FEATURE ARTICLES
12 Q and A: American Medical Association President
Jack Resneck, MD
Alice Miranda Ollstein
SPECIAL SECTION: EMERGENCY!
16 A Path to Recovery: Confronting the Addiction and Mental Health Crisis One Patient in Crisis at a Time
William Andereck, MD; David Smith, MD and Steve Heilig, MPH
20 Emergency Department Crowding in San Francisco
John Brown, MD; Christopher Colwell, MD and Joseph Cuschieri, MD
22 A Wake-Up Call: Confronting Street Addiction
Haining Yu, MD and John Maa, MD
24 CME: Good Intentions Gone Awry
Steven Reidbord, MD
26 Health Leaders Should Speak Out for Proposed Carbon Emission Regulation
Lisa Patel, MD, MESc
28 California Lacks Black Doctors. Here's How the State Can Add More.
Wynton Sims, MPH
30 Physician Wellness = Sustainability + Self Advocacy
Jessie Mahoney, MD
SAN FRANCISCO MARIN MEDICINE
April/May/June 2023
Volume 96, Number 2
MONTHLY COLUMNS
2 Membership Matters
5 President's Message: When in Doubt, Just Show Up Heyman Oo, MD, MPH
6 Executive Memo: Looking Back on a Year of Member Engagement Data
Conrad Amenta
7 CMA House of Delegates Report
Michael Schrader, MD; Ameena Ahmed, MD and Steve Heilig, MPH
COMMUNITY NEWS
29 Kaiser News
Monica Kendrick, MD
OF INTEREST
8 SFMMS Board Sets 2023 Legislative Priorities Adam Francis, CAE
14 Recommended Use of Walgreens Settlement Funds: Letter to Mayor London Breed
15 Media Statement on CMS Decision to Extend Deadlines at Laguna Honda
36 Advertiser Index
“ Major players in California’s health care field have reached a deal on how they want the state to spend $19 billion in proceeds of a renewed tax on insurance plans plus the federal funds that go with it — a development that followed months of private negotiations. It’s a massive victory… They did it by meeting for two hours each week since November, debating spending details at the headquarters of the California Medical Association over lunch, where they filled the conference room whiteboards with calculations. Dustin Corcoran, the CEO of the medical association who chairs the coalition, said he’s even had dreams about the tax. “There was a lot of sausage making,” Corcoran said. “It’s not always pleasant or fun, but we landed in a spot we can be really proud of.”
The deal includes money to bolster struggling hospitals, ease workforce shortages and entice more specialists to see Medi-Cal patients. Three specialties will get a boost to their reimbursement rates: Primary care, OBGYN and some mental health care services will start being paid 87.5 percent of what the federal government pays them through Medicare. And $75 million will be used to create new residency slots for medical school graduates.
– Politico, June 24. Full story: https://www.politico.com/news/2023/06/24/ california-strikes-huge-deal-unlocking-billions-for-health-care-00103476
Governor Gavin Newsom released his revised 2023-24 state budget, proposing the reinstatement of the Managed Care Organization (MCO) Tax, which will result in $19.4 billion in revenue from April 1, 2023, through December 31, 2026, to help maintain and increase investment in the Medi-Cal program.
Over the past several months, the California Medical Association (CMA) has advocated to reinstate and increase the MCO tax, which expired late last year, to improve Medi-Cal access to care by raising physician reimbursement rates.
In a win for physicians and patients, the budget proposal released includes an increase to some Medi-Cal provider rates for the first time in more than two decades. Effective January 1, 2024, the budget proposal would increase provider rates to at least 87.5% of Medicare for primary care, maternity care and non-specialty mental health services. Starting in the 2024-25 budget year, the provider rate increases would be expanded to some additional health care services and specialists.
The rate increase announced is due in part to the proposed elimination of the 10% Medi-Cal provider cuts authorized as part of the health services trailer bill (AB 97) to the 2011-12 state budget, which CMA has long advocated to undo. CMA had filed a lawsuit in federal court (CMA et al. v. Douglas) to stop the cuts, but ultimately a three-judge panel of the 9th Circuit Court of Appeals court ruled in 2013 that the state could move forward with the rate cuts.
Despite the disappointing 9th Circuit ruling, CMA never stopped advocating for a reversal of these cuts, which have had devastating effects on access to care for California’s poorest and most vulnerable patients.
“The provider reimbursement rate cuts from 2011 have had a detrimental impact on patient access to care for more than a decade and I am very happy to see the Governor’s May revised budget, which will help us achieve justice and equity in access
to care for Medi-Cal patients,” said CMA President Donaldo Hernandez, M.D. “It is more important than ever to address the underfunding of the Medi-Cal system that makes it difficult for many patients to get access to primary and specialty care when they need it.”
Gov. Newsom’s newly proposed rate increases will be an adjustment to base rates, and the California Department of Health Care Services has indicated it will direct managed care plans to pay providers at least these rates.
The rate increases will be paid for by Gov. Newsom’s updated plan to tax managed care organizations. In his May budget proposal, Gov. Newsom announced a commitment to invest additional funds in the Medi-Cal program to improve access and equity. The MCO tax, which allows the state to receive federal matching funds, had been in place for more than a decade and expired in December 2022.
“There is much more to be done,” said Dr. Hernandez. “CMA looks forward to working with the Administration and the Legislature in the coming weeks to seize this rare opportunity to make meaningful change in the lives of Californians by making timely access to health care a reality for all.” See more on page 29.
Adverse Childhood Experiences (or ACEs) are associated with some of the most common, serious, and intractable health conditions facing our patients. This performance improvement project is designed to improve patient and physician awareness on ACEs and toxic stress, and to study the impact of educational materials on patients’ understanding of ACEs and its health impacts.
Participating physicians will survey ten patients, distribute two educational flyers, survey ten more patients, analyze survey data, and reflect on resulting practice improvement. For information, see https://www.cmadocs.org/aces.
The DEA has released guidance on the new one-time requirement for eight hours of training on the treatment and management of patients with opioid or other substance use disorders.
See the official DEA letter to registered practitioners for more details and SAMHSA for additional guidance and recommendations for core elements of the required training.
CSAM members should know they likely have already met the requirements. You do not have to complete this training if you:
• Hold Board Certification in addiction medicine or addiction psychiatry through the American Board of Medical Specialties, American Board of Addiction Medicine, or American Osteopathic Association
• Previously completed the DATA-2000 Waiver training to prescribe buprenorphine for opioid use disorder (aka X-Waiver)
• Completed education (8 cumulative hours), prior to December
29, 2022, related to the treatment and management of patients with opioid or other substance use disorders from accredited groups named in the guidance document
• Graduated in good standing from a medical (allopathic or osteopathic), dental, physician assistant, or advanced practice nursing school in the United States within five years of June 27, 2023, and successfully completed a comprehensive curriculum that included at least eight hours of training on the treatment and management of patients with opioid or other substance use disorders, including the appropriate clinical use of all drugs approved by the Food and Drug Administration for the treatment of a substance use disorder
For those that need training, CSAM has a new collection in its online education center that will help satisfy the requirements: https://cme.csam-asam.org/
Reminder: Medical board will no longer accept paper applications after June 1
Effective June 1, 2023, the Medical Board of California will no longer accept or process paper-based applications for a Physician’s and Surgeon’s (P&S) License. The paper application was removed from the medical board’s website on May 19. Except under limited circumstances, paper applications submitted on or after June 1 will not be processed.
April/May/June 2023
Volume 96, Number 2
Editor Gordon L. Fung, MD, PhD, FACC, FACP
Managing Editor Steve Heilig, MPH
Production Maureen Erwin
SFMMS OFFICERS
President Heyman Oo, MD, MPH
President-elect Dennis Song , MD, DDS
Secretary Sarita Satpathy, MD
Treasurer Jason Nau, MD
Immediate Past President Michael Schrader, MD
SFMMS STAFF
Executive Director
Conrad Amenta
Associate Executive Director, Public Health and Education
Steve Heilig, MPH
Director of Operations and Governance
Ian Knox
Director of Engagement
Molly Baldridge, MPH
Senior Director, Advocacy and Policy
Adam Francis
2023 SFMMS BOARD OF DIRECTORS
Edward Alfrey, MD
Melinda Aquino, MD
Ayanna Bennett, MD
Julie Bokser, MD
Kristina Casadei, MD
Clifford Chew, MD
Esme Cullen, MD
Manal Elkarra, MD
Mihal Emberton, MD
Cindy Greenberg, MD
Gordon L. Fung - MD, Editor
Beth Griffiths, MD
Ian McLachlan, MD
Jason Nau, MD, Treasurer
Heyman Oo, MD, President
Sarita Satpathy, MD, Secretary
Michael Schrader, MD, Immediate Past-President
Yalda Shahram, MD
Neeru Singh, MD
Dennis Song, MD, DDS, President-Elect
Kristen Swann, MD
Kenneth Tai, MD
Melanie Thompson, MD
Matthew D. Willis, MD
Kristen Wong, MD
Andrea Yeung, MD
Helen Yu, MD
For questions regarding journal, including possible submissions, contact Steve Heilig: Heilig@sfmms.org
Additionally, SFMMS has met with SF Supervisors Aaron Peskin and Rafael Mandelman, as well as Marin County Supervisor Eric Lucan. SFMMS plans to meet with all SF and Marin County Supervisors in the coming weeks to discuss emerging health issues and build relationships for future advocacy efforts.
We have had quite the busy first few months as a Society this year! In April, we had a very successful Legislative Advocacy Day in Sacramento with the California Medical Association (CMA), where we met with each and every one of our local legislators. It was so heartening for me to see so many new faces show up and join in the important work of speaking directly with our elected representatives, many for whom it was their first time doing so! Our delegation addressed a number of CMA priority issues and we passionately spoke to the imperative for the state to increase MediCal reimbursement rates for physicians to allow for real patient access, not just coverage on paper.
Finding the best path to become involved in advocacy efforts can seem intimidating, but I have found that sometimes just showing up is the most important thing you can do. When I was a resident, I was watching the news about the wave of unaccompanied minors crossing the southern border and I felt like I had to do something. After discussing avenues for us to engage, a co-resident and I decided at first to just show up—to attend a community meeting we had heard about that was being organized by community based organizations, behavioral health providers and social workers involved in the Latinx community. We were mindful of being the only physicians at the meeting and aware of having little expertise to care for the needs of these recently-arrived young people.
However, we did what physicians do best—we asked questions, listened carefully, synthesized the information from different perspectives, and offered to help in whatever way we could. We conducted focus groups with school officials, community clinic workers, and the teens themselves. The responses we heard were loud and clear that there was a pressing need for an easily accessible resource or program to help these teens adapt more smoothly to their new lives here.
These children were experiencing exceptionally difficult psycho-social transitions. The homes and histories they left behind often contained unimaginable traumas, their travels even more so. Landing in San Francisco alone, they then often reunited with parents whom they had not seen for years. Working with
behavioral health providers, we developed FUERTE, a schoolbased, group-format, mental health curriculum which used evidence-based techniques to normalize and support these kids’ acculturation while honoring their identities. One meeting led to another, and after five years of creating the curriculum, piloting the program, hosting “train the trainer” workshops, and sharing the program through word of mouth, we were awarded a $1.5M Innovations Project grant through a partnership with SFDPH. I’m still amazed by how we accomplished so much in just a few short years—simply because one day, my co-resident and I decided to show up.
So thank you again to those of you who showed up and joined us on Legislative Advocacy Day; thank you to those of you who showed up to celebrate at our Gala; and thank you to those of you who have shown up and attended our committee meetings, our webinars, our in-person mixers—I know it is no small feat to fit another thing into your busy days. And for those of you who are considering our events and gatherings in the future, please know that you are more than welcome and I look forward to meeting you! It always amazes me what’s possible from the sparks that are created when people decide to just show up.
Heyman Oo, MD, MPH is a primary care pediatrician and Site Medical Director at Marin Community Clinics in Novato. She also serves as an Information & Guidance Clinical Lead for the San Francisco Department of Public Health under the COVID-19 Task Force. She is a graduate of the UCSF Pediatric Leaders Advancing Health Equity (PLUS) Residency Program and obtained her MPH in Healthcare Policy and Administration at the Harvard T.H. Chan School of Public Health. She has been involved in organized medicine since the beginning of her medical school years at UC San Diego and has been a member of SFMMS for almost a decade.
In early 2022, the San Francisco Marin Medical Society (SFMMS) went live with a first-of-its-kind physician engagement tracking system. The purpose of the system is to quantify, track, and systematically increase the engagement of physician members with SFMMS.
Why bother tracking and increasing engagement? We've made this key, strategic investment because we believe that understanding if and how physicians engage with their professional society is an effective response to the experience of physicians practicing in an increasingly consolidated labor force.
That experience can, at times, feel at odds with the identity of the physician as an autonomous, independent decision-maker. The literature on physician wellness bears this out: physicians in highly consolidated labor markets are more likely to report feeling disconnected from their profession, from their community, and from emerging innovations, and there's a relationship between engagement with one's professional association and professional satisfaction.
Now that we have over a year's worth of data under our belts, we're beginning to understand our members like never before: what inspires them to act, and how best to empower them. We understand where every physician in our counties sits on our ‘ladder of engagement’ and so can be strategic in offering them practical, timely opportunities that fit their needs and reflect their values.
We understand engagement, roughly, as follows:
• Light engagers prefer to interact with the Medical Society electronically, by opening our weekly emails and clicking on online advocacy campaigns.
• Medium engagers, in addition to the above, will attend virtual events and trainings.
• Heavy engagers, in addition to the above, will attend in-person events and may consider contributing to the SFMMS Political Action Committee or Community Service Foundation.
• Super heavy engagers, in addition to the above, will run for elected positions within the Society or with the California Medical Association.
Here are a few early takeaways:
• We see comparable amounts of engagement across practice types, from small and solo private practice to large, integrated health systems. However, the way in which these members engage can be different.
• As expected, private practice is more likely to access practice support tools. Physicians in integrated health systems are more likely to access advocacy and volunteerism opportunities.
• Our Marin-based physicians are slightly more likely to engage with the Medical Society than San Francisco-based physicians.
• Primary care specialties, like family medicine, internal medicine, and pediatrics, are more likely to participate in advocacy campaigns.
• Permanente Medical Group physicians engage with a notably higher intensity than physicians in other large, integrated health systems, and are more likely to seek leadership positions.
• Our Super Heavy engagers engage with about 160 times more intensity than our median engager.
• In the coming months, we'll build on this engagement tracking system by advancing marketing automation, and — the brass ring — working to demonstrate a concrete relationship between physician engagement and physician wellness.
I believe that physician engagement should no longer just be organized medicine's "how." It should be our "why."
I'm excited to share more with you soon in the latest SFMMS Annual Report.
The California Medical Association’s House of Delegates (HOD) is loosely modeled on our government’s Congress, although with less dysfunction and polarization. Elected delegates from around the state propose and debate policy for the CMA, using an online quarterly forum and the annual statewide meeting each October. The two primary avenues for this process are the “major issues” chosen each year for the CMA to research and report on for debate and adoption, and the yearround policy resolution forum, where any CMA member and delegation can draft policy statements for statewide debate.
The primary function of this work is to guide CMA’s advocacy work, a potent factor in our state, and sometimes national, medical and public health arenas. Policies begin at SFMMS, adopted by CMA and sometimes AMA, have been influential on many important topics, from reproductive health to end-of-life care and much in-between. Here’s a brief primer and update on recent activities.
Potential major issues are submitted by each delegation and this year there were many to consider. A committee of the chairs of each delegation makes the selection in a sometimes intense and sometimes contentious democratic procedural meeting. Last year our “emergency” proposal, submitted just after Roe v. Wade was overturned, formed the basis for much debate and policy). The SFMMS this year submitted three topics for consideration: Drug Addiction, Treatment, and Prevention, Combatting Health Misinformation, and Addressing the Emergency Medical Services Crisis (including violence against clinicians). In this year’s process the final selections are (1) Artificial Intelligence in Medicine, including consumer health technology; (2) Climate Change/Action (Promoting Sustainability/Public Health), and (3) the new state Office of Healthcare Affordability. It’s thus a broad menu and CMA staff and leaders will prepare in-depth reports to guide CMA’s practical work on these topics.
Resolutions may be submitted quarterly for online debate and eventual vote. For the upcoming batch the SFMMS delegation has submitted three resolutions for consideration. The format is a parliamentary “Whereas/Therefore” format, with a few evidence-based arguments leading to a statement that will become formal policy if adopted by vote. The three such statements we submitted minus the “whereases” and references due to space constraints, follow here:
Authors: Ameena Ahmed, MD, John Maa, MD, Dennis Song, MD, DDS, Heyman Oo, MD
RESOLVED: That CMA support the concept of generational tobacco and vaping phaseouts of sales wherein those born after a defined year are prohibited from purchase of any tobacco products in their lifetimes; and be it further
RESOLVED: That CMA will work with interested elected officials and health authorities to develop and support plans and proposals for effective generational tobacco phaseouts; and be it further
RESOLVED: That this be referred for national action (AMA).
Reducing Harm from Alcohol and Funding Medi-Cal Access
SFMMS District VIII
Authors: Michael Schrader, MD, Andrew Calman, MD, PhD
RESOLVED: That the CMA endorse a “quarter-a-drink” tax on alcoholic beverages, with the revenues specifically assigned to bolstering reimbursement rates for healthcare providers (both directly and via Medi-Cal managed care plans) to achieve rough parity between Medi-Cal and Medicare rates for comparable services, and
RESOLVED: that CME support harm reduction strategies for alcohol related disease including public education, and increased access to inpatient and outpatient treatment, and
RESOLVED: that because similar Medicaid access problems plague many other states, that this be referred for national action (AMA).
Support for K-12 STEM (Science, Technology, Engineering & Mathematics) education to increase the physician pipeline among underrepresented communities.
Authors: Ameena Ahmed, MD MPH, Haining Yu MD, Roger Eng MD
Be it resolved that:
1. CMA support educational organizations that provide or promote science, technology, engineering and mathematics (STEM) education to K-12 students, with the intention of expanding pipeline programs to careers in medicine; and
2. CMA support STEM education that targets K-12 schools that disproportionately serve low income students; black, Latinx, and Native American students; and other socioeconomically disadvantaged students; and
3. That this be referred for national action (AMA).
Policymaking has long been likened to making sausage, an unappetizing process even if one favors the outcome. The CMA HOD on the other hand has long been a model of collegiality and reality-based debate (and SFMMS is particularly glad to have our own Past-President Lawrence Cheung MD as Vice-Speaker of the HOD, helping guide the complex deliberations). We also, due to the expansion of SFMMS membership in recent years, have a significantly expanded roster of delegates from all over San Francisco and Marin. If any member has questions or ideas for potential policy, please don’t hesitate to get in touch!
Drs. Schrader and Ahmed are the chair and vice-chair of the SFMMS delegation, and Steve Heilig is primary staff coordinator. Contact: heilig@sfmms.org
Every year, state legislators introduce thousands of bills addressing all topics of law. Several hundred pieces of legislation relate to health care. The California Medical Association (CMA) and your SFMMS staff review each bill to analyze how it might affect your patients and practice. The SFMMS Board met recently to decide which state legislation to act on, and of those bills, which would be a focal point of SFMMS advocacy. Below is a list of state bills SFMMS will support, the first three of which have been identified as top SFMMS priorities.
In the following bill descriptions, you will find quotes from SFMMS physician leaders about why the three bills SFMMS has prioritized for action are important to their practices.
AB 816 (Haney) Minors: consent to medical care
This bill allows a minor who is 16 years of age or older to consent to replacement narcotic abuse treatment that uses buprenorphine, while maintaining the requirement that the professional person providing the treatment shall include the parent in the treatment plan, unless the professional determines it would be inappropriate.
AB 816 (Haney) – Jayme Congdon, MD, MS, FAAP, General Pediatrician and Health
Services Researcher, San Francisco, CA
As a pediatrician, I consistently make every effort to engage families in the care of my patients. This is especially true with substance use disorders, for which parental involvement in recovery has been shown to improve treatment outcomes. However, for patients without an available or supportive caregiver (e.g., unhoused youth), or for those unwilling to disclose their substance use to caregivers, parental consent should not be a barrier to safe and effective care. Just one example is CB, a 17-year-old daily fentanyl user. She came in for treatment with her mother, a single parent who was already in treatment for opioid use disorder. Before CB’s outpatient appointment, her mother relapsed and left their home, and CB was left to care for herself and her younger siblings. CB could not receive ongoing treatment without parental consent, per California law. Without access to treatment, CB ultimately relapsed as well. AB 816 will ensure this unnecessary outcome does not occur again.
AB 1644 (Bonta) Medi-Cal: medically supportive food and nutrition services.
Makes medically supportive food and nutrition intervention plans, as defined, a covered benefit under the Medi-Cal program.
Adam Francis, CAE
AB 1644 (Bonta) – Melanie Thompson, DO – Chief Medical Officer, Marin Community Clinics
Too often, as a primary care physician I see the fallout when patients are discharged from the hospital with a scary, new diagnosis or are grappling with a chronic disease, in which diet plays a key role. Early on in my practice, I had a very young patient diagnosed with kidney failure who ended up requiring dialysis. I remember trying to explain how the eventual outcome would likely be a kidney transplant and provided a list of very common foods to avoid or the patient could become terribly sick and possibly die. My patient eventually quit school because she was so overwhelmed, and her parents struggled to understand and care for her. When I think of that family, I can’t help but wonder if her difficulties would have been lessened if AB 1644 had already been in place. One of my patients with diabetes never knew what cottage cheese was until he attended our diabetes group! Imagine how others must feel when we print out a list and make assumptions that a trip to the grocery store might be so simple. It is past time that we recognize food as medicine and like any medicine that is critical for the management of a disease, it should be a covered benefit for our most vulnerable. AB 1644 is an innovative way to provide some of those key supports.
SB 70 (Wiener) Prescription drug coverage. Ensures insurance coverage for a prescription drug that is prescribed appropriately for off-label use.
SB 70 (Wiener) – Haining Yu, MD, MPH –Child & Adolescent Psychiatry, San Francisco, CA
As we continue to face a youth mental health crisis, it’s clear that mental health treatments, including medications, are lifesaving and lifechanging, particularly for children and adolescents facing anxiety and depression. However, of the seven SSRIs that are approved for use in the U.S., only two (Fluoxetine for 8 and up, Escitalopram for 12 and up) are approved by the FDA to treat depression for patients under 18 years of age. Of the 10 other common non-SSRI antidepressants (often used for patients who do not respond to or cannot tolerate a first line SSRI), none are approved for use to treat depression in patients under 18 years of age. SB 70 helps address this by lowering common hurdles that I face in my practice as a child and adolescent psychiatrist. This legislation helps ensure that insurances are not limiting which formulation of a medication is covered for patients. My patient Katie has significant anxiety and OCD which makes it difficult for her to swallow pills. The process of getting approved for liquid fluox-
etine led to unnecessary interruptions in getting the medication that she needed in a formulation that she could actually use. My patient Dan experienced significant side effects on both fluoxetine and escitalopram, and had to deal with insurance push back when we wanted to try another commonly used antidepressant. SB 70 ensures these patients and many more in my practice do not face bureaucratic barriers to life-saving medications.
AB 470 (Valencia) Continuing medical education: physicians and surgeons.
This CMA-sponsored bill allows continuing medical education (CME) requirements to include courses that are designed to improve the quality of physician-patient communication through culturally and linguistically competent education.
AB 571 (Petrie-Norris) Medical malpractice insurance.
This CMA-sponsored bill ensures licensed medical providers have access to professional liability insurance coverage without discrimination for providing abortion care, contraception and gender affirming care.
AB 620 (Connolly) Health care coverage for metabolic disorders.
Extends health plan coverage for medical nutrition therapies that benefit pediatric patients (children) who may not be able to use, or are sensitive to, certain medications.
AB 765 (Wood) Truth in Advertising: medical specialty titles.
This CMA-sponsored bill ensures health care consumers are not mislead or deceived into believing their health care provider is a physician or surgeon by preventing non-physician health care providers from using terms like “-ologist" or "surgeon" or “medical doctor” or other similar combination of “physicianequivalent” titles.
AB 815 (Wood) Health care coverage: provider credentials.
This CMA-sponsored bill requires the California Health and Human Services Agency to create and maintain a provider credentialing board, with specified membership, to certify private and public entities for purposes of credentialing physicians and surgeons and other health care providers in lieu of a health care service plan’s or health insurer’s credentialing process. A health care service plan or health insurer, or its delegated entity, would be required to accept a valid credential from a board-certified entity without imposing additional criteria requirements and to pay a fee to a board-certified entity based on the number of contracted providers credentialed through the board-certified entity.
AB 864 (Haney) Substance use disorder: telephone system.
This bill would create a 3-digit phone number to a statemanaged crisis center that gives public health information on the prevention of drug overdoses, advice for family members and people experiencing drug addiction, and referrals to substance use disorder treatment.
AB 935 (Connolly) Tobacco sales: flavored tobacco ban.
Existing law makes selling flavored tobacco punishable as an infraction. This bill makes it punishable by civil penalties in the same manner as the STAKE Act.
SB 90 (Wiener) Health care coverage: insulin affordability.
Prohibits a deductible for insulin or imposing a copayment of more than $35 for a 30-day supply for a high deductible health plan.
SB 487 (Atkins) Abortion: provider protections.
This CMA-sponsored bill protects California health care providers from automatic suspension from the Medi-Cal program if they are suspended from a Medicaid program in another state as a result of providing health care services that are legal in California. It will also prohibit health insurers from discriminating against or refusing to contract with a health care provider who may have been sanctioned in another state as a result of providing health care services that are prohibited or restricted in that state, but are legal in California. SB 487 also strengthens civil protections and provides additional safeguards for California abortion providers and other entities and individuals that serve and support abortion patients that reside in states with hostile abortion laws.
SB 582 (Becker) Health records: EHR vendors.
This CMA-sponsored bill requires the state entity regulating physician compliance with data exchange regulations to create policies and procedures for including EHR vendors in the legal structure of the framework, and incorporate federal standards for the reasonableness of vendor fees. These changes will allow regulators to crack down on exorbitant pricing schemes and guarantee that physicians are not hampered in complying by vendor practices.
SB 598 (Skinner) Health care coverage: prior authorization.
This CMA-sponsored bill requires health plans to create exemption programs that allow physicians who are practicing within the plan's criteria 90% of the time to receive a one-year exemption from the plan's prior authorization requirements. Additionally, the legislation will give a treating physician the right to have an appeal of a prior authorization denial conducted by a physician peer of the same or similar specialty. (Delegated physician groups would be exempt from these requirements, meaning the legislation will only apply to health plans.)
SB 634 (Becker) Low Barrier Navigation Center: opportunity housing
Streamlines the process to create an "opportunity housing project," which is a project that provides non-congregate housing which is relocatable, and reserved for one or more target populations (i.e., tiny houses for underserved homeless populations).
On May 12th, SFMMS hosted our Annual Gala at the Asian Art Museum in San Francisco. The evening included the recognition of Michael Schrader, MD, SFMMS Outgoing President, for his dedication and leadership to the SFMMS membership and communities of San Francisco and Marin during his 2022 Presidency; the welcoming of Heyman Oo MD, SFMMS 2023 President; speeches from local and national elected officials; and a performance by the Chitresh Das Youth Company. We are so thankful to our SFMMS members and leaders for making this such a lovely and memorable evening. We look forward to seeing everyone at next year’s SFMMS Gala!
Paul Katz, MD
Robert Lowell, MD
Mark Taylor, MD
Michael Parnes, MD
Gina Gregory-Burns, MD
Jacqueline Poggi, MD
Ian Leverton, MD
Michael Coppolino, MD
Peggy Crawford, MD
Kandice Strako, MD
Sid Borirak-Chanyavat, MD
Alison Niederer, MD
Carlos Botas, MD
Leonard Rothman, MD
Nora Hirschler, MD
Luke Perkocha, MD
Gamin Thomason, MD
Maureen Park, MD
Robert Mickel, MD
Eugene Karandy, MD
Stephanie Lowe, MD
Janet Stafford, MD
Mariano Rayos, MD
Gabriel Gregoratos, MD
Robert Schindler, MD
Jack Stage, MD
J Kwei, MD
Jorge Werbin, MD
James Kauth, MD
John Howse, MD
Paul Alpert, MD
Janet Bodle, MD
Carolyn Gracie, MD
Sandra Grant, MD
Howard Kornfeld, MD
Hanh Nguyen, MD
Rhoda Nussbaum, MD
William Prey, MD
Richard Leeds, MD
Robert Schneider, MD
Howard Kleckner, MD
Joseph Barbaccia, MD
Richard Geist, MD
George Yavorsky, MD
David Chittenden, MD
Leon Smith, MD
Ann Meagher, MD
Alan Teitelbaum, MD
Douglas Ousterhout, MD
Robert Owen, MD
David Schindler, MD
Russell Woo, MD
Keith Cohn, MD
Ivan Diamond, MD
Martin Liberman, MD
Leslie Preger, MD
Estelita Miravite-Christobal, MD
Anthony Errichetti, MD
Robert Wald, MD
Allen Dekelboum, MD
Paul Davidson, MD
Robert Pedrin, MD
Leonard Brant, MD
Mark Oscherwitz, MD
But there are areas where we actually feel enthusiastic and see positive signs and momentum shifting. On Medicare payments, we’ve got a bill introduced. The news from the FDA advisory panels [on over-the-counter birth control pills] is a positive sign. We’ve got CMS dropping two rules on prior authorization that were transformative and the profession felt incredibly heard by the administration on what a burden this is for doctors and patients.
You recently wrote an op-ed about your fears that the legal challenge to FDA regulation of the abortion drug mifepristone could impact your members’ work more broadly. What specifically worries you?
The overall general assault on the doctor-patient relationship and the criminalization of health care has ended up being a rather large, unexpected piece of my presidency.
Jack Resneck was just days into his term as president of the American Medical Association when the Supreme Court overturned Roe v. Wade last summer.
The board-certified dermatologist suddenly found himself bombarded with questions from physicians who were struggling to navigate the national war over the right to terminate a pregnancy.
Pharmacists refused to fill prescriptions for patients suffering from everything from psoriasis to rheumatoid arthritis out of fear the medications could also be used for abortions. ER physicians pleaded for help squaring conflicting state and federal laws around abortions for patients facing obstetric emergencies. Doctors became both the plaintiffs and the targets of abortion-related lawsuits.
Resneck has also grappled over the past year with a workforce hollowed by pandemic burnout, the dilemma of whether and how to integrate AI into medicine, a wave of Covid disinformation and growing hostility to public health work.
As the mid-June end date to his one-year term as president approaches, he sat down with POLITICO to reflect on his tenure and share thoughts on how the field can adapt and rebuild after a brutal few years.
This conversation has been edited for length and clarity. What’stopofmindasyouneartheendofyourpresidency?
People love their jobs but there are a lot of things getting in the way of what drew them to medicine in the first place — whether it’s government interference in health care, whether it’s all the disinformation they’ve had to fight back against in the last few years, whether it’s all the administrative burdens and Medicare payment issue. Frankly, it’s a lot for physicians to deal with.
On the one hand, you have the reproductive health issue itself and mifepristone itself being a safe and effective drug that is absurdly being painted as something that it isn’t — and the implications both for medication abortions but also the management of miscarriages and all the threats and implications for public health.
And then what is getting less attention is the potential upending of the entire drug approval process that had been relatively stable for 85 years. I feel certain that if the entire Texas decision is not overturned, we could have [challenges to] contraception and vaccines and HIV drugs and cancer drugs and a whole line of other things following pretty quickly.
It’s a horrific thought, as a physician who is trying to practice medicine with things that we know work and are safe, to all of a sudden have individual judges with no medical or scientific training able to undo all of the expertise of the FDA.
Outside of the fight over the abortion pill, how else has the fall of Roe impacted your members?
In one category are the terrible impacts in restrictive states: people having to carry unwanted pregnancies, people with ectopics and miscarriages getting packed up in ambulances and sent across state lines or sent home until they get sicker, and doctors actually having to call attorneys to ask what to do next. But in the last few weeks, we also really started to see some of the downstream consequences that we predicted but are unfortunately coming to pass.
“The overall general assault on the doctor-patient relationship and the criminalization of health care has ended up being a rather large, unexpected piece of my presidency.”
– American Medical Association
President Jack ResneckOver the past year, Jack Resneck has grappled with a workforce hollowed by pandemic burnout, the dilemma of whether and how to integrate AI into medicine and more.
In Idaho, physicians are facing really hard decisions about having to abandon communities that they feel so connected to and so a part of because they just don’t feel like they can safely practice there anymore. Labor and delivery units in Idaho are closing and women are literally going to have to leave the state with any high risk pregnancies.
We’re also in that season of the year where medical students who have applied for residency get their match, and we’re seeing decreases of 10 percent or more [applications] in restrictive states — and that’s across the board, not just in OB. There’s been a major uptick in physician advocacy and activism. What does that mean for the AMA? Does it change the nature of the group?
People think of us in our advocacy role in terms of the congressional and judicial litigation pieces and our work with the administration and our collaboration with state medical associations and state houses. But they don’t always think of our leadership for medical education, and the huge role the AMA has played in funding and convening medical schools around the country to reform their curricula, or our large, growing and very dedicated Center for Health Equity or our group that thinks about innovation in healthcare, the future of AI and digital health and how’s that going to happen in ways that actually advance health and help patients instead of harming patients. We depend on the involvement of grassroots physicians in addition to national leaders and each and every one of those areas. To move forward, we need physicians to bring their background and their experience to running for local office, engaging with their school board when it’s thinking about public health policies in schools — all of those types of areas.
As you noted, doctors are working to change political debates,butthecountry’spoliticaldebatesarealsochanging the medical profession. What are you seeing on that front?
The politicization of science that we have all seen in the last few years has affected us.
What we have had to do in that changing environment is relentlessly focus on science and evidence. That is our hallmark and our calling card is we always have to come back to the best science and evidence and use that as the basis of our judgment.
So, we’re engaging on gender affirming care and trans issues because there is overwhelming evidence from the medical community and from science and well done studies about the impact on trans adolescents in particular and depression rates and suicide rates. We know what makes a difference and helps our patients, so we have an ethical and moral obligation to speak up on those things.
Areyouworriedthatphysiciansarelosingtheirconnection with a country that is seemingly less interested in evidence-based reasoning and more interested in politicized reasoning?
I think every physician, whether it’s from an organized medicine standpoint, or just working in their offices or hospitals every day and running into patients who have been influenced by sources of disinformation, is worried about the level of respect for science and evidence in the country. Whether it’s
a politician doing it or whether it’s physicians actually being spreaders of disinformation, it’s been a wake up call. The public health community now realizes it has to fight back.
We can’t sit quietly and let these forces dominate the social media space or any other space. For example, we have to think about going all the way back to elementary and secondary education about science, and making sure we have a population that’s actually able to engage in these conversations — whether it’s about weather forecasts or the risks and benefits of any treatment or vaccine or preventative [care].
Was this month the right time to end the public health emergency?
This had to happen sometime. And it does feel like the country is in a different place.
Having an end date also meant there were some must-do things in order to protect patients, and a lot of those things have happened, including extensions for telehealth coverage for Medicare patients. But I think there are still ongoing concerns around patient access to testing, therapeutics, vaccines, etc. We need to make sure that patients who are insured continue to have access — preferably without co-pays or cuts to their deductibles — and we need good access for patients outside those coverage spaces. And then we still have a lot of questions and are doing a lot of work on [securing] ongoing federal funding for more vaccines and thinking about the next pandemic. We need public health departments actually funded and staffed and we need plans in place for future health emergencies — we continue to try to shine more light on that.
Amajorimpactofthepandemichasbeenphysiciansburning out and leaving the field. What needs to be done to prevent shortages from getting worse?
This is what keeps me up at night as AMA president.
But there are things we can do to make a difference. I think of the workforce as a pipeline with two openings. There’s the incoming on the front end, and we have been fighting for a long time for more funding for residency positions, because even if nobody leaves medicine, we don’t have enough doctors to take care of baby boomers as they age — across primary care, specialty care, you name it.
The challenge there is that Congress does not tend to do things with an eye towards 10 or 15 years away but rather with an eye towards next week. We have to convince them that this is where they should put investment, even though it’s not going to pay off for a while.
So we have to grow more doctors, but oh my goodness, in the meantime, while we’re trying to do that and trying to get Congress to support more funding, we’re lopping off people at the back end early because they’ve gotten burnt out.
That’s part of what drives a lot of our work around [prior authorization] and it’s why we have to have Medicare payment reform.
If you look back 10 years at the focus on physician wellness, you saw health systems and hospitals offering yoga classes continued on page 36
TheSFMMSsentthislettertolocalelectedleadersinMay. May 18, 2023
San Francisco Marin Medical Society (SFMMS)
Phone: (415) 561-0850
Dear Mayor London Breed, City Attorney Chiu, and San Francisco Board of Supervisors: The San Francisco Marin Medical Society (SFMMS), representing thousands of physicians in San Francisco and Marin Counties, deeply appreciates the leadership and dedication of the San Francisco City Attorney’s Office and the San Francisco Department of Public Health (SFDPH) in holding Walgreens accountable for exacerbating the epidemic of opioid addiction and overdoses in San Francisco. SFMMS remains concerned about the ongoing health crises for individuals without adequate support services for substance use disorders, and the $230 million settlement represents a significant opportunity to invest in care for some of the city’s most vulnerable populations.
SFMMS recommends that settlement funds be used to:
1. Fund SFDPH projects that most immediately advance services identified in its 2022 Overdose Prevention Plan,1 specifically:
a. The establishment of at least two “Wellness Hubs.”
b. Augmenting programs that improve appropriate access to medication-assisted treatment (MAT).
2. Increase workforce capacity by increasing the number of mental health/substance use care providers (through work/site commitments tied to loan repayment, hiring bonuses, scholarships, etc.) with prioritization of bilingual individuals. Specifically:
a. Psychiatrists within SFPDH and those serving predominantly uninsured/Medi-Cal patients in San Francisco.
b. School-based behavioral health care staff.
c. Safety net primary care physicians, particularly those providing MAT.2
d. Physicians and/or nurse practitioners to staff Wellness Hubs for the provision of MAT.
3. Patient navigation staff dedicated to creating warm handoffs/transportation to better utilize increased treatment bed capacity for patients diverted from or stabilized and referred to those locations (e.g., DPH affiliated substance abuse expert(s) either located in or responsible for liaising with each local hospital to assist with referral to treatment).
4. Replicate the success of Marin County’s ‘OD Free Marin’ initiative by placing free naloxone vending machines in key locations across the county.
Background
In late 2022, SFDPH released its Overdose Prevention Plan, which articulated a comprehensive approach to the reduction of opioid overdoses in San Francisco. In this plan, DPH calls for the county to establish “Wellness Hubs” as “a cornerstone of the City’s efforts, which will provide overdose prevention services and resources, services to improve health, and linkages to treatment.” In January 2023, SFMMS wrote to San Francisco’s Board of Supervisors encouraging the timely funding of the Overdose Prevention Plan, including components of the plan related to the establishment of Wellness Hubs. The Wellness Hubs as originally proposed included overdose prevention sites, which are sometimes referred to as supervised consumption sites, which local, state, and national medical societies support. Even if Wellness Hubs are not permitted to provide supervised consumption services, they provide other vital resources for at-risk populations, including linkage to services and treatment elsewhere in the city, distribution of naloxone to the public and to at-risk individuals, and serve as visible public health infrastructure, improving public confidence in the county’s response to the substance use crisis.
Additionally, settlement funds should be used to increase San Francisco’s behavioral health workforce. Even before the health care workforce crisis created by COVID-19, the county and state faced a severe shortage of primary care and mental health providers. This issue has been particularly acute for teenagers, who have seen an exponential increase in depression and anxiety.3 SFMMS recognizes that these funds are time-limited, but there are several ways to incentivize, attract, and retain care providers where they are needed most through one-time signing bonuses, scholarships, and loan repayment tied to specific locations and populations. Data consistently shows a dire need for psychiatrists and primary care physicians to treat those currently affected by substance use disorders, as well as upstream behavioral health (particularly for youth) to prevent addiction before it starts. In addition, safety net clinics and Wellness Hub services should be supported in the hiring and retention of primary care providers4 for the provision of MAT on-site.
One of the most pressing issues facing this patient population, as well as the medical community, is the inappropriate and expensive use of emergency rooms to treat those suffering from addiction, behavioral health conditions, and lack of housing. The creation of treatment locations/beds, and a highly coordinated, hands-on patient navigations system and workforce is desperately needed to link patients to longer-term treatment, including patient transport options. For example, a DPH substance abuse expert could be funded to operate within or liaise with each local hospital to assist with referral to treatment.
Finally, San Francisco County should explore replicating the success of Marin County’s ‘OD Free Marin’ initiative.5 To increase access to naloxone, the lifesaving antidote to a fentanyl overdose, Marin County and OD Free Marin placed five free Narcan vending machines across the county. More than 4,000 kits have been distributed so far. Residents are also encouraged to take a Narcan video training, followed by the Narcan Proficiency Quiz.
We hope that the funds received by the city and county of San Francisco represent an opportunity to make tangible progress toward the goal of treating and preventing opioid addiction and overdose in San Francisco. Please do not hesitate to contact Conrad Amenta, Executive Director of SFMMS, at camenta@sfmms.org or (415) 706-3161, should you have questions about our recommendations or wish to receive more information from SFMMS physician leaders.
Sincerely,
Heyman Oo, MD, MPH SFMMS President1 https://sf.gov/sites/default/files/2022-09/SFDPH%20Overdose%20Plan%202022.pdf
2 https://www.acpjournals.org/doi/full/10.7326/M16-2149
3 https://www.cdc.gov/media/releases/2023/p0213-yrbs.html
4 https://www.chcf.org/publication/recovery-within-reach-medication-assisted-treatmentof-opioid-addiction-comes-to-primary-care/#related-links- and-downloads 5https://odfreemarin.org/
The Problem:
They have too often been called “frequent flyers”—severely ill patients suffering serious medical conditions, from overwhelming infection and festering wounds to coma. We are not referring to patients with ongoing medical issues receiving emergency treatment from their regular physicians. Instead, these are patients who may not have come to the emergency room voluntarily, and if they did, they want to leave quickly. They are flooding our emergency rooms and acute hospitals. Frequently, there is no one else to represent them. Many have significant mental health issues, a substance use disorder, or both. They show up in our hospital emergency departments over and over, brought by ambulance, friends, or by themselves.
Sometimes they require a ventilator and admission to the ICU for a few days. They are helped as much as possible and, before much time has passed, hours or days, they feel a bit better and, despite ongoing medical needs, leave the hospital against medical advice—only to show up at the same emergency department, or another, with the same condition, only worse. This can continue for years while they keep suffering, healthcare staff get increasingly frustrated, and costs pile up, to no good end.
The current system of letting someone come to death’s door, then resuscitating them before turning them loose to repeat the process is, in our mind, an eerie form of medical waterboarding, with the patient’s disease as the tormenter and the medical team as the frustrated rescuer. We define this select group of patients as: those who suffer from medical conditions severe enough to require hospitalization, but, due to substance use or psychiatric disorders, repetitively demonstrate a lack of capacity to understand the nature of their disease, the recommended treatment, or the consequences of non-compliance. Their only hope is for a comprehensive path to recovery that provides a meaningful and effective benefit to those who qualify. That path requires a clearer understanding of addiction and mental illness.
Substance use disorder (SUD) affects millions of Americans and costs society billions of dollars1. It is a chronic, relapsing, and potentially fatal condition characterized by compulsion, loss of control, and continued use despite adverse consequences. Addiction, the earlier name, was recognized as a disease by the AMA in 1987. The current term, Substance Use Disorder even has its own ICD-10 diagnosis code, F19.10. Most people think of SUD as an episode of intoxication followed by a period of withdrawal. The withdrawal state has physical manifestations which are quite evident, and these symptoms become more intense after each exposure to the drug in question. What follows withdrawal, however, is more subtle and even more nefarious. Repeated episodes of withdrawal begin to change the very nature of the brain. The withdrawal response activates neural pathways in the brain at the most primitive levels of the subcortex (where the conscious brain never goes), inducing a profound sense of desire and craving for the previous substance. An individual’s capacity to make rational decisions can become overwhelmed by these cravings. This positive feedback loop of intoxication and withdrawal, followed by craving, is heightened in duration and intensity with continued use. It is the presence of the intense craving, not just the physical withdrawal, that uniquely characterizes what we call addiction.
It usually takes at least 90 days of sobriety for the brain to begin to stabilize and the cravings to begin to dissipate. 2 Although not as recognizable as withdrawal to the observer, craving is intense, and it diminishes slowly over months to years. It is the most common cause of relapse. The power of craving is well known to any former cigarette smoker who enters a room ten years after quitting and is triggered by a familiar old friend, situation, or place where they used to smoke. Now, added to our long-standing chronic epidemics of alcohol and heroin addiction, we have fentanyl and methamphetamine. Fentanyl is over 50 times more potent than heroin and the resultant withdrawal and craving are magnified proportionately. Methamphetamine,
especially, results in hyperactive and dangerous behavior, including in the hospital. The standard 28 days in treatment is not nearly enough time to recover from drugs like these. It could, and often does, take years.
Our patient cohort is complicated by a high frequency of other psychiatric diseases. Schizophrenia is common, and its symptoms are compounded by substance use. Dementia of various causes also leads to non-compliance. There are powerful antipsychotic drugs at our disposal for some conditions such as acute psychosis, but it is a misconception to think that these agents treat the disease itself. They only help control some of the symptoms. Our treatments for dementia are even less helpful. The most effective treatment for all these conditions is trauma-informed and requires a safe, accepting, and comfortable environment without the triggers and distractions of the patient’s previous circumstances. Any significant healing will require time and rehabilitation in a supportive environment, in addition to any medications needed.
It is important to recognize that these fellow human beings are victims of a disease, not simply criminals. Many if not most have a history of severe early-life trauma. A disproportionate percentage are people of color and economically disadvantaged. Any successful approach to their treatment and healing must differ from the criminal justice system in its purpose, goals, and environment. Our purpose must be to provide compassionate, appropriate medical and psychiatric treatment to this subset of patients. One immediate goal is to keep them out of the criminal justice system, ensure their physical and emotional safety, and return them to a functional lifestyle, which includes food, shelter, clothing, and access to healthcare and employment opportunities where possible, offered in a supportive environment conducive to healing.
Codes of medical ethics have emphasized respect for individual autonomy for over fifty years, and the principle is highly regarded in clinical medicine. However, Medicine’s initial obligation was to “do no harm”. As the profession matured, it proclaimed a distinct obligation to place the patient’s benefit above other concerns. We recognize our duty to help these patients. More pressing is our duty to prevent continued harm. When harm is imminent, autonomy to refuse aid becomes suspect. The concept of autonomy depends on a rational and “in-control” actor, free of compulsion. Our subset of patients, by definition, are suffering severely disordered control of their mental faculties as well as substance abuse.
The history of “deinstitutionalization” of the mentally ill, however well-intentioned (or not), has resulted in thousands of people chronically on the streets and in dangerous living situations.3,4 Civil rights are crucial, but there is no beneficence in continuing to allow, and even enable, countless people who cannot make rational decisions to live in misery. Paternalism has become a bad term in medicine and society but the current prevalence of homelessness, misery, and premature death
among the mentally ill and addicted is worse. As was first noted a half century ago and is even more true today, we are letting people “die with their rights on”.5,6
Some argue that no one can stop substance use unless they want to. Clearly, recognition of the problem is necessary, but an essential characteristic of the disease of addiction is denial. Consequences are usually required to break through the denial and move to recovery. Those that succeed move into treatment when they recognize the source of the problem and are ready to begin a rehabilitation process. In a small percentage, brain function is so impaired that they are unable to make voluntary choices like this for quite some time. While numerous reports support the value of intervention7, It seems to us that requiring someone’s volition to enter rehab is another way of blaming the victim in denial for their lack of will. And it is important to note that SUD treatment has advanced considerably, especially with the development of much more effective medications, than decades ago when many residential treatment facilities were emptied due partly to some inhumane conditions and practices.
We recognize that “compulsory rehabilitation” could be abused and result in the inappropriate conservation of some people, but the possibility does not insure it will happen. Conflating the demographic that we are talking about to include people like Britney Spears, or the thousands of patients who can continue to function in an outpatient setting, is demeaning to the victims, and fallacious. As with much medical treatment for those too ill and impaired, we need to help those who cannot help themselves—until, hopefully, they can. This is in fact a crucial role of medicine as a profession.
Medicine cannot solve this problem alone, but it does act as the portal of entry to a recovery program. Medication treatment for SUD and psychiatric disorders has improved markedly in recent decades but is still underutilized. Treatment also requires patient cooperation. But when such patients show up in distress at a hospital there is a chance to address their needs, even if they can’t recognize them clearly yet themselves. We can no longer waste the opportunity to begin appropriate treatment with a plan to supportive discharge. It is not enough to recognize the problem; we present the outline of a plan to offer some improvements.
Effective substance abuse disorder (SUD) addiction treatment should begin when the patient is encountered at hospital admission with appropriate agents such as buprenorphine, suboxone, or the necessary antipsychotic. The goal is to stabilize the patient’s psychiatric and/or substance use needs with the same dispatch afforded other medical conditions. Currently hospital staff complain that they do not have the training or the specialty support to address the addiction needs of their patients8. This is an explanation, not an excuse. What if they were not given the training to address diabetes? Failing to control the withdrawal symptoms of a critically ill patient is like neglecting to manage their blood sugar. The health care institucontinued on page 18
continued from page 17
tions of our city have the responsibility to manage substance abuse disorder with the same efficiency as any other disease. The Joint Commission, responsible for accrediting acute care hospitals, should assure standards for SUD equivalent to those for all other medical conditions. Public prodding may be necessary.
Patients unable to cooperate with their recovery, as defined above, should also be unable to leave the hospital against medical advice, unless they obtain a legal release. Although it may seem like common sense, the idea of a medical hold to preserve a patient’s life would require changes in the 5150 statutes of the California Welfare and Institutions Code. The necessary changes would include provisions for expanding the criteria for what is now strictly a psychiatric hold to include medical conditions and treatment.
Enacting changes like this, unfortunately, could take years in today’s legislative climate. But there are allies in the legislature. California Senate Bill SB 43, sponsored by State Senator Susan Eggman, is currently in the legislature and offers a plan for more sensible and rapid conservatorship process. It represents an essential element of our plan. Even with passage, the public guardian’s office will need to be adequately staffed and funded to evaluate and conserve appropriate patients within the time constraints of an acute hospitalization. The aim is to get patients into appropriate longer-term care where they can truly begin, and stay in, the recovery process that will change their lives for the better. They of course must be provided with a workable appeals and representation process if they remain resistant to treatment in an institutionalized setting.
Too often, conservatorship is equated with criminalization This notion needs to be dispelled by assuring that the continuum of care is truly compassionate and supportive. To begin, administration of this program would be the responsibility of the Department of Public Health and related health authorities, not the Department of Corrections and other law enforcement entities—although collaboration by these sectors will be important.
For such efforts to be successful, the post-hospital management must be closely coordinated with the inpatient hospital plan. Conservatorship without placement in a facility that can expertly and compassionately meet the needs of those who are conserved is a waste of time and resources. Discharge would not be to the street, but to a closed residential facility for ongoing medical management and rehabilitation. Addiction medicine specialists as well as psychiatrists and psychologists should be integral to the program. The environment should be welcoming, free of judgement, and respectful of the patients for who they are.
The length of stay in the rehabilitation facility would be determined by the individual’s progress and, for our patients, last a minimum of several months, and must not be predetermined by rote or financially limited. Recognizing the role of
triggers that induce cravings, the facility should ideally be geographically isolated, and visitors strictly limited. The facility would have programs from addiction medicine and counseling to job training, as well as tiered living arrangements based on progress.
These recommendations of course imply a significant increase in residential treatment capacity and quality. Programs that provide a path to recovery are expensive because they are necessarily human resource-intensive and can take considerable time. As with mental health treatment, successful requires trust and compassionate human connection in addition to whatever indicated medication and other interventions. However, over 15 years ago, studies showed that every dollar in treatment saved the society seven dollars in health and social costs.9
Treatment for substance use disorder is beneficial for a significant portion of the population, but those individuals who have deteriorated to the level of our defined subset of patients are a group whose prognosis for meaningful recovery is much more guarded. It is possible that many will not be able to return to a functional lifestyle even with a year or more of therapy. This means that a large portion of this population could become long-term wards of the state. The initial costs of this program could exceed the current costs of dealing with the problem. But the situation, fueled by fentanyl and methamphetamine, is clearly getting worse and the solutions will only become more expensive with further delay.
The “drug war” has failed on many counts and, while we support harm reduction strategies as well as the arrest and punishment of drug dealers, our plan is more focused on the most severely impacted victims. At this point we too often continue to “catch and release” addicted users to no useful end. We must recognize them as people with a treatable disease, and see them not as “frequent flyers”, but as people whom the system has failed. We can’t keep kicking the can down the road. Inaction is not just counterproductive and costly, but also immoral.
The authors thank the numerous colleagues who provided review and comments, including Drs. Robert Margolin, Keith Loring, Ruchika Mishra, Jack Chase, Lawrence Chyall and ethics committee representatives from various local hospitals and public health. The content remains solely the responsibility of the authors.
David Smith was the founder of the HaightAshbury Free Medical Clinics and President of the California and American Societies of Addiction Medicine, a specialty he co-founded, and founding editor of the Journal of Psychoactive Drugs.
Steve Heilig is Director of Public Health and Education for the SFMMS, Co-Editor of the Cambridge Quarter Of Healthcare Ethics, and a former Robert Wood Johnson drug policy fellow.
1. Assessment of Annual Cost of Substance Use Disorder in US Hospitals. Peterson,C. Li, M. xu,L. Mikosz, C. Luo, F. JAMA 2021;4(3): e210242.
2. Brain-Wide functional architecture remodeling by alcohol dependence and abstinence. Adam Kimbrough https://orcid.org/0000-0001-9434-4987, Daniel J. Lurie, Andres Collazo, and Olivier George olgeorge@ucsd.e.
PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES
Vol. 117 | No. 4, January 28, 2020
3. Deinstitutionalization of People with Mental Illness: Causes and Consequences. Virtual Mentor. 2013;15(10):886-891. doi: 10.1001/virtualmentor.2013.15.10.mhst1-1310.
4. Bring Back the Asylum Dominic A. Sisti, PhD1; Andrea G. Segal, MS1; Ezekiel J. Emanuel, MD, PhD1 JAMA 2015;313(3):243-244. doi:10.1001/jama.2014.16088
5. Treffert, DA. 1973. Dying With Their Rights On. American J. Psychiatry 130(9):1041.
6. When homelessness and mental illness overlap, is forced treatment compassionate? April Dembosky, Amelia Templeton, Carrie Feibel NPR . March 31, 2023 https://www.npr.org/sections/health-shots/ 2023/ 03/31/1164281917/when-homelessness-and-mentalillness-overlap-is-compulsory-treatment-compassiona
7. My Son Was Addicted and Refused Treatment. We Needed More Options. David Scheff, New York Times, April 12, 2023 https://www.nytimes.com/2023/04/12/opinion/addiction-treatment.html
8. Hospital Standards for People with Substance Abuse Disorder. NEJM 387;8 August 25, 2022. pp 672-675
9. Health Serv Res. 2006 Feb; 41(1): 192–213.
Our current approach to San Francisco’s most vulnerable citizens is well intentioned, costly, and insufficient. There is the sense that we have an orchestra of musicians each playing without the benefit of a conductor. Solving this problem of the most vulnerable will require close coordination at every level, from the hospital admission through inpatient rehabilitation and longterm residential recovery. We must work in harmony, or we will continue to fail.
The individuals we propose to address are defined as: those who suffer from medical conditions, especially substance use disorders, severe enough to require hospitalization, but, due to substance use or psychiatric disorders, repetitively demonstrate a lack of capacity to understand the nature of their disease, the recommended treatment, or the consequences of non-compliance.
Five Recommendations:
1) Harm Reduction
Control of the drug supply must be accompanied by other harm reduction strategies such as overdose reversal, syringe exchange, and safe injection settings, all linked wherever possible to quality substance use disorder treatment without delay.
2) Stabilization
Formal clinical services, reflecting best practices in Addiction Medicine and Psychiatry, should be established at every local hospital, with coordinated linkage to longer-term treatment settings.
3) Conservatorship
We should reform the criteria and process to allow for patients who meet our criteria to be placed into a residential treatment facility for their conditions in a timely manner. This can be achieved with adequate protection of their well-being, until they are evaluated as being able to function safely in the community.
4) Placement
San Francisco should provide an appropriate residential facility for this specific subset of patients where they can continue to receive necessary medical and psychiatric care along with appropriate rehabilitation services.
5) Funding
Redirection of existing funds could offer a more expedient way to rapidly advance the goals of this plan. New sources such as public bond funding and targeted taxes or fees on legal addictive substances and/or other sources should also be considered.
The San Francisco Emergency Medical Services (911) System, like much of the City’s health care delivery system, has been struggling to cope with COVID pandemic surges, increases in opiate overdoses, behavioral health patients and staffing challenges despite an overall decrease in patients accessing the system for care. EMS is often the health care provider of last resort especially for patients who cannot access more traditional sources of both primary and emergency care services. Our long standing, strong relationship with our Receiving Hospitals from multiple health care systems, has come under pressure from Emergency Department crowding that threatens to undermine our ability to respond appropriately to EMS calls.
During the past 18 months of the COVID pandemic, EMS call volume dropped precipitously but has been increasing at a rapid pace over the last several months as illustrated in this chart showing the volume of EMS incidents per month since 2017.
Our ambulance diversion policy allows emergency departments that are under stress and believe that they cannot accept another patient without providing them a lowered standard of care can divert ambulances away until the system has 50% of our core receiving facilities on diversion. The rate of change in ambulance diversion has accelerated past EMS transports since mid-May of this year as illustrated in this chart contrasting the percent of change of ambulance diversion and EMS transports.
An additional complication is that ambulance patients have experienced offload delays at an increasing rate in the same timeframe, far exceeding the California state goal of :20 illustrated in this chart of the average number of minutes of APOT interval over the last two years.
These factors, along with staffing issues caused by anti-COVID measures and retirements are causing increased frequency of ambulance depletion in the 911 system. We are having more and more frequent periods of time when we cannot assign an ambulance to a 911 call as shown in the following chart of 30 day average daily events when we ran out of ambulances (called Medic to Follow, or MTF events).
This means that patients who could potentially have the greatest medical need are unable to obtain ambulance assistance more and more frequently in San Francisco. While not the
only contributing factor, having ambulances delayed at hospitals or delayed driving longer distances to hospitals not on ambulance diversion adds to this resource depletion. We have never experienced this degree of depletion before even at higher volumes of 911 calls.
The San Francisco EMS Agency recognizes the severity of the problem and the increasing likelihood of negative impact on patient care. We have supported countermeasures to both decrease the flow of patients into the Emergency Departments from EMS and to improve / level load the distribution of patients to hospitals in the system.
Our first intervention will be at the intake of the 911 call at our dispatch center (Division of Emergency Communications). The Department of Emergency Management is pursuing funding for RNs to work side-by-side with 911 dispatchers to refer low acuity calls once processed through our triage protocols to medical advice and appointment lines. We are also pursuing links with non-ambulance transport services and response by behavioral health and other specialized, non-transporting prehospital teams (this has already started with the Crisis Response Teams system). We now have a cadre of over 30 Community Paramedics in partnership with the San Francisco Fire Department that also respond on special “EMS 6” units, engaging patients who are high utilizers of medical services and attempting to redirect their use of 911 to more appropriate and effective services. We continue to promote transport of appropriately screened 911 patients to the Sobering Center and Psychiatric Emergency Services at Zuckerberg San Francisco General Hospital without having to utilize Emergency Department services. We have assisted EMS provider agencies with training material and secured state approval to provide point of care COVID testing of patients so that the capacity of both Sobering and PES facilities will increase to pre-pandemic levels and beyond.
Finally, we developed a means to level load the 911 patient destinations across all receiving hospitals in the system, which is called Centralized Ambulance Dispatch Determination. Currently staffed with either a Base Station Physician or senior Paramedic Supervisor, the CADDie pilot has access to ambulance data system-wide and for the busiest eight system hours per day redirects ambulance traffic away from critically impacted emergency departments. The EMS Agency is actively pursuing
ongoing and expanded funding for this system, likely next moving to 12 hours/day live coverage and eventually to 24 hour a day coverage based out of the 911 dispatch center.
Despite these measures, our ability to respond to our patients is diminished. Therefore, we are planning to institute changes in our ambulance diversion and ambulance patient offload time policies to decrease reliance on these measures to solve the emergency department crowding issue. There are many similar jurisdictions in both California and through the United States that have successfully eliminated ambulance diversion and implemented offload delay goals that exceed our own. The state of Massachusetts eliminated ambulance diversion in 2009 and subsequent studies failed to show worsened patient outcomes orincreased ambulance patient offload time delays. While there was interest at the American Medical Association policy level to extend this practice to other states, we have not seen progress elsewhere.
Ambulance patient offload time delays statewide led the legislature in 2019 to task the California EMS Authority to implement a target of :20 and initiate statewide reporting on progress. You can find their current report and background on the EMSA website at https://emsa.ca.gov/apot/
The EMS Agency has embarked on a collaborative effort to make these policy changes as implementable and able to succeed as possible. I am asking the SFMMS members with active hospital practices to engage with their facility’s emergency departments and hospital leadership to help improve the crowding situation. We realize that EMS is only a part of the hospitals’ overall mission, which includes patients that self-present for emergency care, patients who utilize other outpatient services at these facilities and patients in need of urgent, semi-elective and elective in-patient procedures. It is only though systematic, consistent, accountable, and equitable processes that we will be able to lessen the impact of this emergency department crisis and improve the outcomes of our EMS patients.
The near-fatal fentanyl overdose in November 2022 of an infant at a Marina playground led to significant media coverage and San Francisco leaders making “strong calls for change” due to this “wake up call” regarding the city’s opioid problem. Heather Knight from the SF Chronicle notes that this is far from a new problem as pills, pipes and syringes regularly litter Tenderloin playgrounds. Knight rightly states that children living in lower income neighborhoods such as the Tenderloin, Bayview and Mission have been affected by the city’s fentanyl crisis (along with chronic homelessness, mental health issues) on a daily basis for years now. Parents regularly make social media posts to share their difficulty to explain to their children why people are passed out on the ground outside of their home. A child in the Tenderloin was attacked on her way to school last year by an individual likely experiencing a combination of homelessness, substance abuse and mental illness. All children are deserving of safety and the freedom to enjoy childhood, and we should all be outraged by the fentanyl crisis’ disproportionate impact on children who live in neighborhoods most impacted by this long-brewing crisis.
Knight’s article also suggests that psychiatrists exacerbate the fentanyl problem on our city streets by not keeping at-risk patients on psychiatric holds. The truth is that after 72 hours a patient can contest their hold before a judge, who often overrules the psychiatrist as the court’s definition of "gravely disabled" is very narrow. When a psychiatrist declines to place a hold, it is often a reflection of past experiences where similar cases have been ruled against them in court. One gaunt patient who illustrates this challenge was found sitting in his own waste, with delusions and very limited motor activity, and a medical record that stretched back years with similar presentations. Many thought “if anyone meets criteria for grave disability, it’s this man.” But he verbalized to the judge that he wanted to leave the hospital and that he knew how to find food and shelter, and so the judge deemed him not “gravely disabled.” In court he was represented by an appointed public defender whose job was to ensure his rights were not infringed upon by an involuntary hold. After he was released from the hospital against medical advice, one wonders who will be looking out for his right to be safe and to have his basic needs met?
The California state law— the Lanterman-Petris-Short Act (LPS) —that regulates psychiatric holds specifically states that psychiatric holds cannot be used solely for drug addiction. It would be illegal to place someone on an LPS hold without evidence that they also have “a primary psychiatric disorder." Even if a patient meets criteria for an initial 72-hour 5150 hold, a serious shortage of psychiatric beds means that often these patients languish in the ED until they recover slightly, and then are released having nowhere else to go. The sad truth is that even if someone gets placed on an extended 5250 hold, which allows for 14 days of involuntary psychiatric hospitalization, that time is often insufficient to help someone with chronic mental illness and substance use recover sufficiently to function on their own, but the threshold for longer term involuntary treatment is even higher, and the threshold for conservatorship and involuntary medication yet higher still.
Even court ordered treatment is hard to obtain. The woman who attacked that child in the Tenderloin last year was arrested and soon released back onto the streets. The woman’s public defender blamed the “underfunding of our mental health system” for her ongoing presence in the community. Again the bed problem rears its ugly head, because these patients often need long term supportive housing to be able to transition successfully towards stable functioning in the community, and those beds are exceedingly rare.
This severe shortage of both acute and long term beds results from intentional political (regulatory and funding) decisions that have been made over decades, leading to a continued reduction in bed numbers. It started with deinstitutionalization, which was an appropriate move to end horrific practices taking place in mental institutions. But it also meant that many who could not care for themselves were released back into communities that did not have the necessary support systems in place to provide the care they needed. Stigma again likely plays a role as cutting psychiatric beds is often a politically expedient thing to do when budgets are tight. Stigma against mental health likely shaped the reimbursement system that continues to systematically underfund psychiatric services compared to other medical services, which has led many large hospital systems to continue to cut down on psychiatric beds. The RAND corpora-
tion estimated in 2021 that the SF Bay Area has 40.5 psychiatric beds (acute, subacute and residential) per 100,000 people, far short of their recommendation of 72.8 beds per 100,000 people. That’s an absolute shortage of 1,832 beds. Even with the proposed increase of 400 new beds (completion date undetermined), our City will still be 1,432 beds short of RAND’s estimate of the needs for our population. Of note, the RAND recommendations for bed numbers is based on a state-wide average, and does not take into account the fact that SF has an oversized need compared to the state average (due to our significant issues with homelessness, mental illness and substance abuse).
The patient repeatedly found lying in his own waste was eventually diagnosed with Huntington’s Disease. His atypical presentation of having limited motor manifestations meant that this diagnosis was missed over and over again, and the fact that he was homeless and was thought to have schizophrenia probably didn’t help. He was eventually sent to Laguna Honda after a long wait for a bed there. One wonders how he is doing during the threatened shut down and forced transfer of patients there, and whether he is still alive.
Knight’s article also highlights Portugal’s success in addressing drug addiction, which combines decriminalizing users with providing increased support services such as mandated treatment (which promotes accountability) along with stepped up enforcement of drug dealers. The infant overdose story led Supervisor Ronen to state that San Francisco “should not be allowing open-air drug use.” However, Ronen continues to shy away from accountability for drug-dealers plaguing the streets of San Francisco, hoping instead that federal level actions against cartels will resolve San Francisco’s local drug problems. That logic is akin to supporting federal efforts to crack down on tobacco companies, while putting zero restrictions on the marketing and sales of tobacco products locally.
Getting people off the streets and to stop abusing substances is the ultimate test of behavior change. The recipe for behavioral change is both simple and exceedingly difficult to follow. Successful behavioral change involves motivation, support to enact the change (social support, emotional support, functional support, tools, skills), being in an environment that supports the change, and then accountability.
Accountability for users needs to involve someone monitoring that changes are happening, and providing reinforcement (both positive rewards and negative penalties). We support decriminalizing users—harsh punishments seldom work, but there is also a middle space between decriminalization and the absence of any consequences. In SF, there is insufficient accountability for both users and suppliers, and so we face these negative externalities of unfettered drug sales and use. When it comes to environmental factors, when someone is addicted to fentanyl, being in an environment where dealers are free to do their business is a recipe for guaranteed failure, no matter how motivated the individual. One can be offered drugs countless times when walking down the streets in San Francisco—how can we expect people to kick a highly addictive substance that is being pushed to them all the time? Most patients who successfully stay in recovery either had to leave San Francisco, or be in a locked facility long enough to stabilize, get into treatment, and change their daily patterns of their life. It’s sad to think about all the people for whom this is not possible due to a lack of support and resources. While street-level dealers are not the root cause of our drug problem, they are part of the problem, and again, not dealing with them is akin to allowing unregulated sales of tobacco products in our city. If we limit access to SF’s open air drug markets, it could help more people who want to get clean do that successfully while staying in our city. And hopefully in the long term, it will also lead to a reduction in the consequences of the ongoing scourge of homelessness/ drug addiction/severe mental illness that we all face, and better protect innocent children in our city.
American physicians attend continuing medical education (CME) courses throughout their careers. Continuing education is a hallmark of medical practice, and state licensing boards require it in order to maintain an active medical license.
However, CME is not without controversy. In addition to concerns about commercial bias 1 and what constitutes “evidencebased” teaching2, social issues and current events also influence the content of CME. State legislatures, and the medical profession itself, tailor CME to embrace topical concerns, either optionally or as educational requirements. Thus, some state licensing boards require CME hours on the opioid crisis, on end of life issues, on domestic violence, and so forth.3
Eighteen years ago, the California legislature sought to tailor CME to address social ills within medicine itself. But instead of mandating education on these topics specifically, as many states do with end of life issues or domestic violence, California required that nearly all CME, on every topic, include this teaching.
Assembly Bill 1195 (Coto, 2005) established that all CME offered by California providers “shall contain curriculum that includes cultural and linguistic competency in the practice of medicine.” The only exclusion: a CME course “dedicated solely to research or other issues that does not include a direct patient care component.”4
Enhancing cultural and linguistic competency (CLC) in physicians addresses clear needs. There is ample evidence that disregard and/or ignorance of cultural factors worsens medical care5,6. Language barriers are an obvious impediment as well. Unfortunately, AB 1195 falls short in practice.
Many CME topics that “include a direct patient care component” lack CLC content to teach. E.g., most procedure-focused education in surgery, interventional radiology, and anesthesiology; advanced cardiac life support and other emergency procedures; and management of comatose patients. Presenters of these topics can artificially add CLC — say, by briefly discussing the demographics of stroke incidence in a presentation that is actually on the use of systemic thrombolytic drugs in stroke. But this begs the question of why CLC must be included in every CME.
As chair of the CME committee at California Pacific Medical Center in San Francisco for the past 14 years, I witnessed how the legislature’s good intentions collide with practicality. Our committee struggled from the start to include CLC where there was no obvious role for it.
We turned to the state accreditor, the California Medical Association, for guidance. CMA assured us that the requirement — the law — to include CLC was not absolute; we should “do our best.” This confirmed for us that it’s not realistic to include CLC in all CME with a direct patient care component. CMA’s 2023 report7 bears this out: over half of the CME providers accredited by CMA admit to not including CLC in all clinical CME. I suspect the honest answer is higher. Efforts to abide by AB 1195’s unrealistic mandate spark a number of problems in practice.
CME planners choose speakers for their expertise in specific medical or surgical domains. Very few are also experts in cultural or linguistic issues. Thus, non-experts convey nearly all CLC material that physician audiences hear or see. Even with the best of intentions, such presenters may be unaware of important CLC teaching points. They may over- or under-emphasize the importance of cultural issues, or provide only superficial attention to cultural and linguistic challenges that deserve a deeper look. Most are simply not well equipped to teach CLC.
The best CME presenters exude enthusiasm for their topics. They speak in a lively manner, and offer clinical “pearls” that add interest to the presentation. In contrast, many CME speakers look and sound coerced when reciting CLC material. Some make little effort to hide their feelings about what they view as an unwanted digression.
In order to include CLC material, speakers often resort to a quick review of the ethnicity, age, and/or gender of the patient population under discussion. Sometimes they mention increased disease incidence in a particular group. These token efforts surely fall short of what AB 1195’s authors had in mind. But since they (barely) fulfill the law’s mandate, they have become the norm.
Since the physicians in the audience sought education on non-CLC topics when they chose to attend, they may experience its inclusion as intrusive. Consider how expectations would differ for CME devoted specifically to CLC, even if mandated. The audience would arrive expecting this education. It would not be a distraction or digression.
More recently, California added a requirement to include teaching about implicit bias in medicine as well. Assembly Bill 241 (Kamlager-Dove, 2019) established that all CME courses “shall contain curriculum that includes the understanding of implicit bias.”8
AB 241’s language parallels AB 1195, and shares AB 1195’s limited exclusion criteria.
Like AB 1195, the newer law is well-intentioned and aims to address a real problem. But it falls prey to all the same drawbacks. It is hard to identify, and thus teach, implicit bias (IB) material that relates to much procedure-focused and technical CME, even that which concerns direct patient care. The same problems of non-expert, unmotivated presenters resorting to token facts arise here as well.
Is there a better way? Several other states think so. They condition licensure or license renewal on CME dedicated specifically to CLC or IB. Connecticut requires one hour of CME on cultural competency every six years. Maryland requires one hour on implicit bias. Michigan requires two. New Jersey requires six CME hours on cultural competency. Washington DC requires two hours on LGBTQ cultural competency.3
Presented by knowledgeable, motivated experts, dedicated CME on these topics can teach what’s really important about CLC and IB — not begrudgingly recite a few token facts in a talk about something else. Dedicated presenters can convey enthusiasm to the audience, offer clinical pearls, and make the material interesting and memorable.
Teaching medical audiences about implicit bias, and about cultural and linguistic issues related to medical practice, is both possible and well worth the effort. What fails in practice is California’s attempt to infuse all CME with this material. Replacing these unrealistic requirements with workable ones would enhance the teaching of cultural competency and implicit bias, make it feasible to obey state law, and improve CME throughout California.
1. Steinman MA, & Baron RB. Is continuing medical education a drug-promotion tool?: YES. Canadian Family Physician Medecin De Famille Canadien, 2007;53(10):1650–1657.
2. Davis NL, Lawrence SL, Morzinski JA, & Radjenovich ME. Improving the value of CME: Impact of an evidence-based CME credit designation on faculty and learners. Family Medicine, 2009;41(10):735–740.
3. Federation of State Medical Boards. Continuing Medical Education Requirements. https://www.fsmb.org/siteassets/advocacy/regulatory/licensure/continuing-medicaleducation-requirements.pdf. Accessed February 4, 2023.
4. AB-1195 Continuing education: Cultural and linguistic competency., 2005. https://leginfo.legislature.ca.gov/faces/ billNavClient.xhtml?bill_id=200520060AB1195
5. Saha S, Korthuis PT, Cohn JA, Sharp VL, Moore RD, Beach MC. Primary care provider cultural competence and racial disparities in HIV care and outcomes. J Gen Intern Med, 2013;28(5):622-629.
6. McQuaid EL, Landier W. Cultural Issues in Medication Adherence: Disparities and Directions. J Gen Intern Med, 2018;33(2):200-206.
7. California Medical Association. Annual Report: Cultural Linguistic Competency and Implicit Bias Standards. https:// www.cmadocs.org/Portals/CMA/files/cme/clc/CLC.IB%20 Annual%20Report%202023%20(050923).pdf Accessed May 18, 2023.
8. AB-241 Implicit bias: Continuing education: Requirements., § 2190.1., 2019. https://leginfo.legislature.ca.gov/faces/ billTextClient.xhtml?bill_id=201920200AB241
Earlier this month, the Environmental Protection Agency (EPA) released a new proposed regulation to limit the release of carbon pollution from power plants, opening a period of time for the public to voice their opinion through the "public comment." I believe the oath that healthcare providers take to care for patients obligates us to speak out enthusiastically in support of this standard to protect health.
As a pediatrician, I know that health professionals want to make sure that our patients, friends, family, and neighbors are healthy and thriving. As a field, health professionals have clearly moved to recognize that factors outside of healthcare—the social determinants of health—are major drivers of health outcomes, and increasingly climate change is recognized as a social determinant of health and one of the greatest threats to public health and safety. Its impact on our health is only growing in significance.
As the executive director of the Medical Society Consortium on Climate & Health—which represents 70% (700,000) of U.S. doctors represented by our 48 member societies—I know climate change threatens my patients' health. More poor air quality days and heat waves mean more children in the emergency room from asthma and more expectant mothers in preterm labor, to name just a few examples of the health harms of climate change.
This new proposed standard, known as the Greenhouse Gas Standards and Guidelines for Fossil Fuel-Fired Power Plants, is part of the Biden administration's effort to achieve the goal of reducing greenhouse gases by 50% by 2030. The Inflation Reduction Act, the largest climate investment in U.S. history, is expected to reduce these emissions by 40%, but it is a suite of robust standards (of which this new proposal is a critical component) that will get us the rest of the way to this ambitious goal. For public health, it is a critical goal we must achieve.
We know we can avoid the worst of the harms brought on by climate change and enjoy rapid improvements in our health if we move quickly toward cleaner, more reliable, and more affordable energy. We can help realize this vision by submitting public comments for this standard to be as strong as possible. The more com-
ments the EPA receives in support of cleaning up pollution for a healthier today and a healthier future, the more likely the EPA will pass a rule with ambitious standards.
Our voice is critical because fossil fuel CEOs and lobbyists are going to once again quickly mount an offensive to weaken these safeguards as much as possible. History has shown us as much. Fossil fuel CEOs and lobbyists continue to follow the playbook of Big Tobacco, which delayed regulation for decades while our patients died from tobacco-related illness. Like tobacco companies today, fossil fuel companies fight regulation behind the scenes while spending millions to make false claims that they are part of the solution. We must counter misinformation campaigns with the truth that our patients' health—not to mention efforts to respond to the threat of climate change—are at stake.
As health leaders, we should also make it clear to healthcare systems and hospitals that have pledged to reduce their greenhouse gas emissions that this change is an easy step to help them reach their climate commitments.
The fact is that this standard, if implemented effectively, will be a boon for healthcare systems that have pledged to reduce greenhouse gas emissions. Healthcare system emissions arise from three main areas: through the activities that take place within their buildings and campuses (think on-site heating or anesthetic gases, which have a very high global warming potential, and vehicles on the grounds); through the purchase of electricity to power their operations; and through the emissions associated with their supply chain, which includes things like the production and transportation of food and medical supplies to their facilities as well as business travel.
Healthcare systems can most easily control what happens in their buildings. But hospitals and health systems also consume a significant amount of electricity, and sourcing electricity through new means can be complicated. Some have made significant reductions in their electricity emissions by installing solar panels at their facilities or by purchasing clean renewable electricity, but for most these have not been viable options. Sector-wide strides
to reduce greenhouse gas emissions from power plants will help move systems toward their goals without needing to make any direct financial investment.
In addition to realizing our commitments to climate action, a strong limit on carbon pollution also helps us meet our commitment to protect our most vulnerable patients. Babies and children, pregnant people, older adults, those with chronic health conditions, people with lower incomes, and communities of color feel the health harms of climate change most intensely. And polluting power plants are often closest—and thus most directly harming —families with low incomes and families of color.
The EPA's new proposed standard is an opportunity to live up to our climate commitments as a country and as a health sector. It is a moment to make our voice loud and clear, so it is not drowned out by companies who would prioritize the size or their wallets over public health and the health of our planet.
Lisa Patel, MD, MESc, is a pediatric hospitalist and the executive director of the Medical Society Consortium on Climate and Health. She trained at Stanford, Yale, and UCSF.
I can still remember one of the first times that I helped treat a Black patient.
I was on my OB-GYN rotation during my clinical year at UCSF School of Medicine, and I did what any other health provider would do. I tried to make the patient feel comfortable. I asked her questions and listened closely to her responses. It felt like a normal conversation where I tried to gather information and provide health advice in equal measure.
But as I was leaving the clinic that day, wearing my white coat, a Black woman from the office ran after me to relay how proud she was—and how important it was for her to see someone like me learning how to become a doctor.
It should come as no surprise that Black Californians want there to be more Black providers in our health system. Black doctors have been few and far between in California, making up around 3% of the state’s total physicians for decades.
What’s becoming clearer with each passing year, though, is the cost of this lack of representation. A recent study from the California Health Care Foundation found that one in three Black people in California say they’ve been treated unfairly by a health care provider because of their race or ethnicity. One in four Black Californians have avoided seeking care altogether because they felt they would be disrespected.
Black patients have the same basic expectations of the health care system as everyone else, the foundation survey found. They want providers who listen to them (98%), spend time answering their questions (97%), and discuss and personalize their health goals (93%).
Black Californians also agree on an obvious way to make the health care system work better: 80% say it is important to increase the number of Black doctors, nurses and other health care providers.
But as the old saying goes, you can’t be what you can’t see.
A UCLA study last year found that the nationwide share of doctors who are Black men has remained basically the same since 1940. The question remains how do we change these abysmal numbers?
As a Black student at one of California’s most selective medical schools, I am the exception that proves the rule. Both of my parents were health professionals in Mississippi. I chose UCSF because I wanted to study at a school committed to cultivating a diverse student body and retaining and supporting Black students.
Wynton Sims, MPHNonetheless, it still took six months of clinical rotations before I worked under a Black physician. That was the first time I experienced that essential feeling of building a professional relationship with a person who looks like me, who is interested in what I hope to achieve, and who is deeply invested in my success.
As I continue to work in clinics and learn my craft, I think every student, patient and provider is looking for the opportunity to see and to be seen. It fosters genuine connections and real exchanges of information that are at the heart of health care. It’s something any good physician can do.
To do it well, especially for Black patients, we need more Black doctors.
The Urban Institute published a report this year outlining some of the most successful policies for establishing a diverse health care workforce—from pathway programs and holistic admissions to diversity initiatives and reducing the financial burden of higher education.
Financial and academic support has to start early— as far back as elementary school—and continue through high school, college and even the medical school application process.
To me, what this comes down to is money and mentorship, which are two of the biggest barriers for Black students who hope to start and finish medical school. Financial and academic support has to start early—as far back as elementary school— and continue through high school, college and even the medical school application process, which itself is a sizable expense.
Mentorship programs are just as important to close what feels like a never-ending loop: We all want more Black doctors, to inspire and to guide us, but it’s hard because there are unfortunately so few.
There are more of us coming, though, and we’re going to do our best to provide the care Black Californians deserve.
Wynton Sims, MPH is a UCSF medical student. This article was produced by CalMatters and first published on November 1, 2022.
Kaiser Permanente employees have access to numerous programs to support their education and professional growth, including resources for career planning, training, and tuition reimbursement. In an effort to work towards providing solutions, we offer programs designed to increase the number of people entering fields that are currently experiencing workforce shortages. One example is the Kaiser Permanente Mental Health Scholars Academy, a $30 million initiative launched in 2020 that provides training and education to current Kaiser Permanente employees who commit to working as mental health professionals in California.
Surveys show that the United States urgently needs more mental health clinicians. To date we have provided tuition support for 236 Kaiser Permanente employees across the state enrolled in master’s and doctorate degree programs in mental health and behavioral health science, helping to increase the number of licensed mental health clinicians while also increasing diversity and representation in the field. Two-thirds of our
Academy class who began study in fall 2022 identify as people of color, Black, or Indigenous, and 46 percent are bilingual, speaking more than 20 different languages. For many patients, seeing a therapist who shares their race or cultural background or speaks their language can overcome stigma and open the door to get the help they need.
The Mental Health Scholars Academy allows students to complete their supervised clinical hours and meet the requirements for licensing while working at Kaiser Permanente and receiving pay and benefits. Recruiters are available for long term placement when students complete their studies.
I’m proud to say that this is just one reason why Kaiser Permanente was named the tenth best workplace in the U.S. to grow a career according to LinkedIn's annual Top Companies list, announced in April. The company utilizes proprietary LinkedIn data to rate companies based on how well they support employees in advancing their careers. The ranking analyzes employees' long term career progress, taking into consideration opportunities for continuing education and upskilling as well as tenure, attrition, and layoffs.
Largest Medi-Cal rate increase in California history begins next year
A budget trailer bill has been introduced that will renew the state's Managed Care Organization (MCO) Tax to provide the largest Medi-Cal rate increase in California history, ensuring that millions of Californians will have greater access to life-saving health care. The proposal represents a generational opportunity to fulfill the promise of Medi-Cal and provide meaningful access to health care for millions of Californians.
Specifically, the legislation would increase provider rates to at least 87.5% of Medicare for certain primary care, maternity care and non-specialty mental health services in 2024 and provide $75 million annually for graduate medical education. Starting in 2025, the bill provides for an annual appropriation of $1.38 billion in primary care rate increases, $1.15 billion in specialty care rate increases, over $500 million for family planning and reproductive health care, and $600 million for behavioral health facilities including increasing inpatient psychiatric beds.
Once the legislation passes, the work to implement these monumental changes will continue over the next few months and into next year. Throughout the process, the California Medical Association (CMA) will continue to advocate on behalf of physicians to ensure the funding flows efficiently to providers.
This is truly a historic moment, and CMA appreciates the Governor and the legislature for their work to achieve justice and equity in access to care for Medi-Cal patients. We are urging swift passage of the budget trailer bill and look forward to working with policymakers on implementing this important investment that will provide millions of California patients with increased access to life-saving health care.
I have worked to support “physician wellness" since 2002. What wellness is and our willingness to accept, support and prioritize physician wellness has changed tremendously over the years. In 2023, the word “wellness” still brings up confusion, resentment, frustration, and blame in many physicians and healthcare institutions.
What does wellness mean? Does wellness conflict with productivity and other “metrics”? How do you measure wellness? Can you/should you measure wellness? Is wellness a worthwhile endeavor or investment? Is it ok to prioritize our own wellness? Is wellness fluff? Does it make a difference? Does prioritizing physician wellness impact our ability to serve the needs of our patients? Do wellness retreats and workshops change anything? Is it possible to be “well” in medicine today? Whose responsibility is physician wellness?
If you are asking yourself these questions, you are not alone. I have recently found it helpful for many physicians to re-define wellness. The most effective definition I have found is Wellness = Sustainability + Self-advocacy. This definition takes out much of the confusion. Wellness is then a shared responsibility between individuals and institutions. How might your relationship with wellness change if you thought of wellness as sustainability + self-advocacy.
Jessie Mahoney is a pediatrician, a certified life coach for physicians, and a yoga instructor. She is the Chair of the SFMMS Physician Wellness Task Force. She practiced pediatrics and was a Physician Wellness leader at Kaiser Permanente for 17 years. She is the founder of Pause and Presence Coaching where she supports and empowers her physician colleagues using mindfulness tools and mindset coaching.
How Mindfulness and Self Compassion Can Help Smooth Your Journey with Real Estate
Lessons from a wise and mindful real estate agent who offers a mindful, caring, and loving approach to buying and selling homes in the Bay Area.
To listen, visit: https://podcasts.apple.com/us/podcast/ mindful-healers-podcast-dr-jessie-mahoney-dr-ni-cheng/ id1542538851?i=1000611193477 or scan the QR Code with your smartphone
Prescribing nature for our patients and ourselves is good medicine. The restorative power of a simple dose of nature is tremendous. How might you incorporate the idea of “prescribing nature” into your own practice of medicine? How might you add more nature to your day and/or your family's life? How might you use nature to help you recover, heal or transform more easefully and effectively?
To listen, visit: https://podcasts.apple.com /us/podcast/ mindful-healers-podcast- dr-jessie-mahoney-dr-ni-cheng/ id1542538851?i=1000610282388 or scan the QR Code with your smartphone.
A vibrant conversation about the win-win of bringing coaching to GME, how to get funding for coaching for your team, residents, and/or fellows. When trainees receive coaching as part of their training it normalizes a culture of getting help. And that carries forward. When attendings and faculty get coaching at the same time, the impact is profound.
To listen, visit: https://podcasts.apple.com/us/podcast/ mindful-healers-podcast-dr-jessie-mahoney-dr-ni-cheng/ id1542538851?i=1000609164142 or scan the QR Code with your smartphone.
In the name of productivity and achievement, we often downplay and minimize the importance of sustainability. This is a mistake. Sustainability should be one of your highest life priorities if you want to be around, happy and healthy, and practice medicine for a long time.
To listen, visit: https://podcasts.apple.com/us/podcast/ mindful-healers-podcast-dr-jessie-mahoney-dr-ni-cheng/ id1542538851?i=1000604841305 or scan the QR Code with your smartphone.
Upcoming 2023 Honoring Diastole Retreats: Sunday, September 24th and Saturday, October 28th
Upcoming Connect in Nature Mindful Healers Retreat: July 14-16th, 2023
Mindful Coaching, Yoga and Culinary Medicine CME
Wellness Retreats for Women Physicians: 4-5 night intimate physician wellness retreat opportunity for women physicians in Santa Margarita CA. September 10-15th, 2023, November 5-10th, 2023, March 17-22nd, April14-18th, May 5-9th, 2024.
Find out more and sign up here: https://www.jessiemahoneymd.com/retreats
SAVE THE DATE: Special IN PERSON Mindful Yoga for Healers in Old Mill Park sponsored by SFMMS
Join SFMMS on Sunday, October 15th 10am - 12pm for IN-PERSON yoga and community building at the Old Mill Park Amphitheatre in Mill Valley. 60 minutes of ALL levels yoga will be led by SFMMS Physician Wellness Committee Chair, Dr. Jessie Mahoney. Yoga will be followed by socializing and community building with your SFMMS physician colleagues. All skill levels welcome! Please bring your own yoga mat or beach towel. This class will be held outdoors, so please be prepared for the weather with appropriate layers. Attendance is limited to the first 50 SFMMS Members and their guests that RSVP.
To register, visit: https://www.eventbrite.com/e/sfmms-in-person-mindful-yoga-for-healers-community-building-registration-494197085787 or scan the QR code with your smartphone.
Practicing Mindful Yoga for Healers with Jessie before this event
Join Dr. Mahoney on Zoom most Saturdays at 9am or anytime on YouTube. For more information visit: https://mindfulyoga.jessiemahoneymd.com/ or https://youtube.com/c/JessieMahoney.
Each month, as part of the Physician Wellness leaders' work, they curate wellness resources around a common theme for our monthly wellness blog. Read, listen, and attend the monthly resources the committee has curated for SFMMS members by visiting: https://www.sfmms.org/news-events/sfmms-blog. aspx?Category=physician-wellness or by scanning the QR with your smartphone.
You can learn more about upcoming wellness events or view recordings of past events on the SFMMS Wellness Page at www.sfmms.org/get-help/physician-wellness.
"During CMA's Legislative Advocacy Day this year, SFMMS physician leaders advocated for expanded access to care for the most underserved members of our communties by expanding Medi-Cal and reducing the burden of prior authorization. Thank you to Assemblymembers Matt Haney, Damon Connolly and Phil Ting, and Senators Mike McGuire and Scott Wiener, for partnering with the profession of medicine to advance health equity."
Hundreds of physicians, residents and medical students gathered in Sacramento on April 19, 2023, for the 49th annual California Medical Association (CMA) Legislative Advocacy Day.
This year’s event was by all accounts a wildly successful endeavor. CMA welcomed nearly 400 attendees, representing 45+ specialties and 24 component medical societies. Attendees participated in a total of 120 legislator meetings as champions for patients and the practice of medicine.
“I think it is so important to advocate for our patients,” said Quinn Lippman, M.D., an ob-gyn who attended advocacy day with her peers from the San Diego County Medical Society. “There’s the one-on-one care we give in our offices every day, but [it's important that we] take a step back and look at the broader picture of who has access to health care, how that care is being delivered, what medications patients have access to.”
Attendees received updates from CMA President Donaldo Hernandez, M.D., and CMA’s chief lobbyist Stuart Thompson about key health care issues before the legislature this year. Attendees
then lobbied their legislators in support of CMA's priority issues, including:
+ SB 598: Prior Authorization Reform, which would significantly reduce the administrative burden physicians must bear because of prior authorization.
+ AB 765: Truth in Advertising, which protects patients AND physicians against allied health professionals who use terminology to misrepresent themselves as physicians.
+ Medi-Cal: While we have made sure that all Californians have health care coverage, it is meaningless if they can’t see a provider or get regular, timely care outside of the emergency room. Access to care is the last leg of the stool that holds this safety- net program up and is the key to unlocking quality health care for all and reducing disparities.
Legislative Advocacy Day attendees also enjoyed an engaging panel discussion from our keynote luncheon speakers, physician Assemblymembers Joaquin Arambula, M.D.; Jasmeet Bains, M.D.; and Akilah Weber, M.D.
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at lunchtime, offering free gift certificates to dinner with the CEO, and that’s lovely, but you can’t yoga your way out of severe burnout because you’re spending hours a day doing prior authorization. You can’t yoga your way out of having to let go of three of your front desk staff because Medicare payments are not adequate. So I think a lot of places get it now and are actually thinking about what obstacles need to get out of the way to actually support physicians and their work.
How do you think that the federal government should be approaching and regulating AI in health care?
There’s tremendous potential to advance health equity with AI but if you don’t start with that at the front end, we see a lot of examples of where that stuff can cause harm. As that [work] progresses, Congress may or may not have to step in.
What we don’t want, what would be a bad outcome, is to have a few spectacular failures of very hyped tools that end up leading Congress or others to just shut this whole thing down.
So we’re not being fuddy-duddies about AI. We’re pretty darn excited about it. But we think doing that homework at the front end to actually make sure that we mitigate the risks and have transparency will help us to avoid that outcome.
First floor medical office/garden style at 900 S. Eliseo, Greenbrae. 1030 square feet consisting of 4 rooms, waiting room, private bathroom, great for medical or office. Plenty of on-site parking. $2.75 per square foot plus PG and E. Call Karen 415-339-2222.
