September/October 2019

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

THE SFMMS ELECTION SLATE - VOTE! PLUS: The Vaping Battles: NO on Proposition C! Expanding Access, Equity, and More: An Interview with Dr. Sandra Hernandez – And much more

ELECTION ISSUE Introducing SFMMS’ New CMA President Volume 92, Number 5 | September / October 2019

SAN FRANCISCO MARIN MEDICINE

IN THIS ISSUE

September/October 2019 Volume 92, Number 5

ELECTION ISSUE FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President’s Message: Our "Lane" is a Wide and Rewarding One Kimberly L. Newell Green, MD

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CMA's Best Year Ever Coming!

Peter N. Bretan, MD, FACS CMA Federal Update Elizabeth McNeil

24 SFMMS Interview: Sandra Hernández, MD

Steve Heilig, MPH

30 Preventive Medicine is Uniting Against Vaping

Brandon Yan

32 San Francisco Banning e-Cigarettes is a Model

for the Nation

John Maa, MD and Jeffrey Wigand, PhD 34 Medicare for All: A Voter's Cheat Sheet

James G. Kahn, MD and Elliot Marseille, DrPH

37 Surprise Medical Billing Needs to be Reined in the Right Way

Kimberly L. Newell-Green, MD and

Mary Lou Licwinko, JD, MHSA

44 Upcoming Events

OF INTEREST 23 Marin County Vaccination Rates are its Highest Ever 23 Buprenorphine: An Overview for Clinicians Scott Steiger, MD and Triveni DeFries, MD

27 Healthy Harbors for All Californians: Addressing Health Consequences of Immigration Policies 33 CMA Announcement: CalMedForce GME Grants 38 CMA FAQ: When am I required to Offer Naloxone to Patients?

39 Welcome New SFMMS/ CMA Members 44 Advertiser Index

SFFMS ELECTION 2019: 8

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Candidate for CMA Vice-Speaker of the House of Delegates Lawrence Cheung, MD 2019 Slate of Candidates

SFMMS 2019 Leadership Election Information

SAN FRANCISCO

MARIN MEDICAL SOCIETY

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

MEMBERSHIP MATTERS Record Attendance at SFMMS General Membership Meeting More than ninety SFMMS members attended the General Membership Meeting held at the Golden Gate Yacht Club in San Francisco on September 9, 2019. Featured speakers included San Francisco Mayor London Breed who spoke about her health policy priorities, and California Medical Association (CMA) President, Dr. David Aizuss. Attendees, including physicians, residents, and medical students mingled with each other and with SFMMS leaders. Long-time SFMMS Executive Director/CEO Mary Lou Licwinko announced she will be retiring at the end of the year (read more at http://bit.ly/2kX3tE8).

AMA/CMA Endorse No on Prop C SFMMS leaders were pleased to announce at a recent press conference that in addition to the CMA, the American Medical Association (AMA) now officially opposes Proposition C, the San Francisco ballot measure submitted by Juul, the e-cigarette company. This has been a long process that started when San Francisco Supervisor Shamann Walton and City Attorney Dennis Herrera first wrote city legislation prohibiting e-cigarette sales until the FDA completes its evaluation of e-cigarettes as medical devices. City supervisors subsequently passed the legislation unanimously and it was signed by Mayor London Breed.

Juul then gathered the requisite number of signatures and submitted a pre-emptive measure that became Proposition C. SFMMS wrote a resolution supporting Supervisor Walton's legislation and submitted it to the CMA. The CMA Council review recommended weakening of the original language but with intensive lobbying, we were able to preserve the original language and the CMA has now endorsed No on Proposition C. The AMA initially declined endorsing No on Proposition C, but again with persistent lobbying by the SFMMS, we were able to persuade them to reconsider. This is an illustration of the important influence of your SFMMS Delegation on building health policy.

SFMMS Delegate Zarah Iqbal, MD said, “I’m so proud to be part of SFMMS, an organization that is always leading the way in public health!” Read the AMA’s letter at http://bit.ly/2moVSyt.

At press time, Juul has ended its support of Prop C and will not put any additional money into the Prop.

C campaign, although it will remain on the ballot.

Juul is the sole funder of the measure. Read more at http://bit.ly/2mHzUY6.

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Governor Signs CMA-Sponsored Bill to Prevent Fraudulent School Vaccine Exemptions Governor Newsom recently signed Senate Bill 276 into law, which will prevent fake medical exemptions and require state oversight of medical exemptions for vaccines required to attend public schools, private schools and day care centers. The bill—authored

by Senator and pediatrician Richard Pan, M.D., and sponsored by the California Medical Association (CMA)—will require physicians to submit information to California Department of Public Health (CDPH), including the physician’s name and license number and the reason for the exemption, which CDPH will check to ensure they are consistent with the Center for Disease Control’s guidelines or standard of care. The physician must also certify that they have examined the patient in person. Additionally, CDPH will create and maintain a database of medical exemptions. CDPH will have the authority to revoke medical exemptions granted by licensed physicians if they are found to be fraudulent or inconsistent with the standard of care. This authority will give the state public health officer the tools necessary to contain and prevent further outbreaks of infectious disease. Read more at http://bit.ly/2kTEBgx.

Legislature Passes CMA-Sponsored Bill to Require Payment for Telehealth Services

The California Legislature approved a California Medical Association (CMA)-sponsored bill to increase patient access through telehealth. The bill (AB 744, Aguiar-Curry) will require health insurers to cover services provided via telehealth in the same way they would an in-person encounter. Telehealth overcomes access and cost barriers by utilizing technology to better harness physician time and expertise, and connects patients to their care providers more quickly, efficiently and conveniently. Studies have demonstrated that telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings. As of this publication date, the bill now heads to Governor Newsom for his signature. Read more at http://bit.ly/2mvZVca.

Proposition 56 Funds: What’s New for FY 19-20 and Beyond

On June 27, 2019, Governor Newsom signed his first state budget, which included significant new funding for health care programs. The funding – made possible by the Proposition 56 tobacco tax – continues the increased payment on 23 CPT codes, including 10 preventive codes, in both the fee-for-service and WWW.SFMMS.ORG

Medi-Cal managed care delivery systems. The budget also includes the following new funding from Prop 56 (and the corresponding federal match): • $544 million for the Medi-Cal Value-Based Payments Program, with

$140 million specifically earmarked for behavioral health integration • $105 million to fund supplemental payments for developmental and

trauma screening • $60 million over three years to train providers to conduct these screenings • Additional $120 million one-time funding for the physician and dentist

loan repayment program (CalHealthCares)Read more at http://bit. ly/2mUxXak.

Altais Teams Up With Aledade and CMA to Offer Unique Patient Care Model Supported By Innovative Technologies

Altais has entered into a collaboration with Washington D.C. area-based Aledade, Inc., and the CMA, to improve patient care and outcomes. The initiative will bring innovative workflow technology and services to physician practices, helping doctors and their staff to focus their efforts on delivering higher quality, affordable care to their patients. The organizations will also work with payers in the state to offer value-based arrangements that reward physicians for improved patient care and outcomes. Blue Shield is the first payer that has agreed to support this collaboration by making a value-based agreement available to physicians working with Altais and Aledade sometime in 2020. Read more at http://bit.ly/2mvH9C4.

September/October 2019 Volume 92, Number 5 Editor Gordon L. Fung, MD, PhD, FACC, FACP Interim Editor Irina deFischer, MD Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Kimberly L. Newell Green, MD President-Elect Brian Grady, MD Secretary Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President John Maa, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA

SAN FRANCISCO

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Associate Executive Director, Public Health and Education Steve Heilig, MPH

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion health care initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone.

Join SFMMS/CMA Today to Receive 15 Months of Membership for the Price of 12 Starting October 1, 2019, new members who join paying full 2020 dues, will receive the remaining months of 2019 membership for free. Join today to start receiving your benefits. Visit www.sfmms. org/membership for more information about SFMMS membership and benefits, or to join online.

Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received by December 15, 2019. Renewing is easy: 1. Mail/fax your completed renewal form when you receive it in the mail; or

Associate Executive Director, Membership and Marketing Erin Henke Membership Coordinator Lynne Deepe Manager, Operations & Administration Ian Knox 2019 SFMMS BOARD OF DIRECTORS Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen N. Kumar, MD Michael K. Kwok, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD William T. Prey, MD Justin P. Quock, M Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD

2. Renew online at www.sfmms.org with a credit card. *5% Early Bird Discount applies to 2019 full dues-paying members only who are renewing at same level for 2020; renewal form and payment must be received by December 15, 2019.

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PRESIDENT’S MESSAGE Kimberly L. Newell Green, MD

OUR "LANE" IS A WIDE AND REWARDING ONE “It’s possible to imagine a new organization of doctors that has ... everything to do with promoting the health of patients and adroitly confronting the transformational challenges that lie ahead for the medical profession. Such an organization wouldn’t be a trade guild protecting the interests of doctors. It would be a doctors’ organization devoted to patients.

Its top priority might be restoring the human factor—the essence of medicine—which has slipped away, taking with it the patient-doctor relationship. It might oppose anti-vaxxers; challenge drug pricing and direct-to-consumer advertisements; denounce predatory, unregulated stem-cell clinics; promote awareness of the health hazards of climate change; and call out the false health claims for products advocated by celebrities such as Gwyneth Paltrow and Mehmet Oz. This partial list provides a sense of how many momentous matters have been left unaddressed by the medical profession as a whole. Tackling any one of them would be hard; perhaps patient-advocacy groups could join in common cause.”

– Eric Topol, MD, "Why Doctors Should Organize." The New Yorker, 2019 As I read Topol's article in the New Yorker, I couldn’t help but feel excited and proud yet again by the work I am privileged to do with the San Francisco Marin Medical Society. This amazing group of physician leaders, supported by

an astounding staff, embodies the vision that Dr. Topol articulates: We are doctors “organized for the common good.”

In this “Elections and Politics” issue of San Francisco Marin Medicine, one of our primary goals is to list the talented and passionate physicians who have agreed to run for the chance to help lead the group in our important work, and I am grateful to them all for stepping up. It's now your turn to vote on them.

We also get insights into some of the vital work being done on the policy front. We turn to Dr. Sandra Hernandez, a longtime warrior in the healthcare realm and the President and CEO of the California Healthcare Foundation, for an update on issues in health policy. We have updates on hot topics such as "Medicare for All," substance abuse and the use of naloxone and buprenorphine. We get an update on Marin vaccination rates: Medical exemptions and vaccines provide a fascinating story of how legislation can improve the health of the public, and how that legislation may need to be updated over time.

A physician/legislator, Senator Richard Pan, has led they way here, with CMA as an ally the whole way.

Drs. John Maa and Jeffrey Wigand write an update on the battle against Big Tobacco in the guise of Proposition C, and I can report that my own involvement with the "No on Prop. C" campaign has been fascinating. Standing with some colleagues on the steps of City Hall with Lieutenant Governor Eleni Kounalakis and a handful of our city supervisors in a press conference to encourage citizens to Vote No on Proposition C, I was buoyed by the impact that the voices of physicians can have. I was then humbled in a Chamber of Commerce meeting when up against the adeptness of the slick, well-paid consultants from Juul. The money available to some of the forces against us is astounding, making it even more important that we train WWW.SFMMS.ORG

an army of physicians with the communication skills necessary to prevail in the room with such adversaries.

It is my hope that we can convince you to join us, to be a part of this vital force for good that we, as physicians, can become if we are well organized. Please come and fight the good fights with SFMMS. Join the many physicians who are active leaders - if you are not on our slate for this year’s election, contact us to be considered for next year and in the meantime, come and join us at our events, reach out to find out about joining a committee or hear about other ways to get involved. There are many other ways to confront the transformational challenges that lie ahead in medicine and health: run for office, work in healthcare administration, or join the teams building the technology that will help us do the work we want to do rather than the work the business people want us to do.

Just last year, gun lobbyists told physicians to shut up about gun violence and to "stay in your lane." But so many people do look to medicine for leadership on issues impacting both public and private health. And as Dr. Topol says, “We have a chance to affect the future of medicine; to advocate for patient interests; to restore the time doctors need to think, to listen, to establish trust, and build bonds, one encounter at a time.

For these purposes, and in these times, an organization of all doctors is necessary. Rebuilding our relationships with our patients: that is our lane.”

Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at UCSF. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team. A graduate of Princeton University, she completed a Fulbright Fellowship in India and produced a documentary film about cross-cultural healthcare at the Harvard School of Public Health.

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CMA’S BEST YEAR EVER COMING! Peter N. Bretan, MD, FACS President-Elect of CMA

As I prepare to become your next President of our CMA, I am very much aware of some of our major accomplishments just in the past year. Here are just a few.

Proposition 56, passed in 2016, imposed a $2/pack tax on tobacco products. It generated about $1.3 billion per year. More than $500 million (which is matched by federal funds) was allocated for increases in payment to physicians for Medi-Cal services. California physicians greatly needed this as about one-third of all Californians and one-half of all children are covered under Medi-Cal. Physician payments have gone up over 33% this year and access has increased.

Another $40 million has been allocated to GME through residency programs (primarily for primary care and emergency physicians). Proposition 56 also provides funds ($190 million) for medical student loan repayment for those physicians practicing in underserved areas with at least 30% of their practice dedicated to Medi-Cal patients.

These programs are administered through CMA’s Physicians for Healthy California (PHC), greatly increasing our importance in increasing access.

CMA helped pass legislation to increase vaccination rates to protect community immunity in California, which has led to a national trend of states seeking to strengthen their laws around vaccination. Inappropriate exemptions were diminishing these gains. SB 276 requires that medical exemptions for vaccinations only be obtained by a Public Health Department physician, and eliminated other exemptions. CMA helped pass this bill despite intense anti-vaccination opposition.

Those are just two of many contributions. It was not long ago that CMA membership was rapidly declining and our organization was seen by some as becoming “largely irrelevant.”

But planning retreats started in 2011, the board and leadership developed several short-term strategies to turn the tide.

Since then CMA has succeeded with implementation of many of these strategies such as developing a stronger staff culture, expanding member services, and protecting MICRA by defeating Proposition 46 in 2014, which significantly increased CMA’s visibility. The decreasing membership trends have not just reversed, but growth has been greatest in the past 3 years and is projected to break 50,000 next year, making CMA the largest state medical association in the country.

In addition, CMA has begun to build a physician wellness

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program to help support physicians’ professional fulfillment and to lessen many of the institutional causes of burnout. In order to help preserve independent physician practices, CMA is developing practice support tools to maintain and increase physicians’ ability to choose how they want to practice. Aledade is a Bethesda, MD based company that helps launch physician-led accountable care organizations (ACOs) and has partnered with CMA to launch a California ACO. As precedent, the Texas Medical Association has been involved with ACOs and currently has over a quarter million lives covered around Texas, generating “shared savings" for their participating physicians. It is projected that CMA and Aledade will surpass these significant shared savings.

Additionally, Blue Shield of California’s new company Altais has partnered with CMA and Aledade to also offer independent doctors and practices tools to improve patient health outcomes. This will enable our California physicians to focus on care instead of administrative tasks.

With the momentum that has been built, complacency is a risk. CMA intends to counteract this by updating its strategic planning, which has involved months of meetings this year with highly engaged conversations with CMA’s stakeholders and our component medical societies’ leadership. The distillation of specific strategies are being fine-tuned by our Board of Trustees and a report is forthcoming.

I believe that we must be bold, but with constant analysis to bring us successfully through this uncharted territory. We must think big, start small and be flexible as our experiences grow.

We can no longer separate the business of medicine from our practice of medicine. We must oversee the whole practice of medicine in the context of how it must function for all, including for the homeless. We must take a comprehensive view of healthcare, including the costs of not providing vital services to those in need. If we accomplish these goals, then we can truly attain sustainable universal access to healthcare for all California patients, developed and led by their physicians.

Finally, we must continue to ensure a vibrant, diverse physician pipeline, including new innovators in medical practice tools and resources, that lead to not only quality care but also physician engagement and wellness. I look forward to developing, implementing and evolving these CMA goals with all of you.

May this be our CMA's finest year!

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CMA FEDERAL UPDATE Elizabeth McNeil, Vice-President for Federal Government Relations, California Medical Association I. LEGISLATION Surprise Medical Bills Legislation CMA is fully engaged in the federal surprise medical billing legislation that would apply to all ERISA SelfInsured Employer Plans not regulated at the state level.

CMA is opposing legislation that mirrors the California surprise billing law.

While the California law protected patients from surprise bills, it has not incented insurers to contract with physicians.

Insurers across the state are refusing to renew longstanding contracts or imposing significant payment cuts which is diminishing physician networks and jeopardizing access to physicians. The California law is reducing access for patients to in-network physicians and harming access to on-call physician specialists needed in medical emergencies. Instead, CMA is urging Congress to support a bipartisan CMA-sponsored bill, H.R. 3502 “Protecting People from Surprise Medical Bills Act,” authored by California physician Congressman Raul Ruiz, MD (D-CA) and Congressman Phil Roe, MD (R-TN). It is modeled after the proven, successful surprise billing law in New York State that has protected patients from surprise bills, incented insurers to contract with physicians resulting in more stable networks, allowed a baseball arbitration process with a payment benchmark of the 80th percentile of billed charges from the independent FAIR Health database, and has not increased costs. Premiums in New York are not rising as quickly as the rest of the nation.

All of organized medicine is unified in support of the Ruiz-Roe legislationRecently, the U.S. Senate Health, Education, Labor, and Pensions Committee adopted on a bipartisan basis a surprise billing bill that protect patients from surprise medical bills but sets a benchmark payment rate for out-of-network services provided in in-network facilities at the median in-network rate. The bill does not include arbitration, an independent databases of in-network rates, or network adequacy requirements. The CMA, AMA and all of organized medicine strongly opposed the bill. During the Committee mark-up several members expressed concerns with the bill and urged the Chairman to continue to work to find a better compromise. The surprise billing provisions were part of a much larger package of health care related bills. Since its passage, ten Senators have placed a “HOLD” on the legislation so it cannot move to the floor for a vote until a compromise can be reached.

Three committees in the U.S. House of Representatives have jurisdiction over this issue. The Ways and Means Committee, the Energy and Commerce Committee and the Education and Labor Committee. The House Energy Commerce Committee’s Health Subcommittee recently adopted a surprise billing provision that mirrors the Senate HELP Committee proposal except it sets the median in-network rate at 2019 levels with an annual CPI-U inflation adjustment and it addresses accurate provider directories.

CMA and all of organized medicine strongly opposed this bill as well. At least ten members of the subcommittee expressed concerns that this approach would harm physicians and seriously compromise patient access to physicians. Members of the subcommittee urged the full Committee Chairman to work with them to develop a compromise before the full committee vote.

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These concerned members, led by California Congressman Raul Ruiz, are meeting with the Committee leadership over the next week to discuss alternatives.

CMA leaders have been in Washington, D.C. advocating for the Ruiz-Roe bill and educating members about the unintended consequences of the California law. CMA has been in a full-court press on this legislation. CMA will be conducting meetings with all Members of the California Congressional delegation at home in their district offices. CMA will undertake a hard-hitting grassroots campaign to educate Members of Congress about the profound negative consequences of the Senate HELP and House Energy Commerce Committee bills.

We will be urging our Congressional delegation to cosponsor the Ruiz-Roe NY model bill.

Additional legislation Prior Authorization Reform: CMA is supporting a bipartisan bill “The Timely Access to Care for Seniors Act,” authored by California physician Congressman Ami Bera, MD that will reform the Medicare Advantage Prior Authorization system by reducing administrative hassles for physicians and patient care delays.

Lowering Prescription Drug Costs: Congress continues to move legislation aimed at curbing prescription drug prices and drug pricing transparency. CMA is fully supportive of these efforts. However, CMA is strongly advocating that Congress authorize Medicare to negotiate drug prices with drug manufacturers. The Veterans Administration is allowed to negotiate with the drug-makers and their prices are much less than Medicare.

Physician Supply: With CMA/AMA support Congress reauthorized the Conrad 30 J-1 VISA physician program and several committees are successfully moving legislation to reauthorize the successful Teaching Health Center Primary Care GME program.

Medicare Physician Payment Update and MACRA Regulatory Relief: CMA continues to work with AMA to achieve Medicare physician payment update in 2019 legislation as physicians face a five-year payment freeze. We are also working to obtain a significant reduction in MACRA-related administrative burdens.

II. REGULATION

Electronic Health Record Interoperability Enforcement Regulations CMA submitted comments on the recent regulations promulgated by the Office of National Coordinator that would promote stronger enforcement of the HIT interoperability laws on vendors and hospitals. It would strengthen enforcement, increase penalties for data blocking, reduce vendor fees and gag clauses, require real-world testing of EHRs, and modernize interoperability standards – all of which are creating practice burdens for physicians.

Trump Administration Rules to Reduce Eligibility for Federal Poverty Programs: CMA joined its coalition of state medical societies in opposing recent Trump Adminitration rules to reduce eligibility for federal poverty programs, including Medicaid.

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ELECTION 2019 CANDIDATE FOR CMA VICE-SPEAKER OF THE HOUSE OF DELEGATES: LAWRENCE CHEUNG, MD My name is Lawrence Cheung and I am the Chair of our District VIII Delegation and your Chair of the California Resolutions Committee of our CMA delegation to the AMA. I ask for your vote as your next Vice-Speaker to the CMA House of Delegates.

Every three years, we have the opportunity to choose a new Vice-Speaker who will help set the tone and determine the course of our House. As your Vice-Speaker, I will seize this opportunity and make it a top priority to increase the engagement and relevancy of our delegates. With my background and experiences, I am fully prepared to take on these challenges and I know that our CMA’s best days are still ahead.

I have always been an out-of-the-box thinker and I truly believe that every challenge is an opportunity. When I was a second year medical student, after a summer internship at a safety net clinic that serves the vulnerable Asian Pacific Islander community, my Dean asked my class for suggestions for curriculum reform. I could not help but notice a lack of diversity training that was already so ingrained in California. I recommended to my Dean that cultural sensitivity training be considered a part of our second year medical school curriculum and she thought that it was a great idea. What I did not expect was that she then assigned me the task of developing this new curriculum. In developing my curriculum, I relied heavily on a series of articles from the Western Journal of Medicine….THE Western Journal of Medicine of our CMA. Our CMA has been a leader in cultural sensitivity and continues to be one today. I am proud to say that cultural sensitivity in medicine is now standard curriculum at Columbia University College of Physician and Surgeons!

As your Vice Speaker, I will tackle the challenge of increasing delegate engagement with the same enthusiasm I had in medical school. How will I achieve this? I remember the first time I served on a reference committee at the CMA like it was yesterday.

Why? Because no matter how many times I attended the CMA HOD, the process never really made sense to me until I served on the reference committee. I realized how things work at the CMA HOD – through hard work of the reference committee members and of the delegates. Since then, I have had the privilege of

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chairing Reference Committee A (Science and Public Health) and I have also served as a reference committee member at the AMA HOD. I believe that creating CMA standing councils and staffing them with physicians with expertise in their field is an extremely positive step.

It allows our CMA HOD to deal with time sensitive issues such as issues that may impact the current election cycle. This year, my delegation submitted a resolution on e-cigarette vaping and health that became CMA policy during Q3 and it will allow our CMA to weigh in on a San Francisco ballot initiative in November. But when we created our CMA standing councils, they replaced our reference committees and I feel that is a lost opportunity.

Why do I think that we need both standing Councils and reference committees? I did not understand how the HOD worked until I served on a reference committee. I think of the reference committee as the “training wheels” that will prepare our medical students, residents / fellows, young physicians, and new delegates on how to author and wordsmith resolutions.

I believe that the value of the standing Council is its ability to deal with time sensitive issues. The Councils will remain to render insight into resolutions that come up during the quarterly cycle that are time sensitive. The Councils will also author reports on major issues that are decided upon by the Council of Delegation Chairs. I would also like to see each Council generate a 5-year plan in which major issues are identified and potential actions mapped out. For highly contentious issues, we can save them for annual House of Delegates meeting and convene reference committees to work on them. This format solves many of the issues raised by delegates – loss of networking time, lack of debate on important issues, and loss of training opportunities via reference committees.

We all joined our CMA for different reasons. My Dean asked for ways to improve our medical school curriculum and I proposed and delivered. I view every challenge as an opportunity and I will take this opportunity to make sure that our CMA will deliver for you, our delegates. I hope to serve as your next ViceSpeaker of the CMA House of Delegates.

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ELECTION 2019 2019 Slate of Candidates

Pursuant to the San Francisco Marin Medical Society (SFMMS) Bylaws Article X Section 2 - Nominations, the Nominations Committee rendered in writing the slate of candidates for the 2019 SFMMS election two weeks ago. The following slate of candidates for the 2019 SFMMS election was read at the September 9, 2019 General Membership Meeting, at which time the SFMMS President called for additional nominations from the floor.

2020 Officers – Term 2020 SFMMS President-Elect: Monique Schaulis, MD, MPH SFMMS Secretary: Heyman Oo, MD, MPH SFMMS Treasurer: Michael Schrader, MD, PhD, FACP (Incumbent Treasurer) SFMMS Editor: Gordon L. Fung, MD, PhD, FACC, FACP (Incumbent Editor)

SFMMS Board of Directors - Term: 2020-2022 Eleven (11) candidates to be elected to the SFMMS Board of Directors: Peter Bretan, MD (Incumbent Director) Anne Cummings, MD (Incumbent Director) Robert Harvey, MD (Incumbent Director) Jason Nau, MD (Incumbent Director) Dennis Song, MD (Incumbent Director) Joseph Woo, MD (Incumbent Director) Kenneth Tai, MD Ayanna Bennett, MD Edward Alfrey, MD Tomas Aragon, MD, MPH Beth Griffiths, MD Andrea Yeung, MD SFMMS Nominations Committee Four (4) candidates to be elected to the SFMMS Nominations Committee: Edward Alfrey, MD Opal Gupta, MD Andrew Tomlinson, MD Helen Yu, MD

SFMMS House of Delegates The candidates receiving the highest number of votes will serve as Delegates; the rest will be Alternate Delegates or on the wait list.

The President-Elect automatically becomes one of the Delegates according to the SFMMS Bylaws: Ameena Ahmed, MD (Incumbent Delegate) Roger Eng, MD (Incumbent Delegate) Kimberly Newell Green, MD (Incumbent Delegate) Man-Kit Leung, MD (Incumbent Delegate) Larry Bedard, MD (Incumbent Delegate) George Fouras, MD (Incumbent Delegate) Michael Kwok, MD (Incumbent Delegate)) Michael Schrader, MD, PhD, FACP (Incumbent Delegate) Matt Willis, MD (Incumbent Delegate) Ben Meisel, MD Jessica Mahoney, MD Keith Chamberlin, MD Tracey Hessel, MD Ellen Chen, MD Emma Steinberg, MD Melanie Southard, MD

NOTES 2019 President-Elect Brian Grady, MD, automatically succeeds to the office of President.

2019 President Kimberly Newell Green, MD, automatically succeeds to the office of Immediate Past President.

Member voting will take place ONLINE ONLY. In order to place your vote, we must have your email address in our database. Please provide us with your email address if we don’t already have it. Paper ballots are NO LONGER MAILED. Please look for a special email from SFMMS on October 22 with detailed information regarding the online voting process, as well as the link to the online ballot.

Your electronic vote must be cast by 5:00 p.m. on Tuesday. November 12, 2019.

Please see candidate biographies and statements on the following pages.

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CANDIDATE BIOGRAPHIES President-Elect

Secretary

Treasurer MICHAEL C. SCHRADER, MD, PHD, FACP

HEYMAN OO, MD, MPH

MONIQUE SCHAULIS, MD

Incumbent Treasurer

Emergency Medicine

Pediatrics

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Senior Physician Kaiser San Francisco, Emergency Medicine Kaiser South San Francisco, Palliative Care Volunteer Clinical Faculty, UCSF Faculty, Vital Talk

UCSF/SFGH Pediatrics Leadership for the Underserved (PLUS) Resident, PGY-2

Private practice, internal medicine; Fellow, American College of Physicians; Volunteer Clinical Professor of Medicine, UCSF; Instructor, Inpatient Medicine CPMC 2000-11; Instructor, UCSF medical student office preceptor 1998-present.

SFMMS Board of Directors, SFMMS Executive Committee, SFMMS PAC, SFMMS CMA Alternate Delegate, SFMMS Marin Committee, CMA Subcommittee on Medi-Cal

SFMMS Treasurer 2019, SFMMS Board of Directors 2015-2018, SFMMS Executive Board 2017-2018, Treasurer SFMMS PAC 2018, Alternate delegate SFMMS CMA Delegation 2017-2019, Vice-Chair SFMMS CMA Delegation 2018, 2019. AMA member (intermittently) since 1986.

As a medical student, I became involved in organized medicine through a health policy course taught by a former CMA President.

We learned local advocacy techniques, media skills and went to Sacramento to lobby with the San Diego County Medical Society (SDCMS) and the CMA. Eventually, I served as a student member for the Board of SDCMS for 3 years, attending political candidate interviews and participating in their advocacy deliberations.

I trained to be a physician-scientist but decided my passion was clinical medicine. I have always participated in teaching the next generation of physicians. I currently serve on the UCSF Volunteer Clinical Professor Advisory Board. I am CEO of an independent physician practice, a small business. I have experience in clinical practice quality and served previously on the Subcommittee on Congestive Heart Failure Outcomes and the Atrial Fibrillation Clinical Pathway Committee at UCSF/ Mt Zion.

As a physician trainee, it is important to remember that I must advocate for my patients in clinic, but also advocate for them in the larger society. Serving as a Board Member would empower me to be both a bigger picture advocate and share that valuable perspective with my co-residents.

I have been privileged to serve as the Treasurer of the SFMMS this past year. In 2019, the Finance Committee has maximized the return of our cash reserve fund, adopted an aggressive long term strategy to grow our portfolio, and proposed an increase in SFMMS membership dues to move toward parity with yearly expenses. If we want to extend our legacy we must manage our portfolio, income, and operating expenses in the best way possible.

SFMMS/CMA Committees or Offices

SFMMS Board of Directors, SFMMS Executive Committee, SFMMS Secretary, 2019

Additional Relevant Experience

I serve as faculty for the Vital Talk Bay Area Hub, a national program that helps physicians improve serious illness communication skills.

I am chair-elect for the American Academy of Hospice and Palliative Medicine Medical Aid in Dying group. I serve as treasurer for our Emergency Department.

Why Are You Interested in Serving?

I am inspired by the incredible advocacy and public health work that I have witnessed while on the SFMMS Board and Executive Committee. I hope to be able to continue to support our physicians to continue this essential service for our communities. I would like to add my own passion for making high quality palliative care accessible and expected.

WWW.SFMMS.ORG

SEPTEMBER/OCTOBER 2019

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors

Editor

TOMÁS J. ARAGÓN, MD, DRPH

GORDON FUNG, MD, PHD, FACC, FACP

AYANNA BENNETT, MD, MPH, FAAP

Incumbent Editor

Cardiology

Public health

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Clinical Professor of Medicine, UCSF Medical Center; Director of Cardiac Services at UCSF Medical Center at Mount Zion; Director of Asian Heart & Vascular Center; Director of Electrocardiography Laboratory at Moffitt-Long Hospital.

SFMMS/CMA Committees or Offices

Editor 2011 to present, Executive Committee 2011-present; Past President; CMA: Delegate since 2000 (Chair since 2014), Member of Council of Scientific Affairs 2004-present, IMQ Surveyor since 1994.

Additional Relevant Experience

None

Why Are You Interested in Serving?

Communicating, educating, and learning are the jobs of an editor. Over the past five years I have learned so much about the topics and issues facing clinicians in practice in the community as well as academics. Working with the SFMS staff, Editorial Board, and Executive Committee and keeping the communication channels open with the membership and other interested parties that interface with SFMS through San Francisco Medicine has been one of the highlights of my involvement with SFMS. In a sense, San Francisco Medicine, our award-winning journal, is one of the oldest still-viable forms of social media used by the physician community serving San Francisco Bay Area. I truly cherish my time on the board and look forward to serving as your editor for 2016.

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I am the health officer of San Francisco and director of public health services at SFDPH. I mobilize people, organizations, and communities to effectively tackle tough and emerging public health challenges, especially racial health disparities. As health officer, I exercise legal authority to protect and promote health.

I am a member of the executive leadership at the San Francisco Department of Public Health, as Director of Interdivisional Initiatives.

I serve as technical consultant to SFMMS. I collect and edit the public health articles for the SFMMS Medicine Journal; I contribute to PAC; I represent SFMMS/SFDPH as a featured speaker at the Dr. David Smith Substance Use Symposium; and I partner with SFMMS on numerous public health issues.

None

Striving to embody and promote the values of dignity, equity, compassion, and humility, I work to convene, connect, and catalyze communities and institutions to transform narratives, policies and systems toward a sustainable culture of equity, healing and health for all people and our planet. I was born and raised in SF’s Mission District, and I live in Glen Park where we raised three children. I have expertise in computational epidemiology and decision sciences.

I have worked in a wide array of settings and roles as a physician: primary care clinician, subspecialty in asthma and adolescent health, medical director, non-profit executive, department leader. I have worked with physicians, nurses, non-clinical support staff and behavior health staff in all of those settings.

My focus has always been moving beyond silos, disciplines and barriers to address the complex health issues that require complex solutions.

Why Are You Interested in Serving?

SF faces enormous challenges—racial disparities, homelessness, mental illness, substance use, an aging population, climate change, and threats to affordable health coverage. SFMMS is a leader in tackling tough challenges. I will bring my expertise, experience and enthusiasm to protecting and promoting health and equity for all in SF.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2019

My primary interest is in grappling with the complexities of social determinants and culture on health. I am interested in working with physicians to make the changes in our thinking, resources and practice required to meet these challenges.

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PETER N. BRETAN, JR., MD, FACS

ANNE CUMMINGS, MD

Incumbent Director

Incumbent Director

Urologic & Laparoscopic Surgery

Hospital / Teaching

BETH GRIFFITHS, MD

Internal Medicine

Current Job Positions and Hospital and Teaching Affiliations

Coastal Health Partners-Urologic & Laparoscopic Surgery

SFMMS/CMA Committees or Offices

Primary Care, Internal Medicine in private practice with concierge style practice since 2007. I have been in Marin since 2002. I am on the Medical Staff at Marin Healthcare. I am also clinical faculty for P.A. program at Dominican University. I was previously with Division of Internal Medicine, UCSF and Marin General Hospital Medical Staff. I am a delegate to the CMA and a fellow of the American College of Physicians.

Assistant Clinical Professor, Division of General Internal Medicine, UCSF

Member, CMA Council onLegislation,Alternate Delegate, CMA House of Delegates; Former: Member, CMA Health Reform Technical Advisory Committee, Vice Chair, CMA Resident & Fellow Section, Chair, CMA Medical Student Section, Vice Chair, Legislative Affairs, CMA Medical Student Section, Council Member, AMA Council on Medical Education, Delegate, AMA House of Delegates

2006-7 ,2010-11, 2015-17 President of the Marin Medical Society California Medical Association 2011-Current Member at Large, Presidents Forum 2006-Current Board of Cal PAC 2018-21-Member of Executive Committee 2019-2020 President CMA

Additional Relevant Experience

Continuous member with the San Francisco, then Marin Medical Society, and now SFMMS since 1998. I have been involved in the wellness program and on committees Disaster preparedness. I’ve been a continuous member of the ACP since 1991 I have advocated for patients and physicians in Sacramento and D.C.

Leadership 2017-Current AMA Delegate, District X CMA 2004-2017 NCH:Past Chief of Staff/MEC/ Chief of Surgery 2017-CurrentAmerican Urological Association’s Healthcare Policy Representative 2018-19President of California Urological Association

I have taught medical students, nurse practitioners, and physician’s assistants in the course of my clinical practice. I have been on budgeting committees and medical staff quality review committee. I was the medical director for the Marin Services for women drug and alcohol program. I have three children and live and work in Marin.

Since working in the U.S. House of Representatives and the California Legislature a decade ago, I have used this experience to advocate for a more equitable health care system.

Currently, I serve as Director of Health Care Advocacy for the Division of General Internal Medicine and Co-Director of the Community Engagement Rotation at UCSF, where I develop curricula in community engagement and advocacy and collaborate with faculty to expand the impact of their work.

I am one of the few concierge style, independent physicians active with the medical society in Marin. I represent a smaller, but very important segment of medical practice with very specific needs and issues. I come from a large Medical Center setting and therefore know the value of having a diverse practice environment for patients and physicians.

Since joining SFMMS four years ago and serving on the CMA Delegation, I have been so impressed by the organization’s focus on patients and public health. Given my current educational leadership roles, on the Board I would seek to create opportunities for trainees and new members interested in advocacy.

Why Are You Interested in Serving?

My father’s surgeon’s simple act of kindness to try something that had never been tried to save his life made him my lifelong hero and inspiration. I knew I could never repay that act but I could attempt to pay it forward by promoting Service above Self for our Profession of Medicine. Help me make this our leading label for the CMA, the AMA and our profession, as it is a fundamental rationale to preserve access of care and no one can argue with that rationale!

WWW.SFMMS.ORG

SEPTEMBER/OCTOBER 2019

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors ROBERT HARVEY, MD

JASON NAU, MD PHD, FACP

DENNIS SONG, MD, DDS

Incumbent Director

Incumbent Director

Incumbent Director

Plastic & Reconstructive Surgery

Emergency Medicine

Oral & Maxillofacial Surgery (ADA)

Current Job Positions and Hospital and Teaching Affiliations

Solo practice of Plastic and Reconstructive Surgery in San Francisco for more than 25 years. 3 years as the President of the Medical Staff at Saint Francis Memorial Hospital.

For 7 years I was Chief of Surgery at Saint Francis. I Chair the Medical Executive Committee at Saint Francis.

Kaiser Permanente San Rafael Medical Center Department of Emergency Medicine Chair of the KP San Rafael Emergency Management Committee

Oral and Maxillofacial Surgeon, Private Practice Associate Clinical Professor, UOP Department of Diagnostic Sciences Chief, Dental Division, Department of General Surgery, California Pacific Medical Center

Medical Staff Liaison to SFMS Board from Saint Francis 2014-2016

Current SFMMS Marin Committee Chair Current SFMMS Board Member

Board Member, SFMS Vice Chair / Board Member, SFMS PAC Member, Solo Small Group Practice Forum, CMA

SFMMS/CMA Committees or Offices

Additional Relevant Experience

2015 President, San Francisco Dental Society Past Chairs of SFDS Membership, New Dentist, Program Development Committees Current/Past Service on SFDS Membership, Legislative, Finance, Community Dental Health, Program Development, Nominating, New Dentist Committees Past Representative to House of Delegates, California Dental Association  Board Member, SFDS PAC Member, General Surgery Quality of Care Committee, CPMC Member, Surgery and Operating Room Committee, CPMC.

Saint Francis Memorial Hospital Board of Trustees 2013-present. Current Secretary of the Board, member of the Executive Committee, and Chair of the Community Advisory Committee of the Board which focuses on the Tenderloin Health Improvement Project

Certified Physician Executive (CPE) by the American Association for Physician Leadership.

Master of Business Administration (MBA).

Why Are You Interested in Serving?

As doctors the main focus of our work is to provide excellent medical care to our patients.

Part of any success in this involves working with and caring for our colleagues, support staff, and ourselves. The SFMS provides an excellent path to help care for all of these stakeholders. I welcome the opportunity to expand this in the future.

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I have been serving as the Marin Committee Chair for the past year and am eager to continue the work on flavor tobacco bans and county emergency preparedness. We are about to start a campaign to reduce binge drinking and bring comprehensive awareness of the risks of both alcohol and cannabis use to Marin County. I am most interested in local community health issues but also share an interest in the greater national healthcare and social debate.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2019

The SFMS is forward thinking and at the forefront of organized medicine representing physicians and public health interests. My unique background in organized dentistry and medicine, leadership, private practice, academia, hospital care, and business brings a different experience and perspective to the board and membership. I would be honored to serve in this position.

WWW.SFMMS.ORG

JOSEPH W. WOO, MD

KENNETH TAI, MD

ANDREA YEUNG, MD

Incumbent Director

Internal Medicine and Pediatrics

Emergency Medicine

Otolaryngology

Current Job Positions and Hospital and Teaching Affiliations

Chief Medical Officer at North East Medical Services

Affiliate Staff, Chinese Hospital; President, Asian American Medical Group; Director of Community Relations, Chinese Community Healthcare Association

Vice president San Francisco Otolaryngology Medical Group, Clinical Assistant Professor UCSF Dept Otolaryngology Head and Neck Surgery, Active staff CPMC, Active staff St Francis and St Mary Hospital, Active clinical staff SFGH

SFMMS Board of Directors 2010–2015, 2017-present; SFMMS PAC and Finance

Nominations committee SFMMS

Former Medical Director Chinese Hospital ER; Former Chief of Medical Staff, Chinese Hospital

Medical Executive Committee Member at Large CPMC Nominations committee CPMC ENT Quality Committee CPMC Community Integrated Network UCSF Admission Committee School of Medicine UCSF UCSF Homeless clinic volunteer

The importance of organized medicine cannot be overstated. While I was in the midst of the controversies that occurred in the Chinese Community health system, it was apparent that the support of SFMMS/CMA was invaluable. Clearly, we must remain united and to exert our collective influences. As a physician, administrator and veteran Board member, I believe I can continue to serve organization.

Thus, I humbly ask for your vote.

Since joining the SFMMS in 2007, I have been able to work with numerous physicians in various hospitals systems throughout the city and have gained an appropriate understanding and perspective of the medical landscape.

I feel that I can serve as an advocate and voice for the opinions of our physician colleagues.

I am excited about the prospect of becoming more heavily involved and have the desire and dedication to contribute further to enact positive changes though SFMMS.

SFMMS/CMA Committees or Offices

Nominations Committee

Additional Relevant Experience

I oversee primary care/specialty services, behavioral health, dentistry, pharmacies, compliance/ privacy and complementary medicine across twelve clinics throughout SF Bay Area. Currently, serving as a Physician Advisory and Quality Improvement Member for Health Plan of San Mateo and San Francisco Health Plan. Also serving in the San Mateo Health Commissions. I was a graduate of California Health Care Foundation Leadership Fellow, 2009-2011.

Why Are You Interested in Serving?

I have special interest in reducing health disparities in the underserved communities; and have presented NEMS' hepatitis B and colorectal cancer screening efforts at conferences on local, state and national levels. I have participated in policy advocacy events such as promotion of soda tax and ban on flavored tobacco.

WWW.SFMMS.ORG

SEPTEMBER/OCTOBER 2019

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CANDIDATE BIOGRAPHIES SFMMS Board of Directors

SFMMS Nominations Committee OPAL GUPTA, MD

EDWARD J. ALFREY MD, FACS

ANDREW TOMLINSON, MD

Also a candidate for Nominations Committee

Transplant Surgery, Trauma Surgery, General and Acute Care Surgery

Allergy & Immunology

Otolaryngology

Current Job Positions and Hospital and Teaching Affiliations Department Chair of Surgery, Marin Health Medical Center (MHMC) Medical Director of Trauma Surgery Program, MHMC Adjunct Clinical Professor, Stanford University Medical Center SFMMS/CMA Committees or Offices

I am in private practice with San Francisco Allergy, Asthma & Immunology. My current hospital affiliations include UC San Francisco and CPMC hospital systems.

San Francisco Otolaryngology, with office hours in San Francisco and San Rafael. I operate at CPMC, Marin General, Novato Community and several surgery centers.

None

This would be my first committee within the SFMMS.

Through my training and practice,I have worked to improve patient care and patient experience by studying the barriers in access to care, the limitations in health care delivery, and the effect of personal characteristics (such as race and socioeconomic status) on disease management. I have mentored fellows, medical students and undergraduates.

I currently serve on the Education Services, Data & Technology Committee as part of the American College of Allergy, Asthma, and Immunology.

I was president of my medical school class all four years, and I was an elected delegate on the Committee of Interns and Residents for three years during residency. I was recently selected to be on the Media and Public Relations Committee of The American Academy of Otolaryngology – Head and Neck Surgery.

Physicians voices are essential in framing health and social policy. As an allergist treating a wide variety of commonconditions, my patient population is diverse in age, ethnicity, and background. As part of the Nominations Committee, I would be honored to recruit potential leaders to represent this heterogeneous community.

I am excited to get more involved with the SFMMS, and the Nominations Committee seems like a good entrance. I want to get to know members of the SFMMS better, and to reach out to physicians in San Francisco and Marin to identify strong leaders and speakers for our field.

Additional Relevant Experience

Chief of Transplant Surgery at Penn State University/ Hershey Medical Center Chair of General Surgery at Southern Illinois University School of Medicine, and Residency Program Director in General Surgery Health Care Management Masters Degree from Harvard School of Public Health Candidate for Marin HealthCare Board District 2018 Chair of the MHMC Surgical Site Infection Committee Abdominal Organ Transplant Program at Stanford University Why Are You Interested in Serving?

I am interested to serve on the SFMMS Board of Directors in this leadership position because I believe that the medical society plays a vital role in the practice of medicine, and that my experiences as a MMHC hospital leader will strengthen the SF – Marin relationship.

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SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2019

WWW.SFMMS.ORG

SFMMS Delegation to the CMA House of Delegates HELEN YU, MD

Child and Adolescent Psychiatry

AMEENA T. AHMED, MD, MPH

LARRY A. BEDARD, MD, FACEP, FIFEM

Incumbent Delegate

Incumbent Delegate

Internal & Preventive Medicine Emergency Medicine

Current Job Positions and Hospital and Teaching Affiliations

I am currently in my last year of training in the Child and Adolescent Psychiatry Fellowship Program at UCSF. I also completed my General Psychiatry Residency at UCSF. SFMMS/CMA Committees or Offices

None

Adult Medicine, Kaiser Permanente San Francisco Medical Center; Chief of Complementary and Integrative Health; Assistant Clinical Professor, Department of Epidemiology and Biostatistics, UCSF

Marin Healthcare District (MHD) Board of Directors MHD, Chair Finance and Audit committee Delta V Bio, Medical Legal Consultant

CMA Delegate 2014-2019; Former SFMS PAC Board Member

I have been a Delegate or Alternate Delegate to the CMA House of Delegates for more than 30 years representing CALACEP in the Specialty Delegation and District X. I served one term on the CMA BODs.

I completed a fellowship in social epidemiology, through which I developed a keen interest in how political and social factors affect health. This background has demonstrated to me how important policy is in shaping health and health care. I've had the privilege to volunteer with Physicians for Human Rights in Central Asia, the Middle East, and South America, working to end human rights abuses and create mechanisms for accountability.

I am serving my fourth elected term on the Marin Healthcare District Board of Directors.

During my terms MHD has separated from Sutter Health and established Marin General Hospital as an independent, full service community hospital. We have established 11 Primary Care Clinics and are building a new $534 million addition. I have learned valuable lessons on how to transition from volume to value and from independent small/solo practice to a hospital integrated or affiliated practices.

I look forward to serving San Francisco's physicians as a leader and advocate. I would be honored to work with my colleagues to shape policy to improve health in San Francisco and statewide.

Throughout my career I have always enjoyed medical advocacy and medical politics. I have served as President of CALACEP and ACEP. As a Delegate or Alternate for 30+ years I have authored many resolutions. I enjoy the debates and the camaraderie and friends at the House.

Additional Relevant Experience

As a resident and fellow, I have been involved in various formal and informal leadership positions that have included working on quality improvement projects in my own department, collaborating with trainees from other departments to improve patient care, and developing community partnerships to link patients to needed services.

Why Are You Interested in Serving?

Our local region is facing many difficult challenges such as homelessness, substance use, and access to mental health care. We need to work across different fields of medicine, and across different organizations. It’s important to bring a diversity of voices to the table in regards to the leadership of SFMMS.

WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates ROGER S. ENG, MD, MPH, FACR

ELLEN CHEN, MD

KEITH J. CHAMBERLIN, MD, MBA

Incumbent Delegate

Cardiac Anesthesiology

Family & Community Medicine

Radiology

Current Job Positions and Hospital and Teaching Affiliations

CEO, Prima Medical Group (large primary care and multi-specialty group in Marin County); Co-Chair Operating Room Management Committee; Medical Director, Perioperative Services SFMMS/CMA Committees or Offices

Primary Care Director of Population Health and Quality and staff physician, SFDPH San Francisco Health Network; Assistant Clinical Professor, UCSF. In my current position, in addition to leading key quality programs, I shepherd initiatives spanning areas from food insecurity and racial equity to chronic disease management and behavioral health integration.

None

SFMMS: President 2015; Director 2009–12; Executive 2010–11, 2013-2016; PAC 2011–present; Nominations 2011; CMA: Board of Trustees 1997–98, 2003–07; Delegate/Alternate Delegate 1995–present; Council on Membership, Bylaws, and Governance, Chair, 2016-2018, member 2016-present, Young Physicians Section, Chair 2001–02; IT Committee, Chair 2004–08; Committee on Nominations 1997–98, 2003–07; Long-Range Planning Committee 2003–07; Chair, CMA Website 2006–07; Health Care Finance Technical Advisory Committee 2004; Committee on Medical Service 1998–99; CMA House of Delegates 2012 Reference Committee C Chair (partial list)

Additional Relevant Experience

Secretary, Board of Directors, Meritage Medical Network Past Chair, Practice Management Committee, California Society of Anesthesiologists Co-Chair, Small and Medium-Sized Group Practices, American Society of Anesthesiologists

Why Are You Interested in Serving?

I am intensely physician-centric. Nothing happens in our medical system without physician input. Yet physicians are often left out of the loop of communication. This is a very tumultuous time for the House of Medicine and I believe I can bring a wide amount of experience and knowledge to encourage physicians and medical networks to see the value in each other. If we can do that, patients win.

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President, Golden Gate Radiology Medical Group; Chief of Radiology, Chinese Hospital

Throughout my career, I have been passionate about improving preventive and primary care delivery systems for underserved patients in SF. Additional experience includes: Medical Executive Committee member, ZSFG; Equity Governing Council member, San Francisco Health Network; Quality Improvement Committee member, San Francisco Health Plan; Medical Director (past), Silver Avenue Family Health Center; Associate Director (past), UCSF Center of Excellence in Primary Care; Core residency faculty (past), UCSF Family and Community Medicine.

AMA offices: AMA Delegate 1996–97; AMA-RPS Delegate 1995–97; AMA-YPS Delegate 1998–99 (Vice Chair, CMA YPS delegation); Related medical affiliations: President, California Radiological Society; Treasurer, San Francisco Bay Radiological Society; Cooperative of American Physicians, Board member 2019-present; Google Brain, medical specialist, 2017-present; Chinese Community Health Care Association IT Committee 2006–present; Carestream Physician Advisory Board 2005–present; American College of Radiology, Councilor, 2008–present; Chinese Hospital, Medical Executive Committee 2004–2010

I would be honored to help shape and represent policy SFMMS resolutions to advocate for our patients and colleagues. I’m particularly interested in issues that are rising up for our state: value based care, access to health care for all Californians, mental and physical health care integration, and immigrant health.

Participating in our local medical society is both a privilege and a professional responsibility. I will continue to represent our diverse membership and public health initiatives at the state level.

SAN FRANCISCO MARIN MEDICINE SEPTEMBER/OCTOBER 2019

WWW.SFMMS.ORG

GEORGE A. FOURAS, MD

KIMBERLY NEWELL GREEN, MD

Incumbent Alternate Delegate

Incumbent Delegate

Child & Adolescent Psychiatry

Pediatrics

TRACEY HESSEL, MD

Pediatrics

Why Are You Interested In Serving?

Current Job Positions and Hospital and Teaching Affiliations

Mental Health Psychiatrist, Los Angeles County Dept. of Mental Health.

Pediatrician; Associate-Clinical Professor, UCSF; Consultant, Digital Health Technology

Lead Pediatrician at the Marin Community Clinics; Volunteer Clinical Faculty, UCSF School of Medicine and UCSF School of Nursing.

SFMMS: President 2019; President Elect 2018; Treasurer 2016-17; Secretary 2015, Board of Directors 2012-2014, Executive Committee 2014-present, Nominations Committee 2010-11

I served on the SFMMS Nominations Committee (2019).

Having trained at UCSF, worked in the community at SFGH and at several private practice offices, and now being in practice at Kaiser San Francisco, I have had experience with a range of medical settings and care delivery systems in this city. I held several local and regional leadership positions at Kaiser Permanente, including Chief Healthcare Innovation Office, Chief of Physician Health and Wellness, Emerging Leaders Program, Department Technology Lead, and CME Coordinator. I help companies in the digital health technology space develop tools that will lead to significant improvements in the work we do.

Champion Provider Fellow, UCSF; Co-chair, Marin County Healthy Eating Active Living Steering Committee; Marin County Oral Health Steering Committee; Head Start Medical Advisory Committee; Board Member, HeadsUp San Rafael City Schools Foundation.

More than ever in these turbulent times, physicians must work to shape how medicine evolves so we can continue to take exemplary care of our patients and attain professional satisfaction. I would be honored to continue to help lead this group of committed physician leaders for the benefit of the entire community.

I have worked at a safety net clinic in Marin County for the past 15 years. There, I have engaged in public health initiatives and partnered with organizations to positively impact the health of our community. I have been inspired by the important health policy work being done at SFMMS and would be grateful for the opportunity become more involved in advocacy and policy work.

SFMMS/CMA Committees or Offices

SFMMS Consultant to Board 2013-present; Immediate Past President 2012; President 2011; President-Elect 2010; Secretary 2009; Director 2003-2008; Executive Committee 2003-2011; SFMS PAC 2004-present (Chair 2015-2016 / 2007-08); Physician Membership Services, 2003-present; CMA Delegate, 2010-2015, 2018-19; CMA Alternate Delegate 2016-17, 2007-09, 2000-02; CMA Alternate Delegate to the AMA 2019-20.

Additional Relevant Experience

Past President, NC Regional Organization of Child and Adolescent Psychiatry; Co-chair, Adoption and Foster Care Committee for the American Academy of Child and Adolescent Psychiatry; Chair, California Psychiatric Association PAC

Why Are You Interested in Serving?

The SFMMS delegation has been one of the most influential groups in the CMA. It has been an honor and joy to participate and to encourage younger physicians to become engaged in organized medicine. I hope that you will allow me to continue to serve the SFMMS in the future. Thank you for your support.

WWW.SFMMS.ORG

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates MICHAEL K. KWOK, MD

MAN-KIT LEUNG, MD

Incumbent Delegate

Incumbent Delegate

Internal Medicine

Otolaryngology

JESSICA MAHONEY, MD

Pediatrics

Current Job Positions and Hospital and Teaching Affiliations

Internal Medicine private practice - both inpatient and outpatient (Kwok Internal Medicine, Inc.) Active Medical Staff - Marin General Hospital Courtesy Medical Staff - Novato Community Hospital

Private practice in small group; affiliations with Chinese Hospital, St. Francis Memorial Hospital, CPMC, St. Mary’s Medical Center; former Adjunct Clinical Instructor, Stanford University School of Medicine Department of Otolaryngology – Head & Neck Surgery

Primary Care Pediatrician, Kaiser Permanente Mission Bay, The Permanente Medical Group, Chief of Physician Health and Wellness, The Permanente Medical Group, San Francisco, Physician Lead, Complimentary and Integrative Health, KP Mission Bay, Assistant Clinical Professor of Pediatrics, UCSF School of Medicine

Member of MMS/SFMMS continuously since 1992 Board of Directors Marin Medical Society 1994-1996, 2012 - 5/2017; Secretary/ Treasurer MMS 2013-2015 & President elect 2016-May 2017 Executive Committee of SFMMS 5/2017 12/2018 Board of Directors SFMMS 5/2017-present Alternate Delegate to CMA House of Delegates 2014-present

SFMMS: Immediate Past President, President, Treasurer; Secretary, Board of Directors, Executive Committee, PAC (former Vice Chair), Nominations Committee (past Chair), Chinese Hospital liaison to SFMMS; CMA: Delegate and Alternate Delegate to HOD, CMA At-Large Delegate to Council on Legislation, CMA Council on Medical Services member, Alternate Delegate to AMA HOD, AMA member

Chair, CMA Subcommittee on Physician Wellness Member, CMA Council on Health Professions and Quality of Care Chair, SFMMS Task Force on Physician Wellness

Marin General Hosp Board of Directors: 2019 - present MGH Quality & Patient Safety Committee, Vice Chair 2019-present Marin General Hospital Strategic Planning Committee 2015-present Novato Community Hospital Board of Directors 1998-2006 (Finance Committee, Nominations Committee, Executive Committee; Secretary of the Board) NCH Medical Staff: Vice Chief of Staff 1997, Secretary/Treasurer 1995-1996 & 2005-2011; Chairman Pharmacy & Therapeutics Committee 1993-1996; Quality Review Committee 1992-2011 & Medical Committee 1992-2011, Medical Executive Committee for 11 yrs

St. Francis Memorial Hospital Board of Trustees, Asian American Medical Group Board of Directors

I have been involved in physician leadership for years including being a Pediatric Site Chief and working on local, regional, and statewide physician wellness strategy. I frequently speak at conferences, facilitate workshops, and work to influence decision makers. I am trained as a coach. I have led patient advisory groups and worked for the National Academy of Sciences in Washington DC, giving me some perspectives on health care from the patient and political perspectives.

My experience in Hospital leadership & governance, Medical Staff leadership & governance, Physician peer review and Medical Society leadership provided me a broad perspective on the practice of medicine and health policy issues. I seek this opportunity to represent my physician colleagues at the CMA House of Delegates and help shape CMA policy.

As an incumbent Delegate, I am interested in continuing to represent this membership at the CMA HOD and to advocate for causes that benefit our patients and our profession.

I am excited to collaborate with other physicians to work to make a positive impact on health, patient care, the future of medical practice, and our health care system. I hope we can work towards making it more effective, efficient, while also sustainable for the physicians providing the care.

SFMMS/CMA Committees or Offices

Additional Relevant Experience

Why Are You Interested in Serving?

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BEN MEISEL, MD

MICHAEL C. SCHRADER, MD, PHD, FACP MD, FACC

MELANIE SOUTHARD, DO

Incumbent Alternate Delegate

Pediatrics

Internal Medicine

Family Medicine

Why Are You Interested In Serving?

Current Job Positions and Hospital and Teaching Affiliations

Medical Director, California Children’s Services – San Francisco Volunteer Associate Professor of Pediatric Medicine, UCSF

Private practice, internal medicine; Fellow, American College of Physicians; Volunteer Clinical Professor of Medicine, UCSF; Instructor, Inpatient Medicine CPMC 200011; Instructor, UCSF medical student office preceptor 1998-present.

Medical Director, Marin Community Clinics. I currently maintain a patient panel while overseeing the daily medical operations of our San Rafael Campus clinic location.

SFMMS Treasurer 2019, SFMMS Board of Directors 2015-2018, SFMMS Executive Board 2017-2018, Treasurer SFMMS PAC 2018, Alternate delegate SFMMS CMA Delegation 2017-2019, Vice-Chair SFMMS CMA Delegation 2018, 2019. AMA member (intermittently) since 1986.

I recently joined the SFMMS Physician Wellness Committee.

From creating therapeutic camp experiences (as Medical Director of California’s preeminent camp for children with complex illnesses) to founding 2 companies “Building Play Into Health” for children with complex health needs, my goal has long been to eliminate barriers to wellbeing for the most medically complex children. Current CMA-relevant activities: • CCS Medical Advisory Council • SF Child to Adult Transition Workgroup Chair • SF Special Needs Anesthesia Dentistry Workgroup Chair • UCSF Chronic Illness Center Advisory Board

I trained to be a physician-scientist but decided my passion was clinical medicine. I have always participated in teaching the next generation of physicians. I currently serve on the UCSF Volunteer Clinical Professor Advisory Board. I am CEO of an independent physician practice, a small business. I am concerned about health of people in the community and have served on the Community Action Committee at Saint Francis Memorial Hospital for the past two years. I have experience in clinical practice quality and served previously on the Subcommittee on Congestive Heart Failure Outcomes and the Atrial Fibrillation Clinical Pathway Committee at UCSF/Mt Zion.

I currently serve as a member on the board of the North Bay Chapter of the California Academy of Family Physicians.Over the last two years we have been active at hosting events related to ACA and physician wellness.

To help SFMMS influence the CMA at a time when the Legislative and Health Leadership of California are aligned as never before to address pediatric health care challenges (especially the gaps in care for medically complex children that affect us all by their unintended cruelty and remarkable expense).

This will be my third year serving as an alternate delegate. I acted as vice chair of the delegation last year and will continue this duty this year. I have been an author of numerous SFMMS resolutions. The HOD is a tremendous venue for CMA delegates to shape medical and social policy. I ask you to send me to the room where it happens so I may represent you at the CMA HOD to shape state and national policy.

Working at a Community Health Center has illuminated the importance of physician voices at the legislative level to shape policy. Whether it’s protecting the doctor-patient relationship from further erosion by the barrage of EHR requirements, ensuring that all people have access to high quality care, or addressing physician burnout, it starts with policy change. I would be honored to have the opportunity to advocate for the issues that brought me into this profession.

SFMMS/CMA Committees or Offices

This is my first SFMM/CMA election experience running for SFMMS Delegate to the CMA.

Additional Relevant Experience

Why Are You Interested in Serving?

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I have also been an active participant at the CAFP’s annual All Members Advocacy Meeting

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CANDIDATE BIOGRAPHIES SFMMS Delegation to the CMA House of Delegates MATTHEW D. WILLIS, MD, MPH

EMMA STEINBERG, MD

Incumbent Alternate Delegate

Pediatrics

Public Health

Current Job Positions and Hospital and Teaching Affiliations

Pediatric Hospitalist, Kaiser Permanente San Francisco and Santa Clara – work with medical students, pediatric and family medicine residents from University of California, San Francisco (UCSF), Stanford, BU, O’Connell, and Kaiser Permanente, Volunteer Clinical Professor, UCSF Department of Pediatrics, Champion Provider Fellow, SF Department of Public Health

Public Health Officer, County of Marin

None

Marin Medical Society Board Member (201517); SFMMS Board of Directors 2017

SFMMS/CMA Committees or Offices

Guest Researcher, U.S. Centers for Disease Control and Prevention

Adjunct Professor in Public Health, Dominican University of California

Additional Relevant Experience

In residency, I received training in legislative advocacy and met with Sacramento legislators twice to advocate for bills related to children’s health. I also was an American Academy of Pediatrics (AAP) program delegate, acting as a liaison between the residency program and the national and local chapters of the AAP and supporting resident legislative advocacy efforts. Finally, I have been consulting for Alameda County to help pilot and implement county wide Food as Medicine Initiatives.

California Conference of Local Health Officers (CCLHO) Executive Board

As a pediatrician, I want to combine clinical practice with efforts to maximize children and families’ health and future well-being through changes in healthcare delivery and public policy. As a delegate, I would work hard to facilitate change and advocate for local programs and initiatives that benefit our community.

The SFMMS can lead the way in supporting health and wellbeing for all in our region. I’m excited to add my voice as a health officer, physician and epidemiologist to make sure public dialogue and policies are grounded in evidence, and informed by the firsthand experience of physicians.

Health Officers Association of California Legislative Committee CCLHO Health Equity Committee co-chair State of California Opioid Workgroup

Why Are You Interested in Serving?

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Marin County Vaccination Rates are its Highest Ever For decades, Marin County has been known for low childhood vaccination rates, raising concerns about the risk of disease outbreaks. Public health officials are breathing more easily now, as kindergarten immunization rates continue to improve and now nearly match the statewide average.

This school year 94.3% percent of Marin kindergarten students have all the immunizations required for school, compared with the statewide average of 94.8%. This is the closest the county has been to the state average since 2001, when rates were first measured. The new Marin average represents a slight increase from last year’s rate of 94%. The lowest rate recorded in Marin was in 2011 at 77.9 percent.

Officials with the Marin County Department of Health and Human Services (HHS) believe the rate increase is the result of education, policy, and the change in social norms around immunization. Marin’s rates have been steadily increasing, while the legislation has become stricter. In 2016, California’s immunization laws became much stricter with the 2015 passage of Senate Bill (SB) 277, which went into effect January 1, 2016. Parents were no longer allowed submit a new personal belief exemption (PBE) to required immunizations for school and childcare.

“We’re much better off than we were a few years ago,” said Dr. Matt Willis, Marin’s Public Health Officer. “More people are understanding that the threat of communicable disease is real and that vaccinations protect our whole community, not just one child. But it’s not just about laws or vaccines, it’s about partnership. Schools, parents, legislators, and medical providers all play a role in promoting health in our community.”

Willis said health officials remain concerned about small pockets of Marin with low vaccination rates. Among the 5.7% that remain unprotected, many are clustered in the same schools. On a related note, the number of children with medical exemptions to required vaccinations grew from eight entering kindergarteners in 2015 (.2%) to 82 (2.6%) in 2018.

To view an interactive map of school and child care immunization levels in Marin and throughout California, or for information on immunization law and requirements, please visit ShotsForSchool.org.

NEW RESOURCE: Buprenorphine: An Overview for Clinicians Scott Steiger, MD UCSF School of Medicine Triveni DeFries, MD UCSF School of Medicine Buprenorphine, an FDA-approved medication for addiction treatment and pain relief, cuts opioid overdose death rates in half. Yet nearly 80% of Americans with opioid use disorder (OUD) do not receive buprenorphine or other medication-assisted treatment (MAT).

Buprenorphine: An Overview for Clinicians provides answers to frequently asked questions, aiming to increase prescriber comfort with prescribing buprenorphine throughout the health care system. Once the basics are mastered, buprenorphine can be as straightforward to prescribe as medications for other medical conditions. It covers the following topics: About Buprenorphine • Buprenorphine compared to methadone and naltrexone • Accessibility obstacles • How to start a patient on buprenorphine • Where can a patient start buprenorphine?

Dosage, Duration, and Monitoring • Maintenance dosage • Treatment duration: detox, maintenance, tapering • Monitoring and diversion • Substance use • Behavioral health treatments Pain Management with Buprenorphine • Advantages of using buprenorphine for chronic pain • Elderly patients with chronic pain • Treating pain in the emergency department and hospital • Hospitalized and perioperative patients on buprenorphine

Legal and Administrative Facts • Laws regulating buprenorphine prescribing • Getting prescriptions approved by health plans • Documentation required by federal and/or California laws

https://www.chcf.org/wp-content/uploads/2019/08/Buprenorphine OverviewClinicians.pdf

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Election Issue

SFMMS INTERVIEW: Sandra Hernández, MD

Steve Heilig, MPH Sandra R. Hernández, MD, is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, and before that director of public health for the City and County of San Francisco. She serves on the Covered California board of directors.

Sandra is an assistant clinical professor at UCSF and practiced at San Francisco General Hospital from 1984 to 2016. A graduate of Yale University and Tufts School of Medicine, she was the keynote speaker at the SFMMS 150th anniversary annual dinner last year.

Let's start with a broad and easy question. Access issues are a priority for your foundation, and it’s a political focus now too. Where do you think this big issue is going at this point?

We've been on a full push to get everybody in California covered. Our state has been a leader in implementation of the Affordable Care Act (ACA), and a key part of that is the Covered California exchange, which I think has been working exceptionally well. In response to the repeal of the federal insurance mandate, California lawmakers passed a state mandate, keeping a core tenet of the ACA in place.

And then of course there's Medi-Cal. One hand we're working really hard to get eligible folks enrolled in the program. And on the other hand, we’re playing defense against the incredibly aggressive anti-immigration policies that the Trump administration has been promulgating. The largest of those by far is the new "public charge" rule, which is scheduled to go into effect next month. We've been analyzing its implications. One problem is that the new rule is exacerbating fears that are already heightened in an environment of anti-immigration rhetoric, aggressive detention policies, and highly-publicized raids. That fear is driving people who are legally eligible for coverage and care to avoid enrolling in Medi-Cal or even going to the doctor because they are afraid to put their or their family’s immigration status at risk.

People in the field say they have never seen anything like this.

It puts us in a unique and challenging place philanthropically. We have to be very careful not to give any advice or information that might further jeopardize anybody's legal status. We have supported research so that lawmakers have credible information about the consequences of the new public charge rule. We are also helping to develop a digital tool that would allow people to confidentially ascertain their status and options, with information on where to go to get further questions answered. We believe it is important to provide people with safe ways to get information that applies to their specific situation.

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The public health argument I expect you agree with is that getting people access regardless of immigration status is both the clinically and economically right thing to do – not to mention the ethical one as well.

Yes. I think doctors really need to get into this conversation more. We don’t want a world where people only show up in emergency rooms after long delaying their care because they are afraid to go anywhere else. Policies like the new public charge rule take us backwards in terms of public health and health care spending.

What about the problem of inadequate provider resources?

It's a big issue. Of course, once you're enrolled in Medi-Cal, we want to make sure you get into a medical home with access to good primary care and specialty care as needed. But we have a big and growing shortage and maldistribution of primary care, and some specialists as well. We've been working with health plans and their provider networks to take better advantage of existing solutions, like expanding telemedicine where that works, or using more nurse practitioners.

The health policy issues do seem to be heating up prior to the next election, any thoughts?

It's fascinating, going into the 2020 election. In the last presidential election, Republicans campaigned on "repealing and replacing" the ACA. Not four years later, several Democratic candidates are talking about Medicare for All. Of course, there is the big issue of what "Medicare for All" might really mean. Is it truly a single payer approach, where we get rid of health plans? Or is it more like Medicare Advantage? Or is it something in-between? A little while back, we did a primer on what the big questions might be in setting up a single payer program. It showed that you end up with a very different version of single payer depending on what your primary goal is.

Is a state-wide program here likely or even possible?

Our legislature passed a bill to set up a commission to study ways of getting to universal coverage, and our governor worked to ensure that single payer would be a big part of their focus. What that commission learns and recommends will be really important because states are the laboratories for national policy. California is in a position to test some of the ideas that are being discussed at a broader level. It helps that we have a governor who has made health care a signature issue, and a legislature which has the experience of fully implementing the ACA. At CHCF, our job is to make sure the compass keeps pointing toward universal coverage and providing the research to inform how to get there responsibly.

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Mental health and substance abuse are huge issues in California, not to mention our city. The evidence seems strong that expanding access via the ACA has helped tremendously in getting more people evidence-based treatment.

You are absolutely right. Getting people covered is the prerequisite to getting them care and treatment. ACA gave us even more tools to expand behavioral health care specifically, but there is still a lot of work to be done. Fortunately, our governor is aware of the unfinished work. He appointed the state’s first "mental health czar" to help come up with a plan.

Some of the big questions are how to identify people in need and how to redesign services for people with multiple complex needs. No matter how you answer those, they both underscore the need to integrate mental and physical healthcare services.

The good news is that we are starting to see different players in the system, like county behavioral health agencies and health plans, coming together in new and innovative ways to apply a more coordinated, “whole-person” approach to care for people with behavioral health needs. CHCF is providing research and technical assistance for some of those efforts. There are too many examples of where things clearly are not working. We believe it is important to figure out what does work.

But there are big workforce shortages there too.

Yes. Earlier this year, the California Future Health Workforce Commission, which we supported, came out with a big report on looming provider shortages and the steps California must take to solve them. One of their biggest conclusions was that the state is facing deep and growing shortages of psychiatrists and other behavioral health providers, on top of major shortages in primary care.

Both the legislature and Governor responded by putting extra money in the budget this year to build our health workforce, and behavioral health was top of mind for them as they did that. I am thrilled that the budget included a big new loan-repayment program for physicians, including psychiatrists, who agree to work in the safety-net. There is additional money for the Workforce Education and Training Programs specifically to enlist new mental health professionals. There is also a lot of momentum behind the idea of expanding the role of nurse-practitioners, recognizing the particularly important role they can play in behavioral health.

On that nurse practitioner issue, I think you've run up against CMA on this as a scope of practice issue?

The shortages we face in primary care and behavioral health are very, very serious. We absolutely need to train more physicians, but that alone will not solve the problem.

The numbers just don’t add up. What’s more, there are places where doctors just don't want to work. The notion that only doctors will do is outdated. What disturbs me is that we are an evidence and science-based profession in medicine. The evidence is unequivocal now that nurse-practioners working at the top of their license, filling gaps in primary care, with physician oversight and appropriate training, can make a huge difference. The scientific literature from other states that have expanded the role of NPs shows that access, quality, and cost WWW.SFMMS.ORG

of care improve. I don't know how we as a profession can — in good conscience — duck and hide from that evidence.

How about the conservatorship issue for severely compromised patients, and how it can run up against civil rights concerns?

Well, the pendulum swings wide, as you know. I think it's clear we need wide range of options in residential care. Residential care facilities are expensive to build, which is why even when we do build them, they are consistently too small. The situation on our streets and in our communities is grim, with so many people facing chronic, untreated mental health problems.

Everyone agrees we need more tools than we have now.

You've done some great work on end-of-life issues as well.

It so often takes a personal encounter to remind us why this work is so important. I've recently had an experience with a dear and departed friend in her 90s. The facility where she was living didn't even know if they had a palliative care service. I had to call three different doctors to find out. What are people who don't have special connections or expertise supposed to do? We shouldn’t make it so hard for people to get what should be basic, standard support.

Now, it's true that many health systems still don't have palliative care teams in place. So, what are our choices? We can train more and more palliative care clinicians and teams. We can also start end-of-life training earlier, especially as part of primary care training so that we don't have to refer them out. A few years back, we did a big survey of doctors on this issue. They consistently told us, "We'd love to talk with our patients about end of life care but we don't know what to say to them." That needs to change. And doctors don’t have to do it all on their own. Palliative care typically happens in teams. That’s why CHCF has worked with CSU to develop a palliative care online-training program for nurses, social workers, home health aides and others.

This work is not only about training, but also a cultural shift about how we take patients' wishes into account while also providing the best possible care. These two things shouldn't be in tension, and end-of-life care is Exhibit A. People don't want to die in an ICU. They do need to be able to make informed changes about what kind of care they want and where they want to spend the end of their lives — no matter where they live or what their economic or family status is.

You've expressed great distress about the gun issue.

What can be done?

My goddaughter was staying with me when the Gilroy shooting happened. We were watching the reports on the news, and she turned to me and said in a soft voice, “I’m afraid to even go to the movie theater anymore.” It is absurd that so many people have to live in fear, or that our kids have to do active shooter drills in school when there are public health strategies that could save lives. I don't know how close we are to the "tipping point" on this issue, and how many preventable deaths people will tolerate. But it does feel like there is a break in the ice.

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Election Issue On the policy front, I don't think there is one solution that will solve gun violence in our country. It will take a collection of related efforts. One thing we should all agree on is the need for a lot more funded research on gun violence. That research needs to be independent—and not politically censored — so that we can all take an honest look at what policies work best. We need to answer questions like who is most predisposed to shooting people, how effective are background checks, and do ammunition restrictions save lives. There are two or three centers around the country doing this kind of research, but we clearly need more. If this were any other epidemic, the research wouldn’t be an issue.

California is often pitched as some sort of "resistance" to the current federal administration. Do you see any of your work through that lens?

There are so many places where our state is the "lead train" doing the right thing. You see this on coverage, opioid safety, maternal mortality, immigrant health, and more — where California has really been a beacon for the country. Those of us who work in health care and keep making the case for improvement have been part of the reason why.

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That said, I would like to see even more leadership from our profession — to embrace rather than lag behind the evidence, and to step up on behalf of those who lack access to good care, for whatever reasons. These duties are part of our job description.

You kept a part-time clinical practice until just a few years back. Do you miss it?

I do miss it. I had a continuous and long-standing providerrelationship with several patients, some of whom I'd known for ten or fifteen years. It became hard to maintain because of travel and other commitments. Leaving it was the right the thing to do, but I miss that connection with my patients.

I do still teach at UCSF and get to work with lots of students. I really enjoy helping the next generation of physicians to see how they can serve their communities and make their mark on health disparities, mental health, addiction, end-of-life, and all the things we've talked about here. I get a similar inspiration from them that I used to get from my patients.

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Election Issue

PREVENTIVE MEDICINE IS UNITING AGAINST VAPING Brandon W. Yan E a c h t i m e I s e e my closest childhood friend, we recount the days of adolescent drama and classroom mischief.

“Those were the days,” we wo u l d s ay. B u t i n recent years, our rare moments together have included new company.

The conversations are as meaningful as ever but increasingly impeded by his need for breaks–but not those of the excretory flavor.

My friend is addicted to e-cigarettes.

For most of our lives, neither of us knew about “e-cigarettes,” the electronic devices that combust liquids choked with nicotine and carcinogenic compounds for vaping.

As high school came, so came pubertal angst and the longing for an outlet to cope. I became consumed with extracurricular activities, while he and many others found comfort in e-cigarettes, which offered an escape without the social consequences of conventional smoking. In fact, e-cigarettes could elevate your social standing. They not only lacked the pungent smell of tobacco smoke but also included flavors as enticing as “sweet mint,” “summer peach,” and “mango nectar.”

At first, few seemed concerned. Most everyone thought vaping was safe. It was supposedly nothing more than water vapor with a little flavor. And you could do cool tricks like blow O rings with the vapor to impress your friends! Perhaps in hopeful denial, I convinced myself of this lie too.

But as years passed, the rise of youth vaping soon caught the attention of researchers and policymakers. The Centers for Disease Control and Prevention (CDC) reported that in 2018, 21% of high school students in the U.S. used e-cigarettes, a 78% 30

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increase from just the year prior and a 14-fold increase since 2011.1 Cases of associated morbidity and mortality are similarly on the rise. On September 12, the CDC reported 380 confirmed and probable cases of lung disease and 6 deaths associated with e-cigarette use. 2 That same week, the Trump administration announced their intention to finalize a Federal Drug Administration (FDA) policy prohibiting the sale of flavored e-cigarettes.3 In Congress, the House Committee on Oversight and Reform held a two-day hearing on “Examining JUUL’s Role in the Youth Nicotine Epidemic” in July that I attended. JUUL Labs Inc. is the dominant manufacturer of e-cigarettes with 76% marketshare.4 Despite JUUL denying purposeful marketing to children, the hearing exposed the company’s shrewd tactics to reach youth and vulnerable communities.

Meredith Berkman testified that representatives from JUUL went to her son’s high school under the guise of vaping prevention education. The representatives claimed that vaping was not for children but also used the class to introduce and emphasize the “safety” of e-cigarettes.

Representing the Cheyenne River Sioux Tribe Health Committee, Rae O’Leary testified that JUUL offered heavily discounted e-cigarettes to the tribe if they would refer smokers into their “Switching Program.” In exchange, patients would provide data about themselves and their behaviors for JUUL’s research. JUUL pitched their program under as a public health and harm reduction intervention, despite acknowledging that WWW.SFMMS.ORG

their products were not FDA approved for the treatment, prevention, or cure of smoking.

Opinions on the Subcommittee on Economic and Consumer Policy were mixed. Representative Raja Krishnamoorthi, the chairman, stated, “The ability for kids to get addicted to e-cigarettes, and the inability for adults to prevent it, poses an unparalleled and unprecedented challenge.” Nearly all subcommittee members echoed that sentiment but disagreed on potential solutions. Some called for a ban on flavored e-cigarettes, while others questioned its necessity and effectiveness.

While the debate continued in Congress, the San Francisco Board of Supervisors unanimously passed a resolution prohibiting the sale of e-cigarettes without FDA approval in June.

There are currently no FDA-approved e-cigarette products on the market.

However, JUUL and the broader industry have placed proposition C on the November ballot to overturn San Francisco’s ban. Any policy that increases access to e-cigarettes and would put our communities at greater risk of long-term respiratory damage and nicotine addiction.

JUUL has already spent $11 million in support of proposition C.5 Their advertisements have inundated my own Facebook news feed and likely all profiles of young adults in San Francisco.

Hand-held picket signs supporting proposition C have appeared on street corners throughout San Francisco.

My friend and I are part of the first generation that must reckon with the long-term consequences of e-cigarette use. The tobacco industry thinks they can get away with it.

As a medical student and millennial, I am speaking out against the exploitation of my generation for financial gain.

Health care professionals have a duty to advocate against those policies that endanger the health of our communities. With its addictive properties, carcinogenic compounds, and respiratory harm, e-cigarettes threaten to upend decades of progress on smoking cessation and sicken generations to come.

Preventive medicine is uniting against vaping. Preventive medicine is promoting the well-being of our citizens and challenging the cigarette companies by opposing proposition C. If e-cigarettes were indeed intended as harm reduction for current smokers, it ought to undergo FDA review for safety and efficacy like other therapies and have its access regulated.

With cigarettes, the public health community was too late. In college, my professor asked our class a hypothetical question, “If we knew 100 years ago what we now know about tobacco smoking, would you have banned cigarettes back then?” We all nodded yes.

I hope we need not ask that question with regret about e-cigarettes one day.

References 1. Cullen KA, Ambrose BK, Gentske AS, Apelberg BJ, Jamal A, King BA. Notes from the Field: Use of Electronic Cigarettes and Any Tobacco Product Among Middle and High School Students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep. N;67(45):1276-1277. doi:10.15585/mmwr. mm6745a5 2. CDC. Pulmonary Disease Associated with E-cigarettes.

Centers for Disease Control and Prevention. https://www. cdc.gov/media/releases/2019/s0912-update-cases-vaping. html. Published September 12, 2019. Accessed September 17, 2019.

3. Trump Administration Combating Epidemic of Youth ECigarette Use with Plan to Clear Market of Unauthorized, Non-Tobacco-Flavored E-Cigarette Products. U.S. Food & Drug Administration. https://www.fda.gov/news-events/ press-announcements/trump-administration-combatingepidemic-youth-e-cigarette-use-plan-clear-market-unauthorized-non. Published September 11, 2019. Accessed September 17, 2019.

4. Craver R. Juul ends 2018 with 76 percent market share.

Winston-Salem Journal. https://www.journalnow. com/business/juul-ends-with-percent-market-share/ article_6f50f427-19ec-50be-8b0c-d3df18d08759.html.

Published January 8, 2019. Accessed September 17, 2019.

5. Fitzgerald Rodriguez J. JUUL drops $7 million more into pro-vape SF ballot measure. The San Francisco Examiner. https://www.sfexaminer.com/news/juul-drops-7-millionmore-into-pro-vape-sf-ballot-measure/. Published September 24, 2019. Accessed September 25, 2019.

Brandon Yan is a UCSF medical student and an affiliate of the UCSF Philip R. Lee Institute for Health Policy Studies. He grew up in San Francisco and graduated with a bachelors in public policy from Duke University. He serves as a medical student liaison to the SFMMS Board of Directors.

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Election Issue

SAN FRANCISCO BANNING E-CIGARETTES IS A MODEL FOR THE NATION

By Drs. John Maa and Jeffrey Wigand In June of 2019, Mayor London Breed signed an ordinance effective January 2020 to suspend the sales and distribution in San Francisco of electronic cigarettes that have not undergone premarket review by the U.S. Food and Drug Administration (FDA).

This legislation by Supervisor Shamann Walton and unanimously approved by the San Francisco Board of Supervisors represents a logical and powerful public policy strategy to enforce the law. It also compels e-cigarette companies to follow federal requirements regarding FDA scientific and regulatory review of devices marketed with a therapeutic intent. Advertising e-cigarettes as a smoking cessation aid without an FDA marketing order is contrary to the Federal Food, Drug, and Cosmetic Act of 1938, which oversees the safety of food, drugs, medical devices and cosmetics.

In 2016, the Obama administration finalized a rule to expand FDA deeming authority to regulate e-cigarettes. E-cigarette manufacturers were allowed up to two years to submit applications, and a year to win FDA approval (which would have taken effect by today).

But in 2017, the FDA under the Trump administration issued "guidance” exempting e-cigarettes from premarket review until 2022. In 2018, the American Heart Association, American Cancer Society — among others — filed litigation to challenge this delay citing the risk posed to children.

In May 2019, a federal judge ruled that the FDA acted illegally in 2017 by allowing e-cigarettes to remain on the market without a safety review, and later ordered the FDA to impose a ten month deadline for e-cigarettes manufacturers to submit applications, and a one year deadline to obtain pre-market approval. The San Francisco suspension of e-cigarette sales should have a maximum of 17 months duration (shorter if applications are submitted earlier or FDA approval is granted sooner).

The sales of e-cigarettes are illegal in 25 nations worldwide, including Japan, Qatar, Hong Kong, and Thailand. The lack of scientific evidence regarding their efficacy as a smoking cessation aid, and risks of promoting drug abuse in addition to nicotine addiction are cited in support of these proactive public health actions. In August 2019, India’s health ministry proposed a ban on the production and import of e-cigarettes.

Juul’s response to the e-cigarette moratorium is a November 2019 ballot measure to allow them to continue selling e-cig32

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arettes in San Francisco.

It would change existing Tobacco 21 prohibitions on e-cigarette purchases, by now requiring the city to prove that the seller knew the buyer was under 21 for the restriction to be enforced.

The Coalition for Reasonable Vaping Regulations supporting the measure has thus far been funded solely by Juul with millions. Juul has financial reserves to lead this campaign, after Altria announced a $12.8 billion investment in 2018 to acquire a 35 percent interest in the company. The Altria relationship could accelerate youth vaping worldwide. Juul can now benefit from the expertise of the Altria lobbying team and legal division.

The San Francisco legislation serves as a pivotal pilot in long overdue FDA vaping regulation, to minimize the harm worldwide from youth vaping. In July 2019, a House Oversight Subcommittee hearing revealed that Juul spent hundreds of thousands of dollars to fund youth programming, and access students in classrooms.

The Juul leadership were pressed about the company’s role in youth addiction, a problem for which Juul’s CEO had already apologized. Continued congressional and state legislature hearings should explore Juul’s contribution to the vaping epidemic.

Additional scrutiny should come from the Federal Trade Commission, who have already launched in investigation into Juul’s marketing and use of influencers.

Altria is the parent company of Philip Morris, a signatory of the 1998 Tobacco Master Settlement Agreement (MSA). Specific MSA language addresses future successor products owned by Philip Morris that would also be subject to the terms of the MSA. Philip Morris patented a prototype of a functioning e-cigarette by 1996, and perhaps Juul falls into the category of future products subject to MSA constraints on advertising that targets youth, political lobbying, and product placement in print media and television.

In July 2019, the Connecticut Attorney General launched an investigation into Juul’s marketing practices and health claims, following May 2019 action by the North Carolina Attorney General against Juul for targeting youth. Attorneys general across America should work together to ensure the Juul-Altria partnership complies with existing laws.

To assist FDA evaluation now required by 2021, the scientific WWW.SFMMS.ORG

evidence about the risks and benefits of e- cigarettes should be assembled. A starting point could be the World Health Organization 2019 report warning that e-cigarettes do not help reduce cancer, and should be regulated. Areas for further study include the vaping of marijuana, cocaine, heroin and other illicit substances (now linked to possible fatal respiratory disease and hospitalizations), and the global youth impact of e-cigarettes in nations without Tobacco 21 laws.

Ultimately, focusing on the concept of “vaping cessation” may enlighten the debate. Switching to lifelong vaping is not the desired final outcome for adult smokers, or youth who would have never smoked otherwise.

Final success would be a world where e-cigarettes no longer are produced. As e-cigarette sales increase, perhaps the production of combustible cigarettes should be held down accordingly?

Pressing e-cigarette design towards products without nicotine or flavors may reduce the addictiveness and appeal to youth.

Perhaps FDA review will conclude that e-cigarettes should only be available in pharmacies, or through an physician prescription, to assist studies about their safety and efficacy?

During a first interview to become FDA Commissioner, David Kessler stated that his priority would be to “enforce the law.”

The California cities of Livermore and Richmond followed the lead of San Francisco in advancing similar legislation to enforce

CMA announces

GME grants

John Maa M.D. is a general surgeon in San Francisco a former president of the San Francisco-Marin Medical Society, and chair of the California Advocacy Committee for the American Heart Association.

Jeffrey Wigand, Ph.D. is a medical biochemist and former vice president of research and development and environmental affairs at Brown & Williamson Tobacco Corporation who worked on the development of reducedharm cigarettes and in 1996 blew the whistle on tobacco tampering at the company. A version of this piece first appeaerd on The Hill.com

second application cycle for CalMedForce

Physicians for a Healthy California (PHC) is excited to announce the second grant cycle for the graduate medical education (GME) grant program, CalMedForce, which will award approximately $38 million to primary care and emergency medicine residency programs in California. The application will be released September 23, 2019, and is due by October 28, 2019, at 11:59 p.m. (PST). Priority will be given to programs in medically underserved areas and programs who serve medically underserved populations.

All applications submitted will receive a preliminary score.

The preliminary scores will be sent to the primary contact and program director as provided in the application. Applications submitted by October 11, 2019, 11:59 p.m. (PST) will have the opportunity to edit their application, if needed. Early application submission is strongly encouraged. Applications submitted between October 12, 2019 and October 28, 2019 will be considered final, and, no supplemental information or changes can be made to the application.

Programs that plan to apply for funding are encouraged to start gathering the needed information now to ensure they are ready to complete the application by the deadline. While

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FDA regulation and implement a moratorium in July 2019. This enforcement intent highlighted in Supervisor Walton’s legislation may be the most powerful justification for policymakers to regulate e-cigarettes in the face of epidemic levels of use by children.

the application itself is not lengthy, it may take some time to collect and prepare the required information. Among the information needed is: • Health professional shortage area (HPSA) score

• Structure of residency program, including the number of residency positions overall and the number of positions for which you are requesting funds • ACGME/AOA accreditation letters for both the sponsoring institution and specialty

• Information about program graduates, including where they are practicing, in what specialty and in what type of practice from the past three years

• Details about your patient population payor mix • Justification of your funding needs

Please share this information with colleagues who may benefit from this funding. (If you would like to be added to our distribution list for future updates, please email CalMedForce@phcdocs.org with “subscribe” in the subject line).

For more information about CalMedForce, visit phcdocs.org.

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Election Issue

MEDICARE FOR ALL: A Voter's Cheat Sheet

James G. Kahn, MD and Elliot Marseille, DrPH The discussion of "Medicare for all" can be both gratifying and confusing. While it is heartening to see growing agreement on the principle of universal health care as a human right, political debate formats can eliminate any opportunity for nuance.

That’s why we’re clarifying critical issues raised in recent political debates, and which will likely return during the campaign. Full disclosure: We support Medicare for all and we think that with a clear understanding of the facts, most people will too.

1. What is Medicare for all?

It’s a system with a single, public, nonprofit health insurer, instead of the dozens of private and public insurers we have now.

It is not “government-run health care.” It is “government-run health insurance.” Like with Medicare today, health care would be provided by independent doctors and hospitals.

Everyone would be covered for life by a single comprehensive benefit package and would choose their own doctors. Private insurance premiums and out-of-pocket costs would disappear, replaced by taxes that are fair and progressive (richer people pay more). Simplified insurance rules and billing would reduce paperwork costs while negotiations would reduce drug prices.

Overall, we would save money while covering everyone.

2. What is a Medicare expansion, as opposed to Medicare for all?

Several candidates mentioned a public option, such as a Medicare buy-in. A public option could be offered on state health insurance exchanges, providing what might appear to be a cheaper alternative to private insurance. But it won’t solve our problems. A buy-in would leave the complicated multi-payer system in place, so the opportunities for savings on paperwork and pharmaceuticals would disappear. Moreover, the health insurance industry would use every tactic it knows to push the sickest people into the public option, jeopardizing the financial stability of the program.

3. How do you define "working" when it comes to health care?

Today, millions of Americans remain uninsured or underinsured — with exorbitant deductibles and out-of-pocket costs on top of their ever-rising insurance premiums. Medical bankruptcy is common, even among the insured — as Sen. Elizabeth Warren (D-Mass.). And people with employer-sponsored private insurance? They lack health-care security. If they lose their job, they lose their insurance. If “working” means decent and reliable coverage, private health insurance is definitely not cutting it.

4. Which health-care choices really matter?

Beto O’Rourke said “Choice is fundamental” as an argument to retain commercial insurance. Yet it is our choice of doctor (not insurance company) that is fundamental to our care and 34

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that’s exactly the freedom that commercial insurance denies us — for profit.

5. What do we mean by private insurance under Medicare for all?

When asked, “Who would get rid of private insurance?”

Bernie Sanders, Warren, Bill de Blasio, and Kamala Harris raised their hands. Harris later clarified that she wouldn’t want to abolish private insurance altogether. She has a point: Medicare for all could co-exist with private insurance for supplemental services, like fancier hospital rooms, or alternative therapies. However, private insurance for core medical benefits would be unnecessary. In fact, keeping it would undercut the savings we could enjoy from reducing insurance complexity and pharmaceutical prices.

6. What’s a "glide path?”

Buttigieg endorsed a “glide path,” that is, taking intermediate steps to Medicare for all. This makes sense if the timeline is short and the steps are direct. For example, filling in Medicare's existing coverage gaps and adding all 50-65 year-olds would be excellent first steps. Alternatively, we could move quickly to help everyone suffering today. It only took about a year to roll out Medicare in 1966, without the use of the Internet or computers.

7. How will doctors and hospitals fare under Medicare for all?

First, under most Medicare for all plans, hospitals would be paid lump sums to cover operating costs. Second, payments would be negotiated to assure financial viability. Raising the specter of hospital closures is a scare tactic.

8. Should I be afraid of losing my insurance?

Yes — under the current system. Unless you’re on Medicare, your health insurance is not guaranteed. Your employer can cancel the plan you like, forcing you to find a new doctor. You may change jobs, or be laid off and lose your insurance. The premium may rise so much that you can no longer afford it. Coverage that’s guaranteed wherever (or whether) you work requires insurance that covers people based on U.S. residency rather than employment, like Rep. Pramila Jayapal’s (D-Wash.) Medicare for All Act of 2019.

9. Should I worry that taxes will go up?

With Medicare for all, taxes will replace rising premiums, copays and deductibles. These taxes will be progressive. The more you earn, the higher rate you pay. That’s fairer than charging for health insurance based on age, without regard to income, like now. The Affordable Care Act provides premium subsidies for some poorer people, but not for all and requires high deductibles and copays. For most people, the new taxes for health care will WWW.SFMMS.ORG

be less than what they currently pay in premiums and out-ofpocket costs. Low and middle-income families will save money.

High-income families will pay more.

10. Should I fear losing choice of doctor?

Sadly, we already have. Unless you’re on traditional Medicare, you can’t choose any doctor or hospital you like (except if you pay the costs yourself). Some presidential candidates say the choice worth making is between health insurers. Isn’t it more important to choose the doctor and hospital that provides your care, as permitted under Medicare for all?

Medicare for All is a system widely used in other countries — and works incredibly well. The real fairy tale is that we can still afford insurance middlemen taking a cut out of our healthcare budget. Is it too drastic? During the Great Depression, we

launched America’s biggest social insurance program: Social Security. It’s a great example of how the government can protect us against economic risk and improve our lives. Medicare for all is a grand solution in a grand American tradition. This kind of health-care reform is not only possible, it’s essential.

James G. Kahn, M.D., is an emeritus professor of health policy at the University of California San Francisco. Dr. Elliot Marseille, DrPH, is CEO of Health Strategies International.

Parts of this article appeared in posts on The Hill: Medicare for All: Fears and Facts: https://thehill.com/opinion/healthcare/457403medicare-for-all-fears-and-facts Medicare for All: A Voters’ Cheat Sheet: https://thehill.com/opinion/healthcare/453504-medicarefor-all-a-voters-cheat-sheet

A Comparison of Democratic Health Reform Plans

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SURPRISE MEDICAL BILLING NEEDS TO BE REINED IN the right way Kimberly L. Newell Green, MD and Mary Lou Licwinko, JD, MHSA Rising healthcare costs prevent many Californians from accessing the vital treatments and services they need.

One of the most egregious practices in our current healthcare system, which creates unnecessary stress and financial concerns for patients and their families, is surprise medical billing. California’s attempt to resolve surprise billing at the state level has failed miserably, only worsening our physician shortage and undermining patient access to care.

Congress cannot go down this road. It is imperative that federal legislation to address this issue take a different approach than our state lawmakers chose. Like some of the bills being considered in Washington, California chose to implement a government benchmarking solution to resolve payment disputes between physicians and health insurers. Benchmarking at the national level would essentially put the federal government in charge of establishing reimbursement rates for physicians performing out-of-network care here in California and across the country.

Setting arbitrary and often artificially low provider rates ignores the drastically differing levels of cost and difficulty that come along with providing medical services in different geographical regions and at various kinds of healthcare facilities.

This benchmarking would more than likely result in many hospitals and emergency rooms accruing financial losses that would lead to an increase in provider consolidation, as well as hospital and urgent care closures jeopardizing patients across the country, especially in rural areas where resources are already strained.

ADVERTISING Here in California, a government-mandated benchmarking approach has created a take-it-or-leave it system that gives all the leverage to large insurance companies. It essentially gives insurers the green light to determine what kind of care patients can access while also giving them greater power to avoid negotiating

with providers to bring more doctors into their networks. As more doctors are forced out of network, patient access to care is dropping and out-of-pocket costs are expected to rise.

Clearly this is not a sustainable or replicable model.

Rather than benchmarking, Congress should take a closer look at other legislative solutions that would implement an independent dispute resolution as a solution to protect patients from surprise billing. IDR is the approach that New York legislators took when they passed their own surprise billing law back in 2015. It has worked to increase network participation, lower out-of-network rates and bills and control emergency care costs.

IDR provides incentive for both insurers and providers to submit their best and final offer through an online platform.

Within about a month, an assigned, independent mediator helps to determine a fair rate. Until that time, hospitals receive temporary payments based on the market value of the services they provide, which helps provide an additional layer of financial security that is necessary to maintain access for patients.

Californians deserve open access to the highest-quality care at the most affordable prices possible — and no one should ever have to be placed in the middle of a payment dispute between healthcare providers and insurance companies. The only way to truly meet both of these goals is for Congress to pass legislation that includes the IDR framework instead of the potentially devastating benchmarking approach.

As Congress finalizes its plan to address surprise billing, the San Francisco-Marin Medical Society urges California’s entire congressional delegation to fight for a solution that leverages IDR in order to protect patients while preserving access for Californians — and all Americans.

Mary Lou Licwinko, J.D., MHSA, is executive director and CEO of the San Francisco-Marin Medical Society. Kimberly Newell Green, MD, pediatrician, is president of the San Francisco-Marin Medical Society.

This op-ed originally appeard in the Marin Independent Joiurnal in September.

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Election Issue

CMA FAQ: When am I required to offer naloxone to patients?

A new law took effect on January 1, 2019, that requires opioid prescribers to also offer a prescription for an opioidoverdose reversal drug such as naloxone.

Under the new law, physicians must offer a prescription fornaloxone or another drug approved by the U.S. Food and Drug Administration (FDA) for the complete or partial reversal of opioid depression when one or more of the following conditions are present: 4 The patient’s opioid prescription dosage is 90 or more morphine milligram equivalents per day.

4 An opioid medication is prescribed concurrently with a prescription for benzodiazepine.

4 The patient presents with an increased risk for overdose, including a patient with a history of overdose, a patient with a history of substance use disorder, or a patient at risk for returning to a high dose of opioid medication to which the patient is no longer tolerant.

Physicians must then provide patients who are prescribed naloxone with education regarding overdose prevention and use of naloxone or other similar drug approved by the FDA.

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The California Medical Association (CMA) has received calls from physicians regarding the ambiguity of these new requirements. Specifically, there have been questions regarding exactly when co-prescribing is required. Concerns have also been expressed about the applicability of this law to patients receiving hospice care or to patients in inpatient settings whereimmediate medical attention is readily available.

Presently, there is an active bill, AB 714 (Wood) that seeks to address these concerns. CMA continues to work with legislators and other stakeholders to clarify a physician's obligations under the law and will update members as soon as we know more.

To learn more about prescribing controlled substances, including this new requirement, see CMA health law library document#3201, "Controlled Substances: Prescribing."

This document, as well as the rest of CMA’s online health law library, is available free to members at cmadocs.org/healthlaw-library. Nonmembers can purchase documents for $2 per page.

Contact: CMA Legal Information Line, (800) 786-4262 or legalinfo@cmadocs.org.

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WELCOME TO OUR NEW SFMMS/CMA MEMBERS: REGULAR ACTIVE MEMBERS: Kristin Nicole Anderson, MD | Hematology Oncology Henry Daniel Crevensten, MD | Internal Medicine Maya Helfenberger Dulay, MD | Internal Medicine Peter Lloyd Forster, MD | Psychiatry Barbara Marie Galligan, MD | Medical Oncology Bobbie Head, MD | Medical Oncology Martin Edwin Kernberg, MD | Diagnostic Radiology Jaehee Kim, MD | Hospice and Palliative Medicine Jennifer Barbara Lucas, MD | Medical Oncology Alex Samuel Metzger, MD | Medical Oncology

HOUSE OFFICERS:

Flang Nguyen, MD | Hospice and Palliative Medicine Dustin Luke Habitan See, MD | Internal Medicine Tasneam Shagroni, MD | Internal Medicine Emma Bonnar Shak, MD | Internal Medicine Michael Alexander Thomashow, MD | Hospice and Palliative Medicine Yeh-Kuang Tsai, MD | Anesthesiology

Alina Uzelac, DO | Radiology Robert Zhung-Huay Wang, MD | Family Medicine

Leopold Arko, IV, MD | Pediatric Surgery (Neurology) Joanna Balcerek | Pathology John Connor Barnhart | Psychiatry Laura Brown | Pathology Cam Candido | Family Medicine Shirley Chan | Internal Medicine Mike Cheng | Internal Medicine Ai Chien | Occupational and Western Medicine

Stacie Lang Collins, MD | Psychiatry Andrew Curnow | Internal Medicine Alex Ruey Dinh, MD | Nephrology Sienmi Du | Gynecology Reyhan Gedik, MD | Pathology Madeline Grade | Emergency Medicine Kevin Guzman | Internal Medicine Tina Han | Child and Adolescent Psychiatry Zoe Harn Enz | Child Neurology Neslihan Kayraklioglu | Pathology Omid Khalilzadeh, MD | Radiology Bora Kim | Psychiatry

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Eunjeong Kim, MD | Jolene Kokroko | Gynecology Kristiana Lehn | Psychiatry Hannah Leo | Psychiatry Ryan Lichtarge | Emergency Medicine Irene Ly | Family Medicine Trina Mansour, MD | Obstetrics and Gynecology Richard William Mclean, I, MD | Gastroenterology David Benjamin Nagle, MD | Gastroenterology Jennifer Ann Papac, MD | Psychiatry Laura Pasternack, MD | Anesthesiology Aileen Portugal | Obstetrics and Gynecology Elizabeth Qin | Psychiatry Priya Rajagopalan, MD | Neuroradiology Alison Rustagi | Internal Medicine Danielle Sanders | Anesthesiology Minkyung Shin | Pediatrics Xiomara Pinto Urban, MD | Psychiatry Paul Wallace | Psychiatry Kevin Amir Zand, MD | Radiology

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UPCOMING EVENTS President-Elect Reception for Dr. Peter Bretan October 25, 2019, 6:00-7:30pm | Disneyland, Sleeping Beauty Pavilion SFMMS member and past Marin Medical Society President, Peter Bretan, Jr., MD, will be installed as the President of the California Medical Association (CMA) during its upcoming House of Delegates (HOD) meeting at Disneyland.

SFMMS is pleased to be hosting a drop-in reception for Dr. Bretan on October 25 in Anaheim. We are excited for his CMA Presidency and all that he will accomplish! For more information, contact Erin Henke at ehenke@sfmms.org.

2019 CMA House of Delegates October 26-27, 2019 | Disneyland Hotel, Anaheim, CA

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The House of Delegates convenes annually to debate and act on resolutions and reports dealing with myriad medical practice, public health and CMA governance issues. Policies adopted by the House are implemented by the Board of Trustees, which also deals with the many interim policy issues that arise between annual sessions. Visit https:// www.cmadocs.org/hod for more information.

My Stroke of Luck Performance November 10, 2019, 7:00-9:00pm | Marin Showcase Theater, San Rafael,

Join SFMMS members and their guests for a front row seat at a performance of My Stroke of Luck. The performance will be followed by a talk back session with Diane Barnes.

Tickets are limited and are available for $30 per person. "My Stroke of Luck" is the story of a single adoptive mother of special needs and gifted sons, a practicing physician, who forges a new identity after a debilitating stroke. To purchase tickets, visit www.sfmms.org/events.aspx.

San Francisco 2019 Flu and Infectious Disease Forum November 13, 2019, 8:30am–12:00pm | San Francisco Public Library, Koret Auditorium

The San Francisco Department of Public Health invites you to attend the annual San Francisco Flu and Infectious Disease Forum. Join us for an engaging discussion to learn more from experts in the fields of communicable and vaccine preventable diseases. Register at http://bit.ly/2lifww4.

SAVE THE DATE – 2020 SFMMS Annual Gala Friday, January 31, 2020, 5:30-9:30pm | Green Room at the SF War Memorial, San Francisco

The 2020 SFMMS Annual Gala will be held on Friday, January 31, 2020 at the Green Room at the San Francisco War Memorial. President-Elect, Brian Grady, MD will be installed as the 2020 SFMMS President. More information and registration will be available soon at www.sfmms.org/events. aspx. Sponsorship opportunities are available – contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

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CLASSIFIED ADS Plastic Surgery Practice For Sale - Modesto, CA. Revenue $1.4 million on 4 doctor days. Cosmetic (breast, body, facial, hair transplant, stem cell) and otolaryngology services in accredited surgical suite that is included in the transaction. High referral rate from both patients and other doctors.

Third-party appraisal available. Photos available. Offered at only $519,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com Internal Medicine Practice For Sale - Napa County.

Concierge medical practice with revenues averaging $600,000 seeing 8 - 10 patients per day. Seller's net income is near the 90-percentile for IM. Long established in the area, moved to newly renovated 1440 sq. ft. location in 2015; great proximity to hospital. EMR in place. Photos and thirdparty appraisal available. Offered at only $497,000. Contact Medical Practices USA for more information. 925-820 6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com. 58. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com WWW.SFMMS.ORG

San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

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