SCCMA Physicians Participate in Water Reuse Symposium with EPA

Dr. Ken Yew and Dr. Santosh Pandipati attended the WateReuse 2023 Symposium this spring in Atlanta where they participated in a panel discussion, “Water and Health: A Physician Looks at Water Reuse (CA)” on the topic of water reuse, health professional’s perspective and its importance to public acceptance.

The WateReuse Association is dedicated to advancing laws, policy, funding, and public acceptance of recycled water. WateReuse represents a coalition of utilities that recycle water, businesses that support the development of recycled water projects, and consumers of recycled water. Their goal is to increase safe and reliable water supplies.

With support from Valley Water, the US Environmental Protection Agency (EPA) and the Centers for Disease Control and Prevention (CDC), SCCMA physicians wrote a series of articles in 2022 about “Water and Health,” focusing on Valley Water’s Purified Water Project.

The reception to the article series and panel presentation led to discussion about where the work on water reuse might go next, including continued EPA-SCCMA partnership, a possible American Medical Association (AMA) resolution, pollution prevention, medical education, and a possible WRAP item.

EPA-SCCMA Partnership

EPA representatives appreciated that this is the first partnership developed between the Agency and a group of practicing physicians in support of water reuse. The value of this partnership is enhanced by the emergence of regulations regarding the use of recycled water for direct potable reuse which will be emerging, state by state, over the next several years. SCCMA representatives acknowledged that given the role of physicians in responding to environmental health impacts, it is appropriate for EPA and medical associations to work together.

AMA Resolution

The group discussed the value and feasibility of obtaining a resolution from the AMA advocating the use of recycled water as a mitigation for the impacts of climate change for the benefit of public health.

• SCCMA representatives offered to update CMA Resolution 118a-12 adopted in 2012 by the CMA advocating for water reuse, and to propose it for consideration by the CMA at the next meeting of the House of Delegates. The update places the benefits of recycled water in the context of the impacts of climate change and the need to ensure that adequate supplies of clean water are available to the public. Dr. Yew submitted the resolution on the CMA website after getting the endorsement of the SCCMA council and District VII delegation.

• If passed, the resolution could then be forwarded to the AMA Technical Advisory Board (TAB) for consideration as a national resolution. EPA would be willing to provide the TAB with technical background information to support the resolution.

• If the resolution is passed, it would be up to the AMA to bring their position to individual legislators. At that point, it might be possible for the AMA and the EPA to issue a joint statement about the importance of water reuse to mitigate the impacts of climate change in support of public health.

Pollution Prevention

• SCCMA representatives pointed out that any resolution that went forward to EPA would likely include an acknowledgement of the importance of pollution prevention in protecting both conventional and recycled water supplies.

• EPA representatives pointed out that pollutants in drinking water are regulated out of the Office of Groundwater and Drinking Water (OGDW) which is out of their direct purview (as leaders of the Water Reuse Action Plan, or WRAP). They also noted that the Toxics Safety Control Act (TSCA), which establishes the rules for the use of potential pollutants, will not be reopened until 2024, at which point the SCCMA could submit comments. In the meantime, their involvement would be limited to discussion of recycled water. In short, if the resolution focused on pollution prevention, it would not likely receive a formal endorsement from EPA. However, if it simply specified that “AMA (or CMA) endorses the use of advanced water purification for the purpose of potable reuse as a means of adapting to climate change” EPA may formally support it. In that case, the resolution may also need to acknowledge that potable reuse is only appropriate when wastewater is properly treated to meet state regulations.

• SCCMA and EPA identified this issue as a topic for further discussion.

Medical Education

The group discussed the importance of providing medical professionals with accurate and relevant information about water and health, including recycled water, during medical training.

• SCCMA representatives acknowledged that “environmental health is just starting to get into the medical schools” and offered to speak with the American College of Graduate Medical Education about possible distribution of the information through their organization.

• EPA representatives offered to produce a webinar on “Water and Environmental Health.” They could collaborate with SCCMA and others to develop other appropriate webinars on recycled water that might be attended by (and later distributed to) interested health professionals, which might focus more on chemical pollutants in water rather than the pathogens which are the focus of much of the current discussion of recycled water. In short, EPA would develop a webinar that could be used in medical schools that have an environmental health curriculum.

• SCCMA representatives offered to contact Dr. Robert Gould who works with UCSF Medical School about their environmental health program and promote the SCCMA Bulletin Special Issue to other county medical associa- tions.

New WRAP Action Item

EPA and SCCMA representatives agreed to develop and propose an Action Item that would comprehend the recommendations with respect to a webinar on water and health geared towards health professionals and an AMA resolution endorsing water reuse.

• General language for a WRAP Action Item was proposed:

• Engage the medical community to communicate the risks and benefits of water reuse.

Objectives:

1. Develop a webinar on toxic and microbiological risks to drinking water and available treatment methods for use in medical schools.

2. Develop and promote resolutions suitable for adoption by state and national health associations supporting the use of recycled water as an appropriate addition to public water supplies to enhance community resilience.

3. Encourage medical associations and other health institutions to consider the SCCMA “informed consent” model for presenting information about water use to their communities.

Source control regulations continue to be a concern for the physicians. Simply treating water for reuse is like focusing only on treating an acute illness. Prevention is a big part of medicine, and similarly, for clinicians, source control has to be in the discussion. The Environmental Health Committee with continue to discuss, share and support this momentum.

Wealth Management

The 2023–24 health budget trailer bill renews the state’s Managed Care Organization (MCO) Tax and provides the largest Medi-Cal rate increase in California history, ensuring that millions of Californians have greater access to affordable, high-quality, life-saving health care.

Investments in the state’s health care infrastructure will make meaningful strides toward achieving justice and equity by fulfilling Medi-Cal’s promise of access to health care for the more than 14 million Californians – including 6 million children – who rely on the program for their health care.

The California Medical Association (CMA) and other members of the Coalition to Protect Access to Care have been working together over the past few months to ensure that this generational opportunity to make critical and meaningful investments in the Medi-Cal system and shore up our health care delivery system is realized.

The coalition’s goal has been to ensure that Medi-Cal enrollees have the same access to care as those with commercial insurance, and that providers can afford to treat their communities as they present themselves – without worrying about the financial solvency of their practice.

Background

+ Medi-Cal provides essential health coverage to one in three Californians and is foundational to the state’s health care delivery system and economy. In fact, 50% of California children are born into Medi-Cal, making it an essential program for preventive and routine care for children.

+ Medi-Cal provider rates have not increased in more than a decade, and for most physicians it’s been more than 25 years – leaving millions of patients insured, but without meaningful access to health care. Patients with Medi-Cal coverage routinely wait weeks or months for appointments, and oftentimes must travel long distances to receive care.

+ Thanks to a series of Medi-Cal expansions, universal health care coverage will soon be a reality in California, a goal CMA has long advocated for. To fulfill California’s commitment to health care access and equity, we must ensure that the remarkable gains we’ve had expanding health care coverage actually translate to improved access to care for Californians.

+ It has been clear for quite some time that the state needs a new, ongoing revenue stream to improve access for Medi-Cal beneficiaries in a sustainable manner.

+ Historically, California has used the MCO Tax to draw down federal funding and help support the state’s General Fund, but the last MCO Tax expired at the end of 2022. While that revenue stream was used to backfill General Fund obligations, the state was not obligated to use it to increase funding for health care programs.

Over the past several months, CMA and the coalition have advocated to reinstate and increase the MCO Tax and use this important financial mechanism to directly increase access to health care by increasing the funding for Medi-Cal providers to provide care to millions of patients in a variety of care settings.

The New Mco Tax

In a win for physicians and patients, the 2023–24 health budget trailer bill incorporates key pieces of the coalition’s proposal, including an increase to Medi-Cal provider rates for the first time in more than two decades.

THE MCO TAX PLAN IN THE BUDGET TRAILER BILL INCLUDES:

Medi-Cal Rate Increases

PRIMARY CARE

+ Starting in 2024, the budget trailer bill increases provider rates to at least 87.5% of Medicare for primary care, maternity care and non-specialty mental health services.

+ Starting in 2025, an additional annual appropriation of $1.38 billion will be directed to primary care providers in the Medi-Cal program to support the comprehensive services that protect and promote beneficiaries’ overall health.

SPECIALTY CARE

+ Starting in 2025, the bill includes $1.15 billion annually to increase Medi-Cal rates for specialists, which will increase access to care and decrease wait times.

Emergency Services

Emergency Department Access

+ Starting in 2025, the bill includes an annual appropriation of $700 million to be used to support inpatient facilities, most notably through hospital emergency departments, including $200 million to go toward rate increases for emergency physicians seeing Medi-Cal patients in emergency departments.

Ground Emergency Transport

+ Starting in 2025, $100 million annually will be directed to support 911 emergency ground providers and increase staffing capacity to help address increased workforce challenges.

Health Care Workforce

INCREASE GRADUATE MEDICAL EDUCATION

+ Starting in 2024, an additional $75 million will be allocated annually to increase residency slots for primary and specialty care and expand the number of residency programs in California.

WORKFORCE

+ Starting in 2025, $150 million annually will be allocated to grow the health care workforce.

Hospitals

STABILIZE AND INCREASE INPATIENT PSYCHIATRIC BED CAPACITY

+ Starting in 2025, $600 million annually will go toward increasing the number of inpatient psychiatric beds and funding additional care for the severely mentally ill.

PUBLIC HOSPITALS

+ Starting in 2025, $150 million annually will go to increase access to care at public hospitals.

DISTRESSED HOSPITALS

+ The 2023-24 budget includes a one-time allocation of $150 million to the Distressed Hospital Loan Fund.

+ The 2023-24 budget includes a one-time allocation of $50 million for small and rural hospital relief for seismic assessment and construction.

Reproductive Health Care

PROTECT FAMILY PLANNING AND ABORTION ACCESS

+ At least $500 million will be directed to family-planning related services in both Medi-Cal and FPACT and to abortion services.

Next Steps

CMA will continue to remain engaged as implementation details are worked out over the next months and years, and will continue to advocate on behalf of physicians to ensure the funding flows efficiently to providers.

cmadocs.org/access

By Marcia Daszko

Many organizations struggle because they cannot get enough applicants to interview and hire. Once they hire people, they often don’t engage with, appreciate or retain them. Why not?

The Reality. It is true that baby boomers left the workforce in millions. That was no surprise; leaders could anticipate that (but did they?), and crisis times accelerate it. If possible, people choose not to work full-time or in unfriendly work environments; that’s also driven us to the current unemployment rate. But there are many organizations that are booming, and they can hire and retain their talent.

What’s the difference? Why do some organizations have high turnover and others have virtually none?

There are three major reasons. Assess your organization (or better yet, hire someone who can objectively assess it, and give you a rapid perspective based on systems-knowledge from the outside.) Understand the root causes to your employment challenges; create a plan to address them. What is the status of your three variables: leadership, communication, and culture?

Three key strategies can create the workforce you need. Develop and optimize these three systems: leadership continually transforming; effective two-way communica- tion, and a learning focused on continual improvement and innovation to serve your customers.

Leadership. Leaders create the workplace where all staff flourish. It’s where they are self-motivated, appreciated, and can contribute to the compelling Aim or Purpose for the organization. Values are defined and taught, both verbally and behaviorally. Leaders invest in developing their employees. If you’re not continually communicating, educating, and coaching your employees, your organization is in decline. The leadership team creates the system that the staff works in. It must be work-able!

Communication. The leader’s significant role is to communicate, especially in a crisis or uncertain times. He/she communicates clearly and often! Again, leaders create and clearly and repeatedly communicate the aim and the values (in behavior.) Use every method possible to share your messages, direction, and vision. Use Zoom, emails, newsletters, the Intranet, town hall meetings, social events, etc. to repeatedly tell your stories.

Watch for inconsistencies between your values and the vocabulary and actions people use. For example, most companies have a stated value such as teamwork or collaboration. But what practices counter that and are barriers to teamwork? Do you have performance appraisal systems where you rank, rate, judge and criticize people? Then do you tie the appraisal to the compensation system? Nothing erodes teamwork faster than internal competition and team members who can’t trust each other!

Culture. The leader creates the workplace culture. Does your work environment attract new employees? Is your company the place new graduates want to work after graduation, or get excited to go to work, or have an engagement score of over 80 or 90%? What creates a workplace you want to be proud of for the work you do, the peers you support, and the customers you serve? What kind of culture do you want? What do you want to be known for? Quality, fun, speed, dependability, safety? You select it and focus your priorities and activities, so they are consistent with that? Can you imagine if Southwest Airlines hired some of its flight attendants who are shy, introverted, impatient and intolerant? Instead, they are well known for providing a safe, fast, fun experience. They hire and train for the culture they want their customers to also experience.

The foundation for hosting a healthy workforce are these three elements. There are inter-related, inter-dependent, and all connected.

One More Significant Tip for a Stable, Engaged Workplace: People speak, advise, coach, consult, and train to address employment issues in the workplace. Topics include employee engagement; retaining your staff; recruiting and interviewing tips; onboarding; training; mentoring and coaching. There are numerous speeches and workshops! Companies spend millions of dollars to lower their turnover rate. But often there is little impact. Why don’t organizations achieve the results they want? (Their “parts” approach is ineffective.)

The answer is easy! The implementation is a little more challenging, but easily do-able. The above topics are all parts of the system that must flow together. They are All interconnected. Each one relates to the other processes. If they all don’t flow, the system breaks down, and the result is sub-optimal: high turnover or disengaged employees.

For example, if you recruit and interview great candidates, but the hiring system is slow and tedious, you’ll lose the applicants and start over. Research shows that candidates in the current job market expect an offer with a week, at most two weeks (and you take a chance they’ve accepted another offer.) Or if you hire great candidates, but you don’t onboard, train, or mentor them, they’ll realize you don’t plan to invest or develop them, and they’ll move on.

If you want great results, leaders must create and lead an optimal system. The processes, all working together for one aim, make up your system. People work IN the system and continually work to improve the flow. Are you getting the results you want? If not, look at the system. Look at all the processes that must connect in your system.

About the Author:

Marcia Daszko is a board and executive management consultant, speaker, and bestselling author of PIVOT DISRUPT TRANSFORM: How Leaders Beat the Odds and Survive. She can be contacted at md@mdaszko.com.

Dr. Santosh Pandipati acknowledges that our American healthcare delivery system is broken, ranking 55th in the world in maternal mortality despite spending $100 billion annually on pregnancy and newborn care. “Relying on an outdated prenatal practice model that is nearly 100 years old has exacerbated significant inequities in maternal, perinatal, and neonatal outcomes as well as having contributed to rampant clinician burnout,” says Dr. Pandipati. Indeed, ACOG estimates a shortage of nearly 10,000 OB/GYNS currently, that will swell to over 20,000 by 2050. He is focusing the second half of his career to seeking, innovating, and implementing new solutions to fundamentally transform maternal care delivery. This has culminated in the birth of his startup, e-L ōvu Health. “At e-L ōvu Health, my co-founders and I are leveraging the best of emerging technologies to wrap a digital care blanket of holistic services around expectant patients. With frequent human interaction augmented by AI-driven insights, we can finally provide personalized pregnancy and postpartum care, restore access and reduce inequities, all the while generating valuable information to expectant mothers as well as to their clinicians that can finally improve our abysmal perinatal outcomes.”

Dr. Pandipati received his medical degree from the University of Michigan, where he was elected to the Alpha Omega Alpha Honor Medical Society. He completed his OB/GYN residency at the University of Washington Medical Center in Seattle. There, he was asked to serve as administrative chief resident. During residency, he was selected as the Best Teaching Resident for medical students. Subsequently, Dr. Pandipati completed his maternal-fetal medicine fellowship at the University of Colorado Health Sciences Center in Denver.