadership and management skills regarding the staff of bexar County Medical Society, but he has also ensured that our organization is on very solid financial footing. We discussed many things during our Executive Committee meetings. However, we never had to discuss how to handle financial disaster or crisis because that never arose.

We should all be indebted to Steve for the outstanding job he has done. He has enabled the Executive Committee and the board of directors to focus instead on new projects and ideas that can make us a more effective organization. I have the highest regards for all of the staff at bexar County Medical Society.

I started the year off with two broad strategic goals for our Medical Society. I wanted to start a leadership program for those individuals interested in accepting leadership positions in our organization as well as other medical organizations. I have been elated to see how well things have gone with our leadership seminars. I had no idea how effective our faculty from Trinity University would be in discussing various aspects of leadership. I also underestimated the enthusiasm that was demonstrated by the participants in this program. Upon reviewing the critiques of the course, the only real critique was that it was not long enough! People wanted to spend more time discussing different aspects of leadership. I am very optimistic that this group of 21 physicians will be future leaders in San Antonio and will do a superb job largely as the result of skills they acquired during this seminar.

My second strategic goal was to strengthen the bonds between the Medical Society and the Alliance. I am very pleased to say that I see that relationship getting stronger. I am looking forward to having many joint projects with the Alliance and having significant Alliance involvement in many different aspects of our Medical Society and how it functions. Jennifer Shepherd has done a wonderful

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San Antonio Medicine • December 2018

job as Alliance President and has been a joy to work with.

I must also commend the members of the Executive Committee and board or directors of the bexar County Medical Society.

These are individuals who have willingly donated time to serve our organization. I remember a quote by Coach Greg Popovich of the Spurs who said, “All of us are smarter than one of us.” That is certainly true for bexar County Medical Society. The input from our physician leaders have resulted in wiser decisions and better ideas than we would have ever had otherwise.

We hosted a very successful meeting of the Texas Medical Association this past spring. The meeting at the JW Marriott was a complete success. It gave us a chance to demonstrate the wonderful aspects of our city. I very much look forward to the next time that the Texas Medical Association meets in San Antonio.

I have extremely high hopes for dr. Adam Ratner who will serve as next year’s President. He is a man of tremendous energy, judgement, and enthusiasm about our organization. I see several avenues for enhancing our effectiveness in the city. I am hopeful that we can play a larger role on both a city level as well as county level.

I will continue to have great expectations for dr. Alex Kenton as he assumes more and more responsibility within TEXPAC leadership as well as dr. Jay Shah who is our newest San Antonio member of the board of Trustees of the Texas Medical Association. dr. david Henkes continues to do an outstanding job as Chairman of the Texas delegation to the American Medical Association.

In conclusion, it has been one of the great honors of my lifetime to serve as President of bexar County Medical Society. I am more convinced than ever that there is tremendous human potential within San Antonio. It remains the job of bexar County Medical Society to capture as much of that human potential as possible and use it to make us the strongest County Medical Society in Texas.

Thank you again for this great privilege.

Sincerely, SHEldON GROSS, Md President, bexar County Medical Society

BCMS LEGISLATIVE NEWS

FORMER REP. JOHN LUJAN AND REP. PHILIP CORTEZ VISIT WITH MEMBERS OF THE BCMS LEGISLATIVE AND SOCIOECONOMICS COMMITTEE

On Oct. 24, the bCMS legislative and Socioeconomics Committee, led by Chairman Alex Kenton, Md, visited with former state representative John lujan, Republican candidate for House district 118 and state representative Philip Cortez, who currently represents House district 117.

Mr. lujan is a retired firefighter and is also a business owner. He last represented district 118 in 2016. Physicians discussed several issues, including: Medicaid, scope of practice, vaccinations and physician workforce.

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San Antonio Medicine • December 2018

Rep. Cortez currently sits on the House Public Health Committee. Committee members discussed various topics, including: Medicaid and Medicaid reimbursement, vaccinations, scope of practice, GME, balance billing, insurance adequate networks and free-standing ERs. For local discussion on these and other legislative advocacy topics, consider joining the BCMS Legislative and Socioeconomics Committee by contacting Mary Nava, chief government affairs officer at mary.nava@bcms.org.

DIABETES AND OBESITY

THE CONTINUING WAR ON A METABOLIC CRISIS IN BEXAR COUNTY The need for continued promotion of lifestyle changes in metabolic syndrome

By Jacob Vadakekalam, MD and Nicole Sanders, FNP-C

T

he obesity epidemic has spread across the nation with

times per week and nearly 50 percent had been diagnosed with di-

Texas holding rank as the 8th most obese in the U.S. Over

abetes (Sahini, Wu and bhatka, 2016). Thus, recent data indicates

just 10.7 percent in 1990. The association between obesity and dia-

than decrease as we had hoped. Some contributing factors of obe-

33.7 percent of Texans are considered obese compared to

betes is well recognized, and the effects of lifestyle changes in im-

the incidence of obesity in bexar County continues to rise rather

sity run the gamut from behavior, sedentary lifestyle, food, lack of

proving outcomes of both is also well recognized. but despite our

education, as well as community and social environments. Thus, be-

weight and obese adults in bexar County alone exceeded 65 percent

integral in sustained weight loss and improved outcomes.

continued public health education efforts, the percentage of overof the adult population (CdC, 2013).

havior along with lifestyle modification should be addressed and is

Some clinical consequences of obesity include: increased mortal-

department of State Health Services data from 2015 reveals that

ity, hypertension, dyslipidemia, type 2 diabetes, atherosclerosis, gall-

physical activity, 36 percent ate at fast food restaurants two or more

cancers, low quality of life, depression, anxiety, joint pain and limited

less than 30 percent of obese Texans participate in leisure time

12

San Antonio Medicine • December 2018

bladder disease, osteoarthritis, sleep apnea, increased risk of some

DIABETES AND OBESITY physical functioning (CdC, 2018).

The American Association of

Clinical Endocrinologists (AACE)

and American College of En-

docrinology (ACE) emphasize complications associated with

being overweight or obese drasti-

cally increase patient suffering, personal financial burden and medical care costs. The AACE

and ACE (2016) define obesity as

a

“complex,

adiposity-based

chronic disease, where management targets both weight-related

complications and adiposity to

improve overall health and quality of life.”

A complication of obesity, di-

abetes and metabolic syndrome:

non-alcoholic fatty liver disease (NAFld), which is being is being

weight loss of 5 percent can show improvement on the NAFld

ease and hepatocellular carcinoma (HCC). It has been estimated

can improve fibrosis by at least one stage (Romero-Gomez, Zelber-

suffers from NAFld. (Patel, Torres, and Harrison (2009). About

overall carbohydrate intake, refined sugar, and increase in omega 3

least an 88 percent incidence of NAFld in the morbid obese pop-

lized even in the non-diabetic population often include pioglitazone,

to cirrhosis from continued inflammation and fibrosis via multiple

Cusi, 2016). Most recently, empagliflozin (Jardiance) a sodium glu-

recognized more with increased occurrence of end-stage liver disthat at least 40 percent of the population in the industrialized West 31 percent of the U.S. population is affected by NAFld, with at ulation (blendea, Thompson Malkani (2010). NAFld can progress

activity score (NAS) and a 10 percent or greater reduction in weight Sagi and Trenell, 2017). dietary modifications such as reduction in

fatty acids are often suggested. Pharmacological interventions utiliraglutide, vitamin E and pentoxiphylline (barb, Portillo-Sanchez &

inflammatory pathways related to obesity, diabetes, etc. Since liver

cose cotransporter-2 inhibitor (SGlT-2) was studied for its effects

AlT, American College of Gastroenterology (ACG) practice

ising, revealing subjects who received empagliflozin benefited from

to 33 IU/l for males and 19 to 25 IU/l for females to increase

to the control group with a decrease from 16.4 percent to 15.5 per-

disease can progress in the face of normal liver enzymes, AST and

guidelines (2016) now recommend lower AlT reference ranges 29

on NAFld in the type 2 diabetic population. The data was prom-

a reduction in liver fat from 16.2 percent to 11.3 percent; compared

awareness and encourage early intervention. Hepatocellular carci-

cent (Kuchay et al., 2018).

diagnosis most often occurring in the later stages of the disease

Medical Care of Patients with Obesity (2016) recommend using not

noma associated with NAFld is generally more aggressive due to

AACE and ACE Clinical Practice Guidelines for Comprehensive

process, larger tumors and fewer curative options (Said & Ghufran,

only body mass index (bMI) to diagnose obesity but to consider

leading cause for liver transplantation in the next decade and con-

the goal in treating obesity is to improve patient health and quality

2017). It is estimated that hepatocellular carcinoma may be the

sists of 90 percent of liver cancer cases (Cholankeril, Patel, Khu-

rana & Satapathy, 2017).

lifestyle modifications can effectively reduce NAFld. A modest

also the severity of systemic effects related to adiposity. Ultimately,

of life as well as decrease complications associated with obesity and

not necessarily achieve a “preset decline in body weight” (AACE &

ACE, 2016).

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

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DIABETES AND OBESITY (continued from page 13)

References

American Association of Clinical Endocrinologists and American College of Endocrinology. (2016) American association of clinical endocrinologists and American college of endocrinology clinical practice guidelines for comprehensive medical care of patients with obesity – executive summary. Endocrine Practice, S3, 1-203. doi: 10.4158/EP161365 American College of Gastroenterology. (2016). ACG practice guideline: Evaluation of abnormal liver chemistries. American Journal of Gastroenterology. doi: 10.1038/ajg.2016.517. barb, d., Portillo-Sanchez, P. and Cusi, K. (2016). Pharmacological management of nonalcoholic fatty liver disease. Metabolism, 65(8), 1183-1195. doi: https://doi.org/10.1016/j.metabol.2016.04.004: blendea, M.C., Thompson, M.J. and Malkani, S. (2010). diabetes and chronic liver disease: Etiology and pitfalls in monitoring. Clinical diabetes, 28(4), 139144. doi: https://doi.org/10.2337/diaclin.28.4.139 Centers for disease Control. (2018). Adult obesity causes and consequences.

Retrieved from: https://www.cdc.gov/obesity/adult/ causes.html Centers for disease Control. (2013). Community profile: San Antonio, Texas. Retrieved from https://www.cdc.gov/nccdphp/dch/ programs/communitiesputtingpreventiontowork/communities/profiles/obesity-tx_sanantonio.htm Cholankeril, G., Patel, R., Khurana, S. and Satapathy, S. (2017). Hepatocellular carcinoma in non-alcoholic steatohepatitis: Current Knowledge and

14

San Antonio Medicine • December 2018

implications for management. World Journal of Hepatology, 9(11), 533543. doi: 10.4254/wjh.v9.i11.533 dharmalingam, M. and Yamasandhi, P.G. (2018). Nonalcoholic fatty liver disease and Type 2 diabetes mellitus. Indian Journal of Endocrinology and Metabolism, 22(3), 421-428. PMId: 30090738 Kuchay, M.S., Krishan, S., Mishra, S.K., Farooqui, K.J., Singh, M. K., Wasir, J.S., bansal, b., Kaur, P., Jevalikar, G., Gill, H.K., Choudhary, N.S. and Mithal, A. (2018). Effect of empagliflozin on liver fat in patients with type 2 diabetes and nonalcoholic fatty liver disease: A randomized controlled trial (E-lIFT Trial). diabetes Care, 41(9). doi: 10.2337/dc18-0165 Martin, C.b., Herrick, K.A., Sarafrazi, N. and Ogden, C.l. (2018). Attempts to lose weight among adults in the United States, 2013-2016. Retrieved from: https://www.cdc.gov/nchs/data/databriefs/db313.pdf Patel, A.A., Torres, d.M. and Harrison, S.A. (2009). Effect of weight loss on nonalcoholic fatty liver disease. Journal of Clinical Gastroenterology, 43(10), 970-974. doi: 10.1097/MCG.0b013e3181b57475 Robert Wood Johnson Foundation. (2017). The state of obesity: better policies for a healthier America. Retrieved from: https://stateofobesity.org/states/tx/ Romero-Gomez, M., Zelber-Sagi, S. & Trenell, M. (2017). Treatment of NAFld with diet, physical activity and exercise. Journal of Hepatology, 67(4), 829-846. doi: 10.1016/j.jhep.2017.05.016

DIABETES AND OBESITY

DIABETES & OBESITY: How are they related and how we can prevent them.

By Sherryl D. Mitchell Hernandez, MD

A

ll of us love food. We love how it tastes and how it makes

us feel after we eat! Plus, we live in a city with a great culinary background. but we must take into consideration

that if we do not take the necessary measures to either control the

amount and what we eat, we will be at a great risk of obesity and, therefore, diabetes.

Most patients with type 2 diabetes are obese and there has been

a dramatic increase in the incidence and prevalence of type 2 diabetes over the past 20 years. Currently, over a third (34 percent) of

U.S. adults are obese (defined as bMI >30 kg/m2), and over 11 per-

cent of people aged ≥20 years have diabetes.

Excess weight is an established risk factor for type 2 diabetes. Re-

cent studies have identified “links” between obesity and type 2 diabetes involving proinflammatory cells, insulin resistance, deranged

fatty acid metabolism, and cellular processes such as mitochondrial

dysfunction, which is where our energy is produced. The influence

of obesity on type 2 diabetes risk is determined not only by the de-

gree of obesity but also by where fat accumulates. Increased upper

body fat includes visceral adiposity, as reflected in increased abdom-

inal girth or waist-to-hip ratio, which is associated with the metabolic

syndrome, type 2 diabetes, and cardiovascular disease. The link be-

tween obesity and hyperinsulinemia, first identified about 50 years

ago, reflects compensation by insulin-secreting β-cells to systemic insulin resistance. Although mechanisms underlying this coupling

(e.g., mild hyperglycemia and raised levels of circulating free fatty acids) remain elusive, obese normoglycemic individuals have both increased β-cell mass and function. Obesity-induced glucose intol-

erance reflects failure to mount one or more of these compensatory

responses. The Genome-wide association scans (GWAS) and candidate gene approaches now have identified ∼40 genes associated

with type 2 diabetes and a similar number, albeit largely different,

with obesity. Most type 2 diabetes genes appear to be related to βcell dysfunction, with many fewer involved in pathways related to

insulin resistance independent of obesity. Although numerous dia-

betes- and obesity-associated genes have been identified, the known 16

San Antonio Medicine • December 2018

DIABETES AND OBESITY genes are estimated to predict only 15 per-

cent of type 2 diabetes and 5 percent of

obesity risk.

Furthermore, longstanding and not

well-controlled diabetes can lead to vi-

sion problems such as diabetic retinopathy, neuropathy and kidney disease which

unfortunately, once this damage starts on

the kidney, is almost always irreversible and leads to end-stage renal disease and dialysis.

but there is hope! We can take action

and prevention is the key. There is evidence that even modest weight reduction

— whether through lifestyle/behavioral interventions, obesity med-

as diabetes, hypertension, or sleep apnea, develop. because weight

ications, or bariatric surgery — can improve glycemic control and

problems develop over the entire lifespan, emphasizing obesity pre-

In general, programs including individual or group counseling to

institutions, the school systems, and the private (e.g., food industry)

reduce diabetes risk and all of its consequences.

vention is urgent and must include the cooperation of public health

modify behavior result in 5 to 10 percent weight loss and are effec-

sector.

cessful

ment suggests the need to adopt a chronic disease model of care

tive for six to 12 months, after which weight regain is the rule. Suclifestyle

intervention

programs

typically

involve

self-monitoring of weight, dietary intake, and activity; behavioral

modification; frequent contact; and caloric balance through diet,

Current understanding of both pathophysiology and manage-

linking obesity and diabetes care management systems. besides in-

cluding stepped-care approaches similar to those used for other

with or without exercise. For example, short-term intervention stud-

chronic diseases, this model involves basing interventional (phar-

fined carbohydrates, make it easier to reduce total caloric intake in

individual risk/benefit.

ies suggest that dietary changes, which emphasize less fat and reobese adults and overweight children.

Medications have been used to assist in weight loss for almost 80

years, but adverse effects frequently restrict utility. They have been

macological and/or surgical) approaches on severity, duration and In summary, what is needed is a comprehensive social, economic,

and workplace approach to prevention and intervention. In addi-

tion, community-setting approaches supplemented by physician in-

developed based on physiological insights, more recently targeting

volvement can work when combining treatment modalities.

portunistically, when weight loss was noted as a side effect of ap-

and behavioral/mental health professionals can achieve both initial

central nervous system control of appetite and metabolism or, op-

Multidisciplinary teams including nutritionists, exercise physiologists

proved medications. In general, weight loss achieved with these

and sustained weight management and glucose control. This ap-

some suggestion that combination therapy may either increase

portant both in alleviating the intensive defense of body weight by

medications ranges from 2 to 8 percent greater than placebo, with

weight loss or ameliorate side effects and increase tolerability. How-

ever, most drug trials last only six to 12 months, and thus there is little long-term data showing that weight loss can be sustained.

Some physicians often introduce secondary interventions when

patients surpass a bMI threshold or when patients self-identify for

cosmetic or health reasons. They introduce tertiary intervention when obesity-related complications responsive to weight loss, such

proach to attaining and maintaining weight reduction is critically im-

multiple biological systems and in reducing risk of β-cell decom-

pensation and, over the long-term, decreasing the morbidity/mor-

tality associated with diabetes complications and improving the

quality of life of our patients!

Sherryl D. Mitchell Hernandez, MD is with Kidney and Hypertension

Specialists of San Antonio.

visit us at www.bcms.org

17

DIABETES AND OBESITY

FERTILITY ISSUES IN WOMEN WITH DIABETES

By Jaye Adams, MD

T

he prevalence of diabetes, both type 1 and type 2, is increasing in

women of reproductive age and,

as with other chronic diseases, may affect a

woman’s ability to conceive (1, 2). Commonly understood is the increased risk of

adverse maternal and fetal outcomes with

pre-existing diabetes (3, 4), and the need for pre-conception glycemic control (5, 6). Per-

haps less well understood is the effect of diabetes itself on the overall fertility of

women with this health condition. Given

the considerable variability in phenotype

and disease pathophysiology in women with

type 1 and type 2 diabetes, a general summary of fertility implications for women

with diabetes is prone to oversimplification

and may pose more questions than it answers. However, surely

there are some unifying themes that can aid us in the counseling

of women with diabetes who present with concerns about their

ability to conceive.

Does diabetes cause menstrual abnormalities?

Menstrual irregularities and ovulatory dysfunction are increased

in women with both type 1 and 2 diabetes (7, 8). A delay in menar-

Intimately linked with the diagnosis of both type 1 and 2 diabetes

and menstrual abnormalities is the often coexisting diagnosis of

PCOS (polycystic ovarian syndrome), the most common endocrine abnormality of reproductive-aged women (11, 12). While women

with diabetes may have normal ovulatory cycles, or menstrual anomalies not associated with PCOS, the diagnosis of PCOS is increased

in women with both type 1 (13) and type 2 (14) diabetes mellitus.

Using the Rotterdam criterion (15) for the diagnosis of PCOS, with

che and more severe oligomenorrhea in adolescents with type I di-

two of the following three findings: 1) evidence of clinical or bio-

HbA1c and insulin requirements (9). Even with good glycemic con-

cystic appearing ovaries on ultrasound, excluding other

abetes has been shown to correlate with the degree of elevation of

trol, oligomenorrhea remains common in young women with type I diabetes, but may improve with advancing age (7). Women with

chemical hyperandrogenism, 2) oligo-anovulation, and/or 3) poly-

endocrinopathies; approximately 40 percent of women with type 1

diabetes (13) and 26-37 percent of women with type 2 diabetes (8,

type 2 diabetes also have an increased risk of oligomenorrhea which

14) meet the criteria for PCOS. because 50-70 percent of women

ulation worsens (8, 10). Efforts to optimize bMI (body mass index),

16), these women should also be screened for coexistent diabetes

is more prevalent as their degree of obesity and metabolic dysreg-

glycemic control, and hyperinsulinemia may improve spontaneous ovulation and conception rates.

18

San Antonio Medicine • December 2018

with PCOS may have insulin resistance when carefully assessed (14,

and educated about their significantly increased lifetime risk of de-

veloping type 2 diabetes (12). diabetic women with PCOS typically

DIABETES AND OBESITY

respond well to ovulation induction using oral agents (17) such as

letrozole or clomiphene citrate, with injectable gonadotropins recommended as second line ovulation induction agents (18), often in

combination with IvF (in vitro fertilization) to decrease the risk of higher-order multiple gestations.

Is the reproductive window altered in women with diabetes?

Regarding type 1 diabetes, there are some conflicting data over

menopausal type 2 diabetes fail to show a difference when com-

pared to the age at menopause onset for non-diabetic women (20,

27). Interestingly, though, women who experience menopause at

an earlier age are more likely to later develop diabetes in the menopause compared with age-matched menopausal controls,

possibly owing to a protective effect of estrogen on glucose me-

tabolism (28).

whether women may have a shortened reproductive window. While

Does improved glycemic control and prevention of diabetic complications improve fertility rates?

menopause for women with type 1 diabetes (19), particularly in those

despite serious end organ disease associated with uncontrolled or

some studies have detected a significantly earlier average age at with a diagnosis of diabetes made at less than age 20 (20), a more re-

cent large cross-sectional study found no association with type 1 di-

While we have all encountered women who seem quite fertile

long-standing diabetes, the pillar of preconception counseling for women with diabetes is that glycemic control and optimization of

abetes and an earlier age for menopause (21) after adjustment for

any diabetes-related health conditions is critical for decreasing the

monly used as a marker of ovarian reserve, with lowered levels pos-

glycemic control can improve actual fertility is most apparent in

potential confounders. AMH (antimullerian hormone) is now com-

maternal and fetal risks associated with pregnancy. Whether

sibly associated with an earlier menopause in reproductive-aged

the relationship between hyperglycemia and miscarriage rates (29-

with type I diabetes compared to age-matched controls (23, 24) which

nancy loss noted with increasing glycosylated hemoglobin levels.

women (22). Two studies have found lowered AMH levels in women

may support the risk for an earlier onset of menopause in these

women. Some have suggested that poor glycemic control leading to

ovarian vascular compromise may be linked with an earlier

menopause in women with

31), with a proportional increase in the risk of first trimester pregAdditionally, the risk of congenital malformations is strongly related to the degree of hyperglycemia during embryogenesis, and thus also pregnancy loss (32). The American diabetes Association

type 1 diabetes, but studies examining intensive versus

conventional treatment for

glycemic control fail to show

an association with the age at

menopause (25). The less frequent diagnosis of prema-

ture ovarian insufficiency in

women under age 40 due to a possible autoimmune etiol-

ogy may be seen more often in women with other autoimmune disorders such as au-

toimmune thyroid disease

and type 1 diabetes (26).

Studies examining the age

at menopause onset for women

with

pre-

(continued on page 20) visit us at www.bcms.org

19

DIABETES AND OBESITY (continued from page 19)

recommends aiming for an HbA1c <6.5 prior to conception (5),

while the Endocrine Society recommends an HbA1c level “as close to normal as possible” without causing undue hypoglycemia (6).

Particularly in women with type 2 diabetes who may have a high

bMI, weight loss and associated improvements in insulin sensitivity

may help improve ovulation and conception rates (14). Women

with type 1 diabetes who have microvascular disease have lowered

overall fertility rates; however, improved long-term glycemic con-

trol and prevention of end organ damage is associated with an improvement in observed fertility rates (33).

Key Points: •

Menstrual abnormalities, oligomenorrhea, and PCOS are

•

There is controversy as to whether women with type 1 diabetes

•

common in women with diabetes.

may experience an earlier age at menopause.

Preconception glycemic optimization is critical in decreasing t he risk of pregnancy loss and diabetic embryopathy.

References

1. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. diabetes Care. 2004;27(5):1047-53.

2. Writing Group for the SfdiYSG, dabelea d, bell RA, d'Agostino Rb, Jr., Imperatore G, Johansen JM, et al. Incidence of diabetes in youth in the United States. JAMA. 2007;297(24):2716-24.

3. Kitzmiller Jl, Wallerstein R, Correa A, Kwan S. Preconception care for women with diabetes and prevention of major congenital malformations. birth defects Res A Clin Mol Teratol.

2010;88(10):791-803.

4. Persson M, Norman M, Hanson U. Obstetric and perinatal outcomes in type 1 diabetic pregnancies: A large, population-based study. diabetes Care. 2009;32(11):2005-9.

JS. Menstrual cycle differences between women with type 1 diabetes and women without diabetes. diabetes Care.

2003;26(4):1016-21.

8. Sim SY, Chin Sl, Tan Jl, brown SJ, Cussons AJ, Stuckey bG. Polycystic ovary syndrome in type 2 diabetes: does it predict a more severe phenotype? Fertil Steril. 2016;106(5):1258-63.

5. American diabetes A. 13. Management of diabetes in Pregnancy: Standards of Medical Care in diabetes-2018. diabetes Care. 2018;41(Suppl 1):S137-S43.

9. Gaete X, vivanco M, Eyzaguirre FC, lopez P, Rhumie HK, Unanue N, et al. Menstrual cycle irregularities and their relationship with HbA1c and insulin dose in adolescents with type 1 diabetes mellitus. Fertil Steril. 2010;94(5):1822-6.

7. Strotmeyer ES, Steenkiste AR, Foley TP, Jr., berga Sl, dorman

11. lizneva d, Suturina l, Walker W, brakta S, Gavrilova-Jordan l,

6. blumer I, Hadar E, Hadden dR, Jovanovic l, Mestman JH, Murad MH, et al. diabetes and pregnancy: an endocrine society clinical practice guideline. J Clin Endocrinol Metab.

2013;98(11):4227-49.

20

San Antonio Medicine • December 2018

10. Solomon CG, Hu Fb, dunaif A, Rich-Edwards J, Willett WC, Hunter dJ, et al. long or highly irregular menstrual cycles as a marker for risk of type 2 diabetes mellitus. JAMA. 2001;286(19):2421-6.

DIABETES AND OBESITY Azziz R. Criteria, prevalence, and phenotypes of polycystic ovary syndrome. Fertil Steril. 2016;106(1):6-15.

12. Cooney lG, dokras A. beyond fertility: polycystic ovary syndrome and long-term health. Fertil Steril. 2018;110(5):794-809.

13. Codner E, Escobar-Morreale HF. Clinical review: Hyperandrogenism and polycystic ovary syndrome in women with type 1 diabetes mellitus. J Clin Endocrinol Metab. 2007;92(4):1209-16.

14. Ovalle F, Azziz R. Insulin resistance, polycystic ovary syndrome, and type 2 diabetes mellitus. Fertil Steril. 2002;77(6):1095-105.

15. Rotterdam EA-SPCWG. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81(1):19-25.

16. dunaif A. Insulin resistance and the polycystic ovary syndrome: mechanism and implications for pathogenesis. Endocr Rev. 1997;18(6):774-800.

17. legro RS, brzyski RG, diamond MP, Coutifaris C, Schlaff Wd, Casson P, et al. letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med. 2014;371(2):11929.

18. Teede HJ, Misso Ml, Costello MF, dokras A, laven J, Moran l, et al. Recommendations from the international evidencebased guideline for the assessment and management of polycystic ovary syndrome. Clin Endocrinol (Oxf).

2018;89(3):251-68.

19. dorman JS, Steenkiste AR, Foley TP, Strotmeyer ES, burke JP, Kuller lH, et al. Menopause in type 1 diabetic women: is it premature? diabetes. 2001;50(8):1857-62.

20. brand JS, Onland-Moret NC, Eijkemans MJ, Tjonneland A, Roswall N, Overvad K, et al. diabetes and onset of natural menopause: results from the European Prospective Investigation into Cancer and Nutrition. Hum Reprod. 2015;30(6):14918.

21. Yarde F, van der Schouw YT, de valk HW, Franx A, Eijkemans MJ, Spiering W, et al. Age at menopause in women with type 1 diabetes mellitus: the OvAdIA study. Hum Reprod.

2015;30(2):441-6.

22. Freeman EW, Sammel Md, lin H, Gracia CR. Anti-mullerian hormone as a predictor of time to menopause in late reproductive age women. J Clin Endocrinol Metab. 2012;97(5):1673-80.

23. Kim C, Karvonen-Gutierrez C, Kong S, Arends v, Steffes M, McConnell dS, et al. Antimullerian hormone among women with and without type 1 diabetes: the Epidemiology of diabetes Interventions and Complications Study and the Michigan bone Health and Metabolism Study. Fertil Steril. 2016;106(6):1446-52.

24. Soto N, Iniguez G, lopez P, larenas G, Mujica v, Rey RA, et al. Anti-Mullerian hormone and inhibin b levels as markers of premature ovarian aging and transition to menopause in type 1 diabetes mellitus. Hum Reprod. 2009;24(11):2838-44.

25. Kim C, Cleary PA, Cowie CC, braffett bH, dunn Rl, larkin ME, et al. Effect of glycemic treatment and microvascular complications on menopause in women with type 1 diabetes in the diabetes Control and Complications Trial/Epidemiology of diabetes Interventions and Complications (dCCT/EdIC) cohort. diabetes Care. 2014;37(3):701-8.

26. Nelson lM. Clinical practice. Primary ovarian insufficiency. N Engl J Med. 2009;360(6):606-14.

27. li J, Eriksson M, Czene K, Hall P, Rodriguez-Wallberg KA. Common diseases as determinants of menopausal age. Hum Reprod. 2016;31(12):2856-64.

28. brand JS, van der Schouw YT, Onland-Moret NC, Sharp SJ, Ong KK, Khaw KT, et al. Age at menopause, reproductive life span, and type 2 diabetes risk: results from the EPIC-InterAct study. diabetes Care. 2013;36(4):1012-9.

29. Mills Jl, Simpson Jl, driscoll SG, Jovanovic-Peterson l, van Allen M, Aarons JH, et al. Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identified within 21 days of conception. N Engl J Med. 1988;319(25):1617-23.

30. Hanson U, Persson b, Thunell S. Relationship between haemoglobin A1C in early type 1 (insulin-dependent) diabetic pregnancy and the occurrence of spontaneous abortion and fetal malformation in Sweden. diabetologia. 1990;33(2):100-4.

31. Practice Committee of the American Society for Reproductive M. Evaluation and treatment of recurrent pregnancy loss: a committee opinion. Fertil Steril. 2012;98(5):1103-11.

32. Guerin A, Nisenbaum R, Ray JG. Use of maternal GHb concentration to estimate the risk of congenital anomalies in the offspring of women with prepregnancy diabetes. diabetes Care.

2007;30(7):1920-5.

33. Jonasson JM, brismar K, Sparen P, lambe M, Nyren O, Ostenson CG, et al. Fertility in women with type 1 diabetes: a population-based cohort study in Sweden. diabetes Care.

2007;30(9):2271-6.

Jaye Adams, MD, MS, FACOG, practices Reproductive En-

docrinology and Infertility at the Fertility Center of San Antonio.

visit us at www.bcms.org

21

DIABETES AND OBESITY

Addressing Food & Mood FOR IMPROVED OUTCOMES IN OBESITY AND DIABETIC CONTROL

By Edward Dick, MD

W

hile the management of type 2 diabetes and obesity

remain challenging, recent years have seen unprece-

dented availability of new medications and techno-

logical advances promising to enhance their control. despite the

diseases including obesity and metabolic disorders. The science

and treatment of ACES continues to evolve. Appropriate treat-

ment of ACES requires a team with training in trauma informed

care and a system of screening and referral to receive that care.

increase in availability of diabetes drugs and tech, effecting be-

To learn more about ACES start with the websites acesconnec-

healthy eating, active living, and adherence with therapeutic plans.

bexar County has an emerging trauma informed community called

havioral change continues to vex clinicians seeking to encourage

tion.com and the National Pediatric Practice Community websites.

Motivational interviewing offers a framework for discussing goals

the South Texas Trauma Informed Care Consortium (STTICC)

as to why patients seem so reluctant or unable to start new habits

dressing the origins and treatment of ACES.

health detriments.

Psychosocial Factors in Diabetes Management

Adverse Childhood Experiences (ACES)

tion to complex psychosocial factors that may be present together

a patient may wish to achieve but clinicians may still be at a loss that would promote their health or stop practices that result in

Evolving research suggests additional areas that may affect the

development, progress, and control of diabetes and obesity, in-

cluding behavioral factors and social stress. One emerging area of

behavioral stress is the role of Adverse Childhood Experiences

(ACES). ACES first emerged as a major factor in obesity and

metabolic control in work done by Anda and Felitti. Anda and col-

leagues have published data linking ACES to a variety of chronic 22

San Antonio Medicine â&#x20AC;˘ December 2018

which will increasingly serve as a community wide resource in ad-

Successful management of obesity and diabetes requires atten-

but not fully identified by traditional screening tools such as the

PHQ9. This complexity of factors is one reason the American diabetes Association (AdA) Standards of Care includes psychoso-

cial support as a standard element of care. Psychosocial support

must address distinct but sometimes interrelated factors such as

diabetic distress, the language that providers use with patients,

toxic psychosocial trauma, and a spectrum of anxiety and depres-

DIABETES AND OBESITY Conclusion

Physicians and their clinical col-

leagues are challenged by the multi-factorial nature of weight management and diabetic control.

With limited time, decreasing re-

imbursements, and support, building the optimal team to manage

the full spectrum of diabetes care

can be daunting. Physician societies, payers, and professional groups must work together to

identify, build, and support the creation

sive disorders. Partnering with behavioral health specialists may

help primary care and subspecialty physicians to overcome the

complexity of psychosocial trauma, depression, and distress. The

AdA website contains additional resources for physicians on find-

ing trained behavioral health specialists and other resources to ad-

of

multidisciplinary

teams needed to manage the

emerging best practices which are then needed to manage the complex relationships of behavioral health and food.

Edward Dick, MD, is a Board Certified Family Physician. He currently

serves as Senior Vice President of Integrated Health for Methodist Health-

dress diabetic distress and other behavioral challenges.

care Ministries (MHM).

Food Insecurity

References:

health approaches to diabetes and obesity is the role that social de-

American diabetes Association (2018). Standards of Care 2018. diabetes care, 41(1), supplement 1, S1-155.

Further complicating the challenges of adequate behavioral

terminants of health play in their management. lacking the resources to purchase, store, and prepare healthy foods contributes to poor food choices and complicates weight and glycemic control.

Shalowitz and colleagues showed that lacking adequate appropriate food (food insecurity) leads to hospitalizations, emergency room utilization, and other diabetic complications. Food Insecurity can

be screened using a validated two-question item called the “Hunger

vital Sign.” The Hunger vital Sign can be done by itself or as part

of a larger social determinant screening such at the PRAPARE tool from the National Association of Community Health Centers

(NACHC). In a New England Journal Catalyst presentation, the

Geisinger Clinic described the power of addressing food security

in the management of diabetes. Geisinger showed that screening and addressing food security resulted in a 40 percent reduction in

the risk of death or serious complications, a 2.1 percentage point

drop in HgbA1C, and an 80 percent reduction in costs. The San

Antonio Food bank helps with food insecurity screening in the clinical setting and resources to help address it.

https://www.acesconnection.com/

http://care.diabetesjournals.org/content/41/Supplement_1

Anda, R. F., Felitti, v. J., bremner, J. d., Walker, J. d., Whitfield, C., Perry, b. d., dube, S. R., … Giles, W. H. (2005). The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology.

European archives of psychiatry and clinical neuroscience, 256(3), 174-86.

Aw, W., & Fukuda, S. (2017). Understanding the role of the gut ecosystem in diabetes mellitus. Journal of diabetes investigation, 9(1), 5-12. https://catalyst.nejm.org/prescribing-fresh-food-farmacy/

http://www.nachc.org/research-and-data/prapare/

https://nppcaces.org/

https://safoodbank.org/

Shalowitz, M. U., Eng, J. S., McKinney, C. O., Krohn, J., lapin, b., Wang, C. H., & Nodine, E. (2017). Food security is related to adult type 2 diabetes control over time in a United States safety net primary care clinic population. Nutrition & diabetes, 7(5), e277. doi:10.1038/nutd.2017.18 visit us at www.bcms.org

23

DIABETES AND OBESITY

HOW MANAGED CARE COMPANIES ARE MANAGING CARE THE TYPE 2 DIABETES CASE

By Alan Preston, MHA, ScD he Health Maintenance Organization (HMO) Act of

ceived sufficient care at the doctor level in order to keep them out

the Nixon administration and was introduced by a dem-

ment is that it removes the economic incentive of unnecessary

healthcare costs were skyrocketing and something needed to be

care including preventive services, which in turn help to control

T

1973 was federal statute enacted on dec. 29, 1973, under

ocratic senator, Ted Kennedy. In 1973, there was concern that

of the hospital. The most important advantage of capitation pay-

over-utilization while adding an incentive to provide cost-effective

done to curtail the costs of increasing healthcare premiums. Sound

health care costs. This change in economic incentive is related not

preventing the diseases, as opposed to just paying for claims once

tive efficiency.

familiar? The concept was that if more emphasis were placed on

a person acquired a disease, healthcare costs would decrease.

only to cost containment but also to the improvement of allocaAs the HMO model evolved, Medicare created the Medicare

One of the key components of the HMO Act was that it

Advantage program. Medicare Advantage provides the same med-

the Managed Care Organization). doctors and providers con-

payments for inpatient hospital, hospice, and skilled nursing serv-

changed the relationship of the insured to the HMO (or later aka

tracted with HMOs and looked solely to the HMO for payment and were prohibited from seeking additional payments (other than

ical services as Medicare Parts A, and b. Medicare Part A provides ices. Part b provides payments for most physician and surgical

services, including outpatient hospital services such as ER, surgical

co-payments and co-insurance of the patient) from the member.

center, laboratory, X-rays, and durable medical equipment and

of the contracting HMO. Often the payments were tied to im-

typically have additional services, such as prescription drugs (Part

The providers were also "credentialed" to assure they met criteria

supplies. Part C plans, including Medicare Advantage plans, also

proved outcomes that we now characterize as "pay for perform-

d), dental, hearing, vision, and wellness care and often have a

during the 1990s, many providers were capitated for the care

The MA plans are capitated by Center of Medicare Services

ance." And over time, disease management programs were created.

they delivered. Some of the medical groups took on an increasing

level of risk to include PCP, Specialty, and Hospital. The capitated

payments aligned incentives for PCPs to make sure patients re24

San Antonio Medicine â&#x20AC;˘ December 2018

zero-premium amount attached to many of the plans offered.

(CMS), and the capitation is based on many attributes including

the relative risk of the Medicare beneficiary. Often, the MA plans

share upside and downside risk with certain medical groups for

(continued on page 26)

DIABETES AND OBESITY (continued from page 24)

the management of the patients assigned to the group by the MA

patients. There is, in fact, evidence that higher HMO penetration,

plan. Thus, there is a financial incentive for the medical groups to

in both Medicare and commercial, has positive spillover in the

care that produces an improved outcome. Take type 2 diabetes as

doctors tend to practice medicine in a rather consistent manner.

assure the patients are not just receiving care; however, receiving

an example.

In 2012, it was estimated that more than 21.8 million Americans

management of patients. There is a simple explanation for this.

That is a good thing! And when they develop positive patterns of

practice that are imposed upon them by managed care plans, they

had type 2 diabetes. The majority of those were between the ages

tend to adopt the practice patterns on non-managed care plan pa-

many disease progressions, age is indeed an independent risk fac-

MA plans have improved the performance of TM members as a

of 46 and 64 (44 percent), and 65 and older (43 percent). As with

tor for the acquisition of disease. Regarding race/ethnicity, 60 per-

tients as well. Studies suggest that over the past decade that the

result of the "spillover" effect of managing the care of these pa-

cent were non-Hispanic white, 17 percent were Hispanic, 15

tients through population health management techniques. The

ers. Individuals with a high school diploma, the unemployed, and

Furthermore, there is evidence of spillovers from MA to TM,

those with diabetes. About 41 percent of diabetes cases were from

Managed care can influence physician practice styles more

percent were black, 5 percent were Asian, and 3 percent were oththose with incomes below $20,000 accounted for over half of

comparisons of quality between MA and TM tend to favor MA.

which may justify a higher reimbursement rate for MA.

the southern census region, and 83 percent were from urban areas.

broadly if managed care changes the physician treatment of man-

some other health conditions that lead to a deterioration of indi-

treatment of his or her other patients. We have witnessed over the

ulcers, blindness, high blood pressure to name a few of the co-

tice patterns of providers including hospitals. The number of bed

in managing this disease, particularly in the Medicare population?

reimbursement form a Fee-For-Service (FFS) to a prospective pay-

tional Medicare (TM), and often there is a positive spill from MA

deploy many techniques to control utilization, such as pre-autho-

And as we all know, type 2 diabetes is often associated with

vidual health. Heart disease, vascular compromise, diabetic foot morbidities associated with type 2 diabetes. So why do MCOs help

On average, MA plans appear to offer higher value than Tradi-

into TM that suggests that reimbursements effect management of 26

San Antonio Medicine â&#x20AC;˘ December 2018

aged care patients, and then those changes affect the physicianâ&#x20AC;&#x2122;s

years that the method of reimbursement does influence the prac-

days/1,000 were substantially reduced when CMS converted the

ment diagnostic Related Groupings (dRGs). Managed care plans

rization, utilization review, referral requirements, restricted net-

DIABETES AND OBESITY

works, and (full or partial) capitation . These tools may change

enough that the doctor saw the patient, they also need to make

those in the managed care plan.

regarding outcomes.

how physicians practice medicine for all of their patients; not just As the financial incentives change, so do the behaviors of the

providers. Paying physicians for improved outcomes as opposed

to episodic care aligns the financial incentive with the desired improved outcome. Center for Medicare and Medicaid Services (CMS) is very interested in physicians that understand how to per-

sure that the prescribed treatment is heading in the right directions

Star Ratings are driving improvements in Medicare quality. The Star Rating measures span five broad categories: OUTCOMES

form population health management functions. CMS understands

INTERMEdIATE OUTCOMES

management should be paid for their patients’ improved health-

ACCESS

that physicians that understand the benefit of population health

care outcomes.

Population health management involves many aspects of man-

aging a patient. The goal is to assure that for a given disease; the

PATIENT EXPERIENCE PROCESS

Not every domain is weighted equally, however. For 2017 Star

patient is contacted, treated, followed-up, and the outcome is im-

Ratings, outcomes and intermediate outcomes continue to be

to get physicians to adopt components of population health man-

perience and access measures are weighted 1.5 times as much as

proved. There have been some early elementary attempts of trying

agement. The Healthcare Effectiveness data and Information

(HEdIS) is one such attempt.

weighted three times as much as process measures, and patient ex-

process measures. CMS assigns a weight of 1 to all new measures.

Of the 364 health plan contracts that participate in Medicare Ad-

HEdIS is a tool used by more than 90 percent of America's

vantage, there were only 81 with a STAR rating of 4.5 or higher.

of care and service. Many health plans use the HEdIS measure-

we added up all the patients seen by a primary care physician, the

health plans to measure performance on important dimensions

ments to highlight their scores to prospective employers. HEdIS

measures address a broad range of important health issues.

Among them are the following: • Asthma Medication Use

• Persistence of beta-blocker Treatment after a Heart Attack

• Controlling High blood Pressure • Comprehensive diabetes Care

Physician’s manage one patient at a time. Throughout a year, if

entirety of that population may have some common characteris-

tics that may need to be tracked and managed. And to the extent

a primary care physician averaged 20 patients visits a day for 210

days out of the year, they would encounter approximately 4,100

patient visits. Some of the visits are repeat follow-up visits and

probably account for over 50 percent of the patient “population.”

Thus, a primary care physician may have a panel of patients for a

• breast Cancer Screening

year of approximately 2,500 to 3,000 patients.

• Childhood and Adolescent Immunization Status

of patients that have similar disease classifications. Take type 2 di-

• Antidepressant Medication Management

• Childhood and Adult Weight/bMI Assessment

For the Medicare Advantage population, CMS has used another

tracking program called STAR. One of the differences between

Of that “population” of patients, there are some characteristics

abetes for example; The prevalence rate of type 2 is approximately

9.3 percent (i.e., 29 million people) according to the CdC. How-

ever, over 86 million have “pre-diabetes.” And of the 29 million

people who have type 2, approximately 8.1 million people don’t

HEdIS and STAR is that HEdIS is responsible for making sure

know they have it and are undiagnosed!

required by HEdIS and whereas STAR requires both the per-

can play an important role for both the patient and the doctor.

that providers at least perform the activities of measurement as

formance of the measurement activity with the additional requirement of demonstrating improved outcomes. Thus, it is not good

This is a good example where population health management

Imagine if a physician’s practice ran a report that looked at many

of the risk factors for type 2 diabetes. Some of the risk factors

(continued on page 28)

visit us at www.bcms.org

27

DIABETES AND OBESITY (continued from page 24)

would be: Age, weight, ethnicity, and gender, to name a

few. That list could be cross-referenced with known lab

data to determine whether the â&#x20AC;&#x153;population of interestâ&#x20AC;? had their Hba1c or blood sugars tested and resulted. If

not, scheduling the patient for a visit to perform such a

test in the population of interest might reveal undiag-

nosed patients and pre-diabetic patients. Treating the undiagnosed patient and the pre-diabetic patient is the

benefit of population health management.

The implications for physicians is that health plans

want to contract with physicians, IPAs, ACOs, and

MSOs that contract with high-performing physicians, and can

stand how to assist you in the population health management

STAR ratings may find cancelation notices from the managed care

cians do a better job managing the outcome of the patient, they

demonstrate high STAR ratings. Those physicians that have lower

companies. The private Medicare Advantage companies, in the

long run, will not contract with physicians that are doing a poor

job managing their population of patients. Thus, if you are a

physician that is looking to participate in population health management, you might want to first look at organizations that under-

28

San Antonio Medicine â&#x20AC;˘ December 2018

arena. The good news is that to the extent that primary care physi-

will receive additional pay as a result. And it is appropriate to re-

ward physicians that effectuate the improved outcomes of patients.

Alan Preston is a member of the BCMS Publications Committee.

DIABETES AND OBESITY

Diabetes in Veterans DETECTING FRAILTY IN TIME

By Patricia S. Machado, MS2

An

older diabetic man wakes up in the morning feel-

sugar. Patients who are diagnosed with Type II diabetes Mellitus

ing an overwhelming sense of physical exhaus-

are at the highest risk to develop frailty compared to all other med-

day-to-day activities is low. Gripping a cup of coffee is difficult as

strongly correlated with the severity of diabetes because abnor-

tion and fatigue. The motivation to undergo

he notices a greater decline in grip strength and senses a decrease in knee extensor strength. As he walks across the room, there is a

marked decrease in walking speed and he realizes his strength is

ical comorbidities combined. The extensive increase in frailty is

mally high glucose levels in the blood can lead to the development

of an “insulin-resistant environment” in the body, which feeds

into the mechanism of chronic inflammation. This environment

just not as it used to be. but there is no reason to worry as these

has increased circulatory inflammatory cytokines such as CRP (C-

istics are not the natural progression of aging, but a medical syn-

gen, and transferrin which are all are predictive factors of frailty

are all the normal signs of aging, right? Wrong. These character-

reactive protein), Il-6, Il-1,TNF-a,TNFsR1 and TNFs2, fibrino-

drome that can be associated with poor health outcomes. This

impairments of mobility and physical function. This step-wise de-

increases risk of hospitalization, falls, disability, and even death.

studied in several cohorts, including our own San Antonio longi-

syndrome is termed frailty, which is a medical comorbidity that Patients who are “frail,” are shown to exhibit chronic inflam-

mation throughout the muscles, joints, and bones that cause pa-

tients to become exponentially weaker in time. The catalyst for

the increased inflammatory state can be due to chronic high blood pressure, heart disease, obesity, but most importantly high blood

30

San Antonio Medicine • December 2018

cline of physical function related to diabetes has been extensively

tudinal Study of Aging. Which means the negative consequences

of diabetes could already knocking on our own front door.

So how can we help patients that already suffer from frailty?

Unfortunately, there are no definitive treatments or prevention

measures as of today for the management of frailty. However,

DIABETES AND OBESITY the treatment of diabetes exists and has well-known, affordable

medications in the market. Could this possibly also be the solution for frailty?

by asking subjects to walk as fast as they can for 10m and taking

the fastest speed of 3 trials. low physical activity is measured by

the “Minnesota leisure Questionnaire” (MlQ) which calculates

The diabetes meds in the market today have multifactorial ef-

the calories burned through different physical activities conducted

stood by the medical community. but the most important known

database. Weight loss is assessed if there was a 10lb or more un-

fects within the body with mechanisms that are not 100% under-

effect is the increase in glucose uptake within the cells through in-

in one year and the calories are compared to a nationally studied

intentional weight loss or loss of >5 percent body weight in the

sulin. This “insulin sensitizing effect” is mediated via a highly

span of one year and finally exhaustion is recorded via self-re-

effects within the body. One of the most important and relevant

quantify the extent of “frailty” progression throughout the study

complex AMPK signaling pathway which has hundreds of cascade

cascade effects is the overall decrease in inflammatory markers

such as CRP, Il-6, and TNF-a. These are the key inflammatory markers that exacerbate frailty.

So perhaps there can be a way to treat patients that are afflicted

with frailty. This hypothesis is built from two premises. One, an

increase in inflammatory markers can cause or exacerbate frailty.

ported questionnaires. Within these parameters it’s possible to

using a score of 0-5. Within the course of two years I will help

assess patients and see whether diabetes medications may revolu-

tionize the treatment for frailty.

being involved in the MSTAR (Medical Student Training in

Aging Research) program as a first- and second-year medical stu-

dent equipped me with the tools to be involved with the diabetic

Two, diabetes medications work by decreasing inflammation via

patient population. My favorite aspect of this research opportunity

search question is formulated: can diabetes medications be used

interact with the geriatric patients that are within the vA system.

AMPK signaling pathway and insulin sensitization. So, the re-

to ameliorate and even treat frailty?

This was the research question that I worked with in the

MSTAR (Medical Student Training in Aging Research) program

is that I have the opportunity to work in the veterans hospital and

To learn more information about the MSTAR program or vA health system visit:

https://www.afar.org/research/funding/mstar/

as a first- and second-year medical student with dr. Sara Espinoza.

https://www.va.gov/health/vAhealthnews

search here at UT Heath San Antonio School of Medicine. She

Patricia S. Machado, is a medical student at University of Texas Health

dr. Espinoza is one of the pioneers for frailty and diabetes re-

works with the vA hospital and is currently conducting a double-

blinded randomized controlled trial involving

San Antonio, Long School of Medicine and MSTAR program participant.

200 participants within a two-year period to test whether diabetes can be used as a phar-

macological treatment for frailty. The inclusion

criteria are patients over the age 65 that are afflicted with pre-diabetes with OGTT between

140-199 mg/dl that also show signs of

“frailty.” The term frailty that is used by her

team is described by 5 categories that include

weakness, slowness, low physical activity, exhaustion, and weight loss (Fried et al. 2001).

Weakness is assessed via grip strength, where

subjects squeeze into a device called a dy-

namometer that measures force (N) of the dominant hand and the highest number of

two trials is recorded. Slowness is calculated

visit us at www.bcms.org

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PRACTICE GROUPS

Pediatrix Medical Group SERVING SAN ANTONIO SINCE 1979

2018 Women in Medicine Leadership Large Group Award Recipient

By Mike W. Thomas Founded in 1979, Pediatrix Medical Group has been caring for newborns for nearly 40 years and during that time has developed a reputation as one of the leading providers of pediatric services in San Antonio.

This year, Pediatrix Medical Group was recognized by the bexar County Medical Society Women in Medicine Committee with its large Practice Group Award during the 26th Annual Women in Medicine leadership Awards Ceremony on Nov. 15. A 100 percent membership group of Texas Medical Association and bexar County Medical Society, the group offers a whole host of pediatric services including pediatric surgery, pediatric hospitalist services, pediatric cardiology, perinatal and pediatric development services.

Pediatrix is a subsidiary of MEdNAX Inc., a national health solutions partner providing services through a network of more than 4,200 physicians in all 50 states and Puerto Rico.

Pediatrix Medical Group of Texas - San Antonio, through its hospital partners, provides comprehensive clinical services to sup32

San Antonio Medicine â&#x20AC;˘ December 2018

port the most critically-ill and premature newborns. The practice cares for more than 225 newborns each day in multiple neonatal intensive care units (NICUs).

Pediatrix Medical Group is one of the nationâ&#x20AC;&#x2122;s leading providers of maternal-fetal, and pediatric medical and surgical subspecialty physician services. The company is also one of the nation's largest providers of newborn hearing screens.

Company representatives provided answers to the following questions:

What is the MEDNAX difference?

Here in San Antonio, we offer a strategic growth and maturing to meet the needs of our patients and partners, and we have created a family of services that work together across the continuum of care. Our services range from Neonatology, Maternal Fetal Medicine, Pediatric Surgery and Cardiology, developmental Medicine, Pediatric Hospitalist and Pediatric ENT. Our diverse portfolio of

PRACTICE GROUPS Any regional, state or national affiliations?

Pediatrix Medical Group, Obstetrix Medical Group, American Anesthesiology, Meddata, Surgical directions, vRad President and/or lead physician Regional President – bill Cox Regional vice President – Phillip Weinman lead Physician – dr. Michael battista, MEdNAX-affiliated Neonatologist and Medical director.

companies is able to stand alone or work in harmony to improve the clinical, operational and financial performance of health organizations of all shapes and sizes.

What does MEDNAX do to maintain employee morale?

Patient satisfaction? Team building Training (Internal and External), Summer Party, Christmas Party, Meet & Greet Events.

What kind of involvement do your physicians have in the community?

What groups do you support? Mednax has supported the following community organizations: blood and Tissue Center, downs Syndrome Association, Healthy Futures, Kinetic Kids, March of dimes, louise batz Foundation, bCMS, TMA, SAPS, Any baby Can.

Full name of practice, including corporate structure (IPA, LLC, etc.)

Pediatrix Medical Group, a MEdNAX company: Pediatrix Medical Group, San Antonio San Antonio Pediatric Surgery Associates San Antonio Pediatric Hospitalist Services Pediatric Cardiology Associates Texas Perinatal Group San Antonio Pediatric developmental Services

What year was the practice founded?

Pediatrix Medical Group, a MEdNAX company, was founded in 1979. It is the nation’s largest group of pediatric specialists, providing a comprehensive scope of pediatric solutions. Through our hospital-based and clinic programs, we offer a partnership between community-based physicians and hospitals to guarantee children have access to the highest level of care.

Our pediatric specialists are uniquely positioned to collaborate and communicate across practices and specialties, and work collaboratively with primary care providers and other specialists to ensure patients receive coordinated care.

Number of physicians…

Where do they have hospital privileges?

Total Physicians: 82 Methodist Health System, baptist Health System, CHRISTUS Healthcare

Number of staff….

Types of employer benefits provided?

Total Staff: 223 benefits include: Medical, dental, vision, life Insurance, Short-long Term disability, 401K, Profit Sharing

Type of practice and physician specialties; Do you operate under an ACO model?

No. Hospital and office based; Specialties include Neonatology, Pediatric Hospitalist, Pediatric Surgery, Plastic Surgery, Pediatric Cardiology, Maternal Fetal Medicine, and developmental Medicine

What brand of electronic health records is used?

Do you participate in HASA? babySteps, NextGen

Do you accept new Medicare/Medicaid patients?

Yes – primarily Medicaid, specialty physicians must have a referral from the PCP.

Who is your medical liability insurance provider?

Coverys

Which patient health insurance providers do you contract with?

Aetna, blue Cross, Cigna, Community First, Humana, Tricare, Medicaid and Medicaid replacement plans, United Healthcare.

Admin office:

5430 Fredericksburg Road, Suite 508, San Antonio, TX 78229 (210)541-8281 Phone (210)541-9123 Fax http://www.mednax.com/ https://sanantonio.pediatrix.com/

BCMS AUTO SHOW

The 32nd Annual bCMS Auto Show 1. bCMS Circle of Friends members turned out to support the annual Auto Show. (From l-R) Amanda Pllat, land Rover; Andrea Wollenzen, Phyllis browning Co.; Cleo Garza, SWbC Mortgage; August Charles Trevino, bexar County Medical Society; Mark Koehl, Kuper Sotheby’s International Realty.

2. dr. david J. Henkes and his wife, danielle, inspect a Subaru SUv. 3. Ice sculpture courtesy of Heavenly Gourmet.

4. dr. Sheldon G. Gross, bCMS President, speaks with Mr. and dr. Sanchez..

5. Phil Hornbeak, bCMS Auto Program director (seated in foreground), visits with Gary Holgraf of Cavendar Toyota (seated to the left) and a representative of Northside Ford.

6. Music provided by local band “Entourage.”

1

2

3

4

5 7. dr. Jose benavides, a past bCMS President (center back) checks out a yellow Corvette from Gunn Auto.

8. A red Porsche 911 GTS from Porsche of San Antonio.

9. A dodge Charger from Ancira.

10. An SMG Convertible from Mercedes benz of boerne.

11. A family checks out an Audi Quatro from Cavender Audi.

12. Interior of the Range Rover Evoque convertible by land Rover of San Antonio.

13. A lexus Coupe lC 500 by lexus of San Antonio and The dominion.

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San Antonio Medicine • December 2018

BCMS AUTO SHOW

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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”

ASSET MANAGEMENT

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

Eric Kala CFP®, CIMA®, AEP®, CLU®, CRPS® Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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San Antonio Medicine • December 2018

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 William E. Hammel Partner 214-646-8625 whammel@constangy.com John E. Duke Senior Counsel 512-382-8800 jduke@constangy.com www.constangy.com “A wider lens on workplace law.”

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 Vice President, Private Advisor 210-248-1583 CHinojosa@BBandT.com www.bbt.com/wealth/start.page "All we see is you"

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

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

BANKING

Amegy Bank of Texas (HHH Gold Sponsor) We believe that any great relationship starts with five core values: Attention, Accountability, Appreciation, Adaptability and Attainability.

We work hard and together with our clients to accomplish great things.

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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

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

Ken Herring 210-283-4026 kherring@broadwaybank.com www.broadwaybank.com “We’re here for good.”

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

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

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

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

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

Synergy Federal Credit Union (HHH Gold Sponsor) BCMS members are eligible to join

Synergy FCU, a full service financial institution. With high savings rates and low loans rates, Synergy can help you meet your financial goals.

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

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

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

EMPLOYEE MANAGEMENT

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

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

FINANCIAL ADVISOR

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

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

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

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

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

FINANCIAL SERVICES

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

Leslie Barnett SWBC Mortgage lbarnett@swbc.com Gil Castillo SWBC Wealth Management 210-321-7258 gcastillo@swbc.com

Kristine Edge SWBC PEO – Professional Employer Organization 830-980-1207 kedge@swbc.com Cleo Garza SWBC Mortgage – Sr. Loan Officer 210-386-0732 cleogarza@swbc.com Debbie Marino SWBC Insurance & Benefits 210-525-1241 dmarino@swbc.com www.swbc.com SWBC family of services supporting Physicians and the Medical Society

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

Eric Kala CFP, CIMA, AEP, CLU, CRPS Founder & Wealth Management Advisor 210.446.5752 eric.kala@nm.com avidwealthpartners.com “Plan it. Do it. Avid Wealth”

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

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

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

Founding Member

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BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY continued from page 37

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

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

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

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

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

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

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

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San Antonio Medicine • December 2018

Wealth Management 210-650-1759 srolf@rbfcu.org www.rbfcu.org 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.”

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”

HOSPITALS/ HEALTHCARE SERVICES

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

HEALTHCARE BANKING

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

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

HEALTHCARE CONSULTING

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

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 drive your practice forward.

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

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

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

BCMS CIRCLE OF FRIENDS SERVICES DIRECTORY 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

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 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

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

Nathan Dumas Real Estate Advisor, REALTOR 210-667-6499 nathan@kupersir.com www.nathandumas.com Mark Koehl, Real Estate Advisor, REALTOR (210) 683-9545 mark.koehl@kupersir.com www.markkoehl.com "Realtors with experience in healthcare and Physician relations" 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 Genevieve Pineda Business Development Director 210-386-7853 Genevieve@veerspace.com Anna Hernandez Marketing Specialist 210-852-7619 Anna@veerspace.com

MEDICAL BUSINESS CONSULTING

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

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

MEDICAL BILLING AND COLLECTIONS SERVICES

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

Lettie Cantu - Owner 210-363-1735 Lettie@progressivebilling.com Richard Hernandez - Administrator 210-733-1802 richard@progressivebilling.com

www.progressivebilling.com "We provide quality, professionalism and results for your practice."

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

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

MEDICAL SUPPLIES AND EQUIPMENT

Henry Schein Medical (HHH Gold Sponsor) From alcohol pads and bandages to EKGs and ultrasounds, we are the largest worldwide distributor of medical supplies, equipment, vaccines and pharmaceuticals serving office-based practitioners in 20 countries. Recognized as one of the world’s most ethical companies by Ethisphere.

Tom Rosol 210-413-8079 tom.rosol@henryschein.com www.henryschein.com “BCMS members receive GPO discounts of 15 to 50 percent.”

PHYSICIAN SERVICES

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

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

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SWBC family of services supporting Physicians and the Medical Society

PRIVATE EQUITY

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

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

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.

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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.

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REAL ESTATE SERVICES COMMERCIAL

Rastegar Equity Partners (HHHH 10K Platinum Sponsor)

40

San Antonio Medicine • December 2018

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

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

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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.

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

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.

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TOXICOLOGY LABORATORY TESTING

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

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

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

The Swarm

FEATURE

Part 4 of 4

By Allen Cosnow, DVM

have left the original hive, nearly deprived of adults, nearly defenseless. A person observing this hive during the first days after the swarm has left would think that it is empty, or that the colony is nearly dead. Instead of the copious stream of workers that until recently was rushing in and out, all that can be seen now are one or two bees that come out sporadically, fly around a bit, and then return. Hardly any of the more mature workers--those whose task was to collect pollen and nectar and to guard the entrance-have remained. All the others have flown away with the swarm.

However, there are still thousands of larvae and pupae inside, silently developing in their wax cells, almost all workers, but some new drones too. (The adult workers that remained behind were the youngest ones, whose task in any case is to be the nurses, feeding the larvae and covering the brood-containing combs to keep them warm; this they continue to do.) Every day a thousand or more new workers complete their metamorphosis and emerge from their cells.

In a short time, those remaining workers that had at first been nurses for the larvae are mature enough to go out to work on flowers or to stand guard, while the newly-emerged workers take over the care of their younger siblings still developing in their cells. but those are all of the previous generation, the last daughters of their mother, the old queen, who has already begun a new life elsewhere. There can be no new eggs; worker bees are female, but sterile. The future of the colony resides entirely in that queen pupa still in her cocoon inside the sealed cell where she is undergoing her metamorphosis. Without her there can be no new generation, and the colony will die out. It is for this reason that bees never swarm until there is at least one sealed queen cell.

Thus, not more than nine days after the swarm has departed, the virgin queen is fully developed. She chews a hole in her cocoon and then chews an opening in the wax seal of her cell, often while the nurse workers help her, chewing from the outside. When she emerges, the nurse bees surround her, cleaning her and feeding her honey and pollen. but the “princess” doesn't have time to enjoy all this attention.

She has a certain pressing task to attend to: ridding herself of rivals.

She goes through every part of the hive in search of other queen cells (often there is at least one other), and when she finds one, she

We

42

San Antonio Medicine • December 2018

chews a hole in it, plunges in her stinger, and murders her sleeping sister. In a honey bee colony there is room for one queen, one only, and the first one to emerge wins.

The virgin remains in the hive to rest and gain strength for a few days. Then on the first suitable day, the all-important event occurs: the mating flight. A queen bee mates only once in her life, storing the semen in an internal sac and keeping the spermatozoa alive for as long as three years. but she doesn't copulate inside the hive. In fact, when the virgin is inside, the drones, the males, seem not to notice her, even if they are right next to her. To be fertilized, a virgin must leave the hive and fly high in the air, higher than bees normally fly on their working flights, often at a considerable distance from the hive, even at the risk of losing her way back or being eaten by a bird. This serves to increase the probability that she will mate with drones from other colonies, lessening the possibility that she could mate with drones from her own colony, who are her brothers, thus avoiding inbreeding.

High in the air and far from the hive, a large number of drones – from wherever they originated – detect her presence and pursue her. As each of the fastest drones catches up to her he everts his sexual organ, and in an instant the copulation is done; the force of the act tears away the organ, and the “successful” drone falls to earth dead. A number of drones copulate with her on that flight, each contributing his genes and losing his life.* After that busy few hours she returns to the hive. The workers greet her and clean her and feed her. Now there is once again a fertile queen who will lay eggs and be the mother of the colony. Once she has made her mating flight, she will not leave the hive again, unless in the future she herself takes part in a swarm as her mother did. * The first description in English of honey bee mating was written in 1853 by the American l.l. langstroth in his book The Hive and the Honeybee. I have always found it rather quaint that although he wrote the book in English, he cautiously wrote the paragraphs that deal with the copulation in latin, so as not to offend the sensitivities of the victorian public.

Allen Cosnow, DVM, is a retired small animal veterinarian who keeps his several bee colonies on a city lot in Glencoe, Ill., a lakeshore suburb of Chicago.

He is a veterinary school classmate of Fred H. Olin, DVM, MD.

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AUTO REVIEW

2019 Lincoln Navigator

By Stephen Schutz, MD

44

San Antonio Medicine â&#x20AC;¢ December 2018

AUTO REVIEW The 2019 Lincoln Navigator is an excellent full-

size luxury SUv that will appeal to upscale buyers who need

One quirk of the Navigator (and other lincolns) is the push-

button gear selector. Electronics have enabled automobile manu-

extra space and/or need to tow a trailer. Since the Navigator is

facturers to do just about anything they want with those important

best vehicle in its class, it’s logical to conclude that the Navigator

sole that rise up as you start the car or Mercedes’ steering column

right. but it wasn’t long ago — like a year ago before the current

time to get used to pushing a button just above the HvAC con-

ally outgunned and outsold by the Cadillac Escalade.

opens up space in the console and is a reminder that in 2018 leav-

based on the Ford F-150 pickup, which is (in my opinion) the would also be best in class. And for now, I’d say that’s mostly

Navigator launched — that lincoln’s biggest SUv was perenniWhat changed? A lot actually, but I think the most important

thing is that lincoln’s parent company, Ford, decided to get serious about making the Navigator competitive.

For starters, the interior is much more luxurious than it used

controls — witness Jaguar–land Rover’s knobs in the central con-

mounted stalks — and lincoln’s solution is as good as any. It takes

trols whenever you put the Navigator into Park or Reverse, but it

ing a gear lever there is a waste of space.

lincoln has also taken pains to make the exterior design of the

Navigator more distinctive. They succeeded to a point, with a

sleek linear profile accented by clever, even Audi-esque, front and

to be. Thank you, lincoln, because the biggest problem with

rear lights that turn on theatrically as you approach. And I like the

to turn a Ford F-150 interior into a lincoln interior without re-

but the profile and rear views are too conservative for me. While

previous Navigators was that sitting in one was a lesson in how

ally trying. The new one is not only legitimately luxurious but

new grille which manages to be both assertive and understated.

attractive, the Navigator doesn’t have the presence of the Es-

superior to the Escalade’s and arguably better than the ones in

calade, which seems like an automotive bradley Cooper while the

If you choose the highest trim black label option there are

Powering the 6,031-pound Navigator l I tested was the 450 HP

the Infiniti QX80 and lexus lX570.

three interior “packages” to choose from, amusingly called,

Navigator is more like Steve Carell.

eco-boost v6 from the F-150 Raptor. All that horsepower is great,

“Yacht Club,” “Chalet,” and “destination.” Mine featured the

but what buyers will really care about is the 500 pound-per-foot

touch surfaces abound, as do high-quality leather and plenty of

longer offers a v8, once you’ve experienced this wonderful eco-

dark earth-tone destination theme, and it was very nice. Soft

tasteful chrome and shiny black accents.

For the record, about 20 years ago Audi tried this with the A6

sedan, except they called their packages “Atmospheres.” It didn’t

catch on.

Manufacturers like to brag about how adjustable their front

seats are, but in the case of the Navigator there’s more adjusta-

of torque, which enables easy towing. While the Navigator no

boost engine you won’t care. It’s that good. don’t expect great fuel economy though, the Navigator manages just 16MPG in the

city and 23MPG on the highway.

When you’re talking about a 6,000-pound full-size SUv, it’s rea-

sonable to expect a meh driving experience, and that’s the case

here. It is cushy, however, and being able to look down on most

bility there than I’ve ever seen. believe it or not, the front head-

other vehicles is an undeniable plus. Parking is an undeniable

forwards. The seatbacks are split into two halves for even more

The 2019 lincoln Navigator is an excellent full-size luxury SUv,

rests can move electronically up and down and backwards and

customization, and, gulp, so are the front sections of the seats under your thighs. Take that Cadillac.

A wonderfully modern electronic dash with all sorts of con-

figurability is another highlight. Using the gauge area in front of

the driver to deliver most of the information he or she needs is a contemporary trend that I applaud, and I credit Audi’s virtual

Cockpit for encouraging other brands to do more of this. lincoln’s setup isn’t quite up to Audi’s level yet, but then again nei-

downer though, especially parallel parking.

and finally it’s got something for the Cadillac Escalade. The Es-

calade used to be the default domestic choice in this class. It’s not

anymore.

As always, contact Phil Hornbeak at 210-301-4367 to get infor-

mation about options and your best bCMS deal on a Navigator.

Stephen Schutz, MD, is a board-certified gastroenterologist

ther is anybody else’s.

who lived in San Antonio in the 1990s when he was sta-

of seven options, including amber and lilac. Hmm.

reviews for San Antonio Medicine since 1995.

Oh, you can also change the ambient light in the cabin to one

tioned here in the U.S. Air Force. He has been writing auto visit www.bcms.org 45 45 visit us us at at www.bcms.org

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46

San Antonio Medicine â&#x20AC;˘ December 2018