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KEEP AUSTIN WELLYOUR GUIDE TO LIVING WELL EVERY DAY

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CONTRIBUTING WRITERS Roxanne Wilson, Tarie Beldin, Anand D. Patel, MD,

Jerri Lynn Ward

ART DIRECTORDaniel Ramirez

ADVERTISING & CONTACTKristen Donner, kristen@austinlifestylemagazine.com

contents

89 TRIO: The Trifecta Approach

To Healthy Living

90 Eat Right With Color:

Tips For Busy Families

92 Why Do Our Faces Age?

And What Can We Do About It?

94 Innovative Scoliosis

Correction Surgery

95 You Will Be Assimilated:

The Fate of the Independent

Physician under Health Care Reform

Keep Austin Well

Ted Weltzin, MD, Executive Medical DirectorBrad Kennington, LMFT, LPC, Executive Director

Samantha Symons, MD, Staff PsychiatristLea Gebhardt, MS, RD, LD, Nutrition Coordinator

4613 Bee Caves Road, Suite 104 Austin, Texas 78746Toll free: 877.755.2244 Phone: 512.732.2400 Fax: 512.732.2404

wwwww.cedarspringsaustin.comAustin Eating Disorders Partners, LLC

Experienced Multidisciplinary Treatment Team

Assessments and consultations 10 and 6 hour partial hospitalization programs, 7 days a week Intensive outpatient program, 3 days a week Outpatient services and aftercare Comprehens Comprehensive treatment for male and female adults and adolescents

Specializing in the care of anorexia, bulimia, and binge eating disorder

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TRIO The Trifecta Approach to Healthy Living

BY ROXANNE WILSON

T he key to a complete workout is cardio, strength training

and stretching. It’s something long standing exercise pro-

grams have mastered. In this day and age, when time is of

the essence, it is nice to find a fitness center that gives that complete

workout in an interesting package.

Trio Life Fitness, established in November 2010 by Mardee Calkins,

does exactly that. Trio Life incorporates three fitness favorites: Spinning,

Pilates and Yoga, generating the ultimate cardio, strength training and

stretching combination. Although Trio Life o!ers classes dedicated to

each element, as well as Cardiolates (Pilates on trampolines), it is known

for its signature class: Trio Fit - an hour or an hour and fifteen minute class

incorporating all three fitness programs. I had to give it a try!

Part one: 20-25 minutes of Spinning. Although I am an Austinite,

bikes aren’t really “my thing.” I’ve taken less than a handful of spinning

classes. I was a little timid, but the instructor assisted me in setting up

the Spinner bike and my fellow classmates were warm and welcom-

ing. For the next twenty-five minutes we cycled up and down hills in

time with the music as we managed our own resistance accordingly.

Jennifer, the instructor, prepared the class for what was coming up in

the routine, how long the “hill” was and how much resistance to add

or take away. Once I got into the groove of spinning, the music took

over and I could feel the hills naturally and soon found that I could

adjust my Spinner bike gauge to the proper resistance on my own.

Part two: 20-25 minutes of Stick Pilates. Stick? This was a first!

Stick Pilates is a combination of strength training moves for the

abdominals, upper and lower torso with a stick attached by bun-

gees to the wall. As I stood and leaned at least five feet away from

the wall for extra resistance and began bicep and tricep exercises,

I couldn’t help but engage my abdominals to keep my balance. We

moved to the floor for inner and outer thigh repetitions as well

as glute moves. The Stick required extreme muscle control even

as you felt the burn. Whew! And just when the class as a whole

couldn’t go for any more, we moved to…

Part three: Yoga. The trio culminated with yoga to open up the

muscles used during Spinning and Stick Pilates. It was a perfect way

to calm and cool the spirit and ease out of the workout.

I can’t stress how unintimidating the entire experience was. The

students were helpful and inviting, the sta! was first-rate and the facil-

ities were attractive and clean (including the bathrooms)—definitely

setting Trio Life Fitness apart from other fitness center experiences.

If you enjoy variety while you are working out, Trio Life Fitness will

provide you an interesting full body workout in one pretty package.

RoxanneWilson.com | Twitter @RoxanneWilson

To see Roxanne’s workout in action, go to austinlifestyle.com.

Trio Life Fitness12101 Bee Cave Road Suite 5E

Austin, Texas 78738

512.263.9600

triolifefitness.net

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M!arch is National Nutrition Month, which means dietitians

help shift the focus of dietary education to focus on the

basics of healthy eating. This year’s theme, “Eat Right With

Color,” encourages Americans to include a colorful variety of fruits,

vegetables, whole grains, lean proteins and dairy on their plates every

day (even after March!). A rainbow of color on your plate creates a pal-

ette of nutrients, and there are plenty of colorful foods to choose from.

Healthy eating involves more than just calorie counting. In fact,

most children do not get all of the essential nutrients they need for

growth and development. I’m often asked by busy, working parents,

who have a household of picky eaters, “How can I make sure my fam-

ily has enough color in their diet?”

Below are some of the colors that you can include in meals to get

more nutrients in your family’s diet:

Green Produce in shades of green contains antioxidants, which may

help reduce cancer and promote healthy vision. Fruits include avocados,

grapes, honeydew and kiwi. Vegetables include artichokes, asparagus,

broccoli, green beans, green peppers and leafy greens, such as spinach.

Orange or Deep Yellow Produce in shades of orange or deep yel-

low contains nutrients to protect the immune system and vision and

reduce the risk of cancer. Fruits include apricots, mangos, canta-

loupes, peaches and pineapple. Vegetables include carrots, orange

or yellow peppers, corn and sweet potatoes.

Purple or Blue Produce in shades of purple or blue have antioxidant and

anti-aging benefits, which may help with memory, urinary tract health

and reduce the risk of cancer. Fruits include blueberries, blackberries,

plums and raisins. Vegetables include eggplant and purple cabbage.

Red Produce in shades of red can help maintain a healthy heart and

immune system and reduce cancer risk. Fruits include cherries,

cranberries, pomegranates, red or pink grapefruits and watermelon.

Vegetables include beets, red peppers and tomatoes.

White, Tan, or Brown Produce in shades of white, tan or brown con-

tains nutrients that may promote heart health and reduce cancer risk.

Fruits include bananas, pears, dates and white peaches. Vegetables

include cauliflower, mushrooms, onions, parsnips, turnips and

potatoes.

The goal is to include at least three di"erent colors on your plate at

each meal. For example, rather than having a dinner of grilled chicken

with a baked potato, top the chicken with salsa and add mashed sweet

potatoes and a spinach salad with strawberry slices. The more color-

ful your plate, the more visually appealing it is. It should also increase

the natural flavor and will contain more nutrients.

Have your children help plan meals that contain at least three

colors and allow them to help prepare part of the meal. The more

involved children are with the meal planning and preparation, the

more likely they will be to eat—or at least taste—the di"erent colors

and foods.

Remember, it can take up to 20 times for a child to try a food until

they actually enjoy it! Don’t give up. Continue o"ering healthy options

with foods they are familiar with. We are the greatest role models for

our children. When they see mom or dad eating healthy and being

physically active, they are more likely to follow in our footsteps.

Tarie Beldin is a registered and licensed dietitian with the Fit 4 Life Weight

Management program at St. David’s Round Rock Medical Center.

Eat Right With ColorTips for Busy Families BY TARIE BELDIN

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Why DoOur FacesAge?

And What We Can Do About It!BY ANAND D. PATEL, MD

G!etting older would be much more enjoyable if we didn’t

have to look older as well. Many of us feel younger on the

inside than we look on the outside, and that can be tough

to deal with. To make matters worse, our society tends to associate

beauty and youth with value and success. This is especially true when

it comes to our faces. So, it’s no surprise that many of us are constantly

looking out for the miracle product or service that will turn back the clock.

But why does it happen? How does aging cause wrinkles, deep

lines of expression, droopy skin and a sunken look? A simple approach

to understanding facial aging is to think of the e"ects as either qual-

itative or quantitative. The qualitative changes involve the charac-

ter of the skin, which includes dryness and texture, coarse and fine

wrinkling, age spots, prominent blood vessels and the appearance of

benign or precancerous lesions. Over time, the e"ect of facial muscles

pulling on the overlying skin leads to deep wrinkles that worsen with

facial expression. The quantitative changes include skin laxity and

volume loss in the face. Bone loss is seen in the central face and the

jawbone. The fatty pads of the face that give us fullness in the cheeks

and lips tend to thin, while other areas, such as under the chin, tend

to build up fat. Altogether, this leads to the telltale signs of facial aging.

With aged skin, collagen and elastin production begins to break-

down. This leads to loss of volume and strength and more laxity.

The mechanism of this process is still being worked out, but various

enzymes, proteins and free oxygen radicals are thought to contribute.

Both genetic and environmental factors are to blame. It seems that

our cells are genetically programmed to stop replicating after a time.

Protective mechanisms, such as DNA and tissue repair systems, enzy-

matic inhibitors and even antioxidants are produced by the body to

combat aging, but they also decline over time. Why some people age

faster than others is likely due to both behavioral and genetic reasons.

Skin pigmentation, likely the most important genetic factor, is pro-

tective against the most pervasive environmental factor, ultraviolet

radiation (UV). There are two types of UV that contribute to aging, UVA

and UVB, albeit by di"erent mechanisms. The UV radiation results

in photoaging, a chronic inflammation of the skin which not only

accelerates normal aging, but also causes a hardened, leathery qual-

ity to the skin. Other environmental factors that a"ect aging include

an unhealthy diet, alcohol use, smoking and nicotine, pollution and

poor overall health. Scientific studies leave little doubt that smoking

and nicotine markedly trigger premature wrinkling.

The key is prevention, and you’re never too young or too old to

start. Those with healthy lifestyles also tend to look healthier. It seems

the adage “garbage in, garbage out” also applies to aging. That means

good nutrition, regular exercise, proper skin care, and staying away

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from smoking, nicotine and other environmental toxins. It’s not pos-

sible to totally avoid the sun, so the appropriate sunscreen with a high

enough potency (SPF 30) becomes critical. Make sure that your sun-

screen protects against both UVA and UVB, because some do not. In

a world where the e!ectiveness of many products is ill-supported by

hard data, Tretinoin, a form of topical Vitamin A, is one with good evi-

dence of its e"cacy in reversing photoaging. Ask your dermatologist

if you are a good candidate.

For those of us beyond the point of prevention, there are good treat-

ments to turn back time. Botulinum toxin was originally used in high

doses to treat muscles spasms, but has gained widespread success in

much smaller doses to relax facial muscles and soften deep facial lines.

It is particularly good for forehead lines, the glabellar “elevens” between

the eyes and the crow’s feet on the sides of the eyes. Botulinum works

by disrupting communication between the motor nerves from the

brain and the facial muscles. There is an art to these injections and

one can get a “relaxed” look without full paralysis. It takes days to weeks

before the injections take e!ect and they last about three months. Most

importantly, in the relatively small doses used for cosmetic purposes,

Botulinum has proved to be safe over time.

Soft tissue fillers are injected substances that are used to plump

up areas under the skin that lack volume. Fillers have been used in

many parts of the face, but the most common are the smile lines,

marionette lines and lips. These days, the most common types

include collagen, hyaluronic acid, calcium hydroxyapatite and

poly-L-lactic acid components. The fillers di!er in the area or depth

they are injected and how long they last, and some can stimulate

more production of your own collagen. Most fillers can last any-

where from six to fifteen months. Generally, they fade faster in areas

that move a lot (e.g. around the mouth).

For fine, etched lines that do not go away with stretching of the

skin or after Botulinum treatment, a skin resurfacing procedure can

give an amazing result. Skin resurfacing removes the top layers of

skin, allowing new baby skin to take its place. The deeper the resurfac-

ing treatment, the better the result, but the longer the downtime. Skin

resurfacing can also be helpful for age spots and even precancerous

lesions. Generally, there are three types of resurfacing: dermabrasion,

chemical peels and laser. Laser resurfacing has revolutionized the field

by providing a more precise and accurate treatment.

The effects of aging on the face can be disheartening, but we

are lucky to live in an exciting time when we can actually alter our

appearances. The gold standard for patients with significant skin lax-

ity or volume loss is still aesthetic surgery, which aims to restore one’s

previous appearance. There is a multitude of new treatments – many

of which are noninvasive – that can help restore a more refreshed,

youthful appearance. Unfortunately, we have not figured out a way

to stop the aging process altogether – at least, not yet

Anand D. Patel, MD is a Facial Plastic and Reconstructive Surgeon with

Devenir Aesthetics.

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M!any women embrace their curves, but not if they su"er

from scoliosis, a spinal condition causing a curvature of

the spine. Scoliosis is often diagnosed during adolescence

and, if left untreated, can slowly progress and cause serious complica-

tions like breathing problems and pain.

Stephanie Gri#n is an active Central Texas 15-year-old who enjoys

dancing and hanging out with her friends. Like most teens, the idea

of slowing down because of a spinal deformity like scoliosis was not

appealing. Neither was the fact that her spinal curve was worsening.

Stephanie was first diagnosed with scoliosis at age 14. Initially,

she tried a brace, but her curvature worsened to 50 degrees, causing

painful back symptoms. Like many others with scoliosis, her spinal

curvature also began to take an emotional toll. Her mother scoured

the internet for the latest scoliosis correction procedures and treat-

ment options. Their search ended with a local spine surgeon, Dr.

Matthew Geck, from the Seton Spine and Scoliosis Center. He pre-

sented Stephanie and her mother with an innovative treatment option:

a new, minimally invasive scoliosis procedure that corrects the spinal

curve through three small incisions instead of a long incision and scar.

During traditional scoliosis surgery, surgeons must make a large inci-

sion from the top of the scoliosis to the bottom and peel muscles o" the

spine to attach instruments to straighten the spine’s curve. This translates

to significant post-surgery pain and longer recovery times. “It has taken

years to bring minimally-invasive surgery techniques to scoliosis sur-

gery,” explains Dr. Geck, who is one of only three surgeons in the country

– and the first in Texas – to perform minimally invasive scoliosis surgery.

“This isn’t just a new procedure but a new approach to correct

scoliosis,” says Dr. Geck. “It’s a great way to take care of patients and

have them go through less surgery with fewer complications.” With

the newer procedure, screws are percutaneously placed through two

or three tiny incisions, typically three to seven centimeters in length.

It spares muscle surrounding the spine, resulting in a faster recovery

and less post-operative pain.

Dr. Geck corrected Stephanie’s 50 degree curvature to 12 degrees

with a few small incisions and the standard rods and screws to com-

plete the correction. Just four days after surgery, Stephanie slowly

started back with her daily activities. After a few short weeks, she was

back at dance practice and is now able to perform her high stepping

moves and splits with her high school dance team. “I was shocked

at how fast the recovery was and am so happy I had the procedure. I

would do it all over again if I had to,” explains Stephanie.

Dr. Geck has taken his skills with the new minimally-invasive

scoliosis surgery abroad to Cali, Colombia with the global outreach

program, SpineHope. This biannual mission trip involves teaching

a group of neurosurgeons and orthopedic surgeons how to perform

minimally-invasive and complex scoliosis surgeries. Dr. Geck says the

future of minimally-invasive scoliosis surgery is exciting and includes

a combination of imaging guidance surgery and robotics.

Innovative Scoliosis Correction

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Today, this isolated relationship [between doctor and patient] is no longer

tenable or possible. . . Traditional medical ethics, based on the doctor-

patient dyad, must be reformulated to fit the new mold of the delivery

of health care. . . The primary function of regulation in health care…is

to constrain decentralized individualized decision making. –New Rules:

Regulation, Markets, and the Quality of American Health Care (Jossey

Bass/Aha Press Series) by Troyen A. Brennan and Donald M. Berwick MD.

You Will Be Assimilated. –The Borg, Star Trek

T hose of us of a certain age have fond memories of the show,

Marcus Welby, MD. The show glorified the role of physicians in

independent practice. Dr. Welby even made house calls, a near

impossibility after the emergence of the HMO. Since that emergence,

the independence of such physicians—especially primary care physi-

cians—has been slowly eroded by government policy and the dictates of

insurers. A timely question is: How will the recent health reform impact

the independent physician? A historical review is informative.

Since the 1950s, physicians in independent practices began to

form associations called Independent Practice Associations (“IPAs”)

in order to negotiate with insurance companies. The advantage of IPAs

is: “Doctors get a middleman to deal with the insurance bureaucra-

cies, and patients get access to a wide range of health care providers

at discounted prices.”1

However, the federal government has been waging a war on

the independent physician and IPAs through the Federal Trade

Commission (“FTC”) and the Department of Justice Antitrust Division

and their prosecution of 36 IPAs since 2001.2 At least two of those pros-

ecutions have been high-profile cases here in Texas.

North Texas Specialty Physicians fought the FTC all the way to

the U.S. Supreme Court (which denied cert), based on accusations

that it “had engaged in illegal price-fixing when it negotiated con-

tracts that didn’t involve risk sharing with payers on behalf of its 600

doctor members.”3 What the Fort Worth-based IPA had actually done

was to poll its members “annually on the minimum rates each would

accept for certain contracts.” The group then used the poll results

to decide which contracts its members were likely to approve and,

thus, which it would ‘messenger.’ The FTC deemed this arrangement

‘horizontal price fixing.’”4

For some context, IPAs are essentially not permitted by the FTC to

actually negotiate on their behalf with insurance companies unless they

are “clinically and financially integrated” (more about that later). The IPA’s

designated “messengers” are allowed only to relay o!ers from the insur-

ance companies to the members of the IPA, not to respond with the phy-

sician’s demands. The Fifth Circuit apparently agreed, thus squelching

any e!orts for IPAs to discover the positions of their members prior to

“negotiating” with insurers. This is like going into a boxing match with

both hands tied behind your back and your mouth taped shut.

You Will Be AssimilatedThe Fate of the Independent Physician Under Health Care ReformBY JERRI LYNN WARD

1. Oliva, S.M. (2010, November 29). Doctors’ orders: the government’s war on medical ‘price fixing’ squelches speech without helping consumers. Hawaii Reporter, Retrieved from http://www.hawaiireporter.com/doctors%E2%80%99-orders-the-government%E2%80%99s-war-on-medical-%E2%80%9Cprice-fixing%E2%80%9D-squelches-speech-without-helping-consum-ers. 2. Ibid. 3. Sorrel, A.L. (2008, June 23/30). Texas IPA’s contract talks are price-fixing, appeals court rules. American Medical News, Retrieved from http://www.ama-assn.org/amed-news/2008/06/23/gvsc0623.htm. 4. Oliva, Doctor’s Orders, 2010. 5. North Texas Specialty Physicians v. Fed. Trade Comm’n, No. 06-60023 (5th Cir. May 14, 2008). http://www.ftc.gov/os/caselist/0660023/080516opinion.pdf.

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Not only are the independent physicians who make up these IPAs

constrained by the FTC in their ability to negotiate with insurance

companies, the FTC purports to dictate the nature of the IPA business

model. In its action against the Texas-based Southwest Physicians

Association, the FTC prosecuted based on the IPA’s “refusal to continue

following a commission-approved contracting model that resulted in

substantial losses” to the IPA.6

What does all this have to do with health care reform and the future

of the independent physician? The answer lays in the phrase, “clini-

cally and financially integrated.” More than any other policy to date,

the Patient Protection and Affordable Care Act (“PPACA”), enacted

in March 2010, encourages such integration in health care by incen-

tivizing the herding of physicians into what are called Accountable

Care Organizations (“ACOs”). ACOs integrate local physicians with

other members of the health care system, such as hospitals, and

reward them for controlling costs and improving health care quality.

A blunt, if inflammatory description of how they will work is o!ered

by Dr. Fogoros, author of Fixing American Healthcare: Wonkonians,

Gekkonians, and the Grand Unification Theory of Healthcare, on his

indispensible blog: The Covert Rationing Blog.7

The ACOs will be run by administrators who (theoretically) will

become expert at navigating the morass of rules and regula-

tions now being conjured up under Obamacare. These admin-

istrators will interpret the rules and regulations in such a way

as to determine The Way It Must Be Done, and then will pass

The Way It Must Be Done down to the ACOs’ clinical chiefs

(doctors who perhaps used to practice medicine, and maybe

still do, a little, but who are now mainly brevet administrators),

and the clinical chiefs will finally pass the restrictive rules of

engagement down to the doctors who will actually take care

of the patients. These doctors, struggling in the trenches, will

attempt assiduously to follow those rules without exception,

if they would like to keep their jobs as well as avoid a federal

fraud rap. The patients, of course, will get whatever they get,

but always with o"cial assurances that whatever it is they get,

it will be of the highest quality.8

How ACOs will look remains to be seen because the regulations gov-

erning them have not yet been promulgated. The debate about what

those regulations should be is beginning to resemble a mud wres-

tling contest between insurers, hospitals and physicians.9 A provoca-

tive question is what the position of independent physicians, most

of them being primary care physicians, will be once the mud settles?

Will they be the Pygmies in fight against Titans? Can they maintain

their independence?

There are indications that the pressures to go into ACOs may be

too much for independent physicians who take Medicare/Medicaid

and/or private insurance, and that IPAs will be a relic of the past.

Further, it will probably be primary care physicians who will be the

most impacted, as most medical specialists are already part of “clini-

cally and financially integrated” entities because of the expensive

equipment specialists need.10

The first indication is contained in the quote preceding the title

of this article taken from New Rules: Regulation, Markets, and the

Quality of American Health Care (Jossey Bass/Aha Press Series) by

Donald M. Berwick, M.D., Administrator of the Centers for Medicare

& Medicaid Services (CMS). Dr. Berwick seems to have the view that

medical ethics must evolve to fit PPCA’s view of medical care delivery.

So, will physicians who resist be accused of violating newly prevail-

ing medical ethics?

The second indication lays in the earlier discussion about FTC

prosecutions. Very accomplished health care lawyers are warning phy-

sicians and hospitals seeking to form ACOs that no one knows how the

FTC will treat these entities, who by their very definition will be seeking

to “price-fix’ in order to lower costs so that the ACO’s can share sav-

ings with the Medicare program. This seems to be a real risk, if ACOs

are structured as some sort of Supra-IPA. However, if an ACO forms in

accordance with government dictates, the words of FTC Commission

Chairman, John Leibowitz, in his address to the AMA are informative:

[The health care law] establishes pilot programs for Medicare

called “accountable care organizations” or ACOs as possible

devices to improve quality and lower the cost of health care. Each

ACO will be responsible for both the cost and the quality of care

for at least 5,000 patients. ACOs will share with Medicare any

savings that they generate because of their e"ciency in meeting

HHS performance targets. While the details of the ACO program

are not yet available, so long as the government purchases the

services and unilaterally sets payment levels and terms, there

won’t be an antitrust issue. (bold added)11

Given all this, the future of the individual, independent practitioner

appears bleak. The choices seem to be, restructure your practice to opt

out or face the Borg and prepare to be assimilated.* Dr. Welby is about

to become a cog in the machine.

* Attribution for this literary device goes to Richard N. Fogoros, M.D.

Co-founder of Garlo Ward, P.C., Jerri Lynn Ward provides legal representation

to a broad range of health care providers and small businesses. She currently

practices general civil and administrative law, and works with health care facil-

ities and individual providers in federal and state court matters and before gov-

ernment regulatory agencies and boards. She has published articles on various

healthcare and legal topics in several local and national publications. Find out

more about Jerri Lynn at www.garloward.com.

6. Oliva, Doctor’s Orders, 2010. 7. Fogoros, R.N. (2010, December 13). Criminalizing independent physician practices [Web log message]. Retrieved from http://covertrationingblog.com/primary-care-in-america/criminalizing-independent-physician-practices. 8. Ibid. 9. Rau, J. (2011, January 9). Insurers, health-care providers at odds on rules for ‘accountable care organiza-tions’. Washington Post, Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2011/01/09/AR2011010903401.html. 10. Fogoros, R.N. (2010, September 3). PCPs: We are the Borg. Prepare to be assimilated [Web log message]. Retrieved from http://covertrationingblog.com/healthcare-reform/pcps-we-are-the-borg-prepare-to-be-assimilated. 11. Oliva, S.M. (2010, June 14). FTC chair denies he’s a socialist, announces greater role in healthcare [Web log message]. Retrieved from http://blog.mises.org/12964/ftc-chair-denies-hes-a-socialist-announces-greater-role-in-healthcare/.