San Antonio Medicine magazine July 2014

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MEDICINEPROGNOSTICATIONS

4 San Antonio Medicine • July 2014

PrognosticationsPhysician reimbursements predicting the future By Bernard T. Swift Jr., DO, MPH...............................10

How very special(ized)?By Jeffrey J. Meffert, MD............................................12

President’s Message by K. Ashok Kumar, MD, FRCS, FAAP ..............................8

Physician as Patient: Complications of treatment by Jay Ellis, MD ..............................................................14

History of Medicine: A visit with Hippocratesby J.J. Waller Jr., MD ......................................................20

Business of Medicine: Transaction Costs: The friction in healthcare deliveryby Mark J. Bonica, PhD, and Lee W. Bewley, PhD, FACHE ........................................................22

BCMS News ................................................................................................................................24

Nonprofit: The “A: Word: Any Baby Can by Denise Rizzo ..........................................................26

Lifestyle: Best bets for viewing bats by Mauri Elbel ....................................................................28

Lifestyle: Restaurant Week ..........................................................................................................30

HASA: Patient information exchange shows value by Gijs van Oort, PhD............................................32

UTHSCSA Dean’s Message by Francisco González-Scarano, MD ............................................34

Book Review: “An Officer and a Spy: A novel” written by Robert Harris, reviewed by Fred H. Olin, MD ....................................................................................................36

Circle of Friends BCMS Group Purchasing and Service Directory........................................................37

In the Drivers’ Seat ................................................................................................................................43

Auto Review: Subaru Forester by Steve Schutz, MD ............................................................................44

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BOARD OF DIRECTORS

OFFICERSK. Ashok Kumar, MD, PresidentJayesh B. Shah, MD, Vice PresidentLeah Hanselka Jacobson, MD, TreasurerMaria M. Tiamson-Beato, MD, SecretaryJames L. Humphreys, MD, President-electGabriel Ortiz, MD, Immediate Past President

DIRECTORSJosie Ann Cigarroa, MD, MemberChelsea I. Clinton, MD, MemberJohn Robert Holcomb, MD, MemberLuci Katherine Leykum, MD, MemberCarmen Perez, MD, MemberOscar Gilberto Ramirez, MD, MemberAdam V. Ratner, MD, MemberBernard T. Swift, Jr., DO, MPH, MemberMiguel A. Vazquez, MD, MemberFrancisco Gonzalez-Scarano, MD,

Medical School RepresentativeCarlos Alberto Rosende, MD,

Medical School RepresentativeCarlayne E. Jackson, MD,

Medical School RepresentativeLuke Carroll, Medical Student RepresentativeCindy Comfort, BCMS Alliance PresidentNora Olvera Garza, MD, Board of Censors ChairRajaram Bala, MD, Board of Mediations ChairGeorge F. "Rick" Evans Jr., General Counsel

CEO/EXECUTIVE DIRECTORStephen C. Fitzer

CHIEF OPERATING OFFICERMelody Newsom

DIRECTOR OF COMMUNICATIONSSusan A. Merkner

COMMUNICATIONS/PUBLICATIONS COMMITTEEFred H. Olin, MD, ChairEstrella M.C. deForster, MD, MemberJay S. Ellis Jr., MD, MemberDiana H. Henderson, MD, MemberJeffrey J. Meffert, MD, MemberSumeru “Sam” Mehta, MD, MemberRajam S. Ramamurthy, MD, MemberJohn C. Sparks Sr., MD, MemberChittamuru V. Surendranath, MD, MemberJ.J. Waller Jr., MD, MemberJason Ming Zhao, MD, Member

First of all, congratulations to the residents and fellows who are

graduating from their training programs in San Antonio later this

month! I wish each of you great success in your professional ca-

reer and much happiness in your personal lives. I encourage you

to join and actively participate in your local county medical soci-

ety and your specialty society. For those of you who will practice

in Bexar County, I invite you to become active members of the

Bexar County Medical Society (BCMS) and Texas Medical Asso-

ciation (TMA). We need your new ideas, enthusiasm and energy!

Second, I want you to consider using patient-centered care as

a marketing strategy for your practice. Although patient-centered

care is now a trendy phrase in healthcare, we all know that it has

existed since our profession began. I suggest we analyze our prac-

tices and identify specific ways we can make our care more pa-

tient-centered. Such a transformation can produce practices in

which patients become your marketing partners and share their

positive experiences in your practice with their family, friends and

co-workers.

WHAT IS PATIENT-CENTERED CARE? In 2001, the Institute of Medicine’s Crossing the Quality

Chasm report described patient-centered care as one of the six

main elements of high-quality care. Patient-centered care was de-

fined in that report as “respecting and responding to patients’

wants, needs, and preferences, so that they can make choices in

their care that best fit their individual circumstances.”1 There

are many benefits to practicing patient-centered care. Patients

love patient-centered care because it makes them feel like they are

treated like people instead of a case of abdominal pain or a stroke.

Patient-centered care also produces many important patient out-

comes like increased patient knowledge, increased adherence to

treatment and improved self-management.2

Physicians in all specialties can adopt this patient-centered

care strategy. As physicians, we have the obligation to effectively

communicate with our patients so they understand their dis-

eases, the treatment options available to them, and their respon-

sibilities as patients.

Patient-centered care can be used to address obesity and to-

bacco use, the two most common causes of chronic disease, dis-

ability and death in our country. For example, we can talk to (not

scold) patients about what they eat, drink and smoke. In addi-

tion, we can learn about the context in which patients live so we

can talk to them about their family, culture, educational back-

ground and social circumstances. This kind of patient-physician

interaction tells patients that we are genuinely interested in them

as people and not merely as disease entities. In my experience,

patients then listen to our recommendations about medications,

diet, exercise and habits. This trusting relationship results in pa-

tients’ changing their lifestyles and embracing better health prac-

tices. They then attribute the positive outcomes in their health

to their visit with us and praise our bedside manners and caring

attitudes. They now become our marketing allies and tell their

friends and relatives about us and how we helped them achieve

better health. I believe this “word of mouth” marketing is better

than any other advertisement to promote our practices.

1. Institute of Medicine, Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: Na-tional Academies Press, 2001.

2. Levinson W, Lesser CS, Epstein RM. Developing physiciancommunication skills for patient-centered care. Health Affairs2010;29:7, 1310-1318.

Kaparaboyna Ashok Kumar, MD, FRCS, FAAFP, is the 2014

president of the Bexar County Medical Society.

PRESIDENT’SMESSAGE


Patient-centered care:An effective marketing strategyBy K. Ashok Kumar, MD, FRCS, FAAFP2014 BCMS President


PROGNOSTICATIONS

“The times, they are a-changin’…” – Bob DylanIn business, change is the only constant. If a business doesn’t

change with the times and adapt to new market dynamics, it willsoon be out of business. Of course, this applies directly to theprivate practice of medicine as well since we are, after all, in the“business” of providing medical care.

The private practice business model has enjoyed relative stabilityover the years. Yes, reimbursements have gradually come down rel-ative to various inflation indexes, and new models of private practicehave come and gone (HMOs, IPAs and roll-ups come to mind).But the model of private practice physicians being paid by managedcare companies or the government on a fee-for-service (FFS) basishas remained relatively constant. But there’s a new “Center forMedicare and Medicaid innovation” prescribed in the AffordableCare Act, which is charged with coming up with new payment sys-tems. The old FFS model could be on its way out.

PRACTICE INCOME FALLSThe federal government (via CMS) has slowly, but surely, ratch-

eted reimbursements down over the last 10 to 15 years. In fact,while the Medicare Economic Index – a measure of practicecosts – has increased 18 percent over the past 10 years, physicians’overall Medicare reimbursements have gone up a paltry 5 percent.Even more damning, the Medical Group Management Associa-tion has reported a 49 percent increase in per-physician operatingcosts over the same 10-year period (Donna Kinney, Texas MedicalAssociation). Since most managed care contracts into which weenter are based on the CMS conversion factor, those reimburse-ment increases have also been minimal. It isn’t hard to understandwhy physician practice income is down as these office expensescontinue to rise.

As a direct result of reduced reimbursements, private practicephysicians are entering what can be described as the early phaseof consolidation. Payers will increasingly attempt to decreaseprovider payments even further as the easiest way to control theircosts. Just like the old adage, “All bleeding eventually stops,” sotoo, all practices cease to exist when they’ve bled too many ex-penses over an extended period of time with not enough newblood (revenue). Eventually, many physicians (certainly not all –I’m not all gloom and doom) will be faced with stark choices:close, merge, or sell their practice – i.e., “consolidate.”

But who are the buyers? They’re the business guys: the hospi-

tals, venture capitalists, other physician groups. They’re peoplewho can improve the ineffiencies of small practices, achieveeconomies of scale, and bring expertise to creating and managingnew forms of payments.

If a physician makes a decision to sell or merge, what does thatdo to their psyche and the way they care for patients? For some,it will be a big relief from having to worry about the struggles anduncertainties of running a business. For others, it will result inseemingly overbearing control, an expectation of “processing”more patients, and possibly unbearable intrusions into the free-doms once enjoyed in private practice. It certainly can be a help-less feeling, knowing control has been lost. Many of us eitherhave or will experience this.

The practice of medicine is really at a very strange place in his-tory. In a “normal” free market economy the supply/demandcurve plays out. Thus, with an impending shortage of physicians,rates should rise. And that will likely be true for some providersin a few specialties.

BARGAINING POWERBut healthcare is not a “free” market today, as too few payers

(Medicare, Medicaid, a few major carriers) control reimburse-ments for the demand side of the curve, and confer rigid feeschedules that come in the form of “take it or leave it” proposi-tions. Physicians have taken those low rates all too often, for avariety of reasons. The net effect is that the bargaining power be-tween the two sides is significantly in favor of the payers. Formany physicians, unless we start saying “no,” it won’t change any-time soon. But that’s hard to do when a substantial part of a prac-tice’s income may go away.

At some point, however, physicians can only look forward tothe payers running out of physician supply at the low rates they’recurrently willing to pay, and will have to agree to some relief. Justmaybe the supply will then begin to balance the actual demand.

Whether that truly ever comes … and when, is an open ques-tion. I do not have a crystal ball and unfortunately, cannot predictthe future.

Bernard T. Swift Jr., DO, MPH, has been theowner of Texas MedClinic for 32 years. He is thecurrent chair of the TMA Council on Socioeconomicsand is on the BCMS Board of Directors.

Physician reimbursementspredicting the future

By Bernard T. Swift Jr., DO, MPHDiplomat, ABPM in Occupational Medicine


PROGNOSTICATIONS

There was a time when one could go to a medical school of un-examined quality, serve as apprentice to an experienced physicianof unverified sobriety for a few months and then head out to startyour private practice. Doctors of old did everything from generalsurgery to obstetrics to all manners of inpatient medicine.

Although they are now much better trained, some Texan familyphysicians, especially those serving in small towns, have a practicethe “horse and buggy doctor” would recognize. Even in the 18thcentury there were physicians known to be especially good or es-pecially interested in a particular medical niche who began to con-fine their practice to that field of study.

The American Board of Medical Specialties (ABMS) wasformed in 1933 to start to recognize “specialists” and also to tryto ensure the quality of their training. The first members of theboard predated the board itself with the establishment of theboards of Ophthalmology (1917), Otolaryngology (1924), Ob-stetrics and Gynecology (Ob/Gyn)(1930) and Dermatology(1932). There are now 24 host boards and 145 specialties andsubspecialties recognized.

TECHNOLOGY MARCHES FORWARDThis has not been a static process nor one confined merely to

the addition of new boards as technology has marched forward.Subspecialties have merged with host specialty boards or withother subspecialties. Sometimes this is an agreeable arrangementwith the intent to merge two groups into a single stronger one.The American Board of Allergy and Immunology formed in 1971with allergists from both Internal Medicine and Pediatrics. In1982, the American Board of Preventive Medicine began issuingcertificates in “Public Health and General Preventive Medicine”rather than each of those as a separate board certification.

Sometimes it appears that changing names is more for marketingpurposes than building combined political strength. “Pain Man-agement” changed its certification name to “Pain Medicine” in2002. Evolving subspecialty techniques have led others to seekrecognition and certification within their larger host specialty board.

Some of the newest subspecialties are Pediatric Anesthesiology,Sleep Medicine (both under Anesthesiology), and Female PelvicMedicine and Reconstructive Surgery (under Ob/Gyn) whichwere all approved by the ABMS in 2011 and are now issuing theirfirst certificates.

Practicing medicine means job security, although that securitydoes not necessarily apply to the continued existence of a subspe-cialty board certification for the duration of one’s medical career.Over the years no fewer than 26 subspecialties have stopped issu-ing certificates. Anorectal Surgery issued its last certificate in 1954

and Proctology in 1956; both of these are now fully containedwithin the American Board of Colon and Rectal Surgery(ABCRS) so that there are no longer subspecialties in the ABCRS.(Neurologic Surgery, Nuclear Medicine, Ophthalmology, and Al-lergy and Immunology are other current boards without subspe-cialties.) Therapeutic Radiology issued certificates from 1934through 1986 until they changed the name of the certification toRadiation Oncology in 1987.

More than a simple name change, several other subspecialtiesunder the American Board of Radiology have ceased issuing cer-tificates as treatment techniques have changed. No longer can onelimit their practice to Therapeutic Roentgenology (1935-1954) orRadium Therapy (1934-1960) which should not be confused withcertification to practice X-Ray and Radium Physics (1947-1960)or Roentgen Ray and Gamma Ray Physics (1961-1975).

The ABMS is not the only certifying game in town. Doctorsof Osteopathy (DOs) may become certified by either the ABMSor the American Osteopathic Association Bureau of OsteopathicSpecialists (AOABOS). AOABOS has 18 specialty boards of itsown which roughly parallel the ABMS and are open only to DOs.The American Board of Physician Specialties (ABPS) certifiesboth MDs and DOs in 18 different specialties although these cer-tifications are not recognized in every state as they are in Texas.There are frequent battles between the ABPS and ABMS over thevalidity of ABPS certifications with both sides accusing the otherof engaging in political turf warfare.

TIME-LIMITED CERTIFICATESOutliers in certification are groups such as the National Board of

Ophthalmology which objected to the limited time certificates cur-rently issued by ABMS specialties and created its own board andcertification process. Although most ABMS boards have “grandfa-thered”-in diplomats who received non-time-limited, “forever” cer-tification, the trend over the last several decades has been to moveto time-limited certificates with ongoing maintenance of certification(MOC) requirements appropriate to the specialty.

Being double or triple boarded used to look good on the businesscard and was good for the ego but now means having to keep up withthe administrative, educational and financial requirements of MOCand recertification for each of the specialties and subspecialties.

Jeffrey J. Meffert, MD, is an associate professor of der-matology and cutaneous surgery at the University ofTexas Health Science Center at San Antonio and 2013chair of the BCMS Communications/PublicationsCommittee.

How very special(ized)! By Jeffrey J. Meffert, MD

visit us at www.bcms.org 13


PHYSICIANAS PATIENT

as

Complications of treatmentBy Jay Ellis, MD

EDITOR’S NOTE: This is the fourth in a series ofarticles written by San Antonio anesthesiologist JayEllis, MD, a member of the BCMS Communica-tions/Publications Committee. The series, publishedmonthly in San Antonio Medicine, examines thephysical, emotional, financial and spiritual burdenof life-threatening illness.

PhysicianPatient

The enthusiasm generated by my CT scan results was not amatch for the reality of continued chemotherapy treatment. Theexcitement about my CT scan continued with my visit to GregGuzley for my next chemo. I felt as if I had reached a major mile-stone. He tempered my enthusiasm. After my physical exam, Ithanked him for saving my life.

"You aren't out of the woods yet," he replied.

"I know, but if we hadn't started treatment I wouldn't havelived more than two to three months."

Greg looked up from his computer with a quizzical look andsaid, "Two to three months? You weren't going to last two to threeweeks." Some things are best learned after the fact.

My euphoria did not survive much longer. After my thirdround of chemotherapy the cumulative effects of treatment be-came manifest. The fatigue was oppressive and ever present.No matter how much I slept, I always felt tired. I would go tothe gym and try to exercise, but if my heart went over 100 bpmI worried that I would pass out and drop the barbell on myhead. Two flights of stairs looked like Mount Everest. My fin-gers and toes became numb from the vincristine. I had a con-stant metal taste in my mouth and almost no ability to perceivethe taste of food. I stopped drinking alcohol during chemother-apy, though the truth is I couldn’t discriminate Cabernet fromGatorade. Food had no taste, and I ate only because it was timeto do so. I certainly had no appetite. I had the sex drive of the

palace eunuch. It seemed that all of the sensual pleasures of lifewere gone. Worst of all, I feared that I would never ever feelwell again, even though the chemotherapy nurses assured methat it would pass.

I tried to work a full schedule after taking a few days off aftereach session of chemotherapy. I normally keep health issues pri-vate (though these manuscripts would beg otherwise), but mypatients knew something was up when I went bald and lost 25pounds. Coupled with my office staff aggressively screening foranybody who appeared even remotely contagious, my secret wasout. My patients were wonderful. Everyone wanted to hug andpray over me because this is Texas and that’s what we do. It washard to get through clinic because everyone wanted to talkabout my problem instead of theirs. Work remained a refuge,but in retrospect I should have cut back on my hours. I wascompletely spent at the end of each day.

In December I developed recurring fever, and the nightsweats returned. I would go to the ER or to see Greg. TheMethodist ER staff was wonderful with their oncology proto-col. As soon as I hit the door, usually in the middle of the nightor early morning, I would get my IV, blood cultures, lab stud-ies, chest x-ray and my first dose of antibiotics. The profession-alism and attention to detail of the ER staff was reassuring. Theworkup was always negative. I would feel better for a few daysafter the antibiotics, and then repeat the sequence a week later.I secretly feared that despite the excellent CT scan, the lym-phoma was making a comeback against chemotherapy.


PHYSICIANAS PATIENT

With negative cultures and anegative chest x-ray, the most likelydiagnosis was viral illness. That’show I treated it, even though I wasfeeling worse. The day after Christ-mas I went to bed even earlier thanusual, telling myself I would callGreg in the morning because I justfelt awful. I would never make thecall. At 3 a.m. I awoke in a drench-ing sweat with a searing headache.I slipped out of bed so as not towake my wife, Merrill. It is difficultto remember all the details afterthat. I remember being in thekitchen and feeling very ill. Some-how, I made it to the garage, gettingmy bag out of the car. I don't knowhow I got there or how I got my carkeys. I made it to the couch and putmy pulse oximeter on my finger. Itread 66 percent. My first reactionwas, "Crap, this thing is broken." Imoved it from finger to finger tofinger. The results were the same.My saturation was 66 percent, myheart rate was 120, and if I coughedand breathed deeply I could get mysaturation all the way up to 70 per-cent. The pulse oximeter wasn'tbroken, I was. I tried to considermy options, but I was not thinkingclearly. I briefly considered the ideaof Merrill driving me to the hospi-tal, but I realized I might not beconscious much longer. I tried tocall Merrill, but I didn't haveenough wind to shout and wakeher. On the third try I summonedall my breath, shouted and sheheard me.

"Call 911," I told her.

“Why?" she asked.

Continued on page 16

My CT scan from Sept. 29, 2013, showing my mass and the lymphadenopathy from lymphoma.

My CT scan from Dec. 6, 2013, after two rounds of CHOP-R chemotherapy. Arrows point to the mass.


PHYSICIANAS PATIENT

"Because I can't breathe." Merrill sprang into action. Someonewould later ask me if she "was freaking out." The answer is notonce, not ever. She called 911, threw her clothes on and ran out

to flag down the ambulance. I sat on the couch and wondered ifthis was the day I was going to die. I felt surprisingly calm, maybefrom the intoxication of the hypoxia, maybe because lymphomaforced me to ponder my mortality for the previous weeks. I havehad a great life. My faith tells me that I will die and go to a betterplace. If I have anxiety, it is about the possibility of being left apulmonary cripple. We all die, but please, Lord, don't leave mean invalid.

EMS arrived quickly. I would remember a strange momentwhere they held the oxygen mask above my face with me waitingfor them to apply it. Finally, I said, "I am ready for that when youare." With 100 percent oxygen my saturation quickly increasedto 92 percent and my headache melted away. Better yet, the foglifted from my brain. We made the ride to the hospital to find ERswamped with flu patients and the hospital census at 100 percent.We waited four hours for a bed in the ICU. Greg saw me in the

ICU and ER. My chest x-ray showed my lungs in white out withan overwhelming pneumonia. He suspected pneumocystis pneu-monia, but we would need to make sure that we weren't missing

something else.

Once in the medical ICU, I began to accumulate more doctors.Dr. Manica Isiguzo and her partners, Drs. Quresti, Puente-Cuellarand McReynolds, were the critical care/pulmonologists caring forme. Dr. Richard Thorner and Dr. Richard Fetchik were my in-fectious disease doctors. Greg’s partner, Dr. Manuel Santiago, cov-ered for him over the holiday as well. As my list of doctors gotlonger and longer, I remembered my old joke that the more doc-tors you have, the worse the prognosis. The nursing staff of theMethodist medical ICU was outstanding. They made me as com-fortable as possible as I began to spend my first night in the hos-pital as a patient. Merrill insisted on staying in the ICU with me.Both the nurses and I tried to explain to her why that was a verybad idea. She wasn’t leaving. I tried to explain to her that therewas nothing that she could do and both of us had been up since3 a.m.

Continued from page 15

“You need to go home and get some sleep,” I told her.

“What if you get scared?” she replied.

“I’m not scared,” I answered, and I truly wasn’t.

“Well, what if I am?” In the chaos of the day I neglected to stopand think about what all this was doing to her. Her love for mewas never more obvious than in that moment. I promised myselfthat if I survived, I would work every day to make her feel as lovedas I did that night.

I had spent the day on my iPad reviewing the medical literatureon oncology patients who develop respiratory failure, especiallythat due to pneumocystis. I then used my iPad to check my ownlab results. My doctors had many patients, but that day I had onlyone. I was surprised to find out that patients with HIV have ahigher survival rate from pneumocystis pneumonia then do on-cology patients. As I read further, I began to understand why. HIVpatients developed the symptoms gradually over time. Oncology

patients, like me, develop a sudden respiratory illness with littleprodrome. In retrospect, it seems like the diagnosis was obvious.However, during the course of my febrile episodes I saw four dif-

ferent doctors, all of them diligent in looking for a source. Despiteall our modern technology, some diagnoses present only on theirown schedule.

Both of us had a rough night. Every time I fell asleep, my sat-uration fell, and the nurses came in to rouse me. Merrill wouldtry to drift back to sleep, and I would lie awake staring at the ceil-ing, then watch Merrill wrestle with the recliner, trying to find acomfortable position. The recliner got the best of it, one time al-most pitching her out onto the floor.

When you have nothing to do but think, you recall unusualevents. For some reason, I began to think about a young womanI cared for during my first military assignment in Germany. Shewas admitted to our ICU with varicella pneumonia, and my part-ners and I cared for her while she gradually deteriorated, despiteeverybody’s best efforts. We tried truly heroic measures, but she


PHYSICIANAS PATIENT

Continued on page 18


PHYSICIANAS PATIENT

eventually died from overwhelming pulmonary failure after a pro-longed course on the ventilator. I remember thinking how tragicthat she died from chickenpox. Something affected her immunesystem, and she never survived. I wondered if that was going tobe my path.

In the morning, my mother arrived, and Merrill finally agreedto go home and get some rest. My mother just moved to Texasfrom Chicago to avoid, as she puts it, “bad weather and bad gov-ernment.” She also spent years caring for my father as his healthdeteriorated, sitting in hospitals just like she was now. It had beenmy hope that when she moved here that we could care for her asshe had cared for him. Now she was sitting in a hospital again,which just added to my distress.

“I never dreamed that you would have to sit in a hospital watch-ing over me. I am so sorry things turned out this way,” I told her.

“There is no place I’d rather be,” she replied. Mothers always

know the right things to say.

I was blessed with plenty of visitors while I was in the ICU. Mypartners Jim Growney, Tim Orihel and Arnold DeLeon came by.My office manager Marta Reyna brought food and snacks, as didmy running partner and travel companion Dr. Bob Johnson.Friends from my military days came by, Dr. Bob Joyner, just re-inforcing my idea that those ties formed during military serviceare some of the strongest. My son Nathaniel and his wife, Lindsay,sat with me and brought reading material. I communicated withmy daughter Lauren in Germany and her family via my iPad.Their visits brightened my days and kept me from staring at theceiling too long.

Merrill, of course, was a constant presence, leaving only whenmy mother was there, the only one she trusted to monitor mein her absence. She became upset with the quality of the hos-pital food and would call the nurses in to look at my dinnertray, something they of course viewed daily. Merrill would voice

Continued from page 17


PHYSICIANAS PATIENT

her displeasure, and the nurses, ever diplomatic, would say, “Ican understand why you feel that way.” Merrill finally got dis-gusted and just brought me food from Aldo’s, which I enjoyedeven when critically ill. After I ate, I would read my lab resultsand my findings in the medical literature to her, which some-times just increased her distress. All the culture results were neg-ative. The only remaining possibility was pneumocystis andthat would require bronchoscopy for definitive diagnosis. Nei-ther Dr. Fetchik nor Dr. Quresti thought that I would getthrough bronchoscopy without ending up on a ventilator. MyiPad medical research already taught me that if you have pneu-mocystis pneumonia and you’re on a ventilator, the mortalityrate is 90 percent. For the first time, I felt a sense of anxiety.Fortunately, they recommended that we stop all other antibi-otics and start treatment with trimethoprim sulfa. Twenty-fourhours later, my oxygen requirement decreased, and I sleptthrough the night for the first time in weeks without a drench-ing sweat.

After five days of bed rest, I was well enough to leave the ICUand move to the rehab floor. I became friends with Thomas, myrehabilitation aid. He would come by several times a day and helpme get up and walk so I could reach my goal of walking for sixminutes without stopping and while keeping my oxygen satura-tion above 90 percent. On my first try, I made it 285 feet beforeI was gasping for breath and my saturation dropped to 85 percent.Each attempt was better, and after two days, I made the six-minute walk, though Thomas still had to give me a pass on a briefperiod when my saturation hit 89 percent. I could now go home.Greg gave me very strict instructions. I would do no activity morestrenuous than walking at a 15-minute pace. I could lift lightweights, but nothing heavy and nothing strenuous. Most impor-tantly, he told me I would stay home and only at home for amonth. If I were to come down with influenza, I would likely notsurvive. It would be a month of house arrest without the anklebracelet, but it would be a step toward getting better.

Next: The economics of serious illness.


A visit with Hippocrates ... and beyondLecturer to discuss archaeology of health

in ancient Mediterranean worldBy J.J. Waller Jr., MD

HISTORYOF MEDICINE

The Southwest Texas Archeological Society (SWTAS), thelocal branch of the Archeological Institute of America, is organ-izing a series of lectures on the topic of ancient medicine. Thetopics will vary from examination of DNA in Roman skeletonsto Civil War medicine.

One of the lectures will be presented by Dr. Alain Touwaide,a research associate of the National Museum of Natural History,part of the Smithsonian Institution in Washington, DC. He isalso scientific director of the Institute for the Preservation ofMedical Traditions.

Dr. Touwaide is a science historian who specializes in the his-tory of medicinal plants in the cultures that flourished aroundthe Mediterranean Sea from antiquity to the 17th century CE.He has devoted his career to unearthing lost knowledge. Dr.Touwaide, who is proficient in 12 languages, studies ancient textsin their original language (Greek, Latin and Arabic) and prepareseditions of major works with English translations and critical

analysis. He is a lecturer in universities in the United States andthroughout the world.

Dr. Touwaide’s lecture, “The Archaeology of Health in the An-cient Mediterranean World,” will be presented at 7:30 p.m.Monday, Oct. 20, in Chapman Hall at Trinity University. Theevent is free and open to the public.

ABSTRACTMedical archaeology usually deals with the dead and

the identification of diseases, the consequences of stresson health, casualties and major traumas, or any otherevent that had an impact on ancient peoples’ lives andwell-being. Rarely does it take into consideration thefactors that contributed to populations’ health, fromdiet to medicines, apart from rare works devoted tothe identification of foodstuffs and drinks on the basisof remains’ end – or traces on – archaeological mate-


HISTORYOF MEDICINE

rial. I will show that a combined study of remains ortraces of foodstuffs, medical literature, artistic represen-tations, and also remedies provides unsuspected keysabout ancient populations’ health, particularly if it istrans disciplinary and brings together cutting-edge lab-oratory techniques, massive data basing of textual dataand, on this basis, quantitative analysis, botanical read-ing of texts and works of art, and geographical distri-bution and circulation of natural resources. Results areall the more significant if research covers a vast area anda long period of time, and is dynamic over both spaceand time so as to perceive local and chronological dif-ferentiations. The presentation will focus on both Clas-sical Antiquity and Byzantium, and will be lavishlyillustrated by visual material coming from a vast bodyof documents, including Byzantium manuscripts, rep-resentations of plants in books, mosaics and frescoes,archaeological material, and also living plants, dry spec-imina of herbaria, and natural environments in present-day Mediterranean.

We are particularly interested in alerting the medical com-munity to Dr. Touwaide’s presentation because of the scope ofhis lecture and his topics related to the history of medicine,

which are of interest to many BCMS members. I also know himpersonally and have briefly visited with him and his lovely wife,Dr. Emanuela Appetiti, a cultural anthropologist, in Washing-ton this past summer. He is a highly knowledgeable and de-lightful individual.

Not only do I wish to encourage attendance at his lecture butalso am humbly soliciting financial support for this special occa-sion. It costs close to $2,000 to cover expenses, and any contri-butions (no matter how small), will be greatly appreciated by theSWTAS, which is a 501(c)(3) organization, and myself. Contri-butions can be sent to AIA SWTAS. The check should be mailedto: Laura Childs, 2858 Burning Log, San Antonio, TX 78247.The check should stipulate Touwaide Lecture.

For more information on the Southwest Texas ArchaeologicalSociety, visit http://aiaswtas.org.

For more information on the Institute for the Preservation ofMedical Traditions, visit http://medicaltraditions.org.

J.J. Waller Jr., MD, is a member of the BCMSCommunications/Publications Committee.


BUSINESS OFMEDICINE

Accountable care organizations (ACOs) are a key element ofthe Patient Protection and Affordable Care Act (PPACA) of 2010.Ideally, the incentives in the PPACA will encourage the formationof ACOs that will improve the coordination of care in our health-care system by formalizing the relationship between fragmented,independent providers of health services. This increased coordi-nation will be especially helpful to the chronically ill, whose careoften comes from transactions with multiple specialists.

Uncoordinated efforts can result in conditions being missed, orperhaps contradictory treatments. By bringing the coordinationof care under one organization, improvements in coordination ofcare can improve the quality of care delivered and do so in a lesscostly manner. Researchers at the Commonwealth Fund havefound that initial applications of ACO principles can make mean-ingful enhancements to the delivery of healthcare.1

COORDINATION IS NOT FREEUnfortunately, as anyone who works in the healthcare field

knows, coordination is not free. When the patient is treated bymultiple caregivers, there is a cost to coordinating the varioustransactions the patient might have with the healthcare system.These coordination costs are in addition to the actual cost of pro-viding care. The costs of coordination across separate organiza-tions, as opposed to the costs of production, are generally referredto as transaction costs by economists.

Transaction costs can be generally divided into three categories:search and information costs, bargaining and decision costs, andpolicing and enforcement costs. Let’s think about how each ofthese categories of transaction costs apply to the coordination ofpatient care.

Let’s assume a patient has a primary care manager (PCM)through his ACO – perhaps a family physician. The very idea ofa primary care manager implies that the patient has recognizedthat his knowledge of the healthcare market is limited, and thathe needs someone to help him navigate that market. If the patienthas a complaint – perhaps pain in his shoulder that he cannot di-agnose with his lay medical knowledge – he could begin going tospecialists and seeking their advice. The source of the pain couldbe skeletal, in which case he might start with an orthopaedic sur-

geon. The source might be neurological, though, in which caseperhaps a neurologist would be more able to help. To figure thatout, he probably should get some medical imaging, but whichtest? MRI? X-ray? Of course, he would need someone to help in-terpret that imaging. Without the help of a PCM, the patientcould waste time and money trying to guess which services heneeds and which provider might actually be able to help him. Thetraditional role of the PCM is to reduce the patient’s first form oftransaction costs – search and information costs. A visit to hisPCM is not free for our notional patient, but it is cheaper thanthe costs the patient would incur trying to navigate on his own.Furthermore, the PCM not only helps the patient search, but alsounderstand the information he gets back.

Now that the patient has had some initial diagnostic work, per-haps an MRI and an initial consult with an orthopaedic surgeon,the patient has to make a decision about treatment. If the diagnosisisn’t clear cut there might be several potential courses of action: sur-gery might be an option, a referral to physical therapy might be inorder, or simply watching and waiting. Assuming the PCM is work-ing with a network of specialists and facilities through the ACO,there is an incentive for the knowledge within the network to befocused on the least costly, best outcome for the patient. A well-runACO will generate better decisions that result in better outcomesand less cost in order to remain profitable.

One of the complementary technologies mandated by thePPACA is the implementation of electronic medical records(EMRs). Although they are costly to implement, EMRs are trans-action cost-economizing. They reduce transaction costs by makinginformation freely available within systems, which can improvedecision making. The large fixed costs of EMRs are best born bylarger organizations that can spread the fixed cost over many pa-tients – another reason why we will continue to see pressure onsmaller organizations to merge into (or with) larger organizations.

ASYMMETRIC INFORMATIONBy working with an insurer, patients reduce their own efforts

at bargaining, relying on the insurer to negotiate with the systemfor them. This service is partly what patients buy when they paytheir premiums. Our patient can also reduce the third type of

TRANSACTION COSTS:e friction in healthcare delivery

By Mark J. Bonica, PhD, and Lee W. Bewley, PhD, FACHE


BUSINESS OFMEDICINE

transaction cost – those of policing and enforcement – by workingwith an insurer and ACO. When our patient works with theseorganizations, the insurer and the ACO are at risk for the cost ofhis care. Poor outcomes tend to lead to more expense, and there-fore the insurer and the ACO have an incentive to ensure a highquality outcome. It is difficult for a patient without medical train-ing to monitor the quality of the services he receives. This diffi-culty results from what economists call asymmetric information,or a situation where one party has more information than another.Insurers have financial incentives to be just as informed as theproviders, and therefore the cost of enforcement is lower for theinsurer than it is for the patient. ACOs have an incentive to as-semble the best collection of service providers, and enforce qualityof care standards in each part of the patient experience.2

ACOs can be thought about usefully as transaction cost-econ-omizing organizational innovations. Ronald Coase, the economistwho popularized transaction cost economics with his 1937 paper,The Nature of the Firm, asked in his paper, if firms are so great,why don’t we just have one big firm and no market? His answerwas ultimately that coordination within the organization is notfree, as we can see with the high cost of EMRs, or the additionallayers of administration necessary to ensure quality and internalcoordination. We can save on transaction costs by bringing trans-

actions inside of organizations like ACOs. Nevertheless, the costsof coordinating within the ACO will ultimately limit ACO size.3

CITATIONS1Forster, A.J., Childs, B.G., Damore, A.L. et al., (2012) Ac-

countable Care Strategies: Lessons from the Premier Health CareAlliance's Accountable Care Collaborative, The CommonwealthFund. Available at: http://www.commonwealthfund.org/Publica-tions/Fund-Reports/2012/Aug/Accountable-Care-Strategies.aspx.

2Dahlman, Carl J. (1979). "The Problem of Externality". Jour-nal of Law and Economics 22 (1): 141–162.

3Coase, Ronald (1937). "The Nature of the Firm". Economica4 (16): 386–405.

Lt. Col. Mark Bonica, PhD, is an assistant professor and deputy pro-gram director in the Army-Baylor University MHA/MBA program.His focus specialties are economics, financial management and policy.Lee W. Bewley, PhD, FACHE, is an Army officer, associate pro-

fessor of healthcare management, and a board-certified healthcareexecutive. He is the program director of the Army-Baylor UniversityMHA/MBA program, and serves as an adjunct faculty member atthe University of Texas at San Antonio, Trinity University and Uni-versity of the Incarnate Word.


BCMS NEWS

SPRING GENERAL MEMBERSHIP MEETING

Donna Kinney, director of research anddata analysis at the Texas Medical Associ-ation, discussed the impact of healthcarereform on physician practices at the May6 BCMS General Membership Meeting atthe Embassy Suites Northwest.

BCMS members attending the General Membership Meeting received free CME in ethics andenjoyed a buffet meal.


BCMS NEWS

BCMS LEGISLATIVE AND ADVOCACY NEWSPhysicians support elected officials friendly to medicine

(From left) Rodolfo Molina, MD; Alex Kenton, MD; Mary Nava; Janet Realini, MD; andRep. Philip Cortez visit June 4.

Event host Alex Kenton, MD (left),pauses for a photo with Texas HouseSpeaker Joe Straus May 29.

With a very active election year under way, BCMS physicianshave been busy attending and representing their profession at leg-islative receptions supported by TEXPAC, being held in honor ofelected officials who are friendly to medicine. On May 29, Drs.Alex and Candace Kenton hosted a reception in their home inhonor of Texas House Speaker Joe Straus (District 121). On June

4, a group of doctors attended a reception at Mi Tierra Restaurantin honor of Texas State Rep. Philip Cortez (District 117), whosits on the Texas House Committee on Public Health.

For more information, contact Mary Nava, BCMS chief gov-ernmental and community relations officer, [email protected].

BCMS ALLIANCE NEWS

BCMS Alliance member Jennifer Lewis donned a bee costumeto meet with children at the Pre-K 4 SA North Education CenterJan. 29 for a “Be Wise Immunize” influenza immunizationclinic sponsored by the BCMS Alliance.

Mary Sue Koontz Nelson (seated) chats with BCMS Alliance memberswhile signing copies of her cookbook, “Stolen Recipes.” Nelson was the guestspeaker at the Alliance’s general meeting luncheon Feb. 14 at the Argyle Club,describing the health screenings offered by the AugustHeart organization.


Diego was a preemie born six weeks early

to Rachel and Steve Trevino. At an early age,

specialists informed Diego’s parents of the

devastating diagnosis: autism. “I always

knew … you just know when there’s some-

thing wrong with your child,” his mom says.

For families who have a child diagnosed

with autism spectrum disorder (ASD), life

is one scary rollercoaster with no end in

sight. The newest statistical data available

suggests that more families are facing this

daunting ride filled with confusion and

challenges, with one in 68 being diag-

nosed along the spectrum; a 29 percent in-

crease since 2008.

There is an urgent need to assist this

growing population with services begin-

ning with early diagnosis that leads to var-

ious interventions and therapy.

Families affected by autism represent a

mixture of ethnicities, education and so-

cioeconomic status. Oftentimes these par-

ents, in other areas of their lives, are

extremely resourceful with professions in

medicine, law or education; however, they

find themselves encountering the same dif-

ficulties and frustrations as parents with

fewer resources. Steve is a successful local

architect, and as Rachel explains, “We were

doing this all on our own; we didn’t know

about these wonderful services. Our lives

opened up when we found Any Baby Can,

this is where we blossomed.”

SAFETY NET OFSERVICES

Any Baby Can is a local

nonprofit that is dedi-

cated to helping improve

the quality of life, thus

maximizing potential for

every individual and fam-

ily affected by autism and

other chronic health con-

ditions. Any Baby Can

has become the city’s lead-

ing expert in autism serv-

ices; a trusted entity that

fills in the gaps providing

financial and emotional

support, education and

training to the entire fam-

ily regardless of income

and free of charge.

Children with autism have a team of

highly trained physicians and therapists

caring for them; however, when a child is

ill, it affects the entire family and the emo-

tional and financial impact is immense.

Any Baby Can eases these burdens

through Reaching Families Facing Autism

(RFFA), a parent education and support

program that offer many services for fam-

ilies, such as parent training, counseling

and education groups. “When I am at Any

Baby Can, I’m stronger. I understand that

I’m not alone, and I always feel like I’m

getting a big hug,” Rachel says.

Many people with autism go on to live

independent and fulfilling lives and de-

velop meaningful relationships. Although

there is no cure for ASD, there is signifi-

cant proof that symptoms are reduced

with intensive early intervention. With

agencies like Any Baby Can, parents like

Rachel and Steve are equipped with re-

sources and tools to best parent their child

with autism. “My husband and I are

blessed to have Diego in our lives, and we

will do everything we can to prepare him

The “A” word:Any Baby Can helps families facing an autismdiagnosis by offering hope and support

NONPROFIT

By Denise Rizzo


for life,” Rachel says.

Diego’s transformation has been incred-

ible to witness. Initially he was emotion-

ally isolated and unable to communicate;

now he is a confident 7-year-old who has

many friends and believes the party starts

when he walks in. Currently in private

school, he recently was awarded student of

the month and can carry on a conversa-

tion with anyone. He loves eating pizza,

playing with Legos, swimming and gym-

nastics. Rachel credits much of their suc-

cess to Any Baby Can.

“Because of them, I am bet-ter equipped and empowered,so I can equip and empowerDiego,” Rachel says. “There isno cure for autism but we canall learn to cope.”

Autism is a lifelong disability but can

show much improvement. Upon diagnosis

seek the following as soon as possible:

• Early intervention

• Intensive communication and behav-

ioral therapy

• Find an agency like Any Baby Can to

guide you

• Parent training

• Counseling

• Contact local school district.

NONPROFIT

Do you know a family that needs these services? Contact Tisha Gonzalez, autism services director, 210-227-0170.

Families parenting a childwith autism face thefollowing challenges:

Many times parents are confused, iso-lated and overwhelmed and need helpunderstanding what autism is andhow to support their child.

Men and women grieve their child’smedical diagnosis very differently. Di-vorce rate as high as 80 percent forthese families.

Communication skills are a commonstruggle for children with ASD. Chil-dren have difficulty understandingsocial cues and following instructions,leading to frustration and behavior is-sues.

Children with autism typically receivethe majority of financial and emo-tional support. Oftentimes, siblingsare lonely and resentful toward thechild diagnosed with ASD.

Children with autism require addi-tional expenses for healthcare, school-ing, therapy and other services. It cancost a typical family more than$60,000 a year to raise a child withautism.

Sensory issues make eating regularfoods challenging or impossible.Extra-curricular activities are limitedbecause of mobility or excessive timespent in therapy. Adolescents withautism are two times more likely tobe obese, compared to children with-out this developmental disability.

Any Baby Can provides the following solutions:

A five-week parent training serieshelps skill-building in the areas ofpositive behavior supports, using Ap-plied Behavioral Analysis (ABA)strategies in the home, social skillsand school advocacy training.

Individual and group counseling pro-vided by a licensed psychologist helpsparents work through some of thegrief and confusion.

A “toolkit” filled with visual supportshelp parents communicate what theyexpect and allows their child to ex-press his or her wants and needs. Thishas been proven to decrease problembehaviors that result from difficultycommunicating.

A sibling support group allows chil-dren to meet others who have a sib-ling with special needs. Led by alicensed counselor, children are givenunderstanding into the disability. Re-search suggests this is one of the mosteffective ways of promoting well-being and positive adjustment in sib-lings of children with ASD.

All services provided by Any BabyCan are offered at no charge regard-less of the family’s income to ease thefinancial burden.

Any Body Can is an exercise and nu-trition program of Any Baby Can andwas designed specifically for childrenwith unique learning abilities andtheir family, complete with weeklyvisits from an adaptive fitness special-ist, dietitian assessment and nutritioneducation.


LIFESTYLE

By Mauri Elbel

Along with hundreds of others gatheredon top, underneath and around downtownAustin’s Ann W. Richards Congress Bridgeon a still June night, I wait patiently withmy husband and our two young boys. Asthe sun sets, high-pitched squeaks begin toreverberate from beneath the bridge andour boys become impatient.

“Where are they? I want to see them!”my 5-year-old’s inquiry turns into a de-mand as a single bat simultaneously fliesover our heads.

Within minutes, that bat is followed byseveral others, then a couple dozen morebefore a mass emerges from this well-known downtown Austin roost. In CentralTexas, we are lucky to be able to experiencethis phenomenon in numerous locations.But what is even more impressive than theentertainment value bats bring us are theecological benefits they provide. In Texas,and around the world, bats serve as naturalenemies of night-flying insects.

In fact, according to Bat ConservationInternational (BCI), if we were to lose ourbat species, the demand for chemical pesti-cides would increase, jeopardizing the en-tire ecosystem and harming humaneconomies. Bats are the No. 1 eater of bugsat night, says Fran Hutchins, Bracken CavePreserve director for the past eight years,adding that the millions of Mexican free-tailed bats that call Bracken Bat Cave homeeat up to 200 tons of insects nightly.

“This colony will eat over 100 tons ofbugs every night, most of which are agri-

cultural pests,” Hutchins says. “Those 100tons of bugs are saving cotton farmers inCentral Texas three-quarters of a milliondollars in pesticides and crop dusting. Inthe U.S. overall, bats are saving farmersover $4 billion dollars a year.”

So where are the best places to go to viewthese magnificent mammals in all theirsplendor? This summer, head to these fourconvenient locations for your best bets atseeing bats:

BRACKEN CAVE www.batcon.org/index.php/get-involved/

visit-a-bat-location/bracken-bat-cave

Bracken Cave, sitting just outside SanAntonio in southern Comal County sur-rounded by a 700-acre natural preserve, isthe summer home of the world’s largest batcolony. This maternity colony is full of 15million to 20 million hungry females thatneed to generate about twice their bodyweight in milk every day to feed their June-born babies for about six weeks.

The babies are about a quarter of the sizeof their mothers when born, but four tofive weeks later they are the same size andflying and hunting on their own, Hutchins

says. Bracken Bat Cave provides an idealhabitat for pregnant females due to hot, sta-ble air temperatures –– an environmentHutchins compares to a giant incubator.The females will come out earlier than atother locations because they try to eat atleast their body weight in bugs every night,he adds.

“It is a natural wonder to see 15million to 20 million bats pouringout of a cave,” Hutchins says. “Ittakes between three and three and ahalf hours for the bats to empty thecave each night. The mouth of thecave is at the bottom of a sink hole sothey have to spiral up out of that sinkhole to get out –– there is literally atornado of bats in front of you.”

Book a Bracken Cave tour from Maythrough September online at batcon.org.Biweekly tours start at 6 p.m. and run until8:30 p.m., providing an educational walkand talk for $25 a person and free for mem-bers. Here you will see nature in action ––predators such as snakes and raccoons waitat the mouth of the cave to catch bats fordinner, and hawks and owls hover in thesky above hoping for a meal.

“All of this is going on less than 100 feetaway from you,” Hutchins says. “Seeing thatis amazing. The emergence is so intense thatshows up like a cloud on Doppler radar.”

Best bets for viewing bats


LIFESTYLE

CAMDEN STREET BRIDGE Check out the bachelor colony that

roosts at Camden Street Bridge on the mu-seum reach of the San Antonio River Walk.Park at the Pearl Brewery and walk southalong the River Walk toward CamdenStreet where you will find signage along thehike and bike trails fringing the river.Emergence begins around 8 p.m., andstarting the second week in July throughAug. 12, free educational talks take placeevery Tuesday at 7 p.m. –– a collaborationof Texas Parks and Wildlife Department,BCI and the San Antonio River Authority.

“There are about 50,000 batshere,” Hutchins says. “It’s San An-tonio’s version of Congress AvenueBridge.”

Make a night out of the event by headingto the Pearl Brewery, having dinner andseeing the bats. The Bat Loco Bash takesplace Aug. 12 at the intersection of Cam-den and Newell streets, featuring educa-tional activities, food trucks, live music andbat presentations from experts, followed byan emergence of 50,000 Mexican free-tailed bats.

OLD TUNNEL STATE PARK INFREDERICKSBURGwww.tpwd.state.tx.us/state-parks/old-tun-

nel/bat-viewing

Head to Fredericksburg’s Old Tunnel

State Park to watch the bats emerge from theabandoned railroad tunnel which gave thepark its name. Up to 3 million Brazilian free-tailed bats (also called Mexican free-tailedbats) and 3,000 cave myotis bats can be seennightly from May through October. Bat-viewing opportunities are available sevennights a week, and nightly educational pre-sentations are given Thursday through Sun-day. While people can come out any eveningMay through October, the largest popula-tion of bats can be seen in August and Sep-tember, and they tend to come out earlier,making them easier to see then.

“The best months to visit OldTunnel are August and September,”says park superintendent NytaBrown, adding that the lower view-ing area is the best place to viewbats. The lower area is open Thurs-day through Sunday evenings for a$5 fee, while the upper viewing areais free.

“There is someone at Old Tunnel everynight to answer questions, but the lowerprogram is only on Thursday through Sun-day evenings,” Brown says. Visitors shouldcall 866-978-2287 to get the latest emer-gence time information.

AUSTIN’S URBAN BAT COLONYwww.statesman.com/s/bats

More than a million Mexican free-tailedbats call the Ann Richards Congress Av-enue Bridge in downtown Austin home bymid-August, but you can see them afterdusk from April to October. Here up to 1.5million bats form ribbons in the summernight skies, creating a beloved Austin at-traction for tourists and locals alike.

These Mexican free-tailed bats havefound the ideal roost in the middle ofdowntown Austin: the underside concretecrevices that stretch across the bridge. Forthe best lookout, bring along a picnic blan-ket and head to the Austin American-Statesman’s Bat Observation Center whichsits adjacent to the bridge –– parking isavailable at the Statesman after 6 p.m. Youalso can view the evening emergence froma guided riverboat cruise, the top of thebridge, or enjoy a close encounter from un-derneath the bridge like we did.

Emergence times fluctuate from loca-tion to location. The bats at Bracken BatCave emerge earlier in the evening ––around 7 p.m. or 7:30 p.m. –– becausethere are many female bats that forage atleast 60 miles from their roost in searchof extra food to nourish themselves andtheir young, while bridge bats tend totake flight a bit later, often after dark.But, as we discovered, it is well worth thewait to witness bats spiraling into thesummer night sky.

For more information visit: www.bat-con.org.

Photos © Merlin D. Tuttle, Bat Conservation International, www.batcon.org


LIFESTYLE

San Antonio Restaurant Week is a cele-bration of the unique food scene this cityhas to offer. Foodies and those just wantingto dine out come together to enjoy variouscuisines from some of the best restaurantsin the area. Restaurant Week, set for Aug.16-23, is the perfect excuse to inquireabout a new restaurant or revel in an old fa-vorite, and it promotes a unified time to goout and dine.

Each participating restaurant creates aprix-fixe menu for lunch and dinner andoften gives chefs the chance to explore be-yond their typical menus, utilizing spe-cialty ingredients or experimenting withnew trends. And, with the increasing pop-ularity of Restaurant Week, organizers areoffering even more options to appeal toan array of diners while allowing more ca-sual-dining restaurants the opportunity toparticipate.

Whether lunch or dinner, the restau-rants still will feature a three-coursemenu, but new this year are two tiersfrom which to choose. Tier one is thesame as it has always been: lunch for $15and dinner for $35. Tier two is new andstill offers a multiple-course meal, butprices are $10 for lunch and $25 for din-ner. Visitors will not be losing any of thatgreat San Antonio flavor – just some ofthe price.

MENUS WILL BE POSTEDParticipating restaurants and their tier

level will be posted on theCulinariaSA.org website as they are con-firmed. Along with each restaurant listedon the website will be the chef-preparedmenu of lunch and/or dinner, so guestswill know what will be served before theyarrive. Some restaurants even include bev-

erage pairings for an additional price toallow for the exploration of the liquid sideof the culinary arts. Reservations aren’t re-quired to indulge in Restaurant Week butare strongly suggested to ensure seating.Also, be sure to mention when makingreservations that you intend to order fromthe Restaurant Week menu.

Restaurant Week on the Move is backagain this year, after debuting last yearand becoming a big hit. This portion ofRestaurant Week includes many of thecity’s favorite food trucks seen drivingaround town or parked in popular mobilekitchen parks. Restaurant Week on theMove features lunch for $8 and dinner for$15. This option is perfect for those shorton time or for those hoping to get a tasteof what the food trucks have to offer.Food-truck mania is still in full effect, andthese trucks turn out some of San Anto-

Lunch, dinner menus offer choices Aug. 16-23

Restaurant Week celebrates


LIFESTYLE

nio’s most talked-about dishes – gourmetgrub on four wheels.

The restaurants asked for it and thediners asked for it, and Culinaria is an-swering back. Why not add a secondRestaurant Week? Done. A secondRestaurant Week has been added to thelineup of events for Culinaria. The sec-ond week will be Jan. 19-24, so guestscan start off the year with exceptionalfood. No doubt, many of the restaurantsincluded in the first week will return forthe second restaurant week, and thesame rules apply for this week: three-course lunch or dinner. Both weeks offerthe chance to relish great food in SanAntonio.

While patrons of San Antonio Restau-rant Week are exploring cuisine, they arealso savoring every meal as a charitable con-tribution, as well. For each lunch purchased

on the Restaurant Week menu(s), therestaurants will donate $1 to Culinaria andits causes, and with each dinner purchased,restaurants will make a $2 donation. Thismoney goes back into the San Antoniocommunity through Culinaria’s many phil-anthropic means.

Culinaria is a nonprofit organization thatcan be explained with the mantra, Eat.Drink. Give. Restaurant Week is a vehiclethat allows the organization to continue toenrich the city through these efforts andsupports the organization’s mission to ben-efit the San Antonio community and pro-mote San Antonio as an ideal wine andfood destination.

COMMUNITY SUPPORTBy way of providing culinary scholar-

ships and aid to San Antonio’s chefs en-during personal hardships through the

Chefs 4 Chefs programs, Culinaria haslong promoted its support of the commu-nity. Culinaria is ever-growing and tryingto find new ways to enrich San Antonio,and its next big endeavor in aiding thecommunity will take form in the Culi-naria Urban Farm. The purpose of thefarm is to hone in on true nutritional val-ues and education to promote a farm-to-table diet. With each San AntonioRestaurant Week bite, guests help keepthese causes alive.

Tempted but want more information?Visit the Culinaria website at Culinari-aSA.org or call 210-822-9555. Participat-ing restaurants, menus and additionalevents of Culinaria will be added as detailsbecome available. Culinaria also can befound on Facebook at CulinariaSanAnto-nio and Twitter @CulinariaSA.

Special to San Antonio Medicine

s San Antonio’s food scene


HASA

Patient information exchange shows valueBy Gijs van Oort, PhD

Keeping track of your patient information through an electronicmedical record (EMR) is slowly increasing among physicians andphysician groups. While adoption among hospitals is in the 80thpercentile, physician adoption in the South Central Texas area is es-timated around 30 percent but growing. Converting from paper toelectronic is a first step in the overall effort to allow patient infor-mation to be available for medical practitioners in a seamless way atthe time a patient seeks care. As a next step to accomplishing that,health information exchange (HIE) is promoted locally through anonprofit initiative led by local hospitals, physician groups, BCMS,the San Antonio Military Health System and other healthcare stake-holders. Well before the Accountable Care Act, it was recognizedthat the value of electronic medical records lies just in that fact –that information can securely flow to the right point of care at theright time.

Practicing physicians have approached this concept slowly. Con-cerns about cost and disruption to the office workflow are real, cer-tainly with the difficulties and frustrations that many have had inconverting to EMR. In the 2011 Rand Corporation physician sat-isfaction survey (www.rand.org) EMRs were supported in conceptbut with reportedly significant negative experiences because of rigidtechnology, wasted time, complex screens and greater expense thanoriginally planned. However, more physicians are looking beyondthese immediate challenges and can see upsides in the longer term.Following are considerations that physicians are considering whenembracing this next step in the electronic patient evolution.

HASSLE FACTORIn isolated physician offices, a lot of time and resources are ex-

pended on manual processes for sending referrals, copying records,and following up with other offices. Additionally, physicians fre-quently are restricted in timely diagnoses because of missing patienthistory. And a general patient complaint is the repetitive completionof patient information. Patient information sharing can address sev-eral of these issues by streamlining work flow issues.

More hassle can be avoided if submitted patient information canbe automatically abstracted for submission to state offices (immu-nization, labs) or local health department officials. And with out-comes-based reimbursement, having an automated reportingcapability for quality measures can greatly improve the time a physi-cian can spend with a patient, without degrading these reportingrequirements.

CMS has clearly and consistently laid out the pathway from fee-for-service reimbursement to outcomes-based reimbursement. Arecently published dashboard by CMS (http://www.cms.gov/Re-search-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Chronic-Conditions-HRR) for its Medicarepopulation shows that San Antonio patients are increasingly likelyto experience hospital re-admissions as more chronic co-morbidities

exist. Physicians will soon have to show evidence of Medicare pa-tient health status from their own EMR system, but also documenthow they have managed patient care outside their office, specificallythese chronic conditions. Dashboard-driven reports that includepatient information across providers can be of invaluable help forthat. And, if history repeats itself, private insurers will follow CMSif cost and quality can be impacted favorably.

To encourage transitional care, physicians since January 2013 canbill under CPT-codes 99495 and 99496 for discharged Medicarepatient communications and office visits within two days, and sevenor 14 days, respectively. Reimbursement rates are higher than a rou-tine office visit. By sharing health information, an alert from a HIEcan notify your office at the time of discharge, allowing your officestaff to contact the patient in time.

PATIENT COMPLIANCE A general complaint of physicians has been that patients ignore

about half of what they have been advised to do after they leave aclinic. Tools are available to remind patients, educate them on theirspecific needs, and securely and economically communicate withtheir providers’ staff. Furthermore, patients are by law entitled to acopy of their medical information within 10 to 15 days followingan event. Physicians can see this as a tool to engage patients, makethem more accountable for their care, so that complications may beminimized and manageable conditions are indeed managed by thepatient as well. Physicians who encourage the use of such a patientportal will undoubtedly benefit from a loyal and more educated pa-tient base from more discriminate data sources than random Inter-net searches.

The journey to electronic health records has been all but easy orsmooth. However, many physicians have made the trip and are nowready to reap the rewards. The RAND study for physician satisfac-tion also highlighted the fact that few physicians want to go backto the paper age; many are willing to persevere knowing that futureperformance will depend on electronic medical information sharingas the utility to effectively manage patient care. Then the questionremains: Do you want to do it or have it done to you? The HASAboard has taken the first approach since 2006 and invested in thesharing of patient information through a neutral entity. It now isup to the physician community to engage and help improve thequality and access to care for the Central Texas community withoutjeopardizing the business viability.

Gijs van Oort, PhD, is the executive director forHealthcare Access San Antonio (HASA), the local HealthInformation Exchange (HIE) provider authorized by thestate of Texas to create a community-based, regionwideHIE in Bexar County and 22 surrounding counties. Visit

www.hasatx.org.


THANK YOU to the large group practices with

100% MEMBERSHIP in BCMS and TMA

Contact BCMS today to join the 100% Membership Program!*100% member practice participation as of June 12, 2014.

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UTHSCSADEAN’S MESSAGE

When Sam Barshop passed away at 84 just six months ago, SanAntonio lost one of its finest citizens. Mr. Barshop is best knownin the business world for creating the La Quinta Inn hotel chainwith his brother, Phillip. He also was a true philanthropist, con-tributing to the University of the Incarnate Word and foundingthe Barshop Jewish Community Center. In the world of science,the Barshop name is associated with one of the most prestigiousand productive research centers on aging in America – theBarshop Institute for Longevity and Aging Studies.

Arthritis, Parkinson’s disease, cancer, osteoporosis, dementia,heart disease and diabetes are just some of the many diseases andconditions we are at much greater risk for as we age. In its manylaboratories and programs, the Barshop Institute’s 150-plus facultymembers are tackling research related to these conditions andnearly every aspect of aging. The faculty includes many geriatri-cians and other specialists who focus on elderly patients.

The institute was seeded in 2001 with a $4 million donationfrom Sam and Ann Barshop, and with financial support from theBrown Foundation and the National Institute on Aging (NIA),one of the National Institutes of Health (NIH). The Barshopopened its doors four years later with the completion of its mainfacility at the Texas Research Park. Due to the strength of the fac-ulty and their diverse programs, it is a leading recipient of NIAfunds and a prolific venue for discovery.

The Barshop Institute is directed by Nicolas Musi, MD, pro-fessor of medicine. Dr. Musi occupies the Sam and Ann BarshopEndowed Chair in Translational Research and directs the Centerfor Healthy Aging and the Geriatric Research, Education andClinical Center (GRECC) within the South Texas VeteransHealth Care System (VA). Trained in endocrinology and metab-

olism at Harvard’s Joslin Diabetes Center, Dr. Musi sees diabetespatients at the VA while conducting translational research that fo-cuses on aging and metabolism and the cellular and molecular ef-fects of exercise.

“I want to make sure that the Barshop Institute maintains andeven enhances its stature as one of the leading institutes in thebasic biology of aging,” Dr. Musi said of his appointment. “As wedo this, we will have a more comprehensive program that will in-clude a strong translational component to move the research con-ducted at the lab bench and apply it at the bedside.”

Faculty at the Barshop Institute collaborate with hundreds ofother researchers, including other faculty at the Health ScienceCenter, the Texas Biomedical Research Institute, the South TexasVeterans Health Care System, faculty at UT San Antonio and UTAustin, as well as researchers from other institutions in the UnitedStates and around the world. There are so many programs that itwould take more than the allotted space to list them all, so I willlimit myself to several “core” programs:

• The San Antonio Nathan Shock Center, one of the originalShock Centers founded by the NIH’s National Institute onAging in 1995. The center is a national resource that providesa state-of-the-art scientific infrastructure and services used inthe development and study of rodent models to address ques-tions about the basic biological mechanisms of aging. The cen-ters are named after Nathan Wetherell Shock, PhD, whoformed the gerontology division of NIH in the 1940s; this di-vision eventually evolved into the NIA during his 50 years ofleadership. The Barshop Institute’s Shock Center is directed byRandy Strong, PhD.

BARSHOP INSTITUTE ON AGINGAND LONGEVITY STUDIES

Translating results ‘from bench to bedside’By Francisco González-Scarano, MD


UTHSCSADEAN’S MESSAGE

• The San Antonio Aging Interventions Testing Program(ITP), which evaluates treatment strategies likely to prevent ordelay adverse age-dependent changes in cells and tissues, andto diminish the burden of disease in old age. It is also directedby Dr. Strong and co-directed by James Nelson, PhD; this pro-gram is funded by the Biology of Aging Program of the NIA.In 2009, the ITP and collaborators reported that mice giventhe drug Rapamycin had significantly increased lifespan. Thiswas the first report ever to show that a pharmacological agentcould increase the lifespan of a mammal. This study was se-lected by the journal Nature as one of the major scientificbreakthroughs of 2009.

• The Marmoset Aging Center is centered around a highly con-trolled, pathogen-free environment to promote excellent healthin these small primates to produce a large number of aged an-imals. This is the only facility in the world that has created thismarmoset model (close genetic relatives to humans) for thestudy of aging and age-related diseases. It is directed by SuzetteD. Tardif, PhD.

• The Barshop’s Naked Mole-Rat Aging Center uses similarcontrols and environment (to the marmoset program) for itslarge colony of these unique animals. Rochelle Buffenstein,PhD, is the director of the center. The mole-rat is an extraor-dinarily long-lived rodent that she has found shows negligibleaging of both cardiovascular and brain function. It is also veryresistant to cancer, does not go through menopause and hasseveral other interesting characteristics applicable to gero-science. The center has played a large role in mapping thegenome of the mole-rat and determining its specific similari-ties with the human genomes.

The Barshop Institute continues to be a leader in aging researchgrants. Just a month after Dr. Musi’s appointment last year, theNIA announced a $3.4 million training grant for the Barshop In-stitute. The five-year grant will enable 10 graduate students andsix postdoctoral fellows at the Barshop Institute to pursue inno-vative, ground-breaking research on the basic biology of aging.

Around the same time, a $200,000 gift from the Glenn Foun-dation for Medical Research was awarded to fund two Barshopfellows to participate in the PhD program focused on the biologyof aging. Last summer, the Texas Legislature approved of $4 mil-lion in exceptional-item funding over the 2014-15 biennium toestablish a Translational Aging Research Program within theBarshop Institute. This program will focus its efforts on develop-ing the strategies, personnel, infrastructure and study populationsto evaluate whether interventions targeting the fundamentalprocesses of aging can delay the onset of chronic diseases and dis-abilities in humans.

In May, the American Diabetes Association awarded Dr. Musia $600,000 grant for a clinical research study to test whether ahigh-fat diet causes changes in the gut bacteria that lead to an in-crease in endotoxins typically found in older people and patientswith Type 2 diabetes. The study also will explore how the level ofendotoxin might affect glucose metabolism, especially in contextof insulin sensitivity.

Many of the Barshop faculty are cross-appointed from differentdepartments in the school and see patients as well as doing re-search, hoping to translate the results "from bench to bedside" assoon as possible. One such faculty member is Alfred Fisher, MD,PhD, an associate professor of medicine who is the associate di-rector for research at the Veterans Administration’s GRECC andthe Center for Healthy Aging. He is also a geriatrician at the VAAudie L. Murphy Hospital. Another great example is a practicinggeriatrician on the faculty – Sara Espinoza, MD – a professor inthe department of medicine. She combines her geriatrics practiceat the VA with teaching and research. Her practice and researchfocus on aging and frailty, proteomics and epidemiologic studies,including ethnic differences in aging and disease. Like many ofthe faculty, she collaborates with other providers and interdisci-plinary team members to design and implement new models ofcare to improve healthcare for the aging.

The Barshop Institute recently enjoyed an important addi-tion to its faculty with Erzsebet K. Kokovay, PhD, an assistantprofessor in the department of cellular and structural biologywho joined the faculty in 2012 after a post-doctoral fellowshipat the Neural Stem Cell Institute in Rensselaer, N.Y. She stud-ies stem cells and brain function in the aging process as well asneurogenesis.

The Barshop Institute is one of the hidden gems of science –well known to relatively few in San Antonio – but knownaround the world for its collaborations and dedication to dis-coveries that promise to prolong healthy lives. My congratula-tions as well as my gratitude on behalf of myself and everyonewho wishes for a life as healthy as it is long, which is the ulti-mate goal of all their efforts.

Dr. Francisco González-Scarano is dean of the School ofMedicine, vice president for med-ical affairs, professor of neurology,and the John P. Howe III, MD,Distinguished Chair in HealthPolicy at the University of TexasHealth Science Center at San An-tonio. His email address [email protected].


BOOK REVIEW

What do you know about the“Dreyfus Affair”? Probably not alot; maybe you never even heardof it, or you vaguely rememberthat it was a spy scandal of somesort in France in the 1890s, andit had something to do with aplace called Devil’s Island. That’s

what I remembered. Then I read a laudatory review of “An Offi-cer and a Spy: A novel” by Robert Harris in the Wall Street Journaland decided that I’d take a look at it. I am so glad that I did.

Right up front, in an author’s note, Harris tells us that all of thecharacters in the book are taken from the historical record, and allof the events depicted actually happened, sort of. He admits thathe had to modify things a bit, invent conversations, descriptions,etc., to turn what were probably pretty dry contemporaneoussources (except the Paris newspapers) into a novel.

Alfred Dreyfus was an up-and-coming officer in the FrenchArmy. He was from Alsace, which the French had lost to the Ger-mans in their embarrassing defeat in the Franco-Prussian war of1870. Dreyfus was wealthy and Jewish … facts that become afactor in the story. France was pretty rabidly anti-Semitic in thosedays, and when an agent working as a cleaning lady in the Ger-man Embassy in Paris produces a couple of documents that implythat there is a traitor somewhere in the Army, Dreyfus was singledout, tried by court martial, found guilty and sentenced to life im-prisonment in solitary on Devil’s Island, a 1,200-by-400-meterrock in the southern Caribbean.

DEGRADATION CEREMONYThe story is told in the first-person present tense in the voice

of Col. Georges Picquart. At first, Picquart is an officer with therank of major on the staff of the Minister of War. He is assignedto watch the trial and subsequent “degradation” of Dreyfus. Thisis the public ceremony where the prisoner’s insignia, uniform but-tons and even the stripes on his trousers are ripped off, and he ismarched away to his sentence. Soon after, Picquart is promotedand assigned to head the “Statistical Section” of the General Staff,which was the French term for the Intelligence Division. He takesover from an older officer who is dying of tertiary syphilis and isnot welcomed by the other officers in this rather small outfit.

As the story develops, Picquart begins to have doubts about

Dreyfus’ guilt. He notices that what little evidence exists is cir-cumstantial, and that the court martial was not carried out withproper procedure: the prosecution and the seven judges were al-lowed to see a “secret document” but it was withheld from thedefense. (It seems I’ve read about this sort of thing happeningnowadays, right here in Texas.)

Picquart institutes surveillance of the German Embassy in con-junction with the Sûreté, the French version of the FBI. A Frenchofficer named Maj. Charles Ferdinand Walsin Esterhazy is seen(and photographed) entering the embassy with an envelope in hishand and leaving without it. Esterhazy is generally described bythose who know him as what we might call a “scumbag.” WhenPicquart tries to tell his superiors about his suspicions, they refuseto allow him to follow up on his findings, and, in essence, go intofull cover-up mode. When Picquart persists, he is transferred toa tiny outpost in Tunisia, and at one point, an attempt is made tosend him on what amounts to a suicide mission into the desert.

There is no way I am able to write a compact summary of thisnovelized history: there are so many people, so many twists andturns in the story, such evocative descriptions of belle époque Parisand Parisians that I’d likely end up with a 20-page book report.The last time I did one of those it was because Mrs. Lulu I. Mooremade us write them when I was in the fifth grade in Chicago.

‘DRAMATIS PERSONAE’I know a “critic” is supposed to be critical … but I didn’t find

any real shortcomings in this book. In fact, there was a lot to love,not the least being the “Dramatis Personae” at the front of thebook that helped to keep straight all of the characters and theirpositions in society. These include author Émile Zola, whose fa-mous screed “J’Accuse” was instrumental in Dreyfus’s ultimate ac-quittal, Alphonse Bertillon, an early criminologist, and GeorgesClemenceau, prime minister of France during World War I.

Here’s something that made this book even more enjoyable: Iused Google Images and saw photographs of all of the principalplayers. It helped to bring them to life in my mind.

Fred H. Olin, MD, is a semi-retired orthopaedistwhose visual-based memory can still see Mrs. Lulu I.Moore, and he would still be intimidated by her. Dr.Olin is 2014 chair of the BCMS Communications/

Publications Committee.

“An Officer and a Spy: A novel”Written by Robert HarrisReviewed by Fred H. Olin, MD


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continued on page 38


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Humana(HHH Gold Sponsor)Humana is a leading health and

well-being company focused onmaking it easy for people toachieve their best health withclinical excellence through coordi-nated care.Donnie Hromadka, [email protected]

Nationwide Insurance Joel Gonzales Agency(H Bronze Sponsor)What matters to you, matters to us!Joel Gonzales, 210-314-7514 [email protected] www.nationwide.com/jgonzales

Texas Drug Card(H Bronze Sponsor)The Texas Drug Card program is aFREE statewide Rx assistanceprogram available to all residents.Todd Walker, [email protected]://texasdrugcard.com/index.php

• INSURANCE/MEDICAL MALPRACTICE

API/ProAssurance(HH Silver Sponsor)ProAssurance is about YOU —and, more specifically, treatingyou fairly when it comes to pro-fessional liability insurance and re-lated products and services.Paul Schneider, MBA, RPLU, [email protected]

Medical Protective(HHH Gold Sponsor)Medical Protective is the nation'soldest and only AAA-ratedprovider of healthcare malprac-tice insurance. Thomas Mohler, [email protected]

Texas Medical Association Insurance Trust(HHH Gold Sponsor)Created and endorsed by theTexas Medical Association (TMA),the Texas Medical Association In-surance Trust (TMAIT) helpsphysicians, their families, and their

employees get the insurance cov-erage they need.James Prescott, [email protected] Isgitt, 512-370-1776www.tmait.orgWe offer BCMS members a freeinsurance portfolio review.

Texas Medical Liability Trust(HHHH Platinum Sponsor)Texas Medical Liability Trust is aphysician-owned healthcare lia-bility claim trust, providing mal-practice insurance products tothe physicians of Texas. Currently,we protect more than 14,000doctors in all specialties whopractice in all areas of the state.TMLT is endorsed by the TexasMedical Association, the TexasAcademy of Family Physicians,and the Dallas, Harris, Tarrant andTravis county medical societies. Donald J. Chow, [email protected] partner of theBexar County Medical Society.

The Bank of San Antonio Insurance Group Inc.(HHH Gold Sponsor)We specialize in insurance andbanking products for physiciangroups and individual physicians.Our local insurance professionalsare among the few agents in thestate who specialize in medicalmalpractice and all lines of insur-ance for the medical community. Katy Brooks, CIC, 210-807-5593katy.brooks@bosainsurance.comwww.thebankofsa.comServing the medical community.

The Doctors Company(HH Silver Sponsor)Medical malpractice insuranceKirsten Baze, [email protected]



continued on page 40


• INTERNET/TELECOMMUNICATIONS

Time Warner Cable Business Class(HH Silver Sponsor)When you partner with TimeWarner Cable Business Class, youget the advantage of enterprise-class technology and communica-tions that are highly reliable,flexible and priced specifically forthe medical community.Rick Garza, [email protected] Warner Cable Business Classoffers custom pricing for BCMSmembers.

• MARKETING SERVICES

Phiskal LLC Marketing and Promotion(H Bronze Sponsor)A leading-edge marketing anddevelopment firm using propri-etary artificial intelligence enginesto enhance your presence withwebsites, apps and database ap-plications.Sundeep Sadheura, [email protected]://PHISKAL.COM/

• MEDICAL BILLING & COLLECTIONSSERVICES

Commercial & Medical Credit Services(H Bronze Sponsor)A bonded and fully insured SanAntonio-based collection agency.Henry Miranda, [email protected] us the solution for your account receivables.

DataMED(HHH Gold Sponsor)Providing your practice with thelatest compliance solutions, con-centrating on healthcare regula-tions affecting medical billing andcoding changes, allowing you andyour staff to continue deliveringexcellent patient care.Anita Allen, [email protected] members receive a dis-counted rate for our billing services.

PriMedicus Consulting Inc.(H Bronze Sponsor)A physician-founded and -built com-pany, dedicated to your success. Sally Combest, MD, 877-634-5666s.combest@primedicusconsult-ing.comwww.primedicusconsulting.comPriMedicus Consulting for thehealth of your practice.

Urgent Care Billing Solutions LLC(H Bronze Sponsor)UCBS provides superior practicemanagement services and rev-enue optimization services to thehealthcare community in a virtualoffice environment. Ann DeGrassi, CMIS, 210-878-4052 adegrassi@ucbillingsolutions.comwww.urgentcarebillingsolutions.net

• MEDICAL SUPPLIES& EQUIPMENT

Henry Schein Medical(HHHH Platinum Sponsor)From alcohol pads and Band-Aidsto EKGs and ultrasounds, we arethe largest worldwide distributorof medical supplies, equipment,vaccines and pharmaceuticals,serving office-based practitionersin 20 countries. Recognized asone of the world’s most ethicalcompanies by Ethisphere.Tom Rosol, [email protected]/medicalBCMS members receive GPO dis-counts of 15%-50%.

• PAYMENT SYSTEMS/ CARD PROCESSING

Heartland Payment Systems(HH Silver Sponsor)Sherry Willis, [email protected]

• PUBLICATION MANAGEMENT FIRM

Traveling Blender(H Bronze Sponsor)Publication management firm Janis Maxymof, [email protected]% discount on display advertis-ing in magazine for members.

• PRINTING SERVICES

SmithPrint(H Bronze Sponsor)SmithPrint offers custom printing,branding, graphic design, signageand more!Robert Upton, [email protected]/New customers: 10% discount onprint materials at SmithPrint.

• REAL ESTATE/COMMERCIAL

Newmark Grubb Knight Frank(H Bronze Sponsor)Commercial real estateDarian Padua, [email protected]

Stream Realty Partners(H Bronze Sponsor)Carolyn Hinchey Shaw, [email protected]

• REAL ESTATE/RESIDENTIAL

Becky Aranibar Realty Group –Keller Williams(H Bronze Sponsor)Offering real estate services to theSan Antonio medical community.Carlo G. Aranibar, MBA, [email protected] free comparative marketanalysis to determine your home'svalue.

SA Luxury Realty(HH Silver Sponsor)Effective real estate transactions(buy, sell, lease, syndicate, etc.)within the shortest time possibleand for maximum results!Matin Tabbakh, 210-772-7777matin@saluxuryrealty.comwww.saluxuryrealty.comAccredited luxury home special-ist – call us today.

• REAL ESTATE INVESTMENTS

Texas Premier Capital(HH Silver Sponsor)A real estate development com-

pany offering and managing realestate investment funds in theSouth Texas area.H.B. Newman, [email protected] Carter, 210-367-7909rick@texaspremiercapital.comwww.texaspremiercapital.com

• REGULATORY COMPLIANCE

Hildebrand Regulatory Compliance(H Bronze Sponsor)HEDIS, Accreditation, PCMH, ICD-10.Patricia Hildebrand, 432-352-6143Pati.Hildebrand@Hildebrand-Healthcare.comwww.hildebrandhealthcare.com

• RESEARCH STUDIES/ BIOTECHNOLOGY

ICON Development Solutions(HHHH Platinum Sponsor)We are a respected clinical re-search organization that has anextensive reputable history in di-abetes research. Depending uponthe current studies, ICON may es-tablish working relationships withlocal physicians. Your expertisemay be invaluable to our effortsto identify subjects. Dr. Dennis Ruff, [email protected] out how ICON can help yourpractice.

• STAFFING SERVICES

Favorite Healthcare Staffing(HHHH Platinum Sponsor)Serving the Texas healthcarecommunity since 1981, FavoriteHealthcare Staffing is proud to bethe exclusive provider of staffingservices for BCMS. In addition totraditional staffing solutions, Fa-vorite offers a comprehensiverange of staffing services to helpmembers improve cost control, in-crease efficiency, and protecttheir revenue cycle!Brian Cleary, 210-301-4362

continued from page 39


[email protected] Healthcare Staffing offerspreferred pricing for BCMS members.

• TITLE COMPANIES

Alamo Title Company(HH Silver Sponsor)Corina Cashion, [email protected]

• TRANSCRIPT SERVICES

Med MT Inc.(H Bronze Sponsor)Narrative transcription is physi-cians’ preferred way to create pa-tient documents and populateelectronic medical records.Ray Branson, [email protected] Med MT solution allows physi-cians to keep practicing just theway they like.

BECOME A VENDOR/SPONSOR

Are you trying to reach the 4,700-plusphysician-members of the BCMS

with your business message?

Consider joining the BCMS Circle of Friends program.By underwriting society events and programs, Circleof Friends members help fund BCMS’ mission of en-hancing the practice of medicine for healthcareproviders and Bexar County residents.

“The Circle of Friends program is the most efficientand direct method to reach the medical community.”

– August C. Trevino, BCMS Development Director

For more information, call 210-301-4366, email [email protected],

or visit www.bcms.org.

BCMS does not endorse businesses and involves inself only in services and programs that benefit members and their patients.




Gunn Acura11911 IH-10 West

Cavender Audi15447 IH-10 West

BMW of San Antonio8434 Airport Blvd.

Cavender Buick17811 San Pedro Ave.(281 N @ Loop 1604)

Batchelor Cadillac11001 IH-10 at Huebner

Cavendar Cadillac801 Broadway

Tom Benson Chevrolet9400 San Pedro Ave.

Ancira Chrysler10807 IH-10 West

Ingram Park Auto Center7000 NW Loop 410

Ancira Dodge10807 IH-10 West


Ancira Elite Motorcars10835 IH-10 West

Northside Ford12300 San Pedro Ave.

Cavender GMC17811 San Pedro Ave.

*Fernandez Honda8015 IH-35 South

Gunn Honda14610 IH-10 West(@ Loop 1604)

*Gunn Infiniti

12150 IH-10 West

Ancira Jeep10807 IH-10 West


Ancira Kia6125 Bandera Road

*North Park Lexus611 Lockhill Selma

*North Park

Lincoln/ Mercury9207 San Pedro Ave.


Mercedes-Benzof Boerne

31445 IH-10 W, Boerne

Mercedes-Benzof San Antonio

9600 San Pedro Ave.

*Mini Cooper

The BMW Center8434 Airport Blvd.

Ingram Park Nissan7000 NW Loop 410

Porsche Center9455 IH-10 West

Ancira Ram10807 IH-10 West


North Park Subaru9807 San Pedro Ave.

Cavender Toyota5730 NW Loop 410

*Ancira Volkswagen5125 Bandera Rd.

*The Volvo Center1326 NE Loop 410


One of the reasons I enjoy following theautomotive industry is that there’s a never-ending stream of storylines that bubble up,evolve, and then die, only to be replaced byother compelling narratives. In the saturationcoverage of world luxury brand leadership(Audi’s ahead by a nose), CEO news (MaryBarra of GM is all anyone’s talking aboutnow), and the full-size pickup wars (the F-150’s upcoming aluminum architecture isterrifying GM and Ram), there’s a remark-able story that is getting very little press. Sub-aru is absolutely crushing it in the UnitedStates these days.

Some numbers: in 2008, Subaru sold187,699 vehicles in this country. In 2013, itsold 424,683, a gain of 126 percent com-

pared with an increase of 18 percent for theoverall market. Interestingly, Subaru madethat huge leap with virtually no help from anSUV. It was all cars. Furthermore, every carsold by Subaru comes with all-wheel drive, anovelty considered to be a Snow Belt feature,not something for mainstream buyers. (Forthe record, Subaru does actually offer anSUV, the unloved Tribeca crossover, but thatvehicle sells in very small numbers and willbe dropped after the 2014 model year.)

SECRETS TO SUCCESSSo, how did Subaru take an almost all-car

lineup with a boutique drivetrain to suchheights? By creating attractively designedcars, pricing them moderately and advertis-

ing them skillfully. Doing that is easy in the-ory, but unbelievably difficult in practice.

The Subaru Forester I tested recently is agood place to understand why this companyhas been so successful. As the most utilitarianvehicle in the Subaru lineup, the Forester canbe forgiven for being uninteresting to lookat. And to some extent its styling is uninspir-ing, but it’s a functional and honest designnevertheless. Boxy -- though not as boxy asthe first-gen model -- the latest Forester lookslike what you’d get if you mated the originalForester and the new youth-oriented SubaruXV Crosstrek. The windshield is more rakedthan it used to be, the greenhouse is more ta-pered, and the detailing is thoughtful.

Thoughtful also describes the interior,

AUTO REVIEW

Subaru Forester: Boxy but goodBy Steve Schutz, MD


which is well laid-out and easy to use. Thefocus of the center stack is, as it is invariablyin new cars these days, the navigation screen,

which displays audio, HVAC and other in-formation whether or not you actually se-lected the navigation option. Interestingly,the Forester’s backup camera displays on asecond information screen located higher upon the dash.

While the utilitarian nature of the Foresteris reflected in its shape and the excellent useof space in the cabin, it’s also evident thatSubaru worked hard to make their pricepoint as the look and feel of the interior ma-terials are not up to Outback standards.

Driving the Forester is less fun than theXV Crosstrek, as you’d expect since the XVis smaller. Still, the Forester is nimble andquick, thanks to a curb weight of just 3,296pounds. Maximizing the fun factor requiresselecting the manual transmission, though,as the only clutchless option available is thecontinuously variable transmission (CVT),which is not the enthusiast’s choice.

It should be noted that another importantreason the Forester is selling so well is becauseof excellent advertising. Subaru’s recent ad-vertising campaign called “Love” showsyoung couples using their Subarus to explorethe outdoors in various ways, such as visitinga hot springs where one duo encounters an-noying, aging hippies prompting the won-derful line, “We shouldn’t have done that.”Obviously advertising is a tricky business,but successfully connecting Subarus toyoung love is something that can make evencynical viewers like me smile.

Pricing depends on how loaded you wantyour Forester, but the MSRP starts at under$23,000 and stretches up past $30,000 if youcheck off all the boxes. The base engine is anold Subaru standard, the 2.5-liter flat four,which makes just 170 HP. The upgraded en-gine like the one in my test car is the gutsier2.0-liter turbo flat four that makes a morepalatable 250 HP.

Fuel economy is 24 mpg city/32 mpghighway for Foresters with the base engine,and 23/28 if the turbo is selected.

SIX TRIM LEVELS OFFEREDThe 2014 Subaru Forester is available in

six trim levels: 2.5i, 2.5i Premium, 2.5i Lim-ited, and 2.5i Touring, all with the 2.5-literengine, and 2.0 XT Premium and 2.0 XTTouring, both with the turbocharged 2.0-liter motor. As always, Phil Hornbeak isavailable to help BCMS members with anyauto purchasing questions or needs they mayhave (see information below).

At some point, business writers will spreadthe word about Subaru’s amazing sales suc-cess over the past five years. In the meantime,we can enjoy their excellent products, suchas the boxy-but-good 2014 Forester. Here’s

hoping Subaru continues to create attrac-tively designed cars, price them moderately,and sell them with great advertising.

Steve Schutz, MD, is aboard-certified gastroenterol-ogist who lived in San Anto-nio in the 1990s when he wasstationed here in the U.S. AirForce. He has been writingauto reviews for San Antonio

Medicine since 1995.For more information on the BCMS

Auto Program, call Phil Hornbeak at 301-4367 or visit www.bcms.org.

AUTO REVIEW



Documents

San Antonio Medicine magazine July 2014