February 2015

official publication of SDCMS february 2015

the

Affordable Care Act A One-Year Checkup “Physicians United for a Healthy San Diego”

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Leases ▪ Renewals ▪ Sales ▪ Strategic Planning ▪ Demographic & Patient Analysis

February

Contents

Volume 102, Number 2

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: Sherry L. Franklin, MD, James Santiago Grisolía, MD, Theodore M. Mazer, MD, Robert E. Peters, PhD, MD, David M. Priver, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder SDCMS BOARD OF DIRECTORS OFFICERS PRESIDENT: J. Steven Poceta, MD PRESIDENT-ELECT: William T-C Tseng, MD, MPH (CMA Trustee) TREASURER: Mihir Y. Parikh, MD SECRETARY: Mark W. Sornson, MD IMMEDIATE PAST PRESIDENT: Robert E. Peters, PhD, MD GEOGRAPHIC AND GEOGRAPHIC ALTERNATE DIRECTORS EAST COUNTY: Venu Prabaker, MD, Alexandra E. Page, MD, Jay P. Mongiardo, MD, Alt: Susan Kaweski, MD (CALPAC Treasurer) HILLCREST: Gregory M. Balourdas, MD, Thomas C. Lian, MD, Alt: Thomas J. Savides, MD KEARNY MESA: Sergio R. Flores, MD, John G. Lane, MD, Alt: Anthony E. Magit, MD, Alt: Eileen R. Quintela, MD LA JOLLA: Geva E. Mannor, MD, Marc M. Sedwitz, MD, Alt: Lawrence D. Goldberg, MD NORTH COUNTY: James H. Schultz, MD, Eileen S. Natuzzi, MD, Michael A. Lobatz, MD, Alt: Anthony H. Sacks, MD SOUTH BAY: Reno D. Tiangco, MD, Michael H. Verdolin, MD, Alt: Elizabeth Lozada-Pastorio, MD

features

The Affordable Care Act: A One-Year Checkup

AT-LARGE DIRECTORS Lawrence S. Friedman, MD, Karrar H. Ali, MD, Kosala Samarasinghe, MD, David E.J. Bazzo, MD, Stephen R. Hayden, MD, Peter O. Raudaskoski, MD, Vimal Nanavati, MD (Board Representative), Holly B. Yang, MD

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An Interview With Robert E. Hertzka, MD

AT-LARGE ALTERNATE DIRECTORS Karl E. Steinberg, MD, Jeffrey O. Leach, MD, Toluwalase A. Ajayi, MD, Phil Kumar, MD, Wayne C. Sun, MD, Kyle P. Edmonds, MD, Carl A. Powell, DO, Marcella M. Wilson, MD

15

Is the Affordable Care Act Affordable?

BY ROBERT E. HERTZKA, MD

departments 4

Briefly Noted: Calendar • Physician Volunteers Needed • Welcome New Members • And More …

8

8

A New Way to Practice Medicine

BY HELANE FRONEK, MD, FACP, FACPh

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OTHER VOTING MEMBERS COMMUNICATIONS CHAIR: Sherry L. Franklin, MD (CMA Trustee) YOUNG PHYSICIAN DIRECTOR: Edwin S. Chen, MD RESIDENT PHYSICIAN DIRECTOR: Jane Bugea, MD RETIRED PHYSICIAN DIRECTOR: Rosemarie M. Johnson, MD MEDICAL STUDENT DIRECTOR: Spencer D. Fuller OTHER NONVOTING MEMBERS YOUNG PHYSICIAN ALTERNATE DIRECTOR: Daniel D. Klaristenfeld, MD RESIDENT PHYSICIAN ALTERNATE DIRECTOR: Diana C. Gomez, MD RETIRED PHYSICIAN ALTERNATE DIRECTOR: Mitsuo Tomita, MD SDCMS FOUNDATION PRESIDENT: Albert Ray, MD (CMA Trustee, AMA Delegate) CMA SPEAKER: Theodore M. Mazer, MD CMA PAST PRESIDENTS: James T. Hay, MD (AMA Delegate), Robert E. Hertzka, MD (Legislative Committee Chair, AMA Delegate), Ralph R. Ocampo, MD CMA TRUSTEES: Robert E. Wailes, MD, Erin L. Whitaker, MD CMA SSGPF Delegate: James W. Ochi, MD CMA SSGPF ALTERNATE DELEGATES: Dan I. Giurgiu, MD, Ritvik Mehta, MD AMA ALTERNATE DELEGATE: Lisa S. Miller, MD

Telemedicine Improves Access to Care but Creates Liability Risks

BY THE DOCTORS COMPANY

26

Physician Marketplace: Classifieds

28 2

february 2015

28

Thanks for Nothing

BY DANIEL J. BRESSLER, MD, FACP

Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. San Diego Physician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted.

Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in San Diego Physician in no way constitutes approval or endorsement by SDCMS of products or services advertised. San Diego Physician and SDCMS reserve the right to reject any advertising. Address all editorial communications to Editor@SDCMS.org.

All advertising inquiries can be sent to DPebdani@SDCMS.org. San Diego Physician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

“First Republic is always there for us – from remodels to equipment purchases – they are our partner in growth.”

M U I R O R T H O PA E D I C S P E C I A L I S T S

Pictured left to right: John M. Knight, M.D.; George J. Tischenko, M.D.; Charles F. Preston, M.D.; Joseph X. Kou, M.D.

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// giving back

PHYSICIAN VOLUNTEERS NEEDED! Email Your Physician Volunteer Opportunities to Editor@SDCMS.org Volunteer Specialty Physicians Needed for Project Access: Contact Ana

Seda at (858) 565-8161 or at Ana. Seda@SDCMSF.org, or visit www. sdcmsf.org. calendar SDCMS Seminars & Webinars SDCMS.org

For further information or to register for any of the following SDCMS seminars, webinars, workshops, and courses, email Seminars@ SDCMS.org.

HIPAA & EHRs: What Every Practice Must Know (webinar) MAR 4: 11:30am–1:00pm The Leader’s Toolkit (workshop) MAR 14–15: 8:00am– 4:00pm Managing Medicare in 2015: Staying Alive (seminar/webinar) MAR 26: 11:30am– 2:00pm Advocacy Training (workshop) APR 11: 8:00am– 12:00pm Healthcare Facility Employee OSHA & Safety Training (seminar/webinar) APR 16: 11:30am–1:00pm

Community Healthcare Calendar

To submit a community healthcare event for possible publication, email KLewis@SDCMS. org. Events should be physician-focused and should take place in or near San Diego County.

The Future of Genomic Medicine VIII MAR 5–6 at the Robert Paine Scripps Forum for Science, Society, and the Environment (www.scripps.org/ events/the-future-ofgenomic-medicine-viiimarch-5-2015) Safe Prescribing Symposium MAR 11 at the Jacobs Center for Neighborhood Innovation (www. surveymonkey.com/r/?s m=RHCSKrTsLtNQIPrb C0Z6ig%3d%3d) 3rd Annual UC San Diego Essentials and Advances in Apheresis Therapies MAR 12–14 at the Paradise Point Resort & Spa (cme.ucsd.edu/ apheresis) 11th Annual Biomarkers in Heart Failure and Acute Coronary Syndromes: Diagnosis, Treatment, and Devices MAR 13 at the Estancia La Jolla Hotel & Spa (www.ccmmeetings. com/support/

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february 2015

Biomarkers%20 2015%20Brochure.pdf) 8th Annual UC San Diego Urology Postgraduate Course MAR 20–21 at the Estancia La Jolla Hotel & Spa (cme.ucsd.edu/ urology) New Treatments in Chronic Liver Disease MAR 20–22 at the Estancia La Jolla Hotel & Spa (www.scripps.org/ events/new-treatmentsin-chronic-liver-diseasemarch-20-2015) 35th Annual Radiology Review APR 5–11 at the Hotel del Coronado (ucsd. edusymp.com/product/ brochure/52) 16th Annual Sharon’s Ride.Run.Walk for Epilepsy APR 26 at De Anza Cove (sharonsride2015. kintera.org/faf/ home/default. asp?ievent=1118436) 16th Annual UC San Diego Stroke Conference: Stroke 360 MAY 2 at the Skaggs School of Pharmacy and Pharmaceutical Sciences (cme.ucsd. edu/stroke)

Family Medicine/General Internal Medicine Physicians Needed to serve as

role models and teachers to UCSD first- and second-year medical students in their Ambulatory Care Apprenticeship Program. Contact Rusty Kallenberg, MD, at (619) 8388047 or at gkallenberg@ucsd.edu.

Humanitarian Teams Need Medical Volunteers For Haiti: Contact Bob Downey at (619)

905-7157 or at labboy@earthlink.net.

quote of the month

“

Adopt the pace of nature; her secret is patience.

”

— Ralph Waldo Emerson (1803–1882)

/////////////////////////////////////////////////////////////////////////////////////////////////// risk management

in memoriam

Get Patient Safety Insights Delivered to Your Inbox SDCMS invites you to sign up for The Doctor’s Practice, a complimentary monthly newsletter brought to you by our exclusively endorsed partner, The Doctors Company. Each issue of The Doctor’s Practice features a new article or video in a simple, one-click email. These articles feature expert tips to help you reduce malpractice risk, avoid claims, and make the practice of medicine more rewarding.

Sign up at www.thedoctors.com/TheDoctorsPractice. The insightful content in The Doctor’s Practice is part of The Doctors Company’s commitment to defending, protecting, and rewarding the practice of good medicine.

Sam Assam, MD, 49-year member of SDCMS-CMA, passed away on Jan. 28, 2015.

Tom Joseph Decino MD, 29-year member of SDCMS-CMA, passed away on Oct. 2, 2014.

Stuart James Goldstone MD, 43-year member of SDCMS-CMA, passed away on Oct. 13, 2014.

Andrew C. Sabey MD, 44-year member of SDCMS-CMA, passed away on Sept. 24, 2014.

George M. Sanger, MD, 34-year member of SDCMS-CMA, passed away on Jan. 3, 2015.

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// SDCMS-CMA Membership

Welcome New and Returning SDCMS-CMA Members!

New Members Lesly G. Aguilar Tabora, MD Vascular Neurology San Diego (760) 631-3020 Arti Amin, MD Anesthesiology San Diego (858) 565-9666 Joyce C. Arpilleda, MD Pediatric Emergency Medicine San Diego (858) 966-8567 Adam B. Barrus, MD Adult Cardiothoracic Anesthesiology San Diego (858) 565-9666 Patrick W. Blake, MD Dermatology La Jolla (858) 397-5755 Diana M. Cantu, MD Obstetrics and Gynecology San Diego (619) 528-5000

Mark F. Clapper, MD Orthopedic Surgery of the Spine San Diego (619) 528-6381 Gregory J. DeBlasi, MD Orthopedic Surgery San Marcos (619) 528-5000 Robert W. DeMonte, MD Geriatric Medicine La Jolla (858) 455-9100 Smita A. Desai, DO Pulmonary Disease San Diego (619) 528-5000 Mamie H. Dong, MD Gastroenterology San Diego (619) 528-5000 Marc L. Etkin, MD Pediatric Emergency Medicine San Diego (858) 966-8036 Timothy J. Fairbanks, MD Pediatric Surgery San Diego (858) 966-7711

Keri L. Carstairs, MD Pediatric Emergency Medicine San Diego (858) 966-8567

Denison A. Felix, MD Pathology San Diego (800) 290-5000

Bilal A. Choudry, MD Neurology Oceanside (760) 631-3020

Suzanne Goh, MD Child Neurology San Diego (858) 304-6440

Gary P. Chun, MD Pediatrics San Diego (619) 245-2365

Miguel A. Goicoechea, MD Infectious Disease La Jolla (858) 554-8090

Dustin B. Cladera, MD Internal Medicine La Jolla (858) 412-7633 Edward Cladera, MD Hospitalist La Jolla (858) 412-7633

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february 2015

Mary G. Yoo, MD Internal Medicine San Diego (619) 528-5000 Dorothy E. Hairston, MD Internal Medicine National City (619) 472-4690

Jonathan M. Halford, MD Anesthesiology San Diego (858) 565-9666

Karl K. Limmer, MD General Surgery San Diego (858) 939-7471

Tobe Propst, MD Family Medicine Chula Vista (619) 710-8375

Kyoung E. Han, MD Geriatric Medicine San Diego (619) 528-5000

Denise M. Malicki, MD Pediatric Pathology San Diego (858) 966-5944

Phillip E. Reich, MD Diagnostic Radiology La Mesa (619) 460-2770

David J. Hawkins, DO Sports Medicine Santee (858) 554-9100

Kelly A. Martinez, MD Obstetrics and Gynecology Escondido (760) 745-1363

Adeunice SanchezMata, MD Family Medicine San Diego (858) 499-2710

Hector F. MartinezWilson, MD Anesthesiology San Diego (858) 673-6100

David M. Seif, MD Anesthesiology San Diego (858) 565-9666

Anita H. Hickey, MD Pain Medicine Chula Vista (619) 532-8943 Eric A. Hong, MD Cardiovascular Disease Encinitas (760) 944-7300 Kay T. Huber, MD Internal Medicine San Diego (619) 528-5000

Kristin L. Mekeel, MD General Surgery San Diego (619) 543-5870

Samir S. Shah, MD Nephrology San Diego (619) 528-5000

Donna M. Mills, MD Psychiatry San Diego (619) 482-2804

Seema Shah, MD Pediatric Emergency Medicine San Diego (858) 966-8005

Evan R. Minkoff, DO Physical Medicine and Rehabilitation Chula Vista (619) 761-5308

Christopher L. Sherman, DO, MS Orthopedic Surgery San Diego (858) 346-7171

Jun Q. Mo, MD Pediatric Pathology San Diego (858) 966-8567

Michael A. Sirota, MD Orthopedic Surgery San Diego (619) 229-3932

Craig S. Morelan, MD Emergency Medicine San Diego (619) 528-5000

Robert F. Stephens, MD Anesthesiology San Diego (858) 565-9666

Natalie D. Muth, MD Pediatrics Vista (760) 945-3434

Arun P. Venkat, MD Dermatology Oceanside (760) 7577546

Warren P. Klam, MD, MS Child and Adolescent Psychiatry San Diego (619) 532-8551

Anil G. Nair, MD Anesthesiology San Diego (858) 673-6100

Andrew M-Y Wang, MD Geriatric Medicine La Jolla (858) 499-2717

Vijay S. Kollengode, MD Anesthesiology San Diego (858) 565-9666

Jeffrey L. Neul, MD, PhD Child Neurology San Diego (858) 966-5819

Chunyang T. Wang, MD Clinical Neurophysiology Oceanside (760) 631-3020

Jeff M. Lapoint, DO Medical Toxicology San Diego (619) 528-5000

Amy C. Nielsen, DO Clinical Neurophysiology La Jolla (760) 631-3000

Erman Wei, MD Internal Medicine Vista (760) 726-2180

Yenny S. Yen Lim, MD Internal Medicine San Diego (858) 605-7113

Salvatore J. Pacella, MD Plastic Surgery San Diego (858) 554-9930

Peter J. Weis, MD Rheumatology San Diego (858) 554-8643

Paul T. Ishimine, MD Pediatric Emergency Medicine San Diego (858) 966-8036 Maseeha S. Khaleel, MD Anesthesiology San Diego (858) 673-6100 Kourosh Khamooshian, MD Internal Medicine San Diego (888) 475-6662 Bruce J. Kimura, MD Cardiovascular Disease San Diego (619) 297-0014

/////////////////////////////////////////////////////////////////////////////////////////////////// Dylan E. Wessman, MD, FACC, FACP Cardiovascular Disease San Diego (619) 532-7403 Steven C-S Wong, MD Pulmonary Critical Care Medicine San Diego (619) 299-2570 Gary N. Woodall, MD Internal Medicine San Diego (619) 260-3456 WELCOME RETURNING MEMBERS John R. Alm, MD Emergency Medicine Vista (760) 806-5400 Enma M. Alvarado, MD Internal Medicine San Diego (858) 249-8444 Stanley G. Ambo, MD Pediatrics Vista (760) 945-3434 Alan J. Bier, MD Cardiovascular Disease San Diego (858) 939-6564 Jorge L. Castro, MD Pediatrics Vista (760) 945-3434 Roy A. David, MD Facial Plastic and Reconstructive Surgery La Jolla (858) 658-0595 Charles B. Davis, MD Neonatal-Perinatal Medicine San Diego (619) 532-5350 Michele L. DeKorte, MD Hospitalist San Diego (619) 471-9198 Michael F. Erickson, MD Obstetrics and Gynecology San Diego (619) 528-5000

Jonathan J. Gray, MD Anesthesiology San Diego (858) 565-9666 Kinji L. Hawthorne, MD Infectious Disease San Diego (562) 822-9438 Ken R. Iwaoka, MD Family Medicine Vista (760) 806-5400 Howard N. Kaye, MD Rheumatology Vista (760) 806-5890 Shahin Keramati, MD Interventional Cardiology San Diego (619) 435-1660 Kim M. Kerr, MD Pulmonary Disease La Jolla (858) 657-7140 A. Grant Kingsbury, MD, MS Internal Medicine San Diego (619) 298-2900 Steve Laverson, MD Plastic Surgery Encinitas (760) 753-6464 Gerard A. Lumkong, MD Family Medicine Encinitas (760) 479-3900 Hirsch S. Mehta, MD Cardiovascular Disease San Diego (858) 244-6800 Mark D. Mosson, MD Internal Medicine San Diego (619) 298-1318 Veronica L. Naudin, MD Pediatrics Vista (760) 945-3434 Truc H. Nguyen, MD Pediatrics Chula Vista (619) 656-3040

Jigar D. Patel, DO Clinical Cardiac Electrophysiology San Diego (858) 657-5310 Paul S. Phillips, MD Interventional Cardiology San Diego (619) 297-0014

TrusT

Larry H. Pollack, MD Plastic Surgery San Diego (858) 565-7588 Kristy L. Putnam, MD, MPH Pediatric Emergency Medicine San Diego (858) 966-8567 Alexander K. Quick, MD Anesthesiology San Diego (858) 565-9666 Sanjay S. Rao, MD Psychiatry San Diego (619) 500-6202 Edward J. Robertson, MD General Surgery Oceanside (760) 806-5660 Elahe Toulouie, MD Internal Medicine La Mesa (619) 993-8996 Diane Vu, DO Family Medicine Encinitas (760) 479-3900 Manish K. Wadhwa, MD Clinical Cardiac Electrophysiology San Diego (619) 297-0014

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Clayton B. Whiting, MD Emergency Medicine San Diego (619) 686-3800 Anthony M. Whitney, MD Family Medicine Carlsbad (760) 827-7440

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Blake C. Fowler, MD Anesthesiology San Diego (858) 565-9666 SAN DIEGO PHYSICIAN.org

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P e r s o n a l & P r o f e s s i o n a l D e v e lo p m e n t

A New Way to Practice Medicine

by Helane Fronek, MD, FACP, FACPh Medical school, then residency — perhaps fellowship. We physicians followed a prescribed path to an expected future of security, intellectual challenge, and the satisfaction of caring for and developing fulfilling relationships with our patients.

But the game we signed up to play has changed. Statistics on the rates of physician burnout, depression, and suicide are alarming. Seasoned physicians are leaving medicine for nonclinical careers or early retirement. It’s a national tragedy. If we are to thrive as we continue to practice medicine, we need new strategies.

A hospitalist I know has to cover when outpatient physicians are on vacation. Before each clinic day, she is irritable and has difficulty sleeping, dreading being responsible for 30–40 patients, none of whom she knows. “What do you expect of yourself during these visits?” I asked. “Well,” she replied, “I expect to develop rapport with each patient, figure out what’s wrong with them, explain what they have and what we need to do to help them, and motivate them to change.” When I repeated this to her, she began to laugh at the impossible task she sets for herself.

We are in the midst of grand and needed healthcare reform. As we adapt to a greater number of patients, EHR and meaningful use requirements, and continue to acquire new knowledge and technical skills, we should ask ourselves what we need to do this well. As Einstein remarked, we can’t solve problems by using the same kind of thinking we used to create them, so let’s think outside the box.

Some practices post fees for each service, and patients pay for what they use. The physician gains more autonomy and time

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february 2015

with patients and less stress. The patient enjoys greater control, transparency, and their more personal relationship. Concierge practices afford longer patient visits, enhancing the satisfaction of both patient and physician. Large systems create cohorts of patients who share a condition — group visits allow the physician to provide one explanation while the patients learn from and are supported by their cohort. Individual issues are addressed in less frequent private visits. Some practices employ pre-med students as scribes to input data, relieving physicians of mundane work and providing the scribe with experience and a jump on her medical education. Could working for a year as a scribe be an option for all students, who might then receive a reduction in the cost of their pricey education? And for each of us individually, what can we expect from ourselves in this new age of medicine? Taking time to develop reasonable goals can help us

feel satisfied with our work again. It’s time we created new expectations for ourselves and for our patients so we have time for activities that replenish our enthusiasm for our work.

As we adjust to the ongoing demands of reform, how do we each want to reform our practices, our interactions with patients, and our own lives so we thrive and strengthen our love and passion for the practice of medicine?

Dr. Fronek, SDCMS-CMA member since 2010, is assistant clinical professor of medicine at UC San Diego School of Medicine and a certified physician development coach who works with physicians to gain more power in their lives and create lives of greater joy. Read her blog at helanefronekmd.wordpress.com.

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R i s k M a n ag e m e n t

Telemedicine Improves Access to Care But Creates Liability Risks Contributed by SDCMS-endorsed The Doctors Company.

For more patient safety articles and practice tips, visit www.thedoctors.com/patientsafety.

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february 2015

Telemedicine involves the delivery of healthcare to patients in remote locations and to underserved patient populations through audio-visual, online, and wireless applications. This leads to improved access to medical care and consultation, more efficient treatment plan implementation, cost savings for patients, and increased patient satisfaction.

The use of telemedicine is growing, and the Centers for Medicare and Medicaid Services recently announced that in the 2015 physician fee schedule, Medicare payments to telehealth originating sites will increase by 0.8% (1). However, numerous federal and state statutes have created significant liability risks for medical practitioners who engage in any form of telemedicine.

The Health Insurance Portability and Accountability Act (HIPAA) established national standards for the use and disclosure of personal health information (PHI) and the prevention of healthcare

Reference: 1. Wicklund E. CMS boosts telehealth in 2015 physician pay schedule. mHealthNews. www.mhealthnews.com/news/cmsboosts-telehealth-2015-physician-payschedule. Accessed November 25, 2014.

Auditing

Practice Management

Contracting

Relocation Management

Credentialing

Technological Advances

Billing Service Business Growth Executive Assistant Financial Management EHR Meaningful Use Support Operational Management Practice Assessment

te

We can help - absolutely! lutions So Celebrating

Absolu

fraud and abuse. The Health Information Technology for Economic and Clinical Health (HITECH) Act implemented government-mandated requirements for breach notification, authorized random audits, substantially enhanced penalties for statutory violations, and specified that all transmissions of PHI must be “secure” (encrypted). Practices that engage in telemedicine must strictly comply with the various statutory requirements of HIPAA and HITECH or risk an investigation and potential fines.

Physicians who engage in telemedicine across state lines face serious considerations. The scope of practice is generally determined by the location of the patient.

Providing care to a patient located in a different jurisdiction requires the practitioner to satisfy the licensing requirements of the state in which the patient is located.

Without proper licensure, adverse consequences might include criminal prosecution for the unlicensed practice of medicine or disciplinary action by a medical board.

Physicians should also be aware that their professional liability policy may not cover a claim that is filed outside a specific territory or jurisdiction.

To reduce these liability risks and enhance patient safety: • Comply with HIPAA, HITECH, and state-specific laws when transmitting all PHI. • Ask your system vendor to provide training to you and your staff on how to protect and secure your data.

• Ensure robust and reliable high-speed broadband connectivity to support clinical functions.

• Check practice requirements and legal limitations in states where you anticipate providing care to patients.

Understand reimbursement practices for telemedicine services.

• Use telemedicine carefully — and understand any limitations on the reliability and accuracy of the information.

• Communicate directly with your professional liability insurer to make certain that your policy extends coverage to all jurisdictions where you provide services.

858.256.0351 • www.abs-sol.com

2004 - 2014

“think SDCMS FIRST!” Start by contacting SDCMS at (858) 565-8888 or at SDCMS@SDCMS.org.

SAN DIEGO PHYSICIAN.org

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the

Affordable Care Act A One-Year Checkup

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february 2015

A

t the beginning of 2011, 2012, and 2013, San Diego Physician magazine published interviews about the Affordable Care Act (ACA) with our own Bob Hertzka, MD. A past president of the California Medical Association and a 26-year health policy instructor at the UC San Diego School of Medicine, Dr. Hertzka has been tracking the overall progress and implementation of the ACA as much as any practicing physician in San Diego, if not the entire state of California.

And just last year he was elected as the chair-elect of the American Medical Association’s Council on Medical Service, the group of physicians elected within the AMA to develop many of its policies on healthcare access, cost, and quality. ¶ As we pass the first anniversary of the implementation of the ACA, we thought it would be an opportune time to check in again.

An Interview With Robert E. Hertzka, MD

SAN DIEGO PHYSICIAN.org

13

The result of all that was a program that offered about 25 million people healthcare at minuscule or no cost — and less than half of them signed up — and we are supposed to get excited about this?

Really?

San Diego Physician: Good to see you again. We skipped doing this interview last year — any particular reason?

San Diego Physician: OK, what was the breakdown of who became covered in 2014?

Dr. Hertzka: One year ago there were just too many unsettled variables for the ACA, most notably a dysfunctional website that became the dominant point of public discussion. For ACA supporters, it created a situation where it was impossible to see if the ACA was going to be effective at covering the uninsured. But, on the other hand, the website problems distracted ACA opponents by focusing too much criticism on a technical matter that was certain to be fixed eventually. As a result, any discussion of the alleged structural problems suggested by ACA critics was just not happening. So, in my mind, rather than speculate about enrollment numbers and such, I thought it best to wait until the dust settled from the website debacle to continue our discussion.

Dr. Hertzka: Well, the first thing to remember is that the first million of those 12 million were simply people ages 19–26 who have been added to their parents’ health insurance policies since 2011.

This is among the least controversial provisions of the ACA, and one that is preserved in all of the various published ACA “Replace” proposals. It could have easily been passed as an isolated law in 2009 with broad bipartisan support and with no cost to the government.

As to the remaining 11 million who did become covered in 2014, for all the discussion about the insurance exchanges, it turns out that as many as 10 million of those 11 million newly insured were just Medicaid and S-CHIP (Children’s Health Insurance Program) sign-ups.

At the time of the ACA’s passage, it was estimated that some 54%, or about 27 million of the approximately 50 million uninsured, would be eligible for the ACA’s Medicaid expansion (see Figure 1).

And even with multiple states initially declining to expand Medicaid under the ACA, there were still about 14 million people eligible for Medicaid last year, and about half of those folks did sign up, as did about three million people (one million in California alone) who were already eligible for Medicaid and S-CHIP pre-ACA. But, in a more disappointing result, among the +/-23 million people who were felt to be uninsured and eligible for the insurance exchanges, in the end it appears that the level of uninsured in that group only decreased by somewhere between one and two million.

San Diego Physician: We know that we are going to get into some detail today, but overall wouldn’t you have to say that once the website started to work the ACA had a successful year in 2014?

Dr. Hertzka: It depends on how one defines success. At its core the ACA will spend more than $1 trillion over six years (2014–19) to provide otherwise uninsured people with health coverage.

One year into it, the ACA’s political and media supporters are claiming “success” because some 12 million previously uninsured people now have some kind of coverage. But let’s be realistic: If one is in the process of spending a trillion dollars on expanding coverage, we should not be surprised that a significant number of people get covered. If we spend $1 trillion on anything — food, housing, more police — we are guaranteed to get plenty more of whatever it is we are buying.

San Diego Physician: We know that you want to talk about some of the policy issues, but, again, how is it not unequivocally a good thing that the number of medically uninsured people has dropped by 12 million or so?

Dr. Hertzka: Sure, it is a great thing on the surface, but one still has to look at the breakdown of who became covered, the kind of coverage people are getting, and, in the larger scope of things, if we are to spend $1 trillion or more on this, are we doing it in a way that makes the most sense?

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february 2015

San Diego Physician: Now wait a minute; the reported number of sign-ups on the insurance exchanges was 6.6 million, not one to two million.

Dr. Hertzka: 6.6 million, absolutely.

But you have to remember that about five million individual policies were cancelled at the end of 2013 because they were “inadequate” by ACA standards, and that many small employers decided to stop providing insurance as well. So by most estimates the clear majority of the 6.6 million people who signed up with the exchanges in 2014 did so in order to remain insured, as opposed to moving from uninsured to insured.

And two other groups remain unre-

Is the

Affordable Care Act Affordable?

I

magine that back in 2009, President Obama decided that health insurance premiums were too low, and so he assembled a highlevel commission to make recommendations about how to make premiums go up as high as possible — and, notably, with an emphasis on making them as high as possible for young people.

While this is obviously a nonsensical hypothetical, what is remarkable is that the recommendations such a commission would have made, as listed below, are strikingly similar to the provisions of the ACA.

incur as a result of providing care for these Medicaid patients would be cost-shifted to private health insurance premiums, which will in turn make them higher …

*** Such a commission would begin by creating and then expanding a mandated benefit package — if more services are to be covered, then of course the premiums necessary to pay for those services will increase …

The ACA cuts more than $716 billion from a Medicare system by making it more “efficient,” even though Medicare’s own Actuary says that such efficiencies in something as laborintensive as healthcare cannot be achieved. In fact, if implemented, the Medicare Actuary has unwaveringly predicted since the spring of 2010 that as many as 50% of hospitals in the United States would lose significant money on Medicare patients. But these hospitals would in fact not close their doors to Medicare patients; rather, they would, along with most every physician in the nation, and as is presently done with Medicaid, just cost-shift their losses to private health insurance premiums.

The ACA adds many new benefits, including all preventive care for free, which is arguably good as a policy move. But additional coverage mandates for inpatient substance abuse, pediatric dental care, and other services will definitely increase premiums. *** Such a commission would recommend a dramatic expansion of the already underfunded Medicaid system, without any reforms to the Medicaid system itself.

The losses that providers will

The ACA does exactly that. *** Such a commission would recommend steep cuts in Medicare payments, which already pay below the cost of care for many services.

Just like the Medicaid expansion, this would precipitate still another cost-shift to private health insurance premiums that would make them even higher …

*** Such a commission would recommend directly taxation of the healthcare industry, creating new industry costs that would just be passed along to patients as premium increases.

Consider for a moment that if one wanted to expand the food stamp program because one was concerned that the high cost of food was creating a “food access” problem, it would probably be considered silly to pay for that food stamp expansion by taxing farmers and grocery stores, which would obviously raise the cost of food for everyone, as well as to make the food stamp program itself more expensive …

While this gets little attention, a major part of the funding for the ACA comes from a direct tax of health insurers of $14 billion per year and a direct tax on the pharmaceutical industry of $4 billion per year. Moreover, the pharmaceutical industry agreed to an $80 billion discount over 10 years ($8 billion per year) on medications provided in the Medicare Part D program, and this $8 billion per year is also being cost-shifted on to private patients.

Altogether, that means a $26 billion annual increase in the nation’s health insurance premium level — just because of these three provisions in the law.

And beyond these three provisions, there are others, including the much-publicized 2.3% tax on all so-called “medical devices.” *** To make sure that young people in particular would see a large premium increase, such a commission would alter underwriting rules such that a 64-yearold would no longer pay a premium seven times that of someone in their 20s, as actuaries currently dictate. If one lowered that ratio from

7:1, the premiums paid by people in their 60s would decrease, but the premiums paid by younger people would substantially rise …

The ACA did exactly that.

By lowering what is called the “age band” from 7:1 to 3:1, the result is that the premiums paid for individual insurance for people in their twenties rose more than 50% in 2014 — just because of that one change. *** Finally, such a commission would recommend changing the law so as to allow everyone to obtain insurance regardless of their health status (so-called “guaranteed issue”), while penalizing no one for not obtaining it. Notably, this had been the law for some time in states such as New York, and it had resulted in what was referred to as an insurance “death spiral,” wherein all of the people with high healthcare needs sign up, but only a few of the young and healthy do so. Within a few years the premiums increased dramatically as the sicker people kept signing up year after year while fewer and fewer of the healthy people did. This created a situation in New York where the most bare-bones catastrophic plan cost $20,000 per year and almost no healthy people found it worthwhile to sign up.

The ACA did include “guaranteed issue,” and professed to avoid the “death spiral” by imposing the much-publicized individual mandate, but the mandate was so weak (1% of income in 2014) compared to the cost of insurance (8–20% of income for middle-class folks), that to date not a single person has been identified as having purchased insurance in 2014 because of their concern about a penalty.

SAN DIEGO PHYSICIAN.org

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Figure 1. Income of the Nonelderly Uninsured Population, 2010

10%

56.2%

Employer-sponsored Insurance

18.5%

Federal Poverty LeveL 400%+

37%

139–399% (Subsidies)

54%

<139% (Medicaid)

Uninsured

19.8% Medicaid*

5.5% Private Non-group

266 M Nonelderly

49.1 M Uninsured

* Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage. * The federal poverty level for a family of four in 2010 was $22,050. * Numbers may not add up to 100 due to rounding. * SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplements to the CPS.

By the end of this year, the number of Californians on Medi-Cal will have spiked some 60% since 2013, from 7.6 million to 12.2 million people.

ported: those who lost insurance and ended up remaining uninsured, and those who lost private coverage but were placed on Medicaid when they went to the exchange.

Look, there are obviously many moving parts. But when the dust settled in 2014 — as being reported by the CBO and the administration over the past two weeks — the fact is that about 10 million of the 11 million newly insured in 2014 are on Medicaid or S-CHIP, not a private plan.

And there’s more: What was really disturbing about those who did sign up with the exchanges — and this got remarkably little media coverage — was just how low their incomes were.

San Diego Physician: What do you mean?

Dr. Hertzka: This past June the Obama administration released a detailed analy-

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sis of how many people buying insurance through the federal insurance exchanges qualified for subsidies, as well as the size of those subsidies. This was important to know because the average cost for a plan sold on the insurance exchanges was actually about $350/month — not exactly inexpensive for most people.

They reported that 87% of people signing up with the insurance exchanges qualified for subsidies, and mostly very large subsidies. In fact, 80% of those receiving subsidies, or 70% of everyone who signed up, were subsidized so substantially that they paid less than $100/ month in premiums, a full 75% reduction in cost.

This sounds fine on the surface, but it is actually quite telling. Subsidies are based on a sliding scale, as in, the lower your income, the higher your subsidy.

To get a subsidy so large as to only need to pay a premium of less than $100/

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Figure 2. ACA — Sliding Scale for Tax Credits % of Federal Poverty Level Up to 133% 133–150%

% of Income 2% 3–4%

150–200%

4–6.3%

200–250%

6.3–8.05%

250–300%

8.05–9.5%

300–400%

9.5%

The 2014 FPL for one person was $11,670.

month, it meant that the person signing up had to have an annual income of only about $20,000. You might recall that in our prior discussions I expressed concern about whether people making $29,000 would pay $200/month for healthcare, which is about what their subsidized premium would be. Well, it turns out that the answer to that for the most part was in fact a big “no” because few people at the $29,000 income level did sign up, and even fewer did at the $35,000 or $40,000 level — whose premiums would be more like $300 per month. Instead, the reality was that, according to numbers that came straight from the administration, a full 70% of all those who signed up with the insurance exchanges in 2014 had incomes of $20,000 or less.

So, to your original question, yes indeed, last year the number of uninsured in the country dropped by about 12 million people — or from 17% of the population to 13% — but in essence this was done by making healthcare essentially free to certain subsets of people.

All that has really happened to date has been a massive Medicaid expansion (at no cost to the patients), supplemented by a million-plus post-adolescents who have been redefined for health insurance purposes as children (at miniscule cost to their parents), and then just one to two million people net who have become insured with private insurance through the exchanges —most of whom had annual incomes of $20,000 or less and so were able to be subsidized down to a cost of about less than $100 per month.

Bottom line: We underwent an enormous national effort that included hundreds of thousands of recruitment counselors, thousands of “get-insured” events, and hundreds of speeches from President Obama. The result of all that was a program that offered about 25 mil-

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lion people healthcare at minuscule or no cost — and less than half of them signed up — and we are supposed to get excited about this? Really? Rather, in my mind I have to think that the notion that more than half of these people declined free or almost-free coverage has to be viewed privately by ACA supporters as a big disappointment.

San Diego Physician: So what you are saying is that if you were one of the five to eight million people who lost their health insurance in 2014 and your income was $20,000 or less, you probably signed up for insurance on your state exchange, but if your income was more like $30,000 to $40,000, you probably found the exchange offerings so unappealing that you remained uninsured?

Dr. Hertzka: That is exactly what it looks like. The people signed up on the exchanges at the end of 2014 were disproportionately low-income, and, despite the 6.6 million sign-ups, the net increase nationally in those who were privately insured was only in the one-totwo-million range.

San Diego Physician: How about this year — the word from the administration is again very positive.

Dr. Hertzka: Too soon to tell. Just before the exchanges reopened on Nov. 15, the administration suddenly dropped their bar for “success” from 13 million total sign-ups all the way down to 9.1 million, which would mean that only 2.5 million people would have be added to the rolls of the exchanges this year for ACA supporters to claim “success.” And mind you, most likely, a significant number of these sign-ups would again be for the purposes of maintaining rather than gaining coverage. And beyond that, we do not know yet how many of the people who earned $35,000–$40,000 last year and so paid about $300 per month or more for a $2,000 deductible policy will sign up again. I suspect that some, and perhaps many, will have found their insurance to be not “worth it” and will not re-enroll, but we will see.

San Diego Physician: How about that degree of subsidization for people signed up in the exchanges? Is that improving?

Dr. Hertzka: Actually, no. The Dec. 30 interim update from the administration on the second year of sign-ups showed that this number was stable at 87%.

San Diego Physician: Given the high degree of subsidization — and we acknowledge that you are using the administration’s own numbers — it sounds like the pending Supreme Court decision might have a real impact.

Dr. Hertzka: Yes, I presume that you are referring to the King vs. Burwell and Halbig vs. Burwell cases, which both challenge whether the ACA allows people signed up in the federally run exchanges to receive subsidies. Yes, it would be a big deal in some 34 states if the Supreme Court sides with the plaintiffs. However, it would actually not change anything immediately in California because we operate our exchange in the manner that the ACA intended.

But in those 34 states where the federal government had to step up and create the state exchange, there would suddenly be no subsidies, which would instantly increase premium costs about fourfold for most people, from about $85 per month to $350 per month. Estimates are that up to 80% of those signed up with the exchanges in those states would find their coverage unaffordable and immediately drop it as soon as this coming summer, which would, by all accounts, be devastating to those exchanges and to the ACA as a whole.

San Diego Physician: Let’s change gears. Every year that we have talked about the ACA, you have had concerns about the Medicaid expansion. How is that part of the ACA going?

Dr. Hertzka: As everyone predicted, in states such as California that have chosen to expand Medicaid (Medi-Cal in California), millions have signed up, both as a result of the ACA expansion but also from what is called the “woodwork effect,” which is a phenomenon where there is so much publicity about a government program that people come in to sign up who were actually already eligible and could have signed up years ago. In California, by the end of this year, the number of Californians on Medi-Cal will have spiked some 60% since 2013, from 7.6 million to 12.2 million people.

San Diego Physician: Are things going smoothly in California?

Dr. Hertzka: Actually not. Most of the new Medi-Cal recipients had to wait more than six months for their paperwork to be processed. And on the provider side, the access problems are certainly there. At less than $22 per office visit, there are precious

few physicians willing to provide care to these new “childless adult” Medi-Cal patients.

San Diego Physician: We thought that the ACA raised primary care rates from Medicaid to Medicare levels for those patients that became enrolled as a result of the Medicaid expansion?

Dr. Hertzka: Yes, but for 2013 and 2014 only, in what turns out to be a cruel bait-and-switch maneuver. I say cruel because no knowledgeable person, be they a Democrat or Republican in DC, or even a state Medicaid director anywhere in the country, ever thought that this pay bump would be extended beyond the “showcase” year of 2014. Yet some physicians, sadly and perhaps naively, did in fact take on some of these patients and now feel that they have to take a big pay cut in order to continue caring for them. But the money to extend this increase was never going to be there.

San Diego Physician: So, pay bump or not, if physician offices are not accepting these patients, where are they going for care?

Dr. Hertzka: Historically, the one conclusion that has been consistent from various Medicaid expansions pre-ACA is that the without some kind of provider network or structure in place, when people get a Medicaid card and nothing else, they will for the most part be unable to find a physician and so just end up going to the emergency room. Prior adult Medicaid expansions have shown that ER usage can increase as much as 100% from the level seen when these same patients were uninsured. The ER is “free,” and, per the EMTALA law, it is staffed and backed up by a qualified panel of boardcertified specialists.

Now so far, at least in California, with most of the Medi-Cal patients only having received their cards late last year, it is too early to tell if the same pattern of high ER usage is happening in California’s emergency rooms. But it is hard for me to imagine that we won’t see this again.

San Diego Physician: What about the Federally Qualified Health Clinics (FQHCs)?

Dr. Hertzka: They are obviously a great resource, and if we had a Medicaid

expansion that required the use of local FQHCs — or any integrated provider network — for primary care in a capitated model, it would make sense. The providers would be motivated to comprehensively manage the care of their local patients, and the use of ERs for primary care would be discouraged, or even penalized. This is what has been going on for about 10 years in a Johns Hopkinsbased program in inner-city Baltimore called Priority Partners.

Unfortunately, the ACA does not mandate FQHCs usage in this way. Rather, they have left their existing payment structure in place.

San Diego Physician: What is wrong with that payment model for the clinics?

Dr. Hertzka: The historic payment model for the FQHCs has been an appropriately generous system that has intentionally overcompensated these clinics for Medicaid patients to make up for the fact that the clinics took “all comers,” including many with no ability to pay. This has meant that in situations where a physician receives less than $22 for a Medi-Cal office visit, the clinics receive over $150. This

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system has been left in place, even though millions of the previously uninsured are now Medicaid patients.

San Diego Physician: OK now. So just what is your problem with the Medicaid expansion? Lack of physicians? Poorly aligned reimbursements? Or increased ER use?

The fact that premiums are expected to remain relatively stable from 2014 to 2016 is primarily because the ACA includes $25 billion to be paid out in 2014–16 specifically to reimburse up to 80% of what health plans might lose on unhealthy ACA patients.

Dr. Hertzka: All of the above, and probably more. The 2014 Medicaid situation, at least here in California, has been one in which we will have over four million new patients for whom we may well “overpay” for much of their primary care, and yet still have to pay for a significant increase in ER utilization. And all this while continuing to directly disincentivize our individual physicians and physician groups to participate because of our lowest-in-thenation reimbursement rates.

And one final point about Medicaid: Even with all of these inefficiencies, if the patients were truly better off, one might be able to justify it. But the sad fact is that for all the hundreds of billions of dollars that we will spend on the Medicaid expansion, as specified by the ACA, the real problem is that the likely outcome for these patients as measured by mortality and morbidity is likely to be unchanged.

San Diego Physician: Hundreds of billions of dollars spent and no improvement in healthcare outcomes? How can you say that?

Dr. Hertzka: I say it because of the Oregon Medicaid data from 2010–12. Back in 2008, Oregon decided that it could handle an adult Medicaid expansion of just 10,000 people, and identified 90,000 otherwise uninsured candidates. They actually had a lottery, and then followed the progress of all 90,000 people, i.e., the 10,000 who now had Medicaid and the 80,000 “controls.”

San Diego Physician: We notice that you are repeatedly referencing “adult” Medicaid.

Dr. Hertzka: Yes, we always have to remember that for at least the past 20 years, nearly half the births in the United States and subsequently nearly half of all pediatric care in the United States is provided — and often provided quite well — by the existing Medicaid system. Even today, when I give talks, I have to remind people that historically Medicaid has been a categorical program, and that there has

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february 2015

never been a category for childless adults.

So when I said earlier that as many as 27 million people may become eligible for the ACA’s Medicaid expansion, we have to remember that these are all working-age adults, for which the Medicaid system has had relatively little experience.

San Diego Physician: OK, good reminder. So what did they find in Oregon?

Dr. Hertzka: Mostly obvious stuff. They found that the 10,000 people newly on Medicaid had much lower out-of-pocket charges than the uninsured (no surprise since Medicaid basically makes everything free), and that the knowledge that they were protected from medical bills that they could not pay significantly lessened their anxiety level and thus improved their self-assessed “mental health.” But they also used the now “free” ER much more often, at least in part because of an inability to locate physicians who would accept their Medicaid cards.

However, all that said, the real finding was that after three years there was no difference in the rates of hypertension, diabetes, etc., despite having “access to care.”

Without any financial incentive for either the patient or their providers to improve health habits and/or health status, nothing really changed.

Remember, I talked early on about how if we are going to spend $1 trillion to improve access to and the outcomes of the healthcare system, we should be doing it wisely. Well, we are nearly five years from the passage of the ACA, the cornerstone of which is an expansion of Medicaid without any accompanying system reform, and I continue to be concerned that the victory will only be political, as in “wow — fewer uninsured — vote for me,” as opposed to an actual improvement in the health status of all those many millions of new Medicaid patients.

San Diego Physician: What can be done about your concerns with the Medicaid expansion?

Dr. Hertzka: Believe it or not, I am quite hopeful that we will learn something from some of those much-vilified “red states” that initially declined the Medicaid expansion. Now some of those states are going ahead and expanding Medicaid, but with stringent conditions that include financial incentives at both the patient and provider levels. The solutions for how to best expand Medicaid will probably be gleaned by watching the experience of those states.

that of a hospital or hospital system. Still San Diego Physician: Any other effects illegal in the strict sense in California, it on physicians? is something that is being seen with increasing frequency around the country.

Dr. Hertzka: The other area often Now I can understand a 62-year-old discussed, which has been accelerated physician who is looking for stabilby the ACA even if not directly caused ity at the end of his or her career and so by it, would be the pressures from the chooses to sign a five-year contract to exchanges on health plans to hold down be an employee of a hospital. But the premium costs by utilizing (a) narrow 35-year-old physician who is concerned and sometimes very narrow networks, about his or her medical school student and (b) all-products clauses, which are loan burden and does this may find him used to keep physicians in networks or herself very much out of a job at the where they don’t wish to be, and to pay age of 40 if the financial model of the them at rates that they would never hospital has changed five years later. otherwise agree to in a contract. Recent The ACA did not create this situation, weeks have seen front-page headlines but it certainly makes many aspects of it about “error-filled doctor lists” adworse. For starters, it promotes nonvertised by plans to their prospective physician scope-of-practice expansions, enrollees. which makes primary care in particular Notably, these are areas where the seem unappealing. It also does nothing California Medical Association has been to help with medical school debt despite very aggressive in its lobbying with a successful and easy-to-replicate model proposed solutions. But, to date, and in California. And finally, and perhaps this may seem paradoxical, some of the most importantly, via, among other Democrats in our state legislature are things, its Accountable Care Organizaso committed to seeing the ACA “work” tion provisions, it further tips the “balthat they have been reluctant to side with ance of power” between hospitals and the physician community on some of physicians toward hospitals, which is these network and all-products clause just not a good thing for physicians.

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San Diego Physician: We have covered the exchanges and we have covered the Medicaid expansion. Is there anything else that concerns you?

Dr. Hertzka: I would like to bring up a major structural area, but first I would like to briefly comment on the ACA’s impact on physician practices. It could hardly be viewed as positive.

San Diego Physician: Why do you say that?

Dr. Hertzka: Being in practice has become increasingly challenging in recent years. Compliance with regulations, contracting with health plans, and dealing with electronic medical records has, for the most part, been getting steadily worse — no news there. And these trends have resulted in more physicians being a part of larger and larger medical groups, which to me is a natural marketplace phenomenon that can still work if the physicians in the groups are still in charge.

But the more disturbing trend has been for physicians to give up their own practice entirely and to tie their future to

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San Diego Physician: You said that you wanted to bring up one major structural area — that would be?

Dr. Hertzka: That would be the longterm budgetary impact of the ACA. Recall that one of President Obama’s most prominent claims about the ACA is that it would not add one dime to the deficit. And at least for the first 10 years (2010–19), by collecting taxes for 10 years but only providing benefits for six (2014–19), the Congressional Budget Office (CBO) in 2010 did in fact declare the ACA budgetneutral through 2019.

But much has changed since 2010, both as one looks toward 2019, and particularly as one looks beyond it. First of all, the funding for the ACA is being whittled down. The tens of billions in fines to be collected from employers for noncompliance with the ACA’s employer mandate have been delayed twice, and may even be repealed. Ditto the tens of billions to be accrued from the medical device tax.

And no one expects that the $716 billion in Medicare cuts called for in the ACA will ever be fully implemented. I will once again remind you that the independent Medicare Actuary has maintained without equivocation that the $716 billion Medicare cuts as proposed in the ACA would be so devastating that there is zero chance that they will be fully implemented.

Add all that up, and we may actually be looking at the ACA being in deficit by 2019, which would only get worse after that.

San Diego Physician: Sounds bad, but does it really matter?

Dr. Hertzka: I believe that it does. The public’s current level of support for the ACA has never exceeded 50%, and that was with the belief that it was more or less budget neutral. Today we are already dealing with major acknowledged deficits in Medicare and Social Security, as well as huge deficits in federal, state, and local pensions. I believe that the public will have little appetite for any level of support of the ACA if it turns out that not only is it another budget-buster, but a budgetbuster whose benefits go overwhelmingly to people making $20,000 or less.

San Diego Physician: But just a couple of weeks ago the CBO announced that the cost of the ACA through 2019 will actually be $100 billion less than projected. How can you say that the ACA is on its way to adding to the deficit?

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february 2015

Dr. Hertzka: That was actually a fascinating report. They report that the signups on the exchange were so poor, i.e., the plan offerings have been so unpopular, that the cost of the subsidies will be less than expected. Combine that with half the country not offering to expand Medicaid, and the first six years of the ACA (2014–2019) does look less expensive than what was projected back in 2010.

San Diego Physician: So doesn’t that reassure you about the budgetary impact of the ACA? Dr. Hertzka: Short-term perhaps, but certainly not long-term. The Medicaid expansion still has the potential to be more expensive than projected, but the real issue longer-term will be the subsidies. Remember, the premiums paid by people covered in the exchanges are fixed at a percent of income until one reaches 400% FPL (about $46,000 per year). So, as premiums rise, the subsidies rise with them.

As I pointed out a couple of years ago, the ACA is packed with provisions that will lead to much higher health insurance premiums. In fact, I stand by my assertion that if President Obama had assembled a high-level commission in 2009 and tasked them with making private health insurance premiums as high as possible, the result of that commission would have been very close to what is in the ACA. I believe that this is so important that I have outlined this in a separate list (see box).

Because of all those reasons (see box on page 15), premiums will rise, and they will rise substantially. Economists at Johns Hopkins believe that because of the ACA, by 2024, 75% of all individual health insurance policies will cost over $10,000.

And aside from being expensive, premiums will be subject to the 40% “Cadillac Tax” on any amount over $10,000, making them even more costly.

The irony, of course, is that the public will blame health insurance companies for their high premiums, when in fact all they will be doing is passing on all the costs of taxation, expanded benefits, cost-shifting, and what may well be a deteriorating risk pool.

San Diego Physician: Looking at your list of reasons that premiums will rise independent of increasing costs for providing care, we wanted to ask you one question about the last item on your list, which is the notion of a “death spiral” whereby all the sick people buy policies

If one believes that paying much higher premiums as a result of the ACA is a negative, the fact is that the ACA is already having, and will continue to have, a negative impact on many, many more people than it will ever help.

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23

and thus drive up the premium costs, making more and more healthy people drop out, making premiums “spiral” ever higher.

Now we know that we are only in the second year of full ACA implementation, but no one is talking “death spiral.” In fact, premiums are even going down in some parts of the country.

Dr. Hertzka: That is absolutely true. But the fact that premiums are expected to remain relatively stable from 2014 to 2016 is primarily because the ACA includes $25 billion to be paid out in 2014–16 specifically to reimburse up to 80% of what health plans might lose on unhealthy ACA patients.

The programs built into the ACA — and funded to the tune of $25 billion — are called “risk corridors” and “reinsurance.”

The details are somewhat complex, but the short version is that these two programs were specifically designed to compensate insurers for the less healthy patients that they were likely to enroll under the ACA, such that increasing premiums would not be necessary. This has been the key reason for significant insurance company participation and significant insurance company risk-taking in these first two years.

But in 2017 these dollars go away and insurers will be at full risk. At that point, the concern of many actuarial types is that without these two programs to protect them from losses, insurance companies will have to significantly increase premiums, making insurance much less affordable.

San Diego Physician: It is clear that the insurance companies are being protected against any losses in 2014–16. But even if these programs go away as anticipated, why do you seem so sure that there will be this “death spiral” in 2017? Under the ACA, healthy people who do not buy insurance will be subjected to fines, and so they should be expected to buy insurance right along with the unhealthy people.

Dr. Hertzka: Nice thought, but the fine for not having health insurance — 1% of income in 2014, topping out at 2.5% of income in 2016 — is just too small to make much of a difference. And, more significantly, the political pressure against any fine has meant that over 30 categories of exemptions have been created, including, for example, a self-attestation that one was unable to pay their utility bills at one point during

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the year. My favorite exemption though, which is explicitly stated in the text in the ACA, is that if the cost of the health plans available to you exceeds 8% of your income, you are exempted from any fine.

Well, people at 250% of the federal poverty line (FPL, about $29,000 per year) are only subsidized to 8.05% of the FPL (see Figure 2), so, by definition, everyone at or above that income level, and up to relatively high income levels, will be exempt.

The administration estimate has been that only about four million of the previously mentioned 23 million uninsured eligible for the exchanges will be eligible for a fine, but in reality it appears that it will be far less than that — a number so trivial that a death spiral will most likely not be averted.

San Diego Physician: Thanks again for your time. Can you summarize your concerns, particularly for those readers who just skip to the end of an article as a force of habit? What should we be watching over the next year or two to determine if the ACA is — or is not — setting up to be a long-term success?

Dr. Hertzka: The first thing to watch over time is not just whether the Medicaid expansion will not just be a huge expenditure (it will be), but whether it will be a huge expenditure that does not improve the health status of the patients that it is covering. And will it drive up ER utilization as most prior adult Medicaid expansions have?

The other issue with the Medicaid expansion in the ACA is whether the states will have to start to pick up a larger and larger percentage of the costs. As of 2019, the final year of the ACA as passed in 2010, the federal-state “split” will be 90% federal / 10% state. There is a real likelihood that this “split” will drop to 80% / 20% or worse starting in the year 2020, and possibly sooner — President Obama himself proposed changing to an 80% / 20% split back in 2011 during debt ceiling negotiations.

The second thing is that as soon as this year, the ACA is likely to be identified as a major contributor to future federal deficits. That will make it even less popular to the public and will force Congress and the next administration to start making additional reimbursement cuts to physicians and others by the end of the decade, if not sooner.

The third and final thing to watch is whether the exchanges will, over time, attract more high-cost “sick”

people and fewer and fewer “healthy” people, particularly those at low to mid incomes. This destabilization will likely start to manifest in 2017 after the multibillion dollar subsidies to health insurers cease, or as soon as this summer if the Supreme Court sides with the plaintiffs in the King and Halbig cases.

San Diego Physician: Any other final thoughts?

Dr. Hertzka: I have not even mentioned the overall economic impact on the nation outside of healthcare, which actually appears to be substantial — to the negative.

Everyone agrees that there are negative “work” incentives in the ACA, which include a personal incentive to keep your income below 138% FPL so as to maintain your “free” Medicaid, as well as a new incentive to tens of millions of others to work less because of the steep increase in health insurance premiums as income rises. Remember: Make $20,000 per year and pay about $85 per month, or make $29,000 per year and pay about $200 per month — plus thousands of dollars per year in additional co-pays and deductibles.

And don’t forget the incentives in the ACA on employers to keep their workforces below 50 employees and their workers below 30 hours/week. It is now documented that there are millions of “29ers” in large retail and service industries, and even on college campuses among adjunct professors.

Put all this together, and we now have the CBO projecting that 2.5 million people will either not be working or working less as a result of the ACA, with a drop in the nation’s economic output of 2%. It is amazing, we have never had a law passed that imposed such a “tax on work,” but that is unquestionably what the ACA does.

Final thoughts: If one believes that paying much higher premiums as a result of the ACA is a negative, the fact is that the ACA is already having, and will continue to have, a negative impact on many, many more people than it will ever help. And despite years of presidential and media support, its popularity with the public continues to hover below 50% — a number that will likely plummet if (a) the ACA becomes seen as a budget buster, and/or (b) health insurance premiums rise as dramatically as I fear in 2017 and beyond — and the public correctly concludes that the ACA is the cause.

SAN DI EGO PHYSICIAN.org 25

classifieds PHYSICIAN POSITION WANTED LOOKING FOR PART-TIME FAMILY PRACTICE: D. (Doyle) Eugene Johnson, family physician with a wealth of experience, looking for part-time position, preferably in North County. Have been a full-time practicing certified family physician for 50+ years and would like to continue seeing patients part-time.

Had one of the largest solo family practices in San Diego for 25+ years. Excellent references! Continually certified in family practice, ACLS, BLS, regularly use computerized records. Will consider locum tenens. Please email d.eugenejohnsonMD@gmail.com with particulars. [301] PHYSICIAN POSITIONS AVAILABLE SEEKING PART-TIME PRIMARY CARE / URGENT CARE PHYSICIAN: For a busy, well-established primary care family practice / urgent care medical practice in Pacific Beach. This position could lead to an associate physician position of the practice for the right person. The candidate must be able to provide compassionate care in a fast-paced environment. Knowledge of musculoskeletal medicine and X-Ray is required. Must be able to suture and have experience with wound care.

We have a state-of-the-art medical facility.

Please send your CV in confidence for consideration to pbyrnes@andersonmedicalcenter. com. Compensation: Excellent Pay Rate [317] OCCUPATIONAL AND TRAVEL MEDICINE CLINIC FOR SALE: Physician is retiring after 30-plus years of practice in San Diego. Stable patient base comprising local businesses and federal, state, and international agencies. Xray, audiometry, spirometry, ECG, and treadmill capabilities on site. No nights or weekends. For inquiries, call (858) 560-0764. [316] SEEKING FAMILY PHYSICIAN: Seeking a board-eligible or board-certified family physician to join a four-doctor private family practice in northern San Diego County. Practice is in a thriving community with year-round great weather and numerous outdoor activities. Strong earning potential and fast track to partnership. 2015’s welcome. Send CV to enmgroup@gmail.com. [314] URGENT CARE PHYSICIAN — Per Diem BC/BE: Arch Health Partners is an awardwinning medical foundation affiliated with the Palomar Health System in North San Diego County. Hours: 9:00am–9:00pm. Send CV to catherine.jones@archhealth.org or fax to (858) 618-5820. [312] GENERAL, FAMILY, OR INTERNAL MEDICINE PHYSICIAN NEEDED IMMEDIATELY: This opening is an independent contractor position. We are a house call practice located in beautiful North San Diego County. We will also provide paid training on our EMR. 8–5, Monday–Friday, 10–12 patients per day, and on-call pager 1 week every 3 weeks, telephone call only. No rounds or hospital duties. If interested please submit your CV to julie@sandiego-

mobiledoctor.com. We are very anxious to fill this position, and we look forward to hearing from YOU! No agencies please. [311] DERMATOLOGIST NEEDED: Premier dermatology practice in San Diego seeking a fulltime/part-time BC or BE eligible dermatologist to join our team. Busy practice expanding into high growth area with significant opportunity for a motivated, entrepreneurial physician. Work with two energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical, cosmetic, and surgical dermatology (including MOHs) in a brand new medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your CV to Jaime Maas, Practice Administrator, at jmaas12@hotmail.com. [309] FULL-TIME PRIMARY CARE POSITION IN SAN DIEGO: Outpatient only office, no calls, no weekends. Please send CV to sandiegoprimarycare@yahoo.com. [308] SEEKING URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a part-time physician. Good pay and working conditions along with the potential to become a full-time position. Please send CV to jeff@ eastcountyurgentcare.com. [306] FAMILY MEDICINE AND GENERAL INTERNAL MEDICINE PHYSICIAN OPPORTUNITIES: Kaiser Permanente is seeking physicians who are interested in positions ranging from per diem to full-time to join our team.

We have opportunities throughout the County of San Diego, so, if interested, please submit your CV to david.h.horton@kp.org or call (619) 528-7991. [304] PSYCHIATRISTS NEEDED: Part-time or full-time psychiatrists needed to work at San Diego County jails. Work as an independent contractor with very competitive pay. Contact Steve at steve@cpmedgroup.com or at (619) 885-3907. [302] SEEKING FAMILY MEDICINE AND INTERNAL MEDICINE PHYSICIANS: Sharp ReesStealy Medical Group is seeking full-time or half-time (job share) BC/BE family medicine and internal medicine physicians to join our staff.

We offer a first year competitive compensation guarantee and an excellent benefits package.

Please send CV to SRSMG, Physician Services, 300 Fir Street, San Diego, CA 92101. Fax: (619) 233-4730. Email: lori.miller@sharp.com. [299] PHYSICIANS WANTED FOR OUR GROWING ORGANIZATION: Full, part-time, or per-diem flexible schedules available at locations throughout San Diego. A national leader among community health centers, Family Health Centers of San Diego is a private, nonprofit community clinic organization that is an integral part of San Diego’s healthcare safety net. Since 1970, our mission has been to provide caring, affordable, high-quality healthcare and supportive services to every-

To submit a classified ad, email Kyle Lewis at KLewis@SDCMS.org. SDCMS members place classified ads free of charge (excepting “Services Offered” ads). Nonmembers pay $150 (100-word limit) per ad per month of insertion.

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february 2015

one, with a special commitment to uninsured, low-income, and medically underserved persons. Every member of our team plays an important role in improving the health of our patients and community. We offer an excellent, comprehensive benefits package that includes malpractice coverage, NHSC loan repay eligibility, and much, much more! For more information, please call Anna Jameson at (619) 906-4591 or email ajameson@fhcsd. org. If you would like to fax your CV, fax it to (619) 876-4426. For more information and to apply, visit our website and apply online at www.fhcsd.org [046] BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a full-time opportunity may be offered to the right candidate. Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 569-2590. Visit www.

DoctorsExpressSanDiego.com for more information. [229a] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fast-growing group of house-call doctors.

Great pay ($140–$220+K), flexible hours, choose your own days (full or part time). No ER call or inpatient duties required. Transportation and personal assistant provided. Call Chris Hunt, MD, at (619) 992-5330 or email CV to drhunt@thehousecalldocs.com. Visit www. thehousecalldocs.com. [037] PHYSICIANS NEEDED: Family medicine, pediatrics, and OB/GYN. Vista Community Clinic, a private nonprofit outpatient clinic serving the communities of North San Diego County, has opening for part-time, per-diem positions. Must have current CA and DEA licenses. Malpractice coverage provided. Bilingual English/Spanish preferred. Forward resume to hr@vistacommunityclinic.org or fax to (760) 414-3702. Visit our website at www.vistacommunityclinic.org.

EEO Employer/Vet/Disabled/AA [912] SEEKING BOARD-CERTIFIED PEDIATRICIAN FOR PERMANENT FOUR-DAYS-PERWEEK POSITION: Private practice in La Mesa seeks pediatrician four days per week on partnership track. Modern office setting with a reputation for outstanding patient satisfaction and retention for over 15 years. A dedicated triage and education nurse takes routine patient calls off your hands, and team of eight staff provides attentive support allowing you to focus on direct, quality patient care. Clinic is 24–28 patients per eight-hour day, 1-in-3 call is minimal, rounding on newborns, and occasional admission, NO delivery standby or rushing out in the night. Benefits include tail-covered liability insurance, paid holidays/ vacation/sick time, professional dues, health and dental insurance, uniforms, CME, budgets, disability and life insurance. Please contact Venk at (619) 504-5830 or at venk@gpeds.sdcoxmail.com. Salary $ 102–108,000 annually (equal to $130–135,000 full-time). [778] OFFICE SPACE AVAILABLE BANKER’S HILL OFFICE SPACE: Office space available in beautiful, updated Banker’s Hill medical office that also houses a fully accredited ambulatory surgery center. Great opportunity for a plastic surgeon, facial plastic surgeon, oculoplastic surgeon or dermato-

logical surgeon. Office is conveniently located minutes from freeway access and downtown San Diego. Please contact via email at info@ drhilinski.com. [313] 1,701FT2 OFFICE SPACE AVAILABLE: Approved for medical or business use. Fully built out. First floor with extensive window line. Two entrances. Excellent highway access. Short- or long-term lease available. Easy patient/client parking. 5330 Carroll Canyon Road, Suite 140, San Diego, CA 92121. Contact mobyrne61@ gmail.com or (619) 218-8980. [310] MEDICAL FACILITY AVAILABLE FOR SUBLEASE: Seeking physicians in the fields of orthopedic surgery, sports medicine, primary care, rheumatology, and physical medicine and rehab to sublease a 3,101ft2 office in Sorrento Valley. Built in 2013, the facility includes five exam rooms, a treatment room, onsite X-ray machine, large conference room, doctor’s office, nurses’ station, receptionists’ station, large waiting room, break room, two staff work rooms, and a restroom. The office is also adjacent to a DME supplier and physical therapist and is situated directly above an outpatient surgical center. Rates are negotiable with the terms of the lease. For more information, please contact Jeff Craven at jeff@ sdmoiortho.com or at (858) 245-9109. [300] ALISO VIEJO — 5 JOURNEY: Multi Tenant Medical Building with highly successful medical and dental practices. 2 ground floor medical spaces approx. 2,135 and 2,225 rsf available for lease. $2.90 PSF NNN. Beautifully designed. Tenant Improvement Allowance to customize suite is available. For further information please contact Lucia Shamshoian @ 769-931-1134x13 or Shamshoian@coveycommercial.com. [298] LA JOLLA (NEAR UTC) OFFICE FOR SUBLEASE OR TO SHARE: Scripps Memorial medical office building, 9834 Genesee Ave. — great location by the front of the main entrance of the hospital between I-5 and I-805.

Multidisciplinary group. Excellent referral

Place your ad here Contact Dari Pebdani at 858-231-1231 or DPebdani@sdcms.org

base in the office and on the hospital campus.

Please call (858) 455-7535 or (858) 3200525 and ask for the secretary, Sandy. [127] 3998 VISTA WAY, IN OCEANSIDE: Medical office space approx. 2,488 rsf available for lease. Close proximity to Tri-City Hospital with pedestrian walkway connected to parking lot of hospital, and ground-floor access. Lease price: $1.75+NNN. Tenant improvement allowance to customize the suites is available.

For further information, please contact Lucia Shamshoian at (760) 931-1134, ext. 13, or at shamshoian@coveycommercial.com. [234] BANKERS HILL PRIMARY CARE / HEALTHCARE PROFESSIONAL & RESEARCH OFFICE SPACE TO SUBLEASE: 50-year established primary care practice and clinical research office, with currently two internists, have space to sublease to another primary care or primary care / subspecialist, or other independent healthcare professional, to help curb overhead and, if primary care, help with acute overflow patients’ needs. Also can provide opportunity to get into clinical research.

Contact Jeff at crf@att.net. [265]

fourth large doctor’s office. Ample parking.

Lab and radiology onsite. Ideal sublease / satellite location, flexible days of the week. Contact Nerin at the office at (858) 521-0806 or at mzarei@cox.net. [873] BUILD TO SUIT: Up to 1,900SF office space on University Avenue in vibrant La Mesa / East San Diego, across from the Joan Kroc Center.

Next door to busy pediatrics practice, ideal for medical, dental, optometry, lab, radiology, or ancillary services. Comes with 12 assigned, gated parking spaces, dual restrooms, server room, lighted tower sign. Build-out allowance to $20,000 for 4–5 year lease. $3,700 per month gross (no extras), negotiable. Contact venk@cox.net or (619) 504-5830. [835] SHARE OFFICE SPACE IN LA MESA JUST OFF OF LA MESA BLVD: Two exam rooms and one minor OR room with potential to share other exam rooms in building. Medicare certified ambulatory surgery center next door. Minutes from Sharp Grossmont Hospital.

Very reasonable rent. Please email KLewis@ SDCMS.org for more information. [867] NONPHYSICIAN POSITIONS AVAILABLE

DEL MAR / CARMEL VALLEY MEDICAL OFFICE TO SHARE: Available immediately. Class A medical building. 1,000SF. Two treatment / consultation rooms / office reception / photography room / break room. Full or shared occupancy. Unlimited free parking. Call (858) 4814888 or email mobyrne61@gmail.com. [252] SCRIPPS XIMED MEDICAL CENTER BLDG, LA JOLLA — OFFICE SPACE TO SUBLEASE AVAILABLE: Vascular & General Surgeons have space available. One room consult office available, with one or two exam rooms, to a physician or team. Located on the campus of Scripps Memorial Hospital, The Scripps Ximed Medical Center is the office space location of choice for anyone seeking a presence in the La Jolla/UTC area. Reception and staff may be available. Complete ultrasound lab on site for scans or studies. Full-day or half-day timeslots. For more information, call Irene at (619) 840-2400. [154] NORTH COAST HEALTH CENTER, 477 EL CAMINO REAL, ENCINITAS, OFFICE SPACE TO SUBLEASE: Well-designed office space available, 2,100SF, at the 477-D Bldg.

Occupied by Vascular & General Surgeons.

Excellent and central location at this large medical center. Nice third-floor window views, all new exam tables, equipment, furniture, and hardwood floors. Full Ultrasound lab with tech on site, doubles as procedure room. Will sublease partial suite, one or two exam rooms, half or full day. Will consider subleasing the entire suite, totally furnished, if there is a larger group interest. Plenty of free parking.

For more information, call Irene at (619) 8402400 or at (858) 452-0306. [153]

SEEKING PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Part-time, with possibility of full-time, mid-level provider position available in a primary care office in downtown San Diego. This is a wonderful opportunity to learn all aspects of primary care. Prior experience with family medicine, sports medicine, occupational medicine, and/or urgent care is preferred, but new graduates can apply. Must be a certified PA or NP and possess a current California medical license. A DEA license is helpful, but not necessary. Must be comfortable using an EHR system, but will provide training on our specific system. Wages based on experience.

Please email CV to office.mcmc@gmail.com or fax to (619) 232-6012. [315] PSYCHIATRIC NURSE PRACTITIONER: Part- or full-time psychiatric nurse practitioner needed to work at San Diego County jails.

Work as an independent contractor with very competitive pay. Contact Steve at steve@ cpmedgroup.com or at (619) 885-3907. [303] NURSE PRACTITIONERS WANTED FOR OUR GROWING ORGANIZATION: See ad #046 under “PHYSICIAN POSITIONS AVAILABLE.” BOARD-CERTIFIED PHYSICIANS, PHYSICIAN ASSISTANTS, AND NURSE PRACTITIONERS NEEDED FOR URGENT CARE: Part-time positions available but a full-time opportunity may be offered to the right candidate. Must possess a current California medical license and ACLS certification. Please email or fax CV to (619) 569-2590. Visit www.

DoctorsExpressSanDiego.com for more information. [229b]

POWAY OFFICE SPACE FOR SUBLEASE: Private exam room or rooms available for one day a week or more. Ideal for physician, chiropractor, massage therapist. Low rates. Email inquiries to kathysutton41@yahoo.com. [173]

NURSE PRACTITIONER: Needed for housecall physician in San Diego. Full-time, competitive benefits package and salary. Call (619) 992-5330 or email drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [152]

POWAY / RANCHO BERNARDO — OFFICE FOR SUBLEASE: Spacious, beautiful, newly renovated, 1,467SF furnished suite, on the ground floor, next to main entrance, in a busy class A medical building (Gateway), next to Pomerado Hospital, with three exam rooms,

PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours.

Competitive compensation. Call (619) 9925330 or email drhunt@thehousecalldocs.com.

Visit www.thehousecalldocs.com. [038] SAN DIEGO PHYSICIAN.org

27

poetry and medicine

thanks for nothing

by Daniel J. Bressler, MD, FACP

Introduction Cosmologists can trace the beginning of the 13.8-billion-year-old universe back to 10-43 seconds after the Big Bang, a time they call the Planck epoch. When pressed as to what existed before this time, they say “nothing existed — no matter, no time, nothing.” Nothing.

Meanwhile, quantum physicists have theorized and demonstrated experimentally that a vacuum — the very poster child of nothingness — can give rise to matter and energy. A vacuum has been explained as a reclusive condensate of matter and antimatter which, when provoked just right, reveals its constituent parts. Voila: something from nothing. Or perhaps we should say: nothing as something.

Our human lives are vanishingly transient things in the context of 14 billion years. In a mere century the most long-lived among us are born, grow up, grow old, and die.

From dust to dust as the Hebrew

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Bible says. Or from star-stuff to star-stuff, to paraphrase Carl Sagan. The duration of a “long” human lifetime is less than a rounding error of a rounding error of a rounding error in cosmologic calculations.

In facing mortality — my own, my loved ones’, or my patients’ — I find comfort in the notion that whatever death holds, it involves some kind of reconnection with the “Nothing” that gave rise to the entire universe. That nothing, it turns out, is a fertile and overflowing source. This is, of course, beyond my mathematical understanding, but it is not beyond my imagination. So, yes, thanks for nothing after all.

Dr. Bressler, SDCMS-CMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

Thanks for Nothing, After All The world emerged from Nothing’s darkness In times too distant to recall When something rose in that black starkness Thanks for Nothing, after all Nothing lay in peace and quiet Devoid of movements, large or small The cosmos surged with form and riot Thanks for Nothing after all In that first eyeblink of creation From quark to interstellar sprawl Nothing burst to wild gyration Thanks for Nothing after all I lay my pen upon this table Whose atoms help prevent its fall But Nothing made those atoms able Thanks for Nothing after all Pulling on the string of being Is it attached to some strong wall?

But Nothing’s there and that is freeing Thanks for Nothing after all.

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