August 2016 by San Diego Physician

official publication of SDCMS august 2016

the e l b a d r Affo

CARE act:

Here TO ? y a t s

An Interview With Robert E. Hertzka, MD Pag e 1 6

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Contents

Volume 103, Number 8

the Affordable

EDITOR: James Santiago Grisolía, MD MANAGING EDITOR: Kyle Lewis EDITORIAL BOARD: James Santiago Grisolía, MD • Mihir Parikh, MD • Robert E. Peters, MD, PhD • J. Steven Poceta, MD MARKETING & PRODUCTION MANAGER: Jennifer Rohr SALES DIRECTOR: Dari Pebdani ART DIRECTOR: Lisa Williams COPY EDITOR: Adam Elder

CARE act: feature

The Affordable Care Act: Here to Stay? An Interview With Robert E. Hertzka, MD

OFFICERS President: Mihir Y. Parikh, MD President-elect: Mark W. Sornson, MD Secretary: David E. J. Bazzo, MD Treasurer: James H. Schultz Jr., MD Immediate Past President: William T-C Tseng, MD, MPH (CMA Trustee)

Here TO stay ?

GEOGRAPHIC and GEOGRAPHIC ALTERNATE DIRECTORS East County: Susan Kaweski, MD (Alt) • Jay P. Mongiardo, MD • Venu Prabaker, MD • Kosala Samarasinghe, MD Hillcrest: Gregory M. Balourdas, MD • Kyle P. Edmonds, MD (Alt) • Thomas C. Lian, MD Kearny Mesa: Sergio R. Flores, MD (Board Rep) • John G. Lane, MD • Anthony E. Magit, MD (Alt) • Eileen R. Quintela, MD (Alt) La Jolla: Geva E. Mannor, MD, MPH • Marc M. Sedwitz, MD • Wayne C. Sun, MD (Alt) North County: Neelima V. Chu, MD (Alt) • Michael A. Lobatz, MD • Patrick A. Tellez, MD South Bay: Maria Carriedo, MD (Alt) • Reno D. Tiangco, MD • Michael H. Verdolin, MD

BY SAN DIEGO PHYSICIAN

10 departments 4

riefly Noted: Calendar • Welcome, B Eric Ayaso • History Thumbnails • The Heart of Medicine • And More …

OTHER VOTING MEMBERS Communications Chair: J. Steven Poceta, MD Delegation Chair: Robert E. Peters, MD, PhD Young Physician Director: Edwin S. Chen, MD Resident Physician Director: Michael C. Hann, MD Retired Physician Director: Rosemarie M. Johnson, MD Medical Student Director: David Li

8 Optimize Pediatric Health: 5210 Messaging Across Sectors

OTHER NONVOTING MEMBERS Young Physician Alternate Director: Heidi M. Meyer, MD Resident Physician Alternate Director: Zachary T. Berman, MD Retired Physician Alternate Director: Mitsuo Tomita, MD SDCMS Foundation President: Albert Ray, MD (Delegation Vice Chair) (At-large AMA Delegate, Appointed by CMA) Delegation Chair: Robert E. Peters, MD, PhD CMA Speaker of the House: Theodore M. Mazer, MD (At-large AMA Delegate, Appointed by CMA) CMA Past Presidents: James T. Hay, MD (AMA Delegate) • Robert E. Hertzka, MD (Legislative Committee Chair, At-large AMA Delegate, Appointed by CMA) • Ralph R. Ocampo, MD CMA Trustee: Bob E. Wailes, MD AMA Alternate Delegate: Lisa S. Miller, MD

Y NATALIE DIGATE MUTH, MD, B MPH, RDN, FAAP

Practice Management Tip of the Month BY THE CALIFORNIA MEDICAL ASSOCIATION

Report on the June 11–15 AMA Annual Meeting

BY THEODORE M. MAZER, MD

AT-LARGE and AT-LARGE ALTERNATE DIRECTORS Lase A. Ajayi, MD • Karrar H. Ali, DO, MPH • Steven L-W Chen, MD, MBA (Alt) • Stephen R. Hayden, MD • Vimal I. Nanavati, MD (Alt) • Alexexandra E. Page, MD • Robert E. Peters, MD, PhD (Alt) • Carl A. Powell, DO (Alt) • Peter O. Raudaskoski, MD • Albert Ray, MD (Alt) • Thomas J. Savides, MD • Karl E. Steinberg, MD (Alt) • Erin L. Whitaker, MD (Alt) • Marcella (Marci) M. Wilson, MD (Alt) • Holly B. Yang, MD (Board Rep) • Nicholas J. Yphantides, MD

Choose Freedom

BY HELANE FRONEK, MD, FACP, FACPh

26 Physician Marketplace: Classifieds 28

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BY DANIEL J. BRESSLER, MD, FACP

August 2016

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.]

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// SDCMS STAFF

calendar SDCMS-CMA CALENDAR

For further information or to register for the following, contact Jen at (858) 300-2781 or at JOhmstede@ SDCMS.org. CMA House of Delegates (event) OCT 15–16 at the Sacramento Convention Center

Remaining HOD Resolutions Schedule:

Event

Quarter 4 July 8

30-day Testimony Period

Aug. 5 – Sept. 4

Council Meetings

Sept. 5–12

Comment Period

Sept. 13 – Oct. 10

Board of Trustees Meeting

Oct. 14

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. Financial Dashboard (SDMGMA) SEP 14 at SDCMS 2016 Building Healthy Communities Summit SEP 16–18 at the Marriott Hotel & Spa in Newport Beach 27th Annual Southern California Alzheimer’s Disease Research Conference SEP 30 at the Irvine Marriott Hotel 3rd Annual Solana Beach Sunset 5K Run / Walk OCT 1 at Fletcher Cover in Solana Beach People, Planet, Purpose: Global Practitioners United in Health and Healing OCT 3 – NOV 3 at the Paradise Point Resort & Spa

Physician Networking Opportunity & Mixer (social) NOV 3 at Rock Bottom La Jolla

Resolution Submission Deadline

HEALTHCARE CONFERENCES

August 2016

Left: Eric (middle) at a bar mitzvah with friends. Right: Eric (far left) about to board and explore the Hawaiian Islands.

Work Comp (SDMGMA) OCT 12 at SDCMS CMA President’s Reception and Awards Gala OCT 15 in Sacramento 2nd Annual Advanced Therapeutic Interventions to Optimize Obesity and Diabetes Care OCT 21–22 at the Hilton La Jolla Torrey Pines Top Doctors Celebration 2016 OCT 29 at Coasterra in San Diego 2016 San Diego Day of Trauma NOV 4 at the Kona Kai Resort, San Diego Social Media for the Healthcare Administrator (SDMGMA) NOV 9 at SDCMS AMA House of Delegates Interim Meeting NOV 12–15 in Orlando, Florida

Welcome Eric Ayaso! Eric joins SDCMS with experience in a variety of settings that include healthcare, training and development, consulting, and entertainment. He enjoys combining experience with a team attitude and process-improvement skills to render solutions that create trust and value in organizations. Eric most recently worked for Promises2Kids, a local nonprofit organization that provides services and support to foster youth in San Diego County. As the former volunteer manager, he was responsible for securing volunteer resources to assist in the delivery of the organization’s programs and services. Prior to that, he served as senior implementation project manager for MedImpact, the largest independent pharmacy benefit manager in the United States. He is now with SDCMS as the membership coordinator and can be reached at (858) 300-2782 or via email at Eric. Ayaso@SDCMS.org. Eric holds a bachelor of science from San Diego State University and a master of arts from New York University.

Save the Date

October 15, 2016, CMA President’s Reception and Awards Gala Each year, CMA and the CMA Foundation honor the extraordinary leadership of individuals and organizations making a difference in the health of Californians. And, because 2016 marks 160 years of CMA’s protecting the practice of medicine, there is even more reason to celebrate! Contact Sadye Reish at CMA at sreish@ cmanet.org for details.

/////////////////////////////////////////////////////////////////////////////////////////////////// HISTORY THUMBNAILS

Olive Brasier Cordua, MD

TrusT

By Betty Peabody Olive Brasier Cordua was born in Winnipeg, Canada, on May 14, 1883. Her family moved to Montana, where she graduated from high school in 1902. Her graduation speech quoted Tennyson to illustrate “the ideal to which she (woman) must attain in order to fill adequately and nobly her God-given position as man’s equal.” Upon graduation she traveled to San Francisco for nurse’s training, but, when she was given a pail to wash floors as part of her training, she walked over to the medical school and transferred into the freshman class of the University of California. On April 6, 1906, one month before graduating from medical school, the calamitous San Francisco earthquake destroyed the downtown business district where she lived. Amid the smoke, fire, and dust of collapsed buildings, she made her way to Golden Gate Park where a tent city had been built. The Masonic Lodge recognized her as “kin to a mason” (her father) and sheltered her at their campsite. With further help from the Masons, she retrieved her books and passed her final medical school exams in May. She interned at Women’s and Children’s Hospital, formed by six women physicians in 1875. Dr. Brasier returned home to Butte and, on borrowed money from her father, opened an office in midtown. Each day for the first year, Dr. Olive arrived at 8 a.m. and stayed until 5 p.m., but not one patient crossed her threshold. By 1908 she was in debt. Her application for a $70 a month job at the Elkhorn and Sour Dough mining village was accepted under the assumption she was a man. She traveled over primitive trails on horseback with her black bag attached to the saddle horn delivering babies and treating accident victims down in the mines. On returning to Butte she signed a $1,000 annual contract with the local hospital, where her experience with ether and chloroform anesthesia as an intern was used and her practice grew. Dr. Olive married Harney M. Cordua in November 1913. They moved to Helena, where she continued office

practice and anesthesiology at St. Joseph’s Hospital. On Nov. 9, 1915, her only child, Harney May Cordua Jr., was born. Harney Jr. later became a physician and practiced internal medicine in San Diego for many years. In April of 1919, she was appointed to the Montana State Vocational School for Girls by the governor. The family moved first to Florida for two years then to San Diego, arriving on Dec. 22, 1922. Olive Brasier Cordua, MD, loved San Diego and spent the rest of her career and life here. Dr. Cordua chaired the first San Diego Public Health Committee that obtained the first nurse in California for maternal and infant care under the Federal Sheppard-Towner Act of 1921. The act was a response to women’s suffrage and the lack of adequate medical care for women and children. Reports from the Department of Labor’s Children’s Bureau found that 80% of all expectant mothers did not receive any advice or care. After passing a civil service exam, she became a member of the City Public Health Department that merged with the County in 1925. In that position she was responsible for prevention and control of communicable disease, was on the staff of the Isolation Hospital, and directed the Division of Maternal and Child Health. “My real hobby is people,” she once said, and proved it by giving physical examinations to women and girls using the YWCA. Even after reaching retirement age, the County Department of Public Health renewed her contract on an annual basis until 1958, her 76th year. Dr. J.B. Askew, director of the County Health Department, in a tribute in the November 1962 Medical Bulletin, stated: “Her remarkable vision brought many ‘firsts’ in public health and incalculable benefits to the mothers and children of San Diego County. She was devoted and tireless. She was always looking ahead. She had a genius for living in the world of today in a practical way, and at the same time always anticipating the future maternal and child needs of the community.” Dr. Olive Brasier Cordua died in San Diego in 1970 at the age of 87.

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/////////Briefly /////////////////Noted //////////////////////////////////////////////////////////////////////// the heart of medicine

Hugs By Steven Brozinsky, MD

Yesterday was a good day. I received four hugs: two from the daughters of my patient JM and two from my patient ACS and her husband. ¶ When I went into private practice after nine years in academia, I did both general internal medicine and my specialty, gastroenterology. It was in 1991 that I first met JM, a healthy 60-year-old with a sharp-witted wife and two wonderful daughters.

*JM’s daughters and ACS have granted permission for the above vignettes to appear in print.

“

I spent the next 25 years modifying his anti-hypertension medications, screening him for colon cancer, getting him through triple CABG surgery in 2006, cajoling him to exercise more, and convincing him that the shingles vaccine was worth getting, even after he had endured an attack of zoster on his forehead. His wife died in 2008 and had a very moving memorial service. JM started keeping company with a widowed friend of his wife who lived in Texas. I thoroughly enjoyed hearing about the wonderful times they shared. Alas, JM showed signs of early dementia, and his daughters played an ever-increasing role in making sure Dad took the right medicines at the right time. On April 22 he was admitted to the hospital with a massive inferior wall myocardial infarction and had his right coronary artery emergently stented. He suffered a major thrombotic CVA over the weekend, and, by Monday morning, his

daughters had decided that it was time for comfort care rather than further invasive maneuvers. I fully supported their decision and reminded them what a pleasure and privilege it had been to serve as his physician for a quarter of a century. We hugged at his bedside in the ICU. Later that same afternoon, as I was walking through the hospital parking lot, I heard someone call out my name. I immediately recognized the husband of my patient ACS. He was all smiles as he razzed me about the Yankees’ poor start to the baseball season. He remembered that I was from New York and asked “Hillary or Trump?” I was able to dodge that question and asked how his wife was. He responded, “See for yourself,” and summoned my patient from their SUV. ACS looked great and gave me a big hug, as did her husband. I recalled that he had given me photos of the aurora borealis he had taken while stationed in Alaska during a stint in the military. ACS had been

If everyone is moving forward together, then success takes care of itself.

August 2016

— Henry Ford, American Industrialist (1863–1947)

/////////////////////////////////////////Maximizing /////////////////////the /////// / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / bottom line, referred to me in November 2009 because of urgency and some bleeding. She was 30 years old and had three little children at home. I figured I would find proctitis when I scoped her. Wrong! She had an obstructing stage III C carcinoma for which she underwent a low anterior resection. Five of 17 nodes were positive. Surgery was followed by chemo radiation, and she seemed fine until February 2012 when an enlarging lung nodule was resected: metastatic cancer. All through this, her oncologist and I marveled at her wonderful, optimistic outlook. More chemo followed the lung surgery, and the PET/CTs these past few years have been clean. Her smile is radiant and her husband is thrilled with how well she’s done. We all have our fingers crossed. The hugs they gave me were the perfect end to an emotional day. Getting to know your patients pays dividends that are truly priceless. Those two encounters* got this graybeard to ponder how medicine has changed since my internship 44 years ago. These are not the musings of a fuddyduddy but a still-practicing physician who bemoans that the art of medicine is rapidly vanishing. Sure, an echocardiogram provides invaluable information, but carefully ausculting the chest — dare I say percussing it — tells the patient that you are his or her doctor. CT scans were not yet prime time during my fellowship, but hands on the belly, gently but expertly palpating the abdomen conveys an intimacy that many of today’s newly minted practitioners sorely lack. Most patients, especially those of Medicare vintage, really do expect to be examined, and not just lectured to and sent to the laboratory or radiology departments with some reading material about their illness provided by a pharmaceutical company. Finally, the EMR! It is obviously very helpful for me to easily access lab and imaging reports with a few clicks on my office computer (of course, always paying homage to HIPAA). But those worthless templates! And now scribes? How about a rebirth of eye-to-eye contact, empathy, really listening, and treating Mrs. Smith as though she were your mother? Dr. Brozinsky, 30-year member of SDCMS-CMA, is a board-certified gastroenterologist practicing in Chula Vista.

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P UBL I C H E A LT H

Optimize Pediatric Health 5210 Messaging Across Sectors by Natalie Digate Muth, MD, MPH, RDN, FAAP

As a practicing primary care pediatrician, my well-child checks generally follow a routine. Part of this routine includes reviewing the growth chart and BMI percentiles. I help each family make sense of what all of the lines mean — and then transition the conversation. Of course, growth and weight are important, but they are just one piece of the story. The more important part is the health habits — the healthy behaviors that help you to achieve your height potential and maintain a healthy weight, not to mention do well in school and with friends and at home. And it boils down to this:

Eat five fruit and vegetable servings each day. Make this easy by trying to have at least one fruit or vegetable with each meal and snack. Only getting one or two a day now? Well, then let’s start with small steps.

Spend fewer than two hours on non-educational screen time each day. That means tablets, phones, TV, movies, video games. Yes, I know most teens are spending seven or more hours each day with the screen. Maybe we can reduce that a bit?

Be active at least one hour each day. It doesn’t have to be all at once, but build active play, sports, walking — whatever you enjoy most into your day.

Drink no sugary drinks — including juice, sports drinks, and sodas — most days. The sugar in drinks does not help us to feel full and is a major cause of gaining too much weight. Instead, focus on water.

Download this poster along with other free 5210 materials at www.5210sandiego.org.

August 2016

In most cases, the families and kids listen, remark on how they are or are not in line with these suggestions, and, hopefully, go home and consider making changes that lead them closer to 5210. But on this day, my middle-school-aged patient surprised me. “5210. I know 5210. I learned all about it in school!” Her face lit up. She was excited that she remembered what she had learned and was trying to implement it, and also that her teachers and her doctors were sharing exactly the same message. The concept of 5210 started with a pediatrician in Maine (www.letsgo.org) and has spread throughout pediatrics and into the community. In fact, the San Diego County Childhood Obesity Initiative has adopted 5210 as its primary messaging across all of its domains including healthcare, schools and after-school, early childhood, community, business, media, and government. This aligned messaging strengthens the impact of our advice. In fact, in the W.E.L.L. healthy weight clinic at Children’s Primary Care Medical Group, 5210 is a key facet and sets the stage for goal setting. This messaging provides an opportunity for shared decision-making, not to mention an easy way for pediatricians to meet the HEDIS measurements for dietary surveillance and counseling and exercise counseling. Every time I have an opportunity to spread the 5210 message, I take advantage of it. In fact, one time after a TV appearance where I had discussed 5210, my 5-year-old at the time, who had watched the segment, said, “Mommy, I got it. 5210. But I think you should add a 3. Eat three meals per day!” The message is simple. So simple a 5-year-old can remember it and build upon it to become even healthier. If we all can spread this shared message throughout the different domains in our lives, we can make a difference in helping to support children and their families to make small changes to optimize their health. Dr. Muth, SDCMS-CMA member since 2014, is a pediatrician at Children’s Primary Care Medical Group (CPCMG), the founder of CPCMG’s W.E.L.L. clinic, and a private sector co-chair for the San Diego County Childhood Obesity Initiative.

CALIFORNIA MEDICAL ASSOCIATION

PRACTICE MANAGEMENT:

TIP OF THE MONTH

AUG

The new provider directory accuracy law took effect July 1. Make sure your practice isn’t penalized! The new law not only requires payors to maintain accurate and current directories, but it also requires physicians to do their part in keeping the information up-to-date. Failure to comply with the new requirements may result in payment delays, removal from directories and even contract termination. For more information on physicians’ obligations under the new law, visit http://cal.md/directory-accuracy.

Through its robust webinar series, CMA gives you the opportunity to watch live presentations on important topics from the comfort • SEMINARS • PODCASTS • AND of yourWEBINARS home or office. Webinars are free to members andMORE their staff and provide timely information to help you run a successful medical DID YOU KNOW? practice. Check out the current webinar schedule at www.cmanet.org/webinars.

TROUBLE GETTING PAID? WE CAN HELP! CMA’s Center for Economic Services (CES) is staffed by a team of practice management experts with a combined experience of over 125 years in medical practice operations. Our goal is to empower physician practices by providing resources and guidance to improve the success of your practice. Access to our reimbursement experts is a FREE, members-only benefit. Call (800) 786-4262 or email economicservices@cmanet.org. Meet Your Advocate: Cheryl Bradley

Cheryl Bradley is the newest member of the CES team, specializing in Medicare issues. Before joining CMA, she served as a provider outreach and education specialist for Noridian Healthcare Solutions and as an education and outreach training specialist at Palmetto.

Our goal is to empower CMA member physicians and their staffs to use tools and resources that increase their understanding of the health care topics at hand – and their bottom lines.” Cheryl Bradley, CMA Physician Advocate TO OPT OUT OF FUTURE NOTICES, EMAIL MEMBERSERVICE@CMANET.ORG OR FAX (916) 551-2036. BE SURE TO INCLUDE THE FAX NUMBER YOU WANT REMOVED. SAN DIEGO PHYSICIAN.org

AMA

Report on the June 11–15 Annual Meeting American Medical Association by Theodore M. Mazer, MD

AMA’s 2016 annual meeting has come and gone (June 11–15 in Chicago). New this year, California’s delegation joined with our colleagues from Alaska, Guam, and Hawaii in welcoming back to the Pacific Rim delegations from Washington and Oregon — a very successful reunion that should bode well for further growth and strength of the Rim, along with more collaboration on issues in the future with other states. San Diego was again fully represented by SDCMS’s delegates and alternates, along with individuals attending with other delegations but working together with CMA on many issues. Several locals had notable positions, including Dr. Al Ray as chair of the CMA delegation and the Rim, and Dr. Bob Hertzka as chair of the Council on Medical

august 2016

Services. In addition, several Californians were elected to office, including Dr. Alex Ding (radiology, San Mateo), elected to the Council on Science and Public Health, Dr. Lynn Jeffords (plastics, Ventura), elected to the Council on Medical Services, and Dr. Jack Resneck (dermatology, San Francisco), elected by the board of trustees to the position of secretary. Andy Slavitt, acting CMS administrator, presented to the House on current Medicare actions and MACRA, indicating a goal of reversing a pattern of regulation and frustration and “ultimately unleashing a new wave of collaboration between people who spend their lives taking care of us and those of us whose job it is to support that cause.” Acknowledging concerns expressed

by physicians and physician organizations nationwide during the comment period on MACRA and the current setting of rules for implementation, along with potential obstacles to modifying existing statutes, he stated that the “goal of the program is to return the focus to patient care, not spend more time learning a new program.” Some of his more recent comments hold out hope that CMS is listening to our concerns and may modify initially proposed rules and even consider some delays in reporting or implementation. After several years of debate between the Council on Ethical and Judicial Affairs (CEJA) and the House, a newly modified code of ethics was adopted, including a clarification that the code is a guideline, not a rigid set of rules, nor a legal document. The shooting in Orlando occurred during the AMA House meeting, and AMA reacted promptly and strongly, with adoption of an emergency resolution recognizing gun violence as a ‘public health crisis’ requiring a comprehensive public health response, and calling on Congress to overturn 20-yearold legislation that has prevented the CDC from conducting or funding research on gun violence. AMA’s position on physician aid in dying (PAD) — an issue recently in the forefront in California with a change in California law

and implementation of legalized PAD — was brought to debate by a Louisiana resolution calling on AMA to reaffirm its opposition to PAD as well as active euthanasia. Given the conflict this presents with California law and with CMA’s neutral stance on PAD, and having been presented with a CMA resolution via the year-round process asking that CMA ask AMA to revisit its position, the California delegation and the Oregon delegation together opposed Louisiana’s resolution, with the House adopting an alternative resolution to study PAD as an end-of-life option with a report back next year. That should put the issue front and center next year, where CMA will support a change in AMA policy consistent with CMA’s policy on PAD. In addition to other key debates around a myriad of topics, including the VA’s proposal to substitute physicians with advanced practice registered nurse practitioners in independent practice, loan forgiveness for physicians practicing within the VA, MOC efforts and problems, the opioid overdose epidemic, barriers to pain management,

alternative payment models, and funding to combat Zika, actions were taken on several California-introduced resolutions, including principles of hospital-sponsored EHRs, preserving patient access to small practices under MACRA, changing public policy to address obesity goals, challenging the pro-tobacco actions of the U.S. Chamber of Commerce, opposing tax deductions for direct-to-consumer advertising, reaffirming existing policy on MOC in lieu of Resolution 315 (which opposed the current MOC process and called on AMA to develop an alternative system), and adopting Council on Medical Services Report 02 on ACA Medicaid Expansion Study (Council chaired by Dr. Hertzka). Finally, amid all the work, educational sessions, and debate on these and other important issues affecting our patients and our practices, there were discussions of physician burnout, which we will address at our upcoming CMA House as well. As we said adieu to the very effective Steven Stack, MD, as president of our AMA, we watched our good friend Andrew “Andy”

Gurman, MD, take the oath and helm during a memorable and entertaining inaugural ceremony. As you can see, A-16 was anything but dull. There is much going on, much to be done, and every physician has a role to play in helping develop a sustainable, patientcentric, and physician-respecting future of medicine. I am happy to report that, months ago, Andy accepted my invitation to speak to the CMA House of Delegates in Sacramento in October, and I would encourage all members of CMA to make the effort to attend that meeting and to listen to what he has to say. As we have all heard, we live in interesting times — some would say scary times — with many non-patient-care burdens thrust upon us and regulators piling on all the time. But as President Gurman told us in Chicago: “This is not the time to sit on the sidelines.” Dr. Mazer, a 28-year member of SDCMSCMA, is current speaker of CMA’s House of Delegates and a CMA-appointed at-large alternate delegate to AMA.

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P e r s o na l & P r o f e s s i o na l D e v e lo p m e nt

Choose Freedom by Helane Fronek, MD, FACP, FACPh

Funny thing about freedom. We Americans believe strongly in the concept of freedom and will risk our lives for freedom around the world. And yet, many people live day to day with no sense of freedom at all — they feel trapped in their own lives. What keeps us wrapped in a straitjacket of work and personal responsibilities, unable to create a life of our choosing? 14

august 2016

Often, we are lulled into the feeling that life will go on forever and a better time will come for those things we want to do. Tomorrow, I’ll call that friend. I’ll finish that project next month. Next year, I’ll take that vacation. As we all know, time goes by in its stealthy way. We never get around to many things and feel heavy with regret. We had so many dreams when we were young — how did we let our life slip by without making them a reality? In other ways, we feel as if we are living in a box, unable to penetrate beyond its walls where we imagine fun, excitement, and personal growth might reside. Instead, the responsibilities of work and life expand to fill our time. “It’s just the way it is,” we say to ourselves. But if we look, we see people who have climbed over the walls of their boxes. They cast aside the same limitations that keep us contained and demanded the freedom that we yearn for. What makes it possible for them and not for us? One factor that keeps us stuck is the negative messages we tell ourselves. “You’ll never be able to do that.” “What gives you the right to do that?” Do these messages sound familiar? Consider what you would really do if that voice weren’t filling your mind and defeating your spirit? Reinforcing that box around us is the impression that we need to make big changes in order to create the shifts that will lead to a happier and more fulfilled life. It’s important to not let the perfect be the enemy of the good. Even small things can make a difference. And as our life becomes more fulfilling, we’ll have more confidence that we can accomplish even greater and more meaningful change. So when will you take a stand for your life? Let’s all honor the revolutionary spirit of those

Reinforcing that box around us is the impression that we need to make big changes in order to create the shifts that will lead to a happier and more fulfilled life. who fought for our freedom by getting in touch with our own bravery and making choices that will mold our days into the life we want to be living. Pick one thing you have wanted to do. What needs to happen for you to make it a reality? What obstacles need to be moved? What steps can you take now to add it to your life? Once you’ve accomplished it, take a moment to savor how good it feels. Acknowledge your courage, your dedication to your own freedom and your own life. And then decide what you want next. Dr. Fronek, SDCMSCMA 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.com.

PRESENTED BY:

THE DOCTORS INSURANCE AGENCY Bob DeSimone

SAN DIEGO PHYSICIAN.org

The Affordable Care Act: Here to Stay? An Interview With Robert E. Hertzka, MD

his is the fifth in a series of interviews about the Affordable Care Act (ACA) that San Diego Physician magazine has published with our own Bob Hertzka, MD. A past president of the California Medical Association and a 27-year health policy instructor at the UC San Diego School of Medicine, Dr. Hertzka just completed eight years on the American Medical Association’s Council on Medical Service, the group of physicians elected within AMA to develop many of its policies on healthcare access, cost, and quality. Between his role as chair of that council and his own ongoing research, Dr. Hertzka has been tracking the overall progress and implementation of all the various aspects of the ACA as much as any practicing physician in the country. As we are now well into the third year of the full implementation of the ACA, we thought it would be an opportune time to check in with him again. San Diego Physician: Welcome back, Dr. Hertzka. As always, we are interested in hearing what is going on with the Affordable Care Act (ACA), particularly those things that may be going on behind the headlines. First question: As you follow the ongoing analysis of the ACA from the political left and from the political right, is there anything new this year? What data points are you following most closely? Dr. Hertzka: There has been ongoing analysis of the implementation of the ACA from think tanks from the left

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and the right, along with what is widely viewed as impartial, nonpartisan work from the Congressional Budget Office. The information that we are seeing now is not necessarily “new” but rather much less speculative. All states now have well functioning insurance exchanges (IEs), which have completed three full enrollment periods, so we really have a clear idea of the demographics of those who are signing up for health insurance, as well as the financial performance of the various health insurers within the IEs. And, for those states that have expanded Medicaid, we have a much better idea of what both the enrollment figures and the costs are. As to what I am following, what I still think is most important is the longterm fiscal stability of the ACA. There has been some healthy skepticism from day one about whether the ACA was really going to be budget neutral, and the CBO this past March shed some real light on where the ACA is headed from a budget perspective as it moves into its second decade. I think this is important because the public has never really embraced the ACA, and, to the extent it would start to add significantly to the federal budget deficit by the end of the decade, it could become a really unpopular program. San Diego Physician: Isn’t it a little late to discuss whether the ACA is popular or not? Love it or hate it, as you say, the ACA is well into its third year of full implementation. In particular, right here in California, more than 3 million people have signed up with

Medi-Cal (our version of Medicaid) as part of the national Medicaid expansion under the ACA. And more than 1 million are signed up with Covered California (our IE). On the political side, besides the obvious fact that the ACA never got repealed, we are coming into a presidential election where the Democratic nominee, Hillary Clinton, speaks only of expanding the ACA, and her Republican opponent, businessman Donald Trump, may be calling for repeal, but he has yet to articulate anything close to a coherent alternative. Dr. Hertzka: No disagreement with the current political reality, and, yes, it is true that the ACA will be with us for the indefinite future. That said, what I would like everyone to understand is that the ACA, which was touted when passed as a program that would be both budget-neutral and a net “positive” for our healthcare system, may turn out to be neither. What I want to outline with you today is that the ACA’s current and future financing is problematic, and that, in addition, the ACA has had for the most part a destabilizing impact on the healthcare system for many of the 260 million people who had insurance before it was passed. In my mind, the future for much of the ACA beyond the next few years is actually in doubt. San Diego Physician: How can you say that the future of the ACA is in doubt? Aside from repeal, which would require not just a Republican president but 60 ACA-reform senators, how could the ACA ever go away? Some now say that the ACA is just as much of the permanent landscape of our healthcare system as is Medicare. Most would say, for example, that we are not going back to having 26-year-olds not being able to stay on their parents’ health insurance. Dr. Hertzka: Not to disagree, but every provision of every law has to stand on its own over time. And, over time, people will look at the various provisions of the ACA and ask how well they are working. Post-adolescents on their parents’ plan? Sure, that is probably permanent, particularly because it does not cost the government one dime to change that kind of coverage provi-

sion — all the costs are being borne by employers and employees. But questions will continue to be asked about the populations that are being paid for with taxpayer dollars or from higher healthcare premiums inflated by cost-shifting. Which groups of people are gaining coverage? How much is the coverage costing federal and state governments? Is anyone being disadvantaged by others having this coverage? And I continue to believe that a question that many will find important is whether the ACA in its current form will be adding just a little to the national debt, or will it be a major contributor to future deficits? San Diego Physician: But in the end, if the ACA is in fact covering 20 million people, won’t most everyone want to see it continued? Dr. Hertzka: Perhaps so. But I would suggest that if one takes a closer look at just who is covered, and how much it has been and will be costing us in the future, I don’t see the decision as nearly as automatic as it has been, for example, to continue the Medicare program. San Diego Physician: Something we have to mention is that your comments so far go 100% against what President Obama published recently in JAMA, which was followed by a lengthy Sunday New York Times pro-ACA editorial. They certainly view the ACA as a success in progress. Dr. Hertzka: Yes, I read those two pieces, and there were, quite frankly, some rather startling statements within them. They are part of a series of pro-ACA pronouncements that have come out recently, as if there were a conscious effort to launch a pro-ACA campaign that was timed to hit right before the political conventions. I have gotten so many emails about the two pieces that I have brought a short list of quotes from them that I would like to review for you later. San Diego Physician: All right, fair enough. Let’s walk through the two major components of the ACA. If we review the 20 million people who have become insured because of the ACA, half of them are covered by the Medic-

The Medicaid Actuary report that came out in July of this year was a real shocker: The costs per enrollee in 2015 for the Medicaid expansion came in at $6,366, no less than 49% higher than what was projected just a year ago. aid expansion and half are covered in insurance exchanges, yes? Dr. Hertzka: Actually not. First of all, recall that about 2.3 million of the newly insured are just those post-adolescents on their parents’ policy. And if you recall our discussion from last year, the clear majority of the remaining 17.7 million who became covered as a result of the ACA have gotten their coverage as a result of the Medicaid expansion. Most of those on the exchanges fall into two groups: one being people who were actually insured before the ACA passed but were on the verge of becoming uninsured because their individual coverage was cancelled because it did not have the rich benefit package required by the ACA. This group runs into the millions — as many as 4 million people. The second group was some of those who were declared eligible for Medicaid but lived in a state like Texas or Florida that did not expand Medicaid. This group has actually been documented to be about 3 million people. In my mind they are really part of the Medicaid expansion as opposed to being part of a state IE access expansion. San Diego Physician: We will get to the exchanges later; what can you tell us about the Medicaid expansion to date? Dr. Hertzka: Hopefully quite a bit. The AMA policy council that I chaired until very recently just presented a detailed report about the Medic-

aid expansion to the annual AMA meeting just last June, but, as I will explain, from a fiscal perspective, that report is already somewhat out of date. First a quick review. At the time of the passage of the ACA in March of 2010, there were about 50 million uninsured, and about 27 million of them were at incomes that would have made them immediately eligible for Medicaid in January of 2014. But then in June of 2012, the Supreme Court ruled 7–2 that the ACA provisions requiring Medicaid expansion by the states were “unconstitutionally coercive,” and thus each state could decide whether or not to “opt in” to the expansion. Since then, states that contain about a bit more than half the nation’s population, including California, have opted in, but about half of the country, including large states like Texas and Florida, have not. So, in reality, unless other states “opt in,” the most that the Medicaid expansion can cover will be about 16 million people, and, to date, about 11 million have signed up. San Diego Physician: What do we know about those who have signed up to date? And, by the way, what income levels are we talking about? Dr. Hertzka: By definition in the ACA, one needs to be below 139% of the federal poverty level (FPL) to be eligible, which is right around $16,000 per year for an individual. One thing that we have learned is that these patients are turning out to be much, much more expensive than projected. San Diego Physician: How much more expensive? Dr. Hertzka: There is an annual report from the Medicaid Actuary that comes out every July and details all of the expenditures for Medicaid for the prior calendar year. Prior to the ACA Medicaid expansion, the Actuary felt that the cost per person of the expansion enrollees would approximate the costs per person of pre-ACA adult non-Medicare enrollees, most of those being parents in very-low-income families. Just to review, childless adults have

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never been eligible for Medicaid, but over the past 20 years many states, including California, allowed a limited eligibility for low-income parents, and these enrollees were viewed as the baseline from which to predict the costs of the Medicaid expansion population, almost all of whom are childless adults. But, as it turned out, in July of 2015, the Medicaid Actuary reported that costs in calendar year 2014 turned out to be 19% per person higher than projected ($5,500 vs. $4,600), which obviously has a significant budgetary impact if one is talking about millions of people. That said, the higher projection was attributed to “pent-up demand” from the previously uninsured childless adult population, and so it was expected that the costs per patient in 2015 would settle down back to about $4,300, or $4,281 to be exact. Based on that thinking, the Medicaid Actuary report that came out in July of this year was a real shocker: The costs per enrollee in 2015 for the Medicaid expansion came in at $6,366, no less than 49% higher than what was projected just a year ago. The proposed explanation is that states are being quite generous with their capitation rates for the Medicaid managed care plans. And why not, as they are spending federal dollars when they are being so generous, and then things like “access” and “network adequacy” become the problems of the plans rather than the problems of the states. And, as a side note, I would offer that this apparent unpublicized generosity by state governments spending federal dollars may explain why the two most successful health insurance companies participating in the ACA are the two that specialize in Medicaid managed care: Molina Healthcare, Inc., and Centene Corporation. San Diego Physician: So just how much are we spending on the ACA Medicaid expansion? Dr. Hertzka: $64 billion in 2016, a number that is projected to more than double to $134 billion by 2026. And, notably, just over one quarter of this year’s $64 billion, or $17 billion, is being spent right here in California.

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The federal dollars that the state government is spending this year on the Medicaid expansion would be enough to make the entire University of California system tuition-free for nearly six years. San Diego Physician: $17 billion? Isn’t the entire state budget only $170 billion? Dr. Hertzka: Actually, $171 billion, but you get the idea. In 2016, 10% of all the money that will be spent in the California state budget will be the federal expenditure for the Medicaid expansion. To put that in perspective, the total

tuition collection for the entire University of California system is about $3 billion, so the federal dollars that the state government is spending this year on the Medicaid expansion would be enough to make the entire University of California system tuition-free for nearly six years. At some point the “bang for the buck” argument has to come into play. One has to ask the question, ‘If we knew we had $45 billion of new money in California to spend over three years to aid healthcare access, would we invest those dollars into the current Medi-Cal program or look at other ways that would probably be much more efficient and effective?’ San Diego Physician: Where do our state government finances come in? At some point the federal government will no longer pick up 100% of the tab, correct? Dr. Hertzka: Absolutely correct. In fact, the state is already budgeting over $800 million in 2017 to cover 5% of the Medicaid expansion tab, which

Figure 1: What did it cost and what were the benefits when one signed up with Covered California in 2014?

Obamacare in California

Standard benefits for silver plan in state-based exchange

Monthly Premium (Average)

$321

Annual Deductible (Medical)

$2,000

Primary Care Copay

$45

Specialty Care Copay

$65

Generic Medication Copay

$25

Max Out-of-Pocket for Individual

$6,400

76% will grow to $2 billion (10% of $20 billion) by 2019. San Diego Physician: So let’s talk about the insurance exchanges (IEs). After three years of enrollments, what is going on there? Dr. Hertzka: The IEs have somewhat replaced what was an individual market for health insurance; one for the most part goes less often to an insurance broker or an online vendor; rather, one goes online to their state exchange. For the hundreds of thousands of people with preexisting conditions who were “denied” under the old system, that denial no longer happens. But, frankly, overall the IEs have been far less successful than projected. San Diego Physician: What are the problems with the exchanges? Dr. Hertzka: First and foremost, the offerings on the IEs are so unappealing that, for the most part, people are only signing up for plans if they are heavily subsidized. It turns out that one of the scenarios that I have been laying out in these interviews for years has come true. It goes like this: Imagine someone is at the 250% FPL level, or about $30,000 in income per year. Under the ACA, they now pay no more than 8% of their income to get health insurance, which brings the annual plan cost down to “only” $2,400, or $200 per month. But, at the end of the year, that is still one month’s income for that person, and when one adds that the plan in question has a deductible of $2,000 or more, high copays, and a narrow network (see Figure 1), it turns out that this person just does not sign up. The one exception is that people who have preexisting conditions and/ or predicted high annual medical expenses from something like a planned pregnancy almost always sign up — for them it is a great bargain. San Diego Physician: What about the penalties for not obtaining insurance? Dr. Hertzka: They have turned out not to matter much. In early 2015, much was publicized about the penal-

41% 30% 20%

16% 2%

100-150%

151-200%

201-250%

251-300%

301-400%

Over 400%

Figure 2: Who Signed Up in the Exchanges Percentage of Eligible Individuals Enrolled in Exchange Plans, by Income Source: Avalere Health Care, 2015 Analysis

ties because about 6 million people who remained uninsured in 2014 found out that they owed a 1%-ofincome penalty for doing so, and faced a 2%-of-income penalty for doing so again in 2015. With great fanfare, including a partnership with the H&R Block tax preparation company, the Obama administration extended the enrollment deadline for 2015 from Feb. 1 all the way to April 15 to allow people to “come to their senses” and sign up with their state IEs. But, when April 15 rolled around, only 30,000, or just 0.5% of those facing penalties, had signed up. The “penalties will make a difference” crowd remained undaunted. In June of 2015, the CBO testified in Congress that the combination of publicity, word-of-mouth, and what was now a 2.5%-of-income penalty would result in 21 million being signed up for the exchanges by Feb. 1 of this year. But, when Feb. 1 rolled around, there were only 12 million enrolled, and by March 31, that number had already dropped back down to 11 million. San Diego Physician: What about the demographics of the exchange enrollees? Last year you really emphasized how low their incomes were.

Dr. Hertzka: That pattern continues, and I brought a couple of my slides to demonstrate that. One of the most telling graphs from last year was the breakdown of the sign-ups by income for 2014. This was a survey done by Avalere Health using administration data. You can see that it really skewed toward low-income folks making $20,000 per year or less (see Figure 2), but what was really telling was that of all the millions of uninsured people at over 400% FPL (about $45,000 in 2014), only 2% signed up for exchange plans. Said another way, that means that in 2014, 98% of all the people earning more than $45,000 per year who were uninsured chose to remain uninsured rather than sign up with an IE plan in their state. And, by implication, it seems certain that those 2% who did sign up must have been comprised mostly of those whose expected healthcare costs were very high. I also brought the latest data showing the income distribution of those who signed up in the period just ending February 1 of this year (see Figure 3). You can see that it again really skews toward low-income people, which was very different than what the Urban Institute — and in other surveys the CBO — had projected.

SAN DIEGO PHYSICIAN.org

Figure 3: Exchange Enrollment by Income — 2016 Income Group

Urban Institute Projection

Actual Percentage

< 200% FPL

36%

66%

200-300% FPL

25%

24%

300-400% FPL

14%

> 400% FPL

25%

San Diego Physician: Why are these numbers so far off from the Urban Institute’s and CBO’s projections? Dr. Hertzka: Two reasons, one being the underestimation of how unappealing these high-deductible, high-copay, narrow-network plans would be. The other is the fallout from the June 2012 Supreme Court decision on the Medicaid expansion. San Diego Physician: What fallout? Dr. Hertzka: For whatever reason, the ACA set the Medicaid expansion coverage level at or below 139% FPL, but defined eligibility for the IEs at 100–400% FPL. So in the states that did not expand Medicaid, it turns out that there are at least 4 million people who are between 100 and 138% of FPL, and most of them have signed up on the IEs.

Source: Mercatus Center at George Mason University

San Diego Physician: It is hard to imagine that someone living on roughly $1,000 per month would sign up for anything; wouldn’t the deductibles and such dissuade them from doing so? Dr. Hertzka: Good thought, but they have actually been signing up in droves because they got the deal of the century.

San Diego Physician: The deal of the century? How so? Dr. Hertzka: People living at less than $16,000 per year have been able to access the silver plans shown in Figure 1 for as little as $20 per month, and a supplemental appropriation (known as the Cost-Sharing Reduction program, or CSR) was made such that their copays and deductibles were almost

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completely covered as well. I would also note that these CSR dollars help people all the way up to 250% FPL — in fact, about 57% of all those signed up in the exchanges receive CSR subsidies. But it is those between $12,000 and $16,000 in annual income that receive the very high level of CSR subsidy that makes most of healthcare essentially free. To reemphasize a prior point, what turns out to be 3 million people with the very high CSR subsidy are being counted as being IE enrollees, but if they were in a Medicaid expansion state like California or New York, they would be on Medicaid. Finally, of note, the CSR is the supplemental appropriation that was recently struck down in court. It turned out that in the haste to write and pass the ACA, the money to pay for those copays and deductibles for low-income folks was actually not included in the bill. Again, these dollars are a major part of making healthcare coverage affordable for those below 250% FPL, but they are essential for the 3 million or so below 139% FPL who would have been on Medicaid if they lived in a state that had expanded Medicaid. San Diego Physician: But declaring that appropriation illegal was just the act of one judge; presumably this decision will be overturned and the dollars will continue to flow. Otherwise, as you indicate, most of the 57% of IE enrollees who receive CSR dollars would probably drop out of coverage overnight. Dr. Hertzka: I agree with the consequences, and I certainly want to see those millions of people continue their coverage. But you have to understand, it was not just one judge; no less a source than The New York Times reported this past May 31 that the career financial managers at the IRS felt strongly that this appropriation was illegal. But the presidentially appointed IRS commissioner overruled them. And it has also been documented that the administration did seek this appropriation but was declined by Congress in 2010, when it was still controlled by Democrats, and

declined again in 2013 by the Senate Appropriations Committee when the Senate was also still controlled by Democrats. These dollars may indeed be gone for good, and as those dollars depart, so may depart more than half of the people enrolled in the IEs. San Diego Physician: OK, let’s summarize the IE situation. By the end of 2016, it appears that there will about 10 million people signed up, but about 3 million of those people will be verylow-income people who would have actually been covered by Medicaid if their state had “opted in” to the ACA Medicaid expansion. And another 4 or 5 million are people who had been insured before the ACA but had their policies discontinued by the ACA and so switched to their state IE. So does that mean that only 2 to 3 million people above the Medicaid line of 139% FPL have actually become insured as a result of signing up with their state IE? And many of those may bail out if they lose their CSR subsidy? Dr. Hertzka: Exactly, that is the situation. The overwhelming majority of those who have become insured as a result of the ACA are a combination of Medicaid sign-ups in combination with millions of other very-lowincome people signed up on the IEs. It is safe to say that other than the young adults up to age 26 who got to stay on their parents’ policy (the one provision of the ACA that has worked really well), at least 90% of the direct beneficiaries of the ACA earn less than $20,000 per year. San Diego Physician: One more question about the subsidies for lowincome people: Is the CSR program the reason why the average deductible is so low? The Centers for Medicare and Medicaid Services just released a report this month that said that the average deductible for people in the IEs was just $850, which does not square with what you have been saying today about people making $30,000 per year facing deductibles of $2,000 or more. Dr. Hertzka: No, it does not, but the headlines from that “report” unfortu-

nately make it look like it was put out by a political campaign rather than a factfinding government agency. According to the “headline” of that report, the median deductible for all those insured in the IEs was indeed just $850. But because of the CSR program that we just discussed, 33% of all IE enrollees have a zero deductible. And, if you read the fine print in the report, it states clearly that the median deductible for the 43% of people who do not qualify for the CSR was actually $3,000, with the mean probably even higher than that. San Diego Physician: OK, we see that now. Before we move on to talking about the future of the ACA, we have one more question about the present. What is going on with all the headlines about dramatic premium increases for 2017 for the plans in the IEs? Dr. Hertzka: It is a reality. Just about every insurer around the country has been losing serious money providing care for their IE patients, in some cases more than $1,000/enrollee. San Diego Physician: How can that be, particularly with the high premiums that you have shown to us? Dr. Hertzka: It is clear that as we look around the country, the combination of relatively high premiums and almost trivial penalties has resulted in the much-discussed “death spiral,” in which those who sign up for healthcare coverage in year one have, on average, more serious healthcare problems, and thus cost the plans much more money than they collect in premium. The plans then significantly raise premiums for year two, which does not phase the unhealthy enrollees but does cause some of the healthy enrollees to drop out, making the average cost per enrollee even higher. That cycle just repeats until the cost of health plans is so high that, in the end, health insurance becomes prohibitively expensive for all except the very ill. Many including myself have predicted this since the day that the ACA passed, and it is now playing out before our eyes. I would also note that, in 2017, two “premium stabilization” programs

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that have reimbursed plans for their losses will expire. These programs had reimbursed the plans about $20 billion for their losses for 2014–16, but they will not be around to assist any insurers in 2017. This is another reason that the premium increases around the country for 2017 will dwarf the increases that we saw in 2015 and 2016. And, to digress for a moment, you all might recall that last year I brought some information that was included in last year’s article about how, oddly enough, many of the ACA’s provisions were designed as if the idea was that the ACA make health insurance premiums as high as possible. So these major premium increases are really no surprise at all — you cut Medicare and expand Medicaid, both of which promote cost-shifting to private premiums — you will see premiums rise. You tax health insurers and pharma and they pass it on — you will see higher premiums. Dramatic expansion of covered benefits — higher premiums. And the list goes on. Again, this is not just hype. No less a source than the often pro-ACA Kaiser Family Foundation has acknowledged that premium increases in the IEs will be in double digits in 2017. San Diego Physician: How is California doing? They have been bragging about how little their premiums have increased in 2015 and 2016. Dr. Hertzka: Funny you should ask. One reason that California has fared better than many other states has been that our premiums started out higher than other states in 2014, and that we have more established integrated systems like Kaiser and Sharp. Even so, it had been announced months ago that the premium increases for 2017 in California would be at least 8%, or four times greater than general inflation. However, on July 19 came the big bombshell: Even in California, the premiums for our IE, known as Covered California, will be going up more than 13% in 2017. Not a typo: THIRTEEN PERCENT! San Diego Physician: OK, so premiums may be rising faster than anyone would like as a result of this so-called “death spiral.” But we had thought

August 2016

Remember that one of the signature lines of healthcare reform was, “If you like your doctor, you can keep him or her.” Well, with the ACA, not so much — it has created a kind of bizarro world where, so far, more than 40% of patients in the IEs have substantial financial incentives to switch out all of their physicians each and every year.

that most of the people in the IEs, including those in Covered California, are shielded from any premium increases, since their responsibility is fixed, whether it is $20 per month at very low income or $200 per month at the $30,000 income level. Dr. Hertzka: Agreed, but even if the many subsidized people within the exchange do not pay the higher premium, the higher costs are still there. To the extent an annual premium goes up $1,000 for someone subsidized in the exchange, that person may not notice, but we taxpayers who have to pay that extra $1,000 notice. And as these IE plans continue to lose money, those losses are passed on to their other lines of health insurance, including non-IE individual insurance and group insurance, and the rest of us notice that as well. But one other thing that is very important. While it is true that nearly 90% of people get subsidies that should shield them from any increases, those

subsidies are tied to the second-lowestcosting health plan, and that plan is usually different each year. If someone stays with a plan that was the secondlowest-cost plan in 2015 but is not in 2016, they pay the difference in premium, which could easily be as much as $50 per month — a huge amount of money for someone making $20,000 or $30,000 per year. So as a result, plan switching is rampant: 43% alone this year according to the government’s own data. A typical IE patient in San Diego might have had HealthNet in 2014, Kaiser in 2015, and Sharp in 2016 — and all with narrow networks so that all of their physician continuity was lost each year. Remember that one of the signature lines of healthcare reform was, “If you like your doctor, you can keep him or her.” Well, with the ACA, not so much — it has created a kind of bizarro world where, so far, more than 40% of patients in the IEs have substantial financial incentives to switch out all of their physicians each and every year. San Diego Physician: OK, let’s talk about the important CBO report that came out in late March of this year. Can we say now that the ACA will end up budget-neutral over its first 10 years? President Obama’s piece in JAMA and The New York Times editorial board both agree that the ACA is coming in under budget. Dr. Hertzka: Absolutely true about coming in under budget. You might recall that for 2010–19 the ACA was supposed to cost about $1 trillion, which was matched by about $1 trillion in revenue, thus budget neutral. And, in fact, the administration line on this, as expressed most recently from the two sources that you mention, is that the ACA has come in under projections, on the order of 20%. That means that from 2010 to 2019, we are expected to spend only about $800 billion instead of $1 trillion. That’s fine, but there are two things that are not to be found in the writings of the president and The New York Times editorial board. One is that enrollment is running well below what was projected back when the ACA passed. By now we were supposed to have well over 17 million Medicaid

sign-ups and about 21 million on the IEs (17 million subsidized), but, as I have outlined, the actual numbers are only about two-thirds of those totals. So, frankly, we should have only spent $667 billion by now, not the $800 billion that we will spend. The second thing is that the projected revenue is also coming in way below projections. Among revenue categories, the only one performing well is the 0.9% tax on all income, including capital gains, above $250,000. This is generating about $20 billion per year, and is projected to increase over time with inflation. But most every other category of revenue is underperforming, including premiums from the now-defunct long-term care program (projected to be $60 billion over 10 years, actual number zero), the $14 billion per year tax on insurers (deferred for this year), the medical device tax (deferred until 2018 and possibly forever), the Cadillac tax on high-cost health plans (deferred until 2020 and possibly forever), and the big one, the Medicare cuts (far less than the $500 billion projected). In the end it is hard to see that even $600 billion was raised in revenue for the ACA, let alone the $800 billion that was actually spent.

San Diego Physician: OK, so now tell us, per the CBO, what do the next 10 years look like? Dr. Hertzka: The good news from a fiscal point of view is that the CBO has lowered their expectations for where they believe ACA enrollment will plateau in the next decade. For Medicaid, they project that few additional states will expand Medicaid, meaning that Medicaid enrollment is projected to plateau at about 16 million people by 2026. On the IE side, there are no longer any expectations that enrollment will ever exceed 20 million, let alone the 27 million originally projected. The CBO now says that IE enrollment will plateau at 18 million by 2026 or so. The not-so-good news is that even with these markedly reduced enrollment projections, the projected 2020–29 costs of continuing the ACA will be about $1.2 trillion for the Medicaid expansion and about $1 trillion for the IEs, for a total of $2.2 trillion. And the really-not-so-good news would be the revenue projections, which do not add up to anywhere near $2.2 trillion. On that revenue side (see Figure 4), the backbone remains the 0.9% in the

Medicare tax on all income for those with incomes over $250,000. This, in combination with the net investment tax, which is a 3.9% tax on all capital gains, which, including profits on home sales — again for those making over $250,000 — should continue at about $40–50 billion per year, or about $450 billion for the 10-year period of 2020–29. Next would be the penalty payments for failure to comply with the individual and employer mandates. These penalties are only coming in at about $5 billion annually and are unlikely to grow past $10 billion per year, but let’s call it $100 billion for the next 2020–29 time period. After that, it all gets really dubious. The $14 billion annual health insurers tax (HIT) would project to bring in $140 billion over a decade, but this has always been ridiculous as a sort of revenue — if one taxes health insurers $14 billion, they will just pass that along to the consumer as increased premiums. As I pointed out last year, if a big tax was placed on supermarkets to fund more food stamps, no one would be shocked to see higher prices at supermarkets. Same thing with health insurers as well as pharma, medical devices, etc. — all the taxes

Figure 4: ACA Revenue Sources 2016-2025 Taxes in Billions of Nominal Dollars $125 All other taxes Medical device tax Fee on pharmaceutical companies

$100

Tax on “Cadillac” plans $75

Health insurance tax Individual and employer mandates

$50

Increase in Medicare payroll tax and application to investment income for high earners $25 Net investment tax $0

2016

2017

2018

2019

2020

2021

2022

2023 2024

2025 Source: Congressional Budget Office

SAN DIEGO PHYSICIAN.org

on them to fund healthcare access just lead to higher health insurance premiums. That is one reason that many Democrats have gone along with Republicans in delaying or suspending many of these taxes, including the HIT for this year. And now that it is clear that health insurance premiums within the ACA are careening out of control, taxing health insurers to the tune of $14 billion per year makes even less sense. I see a reduction if not a full repeal of this funding mechanism during the next administration, regardless of who the new president will be. Then there is the so-called “Cadillac Tax” on high-cost health plans, which actually has some merit — if done right — from a policy basis. The version in the ACA is projected to raise $200 billion in the 2020–29 time period, but it is very unpopular on a bipartisan basis (here both presidential candidates have actually already called for its repeal), and its start has already been deferred all the way to 2020. Ditto the medical device tax. Finally there are the entitlement cuts. The ACA was supposed to have cut nearly $500 billion out of Medicare by now, but it is hard to see where that has occurred and all the while, the Medicare Actuary still asserts that cuts of that magnitude will never take place. Medicare cuts in the next decade? Perhaps a few hundred billion over 10 years, albeit with some accounting sleight-of-hand and some skepticism based on the uncertainty about which payment reductions are due to the ACA rather than being due to any number of other Medicare policy innovations. There are a few other provisions in the ACA that may generate a few billion per year here and there, but the bottom line is that when one adds it all up, and mind you, we are using the gold standard of CBO projections, one is hard-pressed to find even $1 trillion in revenue for 2010–29, let alone $2.2 trillion. San Diego Physician: So what you are telling us is that when 2019 rolls around, the CBO will likely tell us that extending the ACA as-is for another 10 years will add more than $1 trillion to the national debt? Dr. Hertzka: Exactly.

august 2016

San Diego Physician: So what happens? Dr. Hertzka: I could only speculate and will not. But now that the CBO has updated their projections to reflect what has happened in the six years since the ACA was passed, what I can do is frame the essential question. San Diego Physician: And that would be? Dr. Hertzka: I will start by repeating the caveat that keeping your kids on a parents’ health policy until they are age 26 is not part of the discussion. It has resulted in an increase in everyone’s “family” premiums, but it requires no additional taxation and is a very popular provision of the ACA. But post-adolescents aside, the essential question is: “Will the American people support the continuation of the ACA in its current form when they realize that doing so for another decade will add over $1 trillion to the national debt, and that at least 90% of the beneficiaries of the program are people who make less than $20,000?” Now I don’t know the answer to that question. All I can state with certainty is that this new essential question is very different from the message of the ACA as signed in 2010, which was then asking the country to support a program that improved healthcare access for everyone in a budget-neutral way. San Diego Physician: OK. One last thing. You had mentioned that you took issue with some of the statements made by President Obama and The New York Times editorial board in their recent pieces. Can you elaborate on that a bit? Dr. Hertzka: Yes, I would be happy to do that. First I would point out a proACA piece from The New York Times editorial board is nothing new — they have been doing that consistently since 2009. But their piece that immediately followed the president’s JAMA piece really raised some eyebrows when they declared not only that the IE subsidies in the ACA should be increased, but that it could “be done at a modest cost paid for by slightly higher taxes, according to several experts.” This just stretches reality — to call for

an increase in the cost of the ACA when the existing ACA is on pace to soon have deficits of $100 billion a year is just reckless, and I know of no “expert” who believes that we can get rid of $3,000 deductibles without a substantial increase in ACA spending. As far as what President Obama wrote in JAMA, it has been criticized — and deservedly so — as a somewhat self-congratulatory opinion piece that is presented instead as a scientific article. Even the editor of JAMA has acknowledged that this piece was not fact-checked as much as other articles would have been, but because he and the executive editor read “many, many articles,” they “felt familiar with much of the data.” Well, I would suggest that the editors of JAMA read some more. I have already discussed one of the major analytic failings of the JAMA article, which is the president’s assertion that the ACA is “under budget.” Again, if you only have two-thirds of your projected enrollees, you had better come more than 20% under budget. And if you are not generating anywhere near the amount of revenue that you need, you are actually adding to the deficit, which is much more important than the spending side alone being “under budget.” The president proudly asserts that the uninsured rate has been dramatically lowered, but avoids any discussion of the fact that more than 90% of that reduction has come about from simply enrolling people for whom healthcare was made free or almost-free by the ACA. The president cites a single July 2015 article in Health Affairs to demonstrate significant improvements in personal health status post-ACA, but the improvements were really quite modest. If one is spending $800 billion on improved health access, a single survey that shows that “having a personal physician” rose from 62% to 65%, or having “easy access to medicine” rose from 83% to 85% are hardly gamechanging numbers. The president goes on to take credit for every positive current trend in healthcare cost control and healthcare quality improvement, but we do not have the time — nor does San Diego Physician have the space — to refute what are a long list of specific claims.

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I will just add one other specific error that the “fact-checkers” at JAMA missed, and it is a big one. The president asserts that “greater insurance coverage appears to have been achieved without negative effects on the labor market.” Wow — this is at best a controversial statement. A Google search of “Obamacare 29ers” will come up with at least 50 articles — from a wide ideological range of sources — that discuss the strong incentives for employers to keep workforces at fewer than 30 hours so as to avoid the ACA employer mandate to provide health coverage. And at a more elegant level, Casey Mulligan at the University of Chicago has written extensively about the incentives in the ACA for individuals to remain unemployed or to decline a pay raise because of the potential loss of significant healthcare subsidies. And the CBO agrees; they now project that by 2025 as many as 2 million people will either not be working or working less as a direct result of the ACA’s disincentives for work. Bottom line: There may have

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Will the American people support the continuation of the ACA in its current form when they realize that doing so for another decade will add over $1 trillion to the national debt, and that at least 90% of the beneficiaries of the program are people who make less than $20,000?

never been a social welfare program in the history of the country that has had a more negative effect on the labor market as has had the ACA. San Diego Physician: Thanks again for your time. We appreciate all of the time that you put into your health policy work as well as your health policy teaching at the UC San Diego School of Medicine; your students must feel fortunate to have you as their professor. And it looks like you will have your hands full if you stay engaged in this debate. Dr. Hertzka: I agree about the challenge, and I am happy to share what I have learned. But I would also encourage my physician colleagues — and others — to pay attention to this issue; I really believe that the notion of a permanent ACA along the lines of how it is currently structured is not a done deal. Note: For a list of references, please email Editor@SDCMS.org.

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classifieds PHYSICIAN POSITIONS AVAILABLE PHYSICIANS WORK FROM HOME: You choose your own shifts. We cover insurance and training in the use of medical cannabis. We take care of staffing, offices, and marketing. If you are a licensed MD or DO in the state of California and would like to find out more, please email yourvideomd@gmail. com or call (760) 703-3767 — include your phone number and CV or LinkedIn profile. [521] SEEKING SPINE SURGEON: California Orthopaedic Institute in San Diego is seeking a board-certified / eligible, fellowship-trained spine surgeon to join our successful seven-physician independent practice, covering all aspects of orthopaedic care and surgery. Please visit our website at www.califortho.com for more details on our group and subspecialties. We offer onsite MRI, PT, OT, and DME ancillary services and a separately owned and operated outpatient ambulatory surgery center is also onsite. Please contact Dr. William Tontz, Jr., at billtontz@gmail.com or on his cell at (619) 5784451, or contact Joan McComb, executive director, at (619) 291-8930, ext. 109. [520] PSYCHIATRIST NEEDED AS MEDICAL DIRECTOR FOR LARGE PSYCHIATRIC GROUP: Previous experience in correctional medicine preferred. Previous experience as a director preferred. Competitive compensation. Please contact steve@cpmedgroup.com or (619) 885-3907. [519] PSYCHIATRISTS NEEDED: Full-time or part-time positions available for a well-managed program at San Diego County correctional facilities. Telepsychiatry position also available. Flexible hours with very competitive pay. Send CV to steve@ cpmedgroup.com or call (619) 885-3907. [518] SEEKING EXPERIENCED, HIGHLY MOTIVATED FAMILY OR INTERNAL MEDICINE PHYSICIAN OR FNP: Federally qualified health center (FQHC) clinic site in Linda Vista seeks an experienced, highly motivated family or internal medicine physician with a vision for the future of community medicine. San Diego Family Care operates seven clinic sites in San Diego to serve the primary care needs of our diverse communities. PCMH model operational and EHR system in place. NCQA recognized. Visit our website at sdfamilycare.org. Must have CA license. Competitive salary/benefits with retirement match. Looking for a special doctor, committed to our mission! Send CV to Arthur “Tony” Blain, MD, MBA, FAAFP, Medical Director, at aablain@lvhcc. com or call (858) 248-1509. [516] SEEKING OCCUPATIONAL MEDICINE PHYSICIAN: Full-time, part-time, or independent contractor for busy workers’ compensation specialist practice. Located in San Diego. Competitive salary. Please email CV or direct any enquiries to Robynne McMurtrie, manager, at rmcmurtrie@davidkupfermd.com or call (858) 560-0242, ext. 101. [515] EMERGENCY (EMS) MEDICAL DIRECTOR: The County of San Diego invites qualified individuals to apply for the position of emergency (EMS) medical director. This unclassified management position will be responsible for ensuring efficient and timely delivery of quality emergency medical care via appropriate medical direction and monitoring of the County’s Emergency Medical Services (EMS) system operations and related support programs, such as pre-hospital services, trauma care services, and specialty care services. For more information about this position and to apply online, please

visit our website at www.sdcounty.ca.gov/hr. [514] LOOKING FOR FAMILY PRACTICE AND INTERNAL MEDICINE PHYSICIANS: Arch Health Partners, a top-rated, multi-specialty medical group located in San Diego, and a proud affiliate of Palomar Pomerado Health, is currently expanding. We are looking for physicians in both family practice and internal medicine. Arch Health Partners has been recognized by CAPG for Standards of Excellence five years in a row with three consecutive years of Elite status. Arch has also been recognized by the IHA as a Top Performing Physician Organization with our physicians’ overall performance score in the top 20% of participating groups statewide. If interested, please send your CV to Joyce Nagel at joyce.nagel@archhealth.org. [511] PHYSIATRIST (PHYSICAL MEDICINE & REHABILITATION): Seeking full- or part-time boardcertified physiatrist to join our privately owned orthopaedic surgery practice in San Diego. Position includes providing direct patient evaluation / care of spine and musculoskeletal cases, coordinating PMR services with all referring providers. Must have excellent interpersonal and communication skills. Existing CA license preferred. Interested parties email your CV in confidence to lisas@sdsm.net. [510] CLINICAL RESEARCH PHYSICIAN WANTED: Profil Institute for Clinical Research, Inc., is an early phase clinical research organization and innovator of research methodologies for diabetes and obesity. We are seeking a physician who will provide medical leadership, oversight, and management of human clinical trials while ensuring the integrity of the studies and the safety and wellbeing of human subjects. Must have current unrestricted license to practice medicine in the State of California. Experience in clinical trials and/or drug development preferred. For more information and to apply, please visit our website at www.profilinstitute.com/ careers/career-opportunities. [507] HIRING PHYSICIANS, NPs, AND PAs: Clinicas de Salud del Pueblo, Inc., is hiring Californialicensed physicians, nurse practitioners, and physician assistants. We are a successful and longstanding nonprofit organization that offers a full range of benefits, including excellent and competitive compensation. Our current need is to serve patients that live in the following communities: Blythe, Brawley, Calexico, Indio, and Mecca. It would be wonderful to hear from you. Please email us at work@cdsdp.org or call us at (760) 344-9951, ext. 120 or 121. [502] SEEKING FAMILY MEDICINE PHYSICIANS: Graybill Medical Group, an independent physician group of 80 + physicians, is seeking full-time BC/ BE family medicine physicians for its offices in Escondido, San Marcos, and Ramona. We offer a competitive compensation package and shareholder opportunity. Please send CV to Jackie Craw, Director Human Resources, via fax at (760) 738-7101 or via email at humanresources@graybill.org. [499]

August 2016

PER DIEM PHYSICIANS NEEDED: The County of San Diego Health and Human Services Agency is seeking physicians to work in sexually transmitted diseases (STD) clinics located in Old Town / Point Loma, City Heights, Chula Vista, and Oceanside. Applicants (MD or DO) must hold a current California medical license. Board certification in internal medicine, family medicine, or preventive medicine is desired but not required. Applicants must be comfortable discussing sexual health and working with diverse patient populations, and willing to work a minimum of three days per week. If interested, please email CV to winston.tilghman@ sdcounty.ca.gov or call (619) 692 8394. [496] PART-TIME URGENT CARE PHYSICIAN: Busy practice in El Cajon, established in 1982, seeks a part-time physician. Flexible hours, strong staff, and good compensation (based on experience). Please send CV to jeff@eastcountyurgentcare.com. [474] SEEKING A FOOT/ANKLE SPECIALIST: Well-established, highly respected, four-physician group, private practice in San Diego seeking a foot/ankle specialist. Our group is expanding to meet high volume of cases and planned expansion. Potential opportunity for any established subspecialist looking for a permanent practice location. We have a broad-based primary care referral base, mature EHR, digital X-ray, ultrasound, and DME program. Interested parties, please email your CV in confidence to lisas@sdsm.net. [461] PRIMARY CARE JOB OPPORTUNITY: Home Physicians (www.thehousecalldocs.com) is a fastgrowing 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) 9925330 or email CV to drhunt@thehousecalldocs. com. Visit www.thehousecalldocs.com. [037] PHYSICIANS NEEDED: Family medicine and pediatric physician positions currently available. Vista Community Clinic is a private, nonprofit, outpatient clinic serving the communities of North San Diego County, Riverside County, and Orange County. We have openings for full-time and part-time physicians. Current CA and DEA licenses required. Malpractice coverage provided. Full benefits packet. Forward resume to hr@ vistacommuntyclinic.org or fax to (760) 414 3702. Visit our website at www.vistacommuntyclinic. org. EEO Employer / Vet / Disabled /AA [912] OFFICE SPACE AVAILABLE

SEEKING CARDIOLOGISTS: Graybill Medical Group is seeking full-time interventional cardiologists and non-invasive cardiologists for its Escondido office. We have a significant patient base and offer competitive compensation packages. Please send CV to Jackie Craw, Director Human Resources, via fax at (760) 738-7101 or via email at humanresources@graybill.org. [498] FULL- AND PART-TIME FAMILY MEDICINE PHYSICIAN POSITIONS: North County Health Services (NCHS) • Job Title: Family Medicine Physician • Location: Multiple Locations • Job

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.

Status: Full Time and Part Time. We have several open family medicine physician positions. Must have active California state license (MD/DO), CPR, board certified or board eligible. Full benefits package, malpractice liability insurance included, CME allowance, and license reimbursement. NCHS is proud to be an equal opportunity workplace and is an affirmative action employer. Contact Araceli Mercado, www.nchs-health.org, araceli.mercado@ nchs-health.org, (760) 736-6780. [497]

OPERATING ROOM BLOCK TIME AVAILABLE MONDAY–SUNDAY: UTC / La Jolla area. AAAASF surgical suite with one OR and two-bed recovery. Exceptionally staffed, well-established, 20-year history, high-quality patient care. Competitive rates. Located directly off the 5 freeway in UTC area, close and convenient. Please call Tam at (858) 450-3377. [513] OFFICE SPACE FOR RENT WITH WELL-ESTABLISHED ORTHOPAEDIC PRACTICE: Located near Alvarado Hospital. Onsite digital X-ray. Ideal for specialties such as pain management, rheumatology, foot/ankle, spine. Interested parties, please email lisas@sdsm.net. [493] 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 base in the office and on the hospital campus. Please call (858) 455-7535 or (858) 320-0525 and ask for the secretary, Sandy. [127] 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] BUILD TO SUIT: 950SF 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 six gated parking spaces, two entryways, restrooms, lighted tower sign space. Build-out allowance to $10,000 for 4–5 year lease, rent $1,800 per month gross (no extras). 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 PSYCHIATRIC NURSE PRACTITIONER NEEDED: For part-time or full-time work at San Diego County correctional facilities. Flexible hours and very competitive pay. Send CV to steve@ cpmedgroup.com or call (619) 885-3907. [517] PSYCHIATRIC NURSE PRACTITIONER: University of San Diego (USD) has a full-time (11-month term) employment opportunity for a psychiatric nurse practitioner in the wellness area. In this position, the incumbent will provide psychiatric care in collaboration with the consulting psychiatrist to students at USD. Qualifications: Graduate of approved training program for graduate nursing program; Current, active California licensure as NP with specialty training as a psychiatric NP; Possession of a current valid CPR certificate is required; Current knowledge of drug and treatment protocols common to ambulatory care; Prior experience in university student health is highly desirable. Interested candidates may apply and submit a cover letter and resume to http://www. sandiego.edu/jobs/ (Job: IRC20994). [512] SEEKING NURSE PRACTITIONER: 2–3 days per week in busy IM practice in Kearny Mesa. Must have experience and be able to work independently. Please fax resume to Monica at (858) 2770690. [508] PHYSICIAN ASSISTANT / NURSE PRACTITIONER (BANKERS HILL): An opportunity for a physician assistant / nurse practitioner in pain management under the direction of the physician supervisor. Apply and modify the principles, methods, and techniques of medicine to provide comprehensive pain management, medical services, and procedures. Diagnose and treat a variety of injuries, chronic and acute pain symptoms. Provide leadership, direction, and coordination of all clinical activities involving professional medical judgment. Work closely with staff to ensure comprehensive quality patient care. This is a fulltime position; Monday–Friday, with competitive salary, sign-on bonus, retention bonus, and more. Please submit CV with cover letter to claudia. steinermd@gmail.com. [506]

vice and interpersonal skills, including outstanding verbal and written communication. Knowledge and understanding of EMR systems and MS Office skills are preferred. Experience with insurance companies, including IPAs, HMO, PPO, and work comp, and familiarity with billing and coding are ideal, but not required. Familiarity with back-office duties or medical assistant certification is an additional benefit. If interested, please forward your resume to office.mcmc@gmail.com. [505] HIRING PHYSICIANS, NPs, AND PAs: Clinicas de Salud del Pueblo, Inc., is hiring Californialicensed physicians, nurse practitioners, and physician assistants. We are a successful and longstanding nonprofit organization that offers a full range of benefits, including excellent and competitive compensation. Our current need is to serve patients that live in the following communities: Blythe, Brawley, Calexico, Indio, and Mecca. It would be wonderful to hear from you. Please email us at work@cdsdp.org or call us at (760) 344-9951, ext. 120 or 121. [502] NURSE PRACTITIONER: Needed for house-call 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] PHYSICIAN ASSISTANT OR NURSE PRACTITIONER: Needed for house-call physician San Diego. Part-time, flexible days / hours. Competitive compensation. Call (619) 992-5330 or email drhunt@thehousecalldocs.com. Visit www.thehousecalldocs.com. [038]

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P o e t r y and M e dicin e

You Say You’ve Lost Your Mother When you were young and tender Jilted by the crowd Your mother held you sweetly And said your name out loud You say you’ve lost your mother But that will never do A constant like no other Magnetic north to you. When you were young and tragic Battered by some storm Your mother’s common magic Would keep you safe from harm You say you’ve lost your mother She’s faded with the light Her image just dimmer Till she merged into the night When you were young and pensive And all your dreams stillborn Your mother softly grieved with you And helped you to be calm

You Say You’ve Lost Your Mother by Daniel J. Bressler, MD, FACP

Over the past year, the mothers of some of my closest friends have died. Some deaths came as the culmination of a long illness. Some were unexpected. Some deaths were seen by my friends as a blessing because their mother was terribly suffering. Some deaths seemed cruelly unfair. There are many polite phrases and euphemisms we use to talk about someone having died. Depending on your cultural and religious orientation, one might say “at rest” or “with the angels” or “left this earthly plane” or “at peace.” The one I hear most often from a bereaved survivor is “to lose” someone. Perhaps

august 2016

this phrase contains within it the implicit hope that the decedent will be found at some future time. This poem, dedicated to my friends and my patients who are bereaved, leaves a suggestion that their mothers can, in fact, be found already. Dr. Bressler, SDCMSCMA member since 1988, is chair of the Biomedical Ethics Committee at Scripps Mercy Hospital and a longtime contributing writer to San Diego Physician.

You say you’ve lost your mother Just her time to go Perhaps you still might find her Within the sun’s last glow When you were young and rootless Bewildered and forlorn Your mother would appear to you And steer you safely home You say you’ve lost your mother That she is gone for good Let’s hope that you’re mistaken Some words misunderstood When you were young and arrogant Spreading boasts around Your mother gave you gravity And drew you back to ground You say you’ve lost your mother That she has gone away She’ll never arm-in-arm with you Nor call from far away But you’re no longer fragile Long flown from childhood woe Your mother’s work long over She chose her time to go You say you lost your mother But that will never do An ingenious undercover Your mother lives in you

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