March 2018

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

150 YEARS OF ADVOCACY SF'S FLAVORED TOBACCO BAN ACCESS TO CARE AT RISK SAFE INJECTION SITES LEGALIZED CANNABIS IMPROVING IMMUNIZATION THE NEW TAX CODE AS HEALTH HAZARD

1868 2018

th

Anniversary

VOL.91 NO.2 March 2018

MIEC just announced $13 Million in dividends.* As a member-owned exchange, MIEC provides policyholders with medical professional liability insurance with a vastly superior dividend policy. Our mission is to deliver innovative and costeffective medical professional liability protection and patient safety services for physicians and other healthcare professionals.

MIEC has never lost sight of the medical associations who support our policyholders, and continues to provide the service and support they deserve.

To learn more about becoming an MIEC policyholder, or to apply, visit miec.com or call 800.227.4527. *On premiums at $1/3 million limits. Future dividends are not guaranteed.

Owned by the policyholders we protect.

800.227.4527 miec.com

IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE March 2018 Volume 91 Number 2

150 Years of Advocacy FEATURE ARTICLES

MONTHLY COLUMNS

10 More Access to Health Care: Opportunities for Leadership in Value, Quality, and Equity

Claire Brindis, PhD

4

Membership Matters

7

Executive Memo Mary Lou Licwinko, JD, MHSA

12 The Future of the ACA: AANHPIs in the Center of the Storm

Winston F. Wong, MD, MS, FAAFP

14 Outlandish New Realities: The SFMMS as Public Policy Catalyst

Steve Heilig, MPH 16 Tax Code Overhaul Impacts: The Tax Bill Threatens Our Health and Our Democracy Sandra R. Hernández, MD, MPH

17 Advocacy Update: Physicians Launch New Coalition to Protect Access to Care

Shannon Udovic-Constant, MD, and the California Medical Association

18 San Francisco Drug Policy: Adult Use of Cannabis and Safe Injection Services Barbara A. Garcia, MPA; Israel Nieves-Rivera; and Tomás J. Aragón, MD, DrPH 20 A Tale of Two Policies: Turning Around Vaccination Rates in Three Years

Matthew Willis, MD, MPH

22 Menthol-Flavored Tobacco: Bans on Sales Increase Efforts to Protect Vulnerable Populations

John Maa, MD, and Man-Kit Leung, MD

23 Ban on Additives: A Proposed Full Ban on Menthol Additives in Tobacco Products

John Maa, MD; Gordon Fung, MD; Leslie Lopato, MD

24 SF Takes on Big Tobacco: The Battle over San Francisco’s Ban on Candy-Flavored Tobacco

Larry Tramutola 25 Time to Talk Against Tobacco: Physicians Need to Speak Out

Against Big Tobacco in the June Referendum

Nisha Parikh MD

8

President’s Message John Maa, MD

38 Upcoming Events

OF INTEREST 9

Welcome New Members

9

In Memoriam: John H. Epstein, MD Erica Goode, MD

26 Leadership Profile: Associate Dean and

Innovator of the Academic Clinician Educator Lawrence Cheung, MD, and John Maa, MD 28 New Laws

California Medical Association

31 Firearm Violence Prevention: A Public Health Approach California Medical Association 34 SFMMS Advocacy Activities 35 Ease Physician Burnout 37 Saint Francis Memorial Hospital: 115 Years and Counting

James Macho, MD, and Kathleen Jordan, MD

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

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members Medical Board Requests Patient Records

Celebrating the 150th Anniversary of SFMMS As SFMMS celebrates our 150th anniversary, we will share historical highlights about the medical society throughout the year. The history of the San Francisco Marin Medical Society dates to a century and a half ago, during a time when the expected American life span was just 50 years. After a few attempts at organizing as a medical society, on February 4, 1868, 57 physicians came together to form the San Francisco Medical Society, the first permanent local medical society in the West.

They adopted bylaws to express their unity and purpose, established membership dues, and elected the first society president, Dr. James Whitney. Their goal was to separate themselves from the quack medicine trade and prove their commitment to high-quality practice standards.

Mark Your Calendars Now for CMA’s 44th Annual Legislative Advocacy Day! The California Medical Association (CMA) will host its 44th annual Legislative Advocacy Day on April 18, 2018. The conference will be held at the Sheraton Grand in Sacramento. Attendees will have the opportunity to go to the Capitol throughout the day to meet with legislators on health care issues. Meetings with Marin and San Francisco legislators will be scheduled and coordinated by SFMMS. This is a unique event for California physicians and is free of charge to all members. Plan to join more than 400 physicians, medical students, and CMA Alliance members who will be coming to Sacramento to lobby their legislative leaders as champions for medicine and their patients.

For more information, please contact: Erin Henke at ehenke@ sfmms.org or (415) 561-0850 x268.

4

CMA has received several inquiries regarding physicians who recently received letters from the Medical Board of California (MBC) requesting medical records for patients who died in 2012 and 2013. The physicians were informed that the records were being requested based on investigation of prescribers connected to opioid-related deaths during this time period. If you receive a letter requesting medical records pursuant to this issue, please contact CMA so we can track the extent to which these letters are impacting our members. Please note that the letters from the Medical Board contain personal health information and as such should not be circulated without redaction. Generally, it is enough for us to know the physician who has been contacted, and we don’t need to see the letter with the patient’s information. If you require additional information about how to respond to inquiries from the Medical Board, please see the CMA website: http://www.cmanet.org/resources/medical-board-assistance/.

If you have any questions, please call CMA’s member help center, (800) 786-4262, or e-mail legalinfo@cmanet.org.

Fake DEA Agents Extortion Scam

Scam artists posing as U.S. Drug Enforcement Administration (DEA) agents are calling California physicians and consumers as part of an international extortion scheme. The scammers target victims who have previously purchased prescriptions by telephone or the internet and identify themselves as DEA agents or other law enforcement. They tell their victims that purchasing drugs over the Internet or telephone is illegal and that enforcement action will be taken against them if they don’t pay a fine, usually thousands of dollars. No DEA agent will ever contact physicians or members of the public by telephone to demand money or any other form of payment. If you receive a call, refuse the demand for payment and immediately report the threat using the DEA’s online form available at http://bit.ly/2nJL5gg. For more information, the DEA’s news release is available at http:// bit.ly/2ERtLNx.

CMA Calls for Investigation into Anthem Policy Restricting Use of Sedation During Cataract Surgery

Anthem Blue Cross recently implemented a clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. The CMA believes this drastic change in policy will cause significant patient safety concerns and put patients at risk of serious complications, including blindness.

The new policy, “Anesthesia for Cataract Surgery,” deems intravenous anesthesia not medically necessary, except in very narrow circumstances. Anthem patients wishing to have any form of intravenous anesthesia during the procedure will now be forced to pay out of pocket. If your practice and patients are affected by this policy change, are receiving medical necessity denials for anesthesia services for cataract surgery since the effective date, or your practice did not receive the required advance notice of the change, please contact CMA at (888) 401-5911 or economicservices@ cmanet.org.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

County Medical Services Loan Repayment Program Now Accepting Applications The County Medical Services Program (CMSP) in partnership with the State Loan Repayment Program (SLRP) has opened a special application cycle to help primary-care health professionals with the repayment of qualified educational loans. Grant recipients can receive up to $50,000 and must commit to a two-year, full-time or four-year, half-time service agreement to provide direct patient care in one of the 35 participating CMSP counties (including Marin) (http://bit.ly/2EbYyHN). The application cycle opened on January 30, 2018, and will close on March 30, 2018. Interested parties can apply online through CalREACH at http://bit.ly/2wVopPD. For more information on the CMSP loan repayment program, please visit http://www.oshpd.ca.gov/ HWDD/CMSPLRP.html or email your questions to SLRP@oshpd.ca.gov.

New Health Laws 2018: Are You Ready?

The California Legislature had an active year, passing many new laws affecting health care—with a strong focus on health care coverage, drug prescribing, public health, and workers’ compensation issues. CMA has published a summary of the most significant new health laws of interest to physicians.

For more details, see “Significant New California Laws of Interest to Physicians for 2018” at http://bit.ly/2BReTjA.

Next Round of Medi-Cal ACA Primary Care Rate Adjustments Forthcoming

The California Department of Health Care Service (DHCS) recently announced that the final round of retroactive interim payment corrections, tied to the primary care physician (PCP) rate increases called for under the Affordable Care Act (ACA), began on January 25, 2018. More information on the primary care rate increase can also be found in our Medi-Cal Primary Care Physician Rate Increase FAQs at http://bit.ly/2shVbcP. View the DHCS announcement at http://bit.ly/2si5AVZ.

Physicians Report Loss of Patients Due to Anthem Error

CMA has received reports that in December 2017, Anthem Blue Cross mistakenly notified some enrollees that their physician had been terminated from the Anthem network. Corrective notices were issued to both physicians and patients. While it’s not clear from the letter, the error appears to be related to Anthem’s notification to exchange enrollees of its exit from the Covered California marketplace in 2018. If your practice was affected by this error, CMA wants to hear from you. Contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org.

UnitedHealthcare to Implement Stricter Notification Requirements for Out-of-Network Laboratory Referrals

UnitedHealthcare (UHC) announced that it will begin enforcing stricter notification requirements related to out-of-network laboratory referrals. Physicians wishing to use an out-of-network laboratory will be required to obtain a completed UHC Member Advance Notice Form from patients authorizing the referral to the nonparticipating laboratory. The new policy does not apply to emergencies. More information regarding this change can be found in the UnitedHealthcare Administrative Guide 2018 located on the UHCProvider.com website. Providers can also contact UHC at (866) 574-6088 for additional information.

WWW.SFMMS.ORG

March 2018

Volume 91, Number 2

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production by Spring Forth Studio EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Erica Goode, MD, MPH Michel Accad, MD Shieva Khayam-Bashi, MD Stephen Askin, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD Linda Hawes Clever, MD David Pating, MD SFMMS OFFICERS President John Maa, MD President-Elect Kimberly L. Newell Green, MD Secretary Benjamin Franc, MD, MS, MBA Treasurer Brian Grady, MD Immediate Past President Man-Kit Leung, MD SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Executive Assistant/Office Manager Maria Vega Membership Coordinator Mina Yoo SFMMS BOARD OF DIRECTORS Charles E. Binkley, MD Peter N. Bretan, Jr., MD Alice Hm Chen, MD Irina S.C. deFischer, MD Nida F. Degesys, MD Robert A. Harvey, MD Imran Junaid, MD Naveen N. Kumar, MD Michael K. Kwok, MD Raymond Liu, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo. MD Rayshad Oshtory, MD David R. Pating, MD William T. Prey, MD Justin P. Quock, MD Michael Scahill, MD, MBA Monique D. Schaulis, MD Michael C. Schrader , MD, PhD, FACP Dennis Song, MD Jeffrey L. Stevenson, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo , MD Albert Y. Yu, MD, MPH, MBA CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

5

EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA

Looking Backward and Forward: 150 Years As we celebrate the 150th anniversary of the founding of the San Francisco Medical Society, we are highlighting the many contributions that SFMS and Marin Medical Societies (now the San Francisco Marin Medical Society) have made to physicians’ practice of medicine and the health of their patients.

The SFMS was founded on February 4, 1868, in order to provide medical education and quality of care to a city with a diverse citizenry formed as a result of the Gold Rush. Thirty years later, the Marin Medical Society was established to serve a burgeoning rural community where physicians traveled by horseback to deliver care to their patients.

While the Medical Society has recorded numerous accomplishments in terms of medical care, public health, and public policy, the SFMMS has also had an interesting history in terms of organizational changes. Following the Gold Rush, the physicians who settled in San Francisco and Marin banded together to establish criteria for quality of care, to educate each other, and to socialize. In its heyday, all physicians who sought hospital privileges had to join the Society after a rigorous screening and later credentialing process. Consequently, nearly every physician was a member and the Society served as the gatekeeper for quality of care.

As a result, the Medical Society became the hub of social gatherings for physicians and their wives (and maybe a husband or two) in the Bay Area. One of the proud accomplishments of the San Francisco Medical Society was the formation of its own orchestra, comprised of talented physicians who used music as a respite from the long hours of practicing medicine. The group continued into the mid-1900s until the demands of medicine superseded the desire for an orchestra. Also, from the close bonds of the Medical Society community grew the active Auxiliary formed by physicians’ wives to support one another, socialize, and serve the community. For many years, the Auxiliary played an important role as the charity arm of the organization. As more and more women became physicians, the interest in the Auxiliary waned and it was finally disbanded in the early years of the 21st century.

Throughout the years there were many growing pains for organization as it struggled to establish itself. Notably, numerous groups that have become the backbone of the Medical Society today were excluded from its ranks early on. This included Chinese, women, and physicians employed by Kaiser Permanente, which was labeled as conducting “socialized medicine.” Today the SFMMS is proud that members from all of these groups have served as SFMMS Presidents and other officers as well as Board Directors and California Medical Association Trustees.

The Medical Society is particularly proud that one if its distinguished members, Dr. Rolland Lowe, was elected the first Chinese-American President of the California Medical Association.

WWW.SFMMS.ORG

Over the years the Society has had many headquarters. Some burned down and took the archives of the SFMS with them. Eventually the SFMS started the Irving Memorial Blood Bank and shared offices on Masonic Street with the Blood Bank until the early 1990s.

At that time, the SFMS sold the Blood Bank and moved to its headquarters to a Victorian mansion at 1409 Sutter Street. The “Mansion” provided a grand location for the Society, but eventually the costs to maintain such a stately home became too much and the property was sold in 2006. Since that time the organization has been housed in the Presidio and now at its current location on Taylor Street.

The latest and greatest organizational achievement has been the 2017 merger of the San Francisco Medical Society and the Marin Medical Society to form the San Francisco Marin Medical Society. In many ways this was a natural fit, with physicians living in Marin and working in San Francisco and vice versa and with a patient population that is often served by physicians from both communities. There was also a fit in terms of physician activism within the two communities and a desire to continually strive for access to care for all.

As the SFMMS turns 150 years old, I am also celebrating my 20th year as CEO of the organization. Over the years there have been some highs and lows, but I am happy to report that the SFMMS is thriving and can look forward to many more great achievements in its future. It has been my honor to serve such a distinguished, caring, and just plain smart community of physicians.

Mary Lou Licwinko, JD, MHSA, is executive director of SFMMS.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

7

PRESIDENT’S MESSAGE John Maa, MD

Health Care Reform in America: A Key Opportunity for SFMMS In an October 2017 New Yorker article, Atul Gawande wrote, “The ACA (Affordable Care Act) postponed reckoning with our generations-old error of yoking health care to our jobs—an error that has made it disastrously difficult to discipline costs and insure quality, while severing care from our foundational agreement that, when it comes to the most basic needs and burdens of life and liberty, all lives have equal worth.”

After the defeat of the health care repeal bill in September 2017, the Republican leadership pledged that after addressing tax reform, the Senate would return to tackle health care reform in the spring of 2018, perhaps as part of the budget process. The December 2017 tax reform bill did succeed in repealing the ACA individual mandate, posing a major challenge to the law’s future sustainability and creating new challenges to Medi-Cal and Covered California. Arizona Senator John McCain’s own health may limit his ability to again cast a deciding vote about health care. In January of 2018, MEDPAC Commissioners voted 14–2 to replace MIPS, which was a major incentive to pass MACRA. Against this background, the tone of the health care debate has shifted significantly in just a few months.

I began a sabbatical in Washington, D.C., in May of 2010, just weeks after the ACA was signed into law by President Obama. I witnessed a pitched battle erupt between the Democrats and Republicans in the summer afterward. The acrimony ultimately led to the historic midterm elections of 2010, when a tidal wave hit Capitol Hill and Democrats lost control of the House of Representatives. By January of 2011, the tenor on Capitol Hill had changed dramatically. Republicans now controlled the House and the agenda for all key committees and hearings and could call key witnesses from the Administration to testify on Capitol Hill, thereby slowing efforts to implement the ACA. The legal challenges that made their way to the U.S. Supreme Court presented a second major obstacle to fulfilling the vision of the ACA. There were several pearls I learned while watching this unfold. A comment from Politico characterized the challenge in leading on health reform: “It is like trench warfare—whoever is advancing is gunned down.” But someone has to lead. A former staffer for Senator Kennedy on Senate HELP shared the difficult decision made at the crossroads of two divergent paths that emerged early in 2009. One path involved reforming the health care delivery system first, to derive savings that could be used to expand coverage to the uninsured. The other path sought to expand insurance coverage first and get as many Americans as possible into the coverage pool, and then tackle the costs of the delivery system later. The latter path was chosen; some believed it was less likely to antagonize powerful interests in the health care industries, such as the medical device and pharma8

ceutical industry, and perhaps win support with voters who might receive coverage and favorably impact the outcome of the 2012 election. But there were detractors of this course of action. As early as July of 2009, Senator Dianne Feinstein said she was “leery of expanding access to insurance unless costs are controlled.”

One irony regarding the recent tax bill is that the individual mandate had actually been first proposed by a conservative think tank—the Heritage Foundation—and it was a key component of the Massachusetts health reform plan (nicknamed Romneycare) championed by a Republican governor. Democrats had originally opposed the individual mandate’s insertion into the ACA, which ultimately was a core complaint in the litigation National Federation of Independent Business v Sebelius. This lawsuit made its way to the Supreme Court, which ruled 5 to 4 that the individual mandate was constitutional as a valid exercise of Congressional taxing authority.

So where do we go from here? I believe that the opportunity presents itself in 2018 for SFMMS to lead the way far forward. SFMMS has convened a Health Care Options Taskforce chaired by Dr. Shannon Udovic-Constant to examine reform options beginning with Healthy San Francisco, and UCSF medical student Rachel Ekaireb serves on the CMA Health Reform Task Force. In the intervening years since the ACA was signed into law, we have arrived as a nation at a deeper understanding of the drivers of rising health care costs. Steven Brill’s article in Time about chargemasters and the way in which hospital prices are set has highlighted the growing need for delivery system reform. The rising costs of insurance exchange premiums have been a focal point of criticism by the Republicans and President Trump, and that has been one catalyst for the rising popularity of single payor proposals, like SB 562 in California, which will likely emerge as a ballot statewide measure for California voters in 2020.

So what are some solutions to explore moving forward?

In late January 2018, Berkshire Hathaway, Amazon, and JP Morgan Chase announced a collaborative venture to attempt to drive down prices in health care and promote efficient management. Immigration reform might help to address the costs of care for undocumented immigrants. Some believe

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

that medical liability reform should be prioritized in 2018, while the Republicans still control Congress and the White House.

But the larger answers are likely best framed by former UCSF Chancellor Phil Lee, who has repeatedly stated that the health care crisis in America will not be solved until our nation comes to regard health care as a public good. This sentiment is reinforced in the conclusion of the 2000 World Health Organization (WHO) report that has not often been covered by the media (which instead focused on a lesser finding that America ranked 37th in the world in potential health system performance). In the WHO report, Executive Director Christopher Murray wrote “although significant progress has been achieved in past decades, virtually all countries are underutilizing the resources that are available to them. This leads to large numbers of preventable deaths and disabilities; unnecessary suffering, injustice, inequality, and denial of an individual’s basic rights to health. The poor are treated with less respect, given less choice of service providers, and offered lower-quality amenities. In trying to buy health from their own pockets, they pay and become poorer.”

Perhaps then, it is finally time to solve the generationsold problem created as the result of a business decision taken decades ago to “yoke health care to our jobs” and to finally disconnect health care coverage from employment. Along the way, it might be useful as a nation to consider adopting a 28th Constitutional amendment: “Equal access to basic and emergency care is a right, along with these equally important responsibilities.” See you at the Gala, where Sandra Hernandez will discuss what SFMMS members can do to move this conversation further.

Dr. Maa attended U.C. Berkeley and then graduated from Harvard Medical School in 1994. He served as a captain in the U.S. Army for eight years, and completed his general surgery residency at UCSF in 2002. He is currently chief of the Division of General and Acute Care Surgery at Marin General Hospital and is on the medical staff of Dignity Health - St. Francis. He can be reached at jmaa@sfmms.org.

SFMMS

ADDICTION SUMMIT Annual David E. Smith, MD Symposium

Welcome New Members!

STUDENTS Thomas Allen Barnett, ANP

IN MEMORIAM: John H. Epstein, MD Dr. John Epstein passed away on January 23, 2018. His loving wife of 64 years, Alice, survived him. Unfortunately, a son, Nick, predeceased him. Surviving family includes his daughter Janice and her husband, Aaron; his dermatologist daughter, Beverly, and her husband, Jim; his daughter-in-law, Carol; and grandchildren, Amanda and Peter.

Dr. Epstein was born in 1926 and raised in San Francisco.

He attended undergraduate college at U.C. Berkeley and medical school at UCSF, and his dermatology residency was at the Mayo Clinic.

He returned to San Francisco, joining his father, Norman Epstein, MD, in his dermatology practice. John continued his alliance with UCSF, doing bench research in dermatology and serving for many years as volunteer faculty with dermatology residents. After his father retired, he was joined in practice

by Dr. Cruciger and later by his daughter, Quita Cruciger; his own daughter, Beverly, also an SFMMS member, later joined him as well.

Despite his busy career, he was a devoted father and husband and an active practitioner until the fall of 2017, when health issues forced him to stop his practice of 60 years.

The family requests that any donations be forwarded to the John H. Epstein Master Teacher Endowed Chair in Dermatology. Contributions should be made by contacting Lindsay Kopecky @UCSF.edu or calling (415) 476-7673.

A private memorial service will be held in April for family and friends.

—Erica Goode, MD

Friday, June 1, 2018 | 8:30am - 5:30pm

UCSF Mission Bay Conference Center, 1675 Owens Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • Opiates • Psychedelic Medicine • Legal Marijuana

• Advances in addiction medicine and primary care • Marin & San Francisco problems and responses

To register, or for more information, please visit www.drsmithsymposium.com Event co-sponsored by: CME provided by CAFP

WWW.SFMMS.ORG

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

9

150 Years of Advocacy

MORE ACCESS TO HEALTH CARE Opportunities for Leadership in Value, Quality, and Equity Claire Brindis, PhD California’s efforts to increase access to health insurance coverage and health care services reflect political, professional, and consumer leadership and a shared sense of social responsibility and will.

This commitment is mirrored in the reduction in the number of the uninsured living in our state, in spite of efforts by the Administration to weaken the necessary infrastructure, which includes funding for outreach and enrollment workers to enroll hardto-reach, eligible populations. Medi-Cal and Covered California leadership (which included extending the amount of time in which eligible individuals could sign up for coverage) combined with a number of activist community-based organizations to enable the state to beat the odds, reaching and retaining millions of beneficiaries. Medicaid Coverage expansions in 32 states and Washington, D.C., was not the only Affordable Care Act (ACA) win. Most notably, the commitment to preventive health care services as part of essential benefits helped to ensure that more than 55 million women gained access to contraceptive coverage without co-payments and deductibles. Additional progress included enabling consumers with a preexisting condition to gain vital access to coverage, young adults up to age 26 gaining coverage through their parents’ plans, retaining foster care youth as they aged out of the system at age 18 up to age 26, and efforts to reduce health care costs through a variety of cost containment learning efforts through the Center for Medicaid and Medicare Innovation (CMMI).

Yet the almost daily barrage of Congressional and Administrative efforts to further weaken the ACA, beyond the elimination of the individual mandate (in 2019) and premium subsidies, will likely not decrease in intensity. Furthermore, the fiscal health of Medicaid and Medicare is also under siege and, until recently, funding commitment to the Children’s Health Insurance Program (CHIP) was also at risk. The danger to the Deferred Action for Childhood Arrivals Program (DACA) and other immigrant populations not only impacts those populations at risk of deportation but unfortunately has caused a substantial chilling effect upon Latino/a populations seeking health care in California and across the nation. In addition, further “rollback” strategies will likely be introduced at the federal level, which will further impinge upon our state’s safety net network and other entities.

Against this backdrop, a number of state-based experiments, including those states that are seeking greater control over their health care programs, may entail: 1) Waivers enabling rollbacks of ACA benefit requirements (Idaho), 2) Weakening of consumer protections that will likely result in insurance companies charging higher premiums to people who are sicker and older, and 3) The availability of cheaper, less comprehensive plans that do not meet ACA requirements.

10

These will likely result in a quilt of dramatic coverage variation across the country. In contrast, in an effort to shore up the ACA and keep premiums lower, California represents one of nine states considering a requirement that residents carry health insurance as a means of ensuring access, while also helping to keep premiums lower.

These and other issues will likely impact the health and wellbeing of Californians, increasing pressures on policymakers to identify alternative ways to expand coverage, while also achieving the triple aim of increasing value, quality, and consumer voice as stepping stones to creating effective learning health care systems, while simultaneously addressing social determinants of health.

Quality, Patient-Centered Care and Value: Building Steps Toward Creating a Learning Health Care Community

While the United States spends more than $3.4 trillion a year on health care (vastly more per person than any other developed country), our average life expectancy is 79.3 years, or 31st among developed countries. Growing awareness that our costly investments have not resulted in improved health outcomes has contributed to the increasing demand from patients, providers, hospitals, and health insurers for higher-quality care and value. This requires a systemic recognition of the inherent and potentially dangerous waste in health care delivery, the need for greater transparency in achieving better outcomes at a reduced cost, and the need for sustained and replicable innovation as part of building a learning health care system.

As one example of efforts to change the paradigm, the Center for Healthcare Value (CHV), under the auspices of the Philip R. Lee Institute for Health Policy Studies at UCSF, is pursuing two kinds of strategic approaches: Caring Wisely™ and the Measuring Value Initiative (MVI). Caring Wisely, launched in 2012, represents an organized process for engaging and supporting frontline clinicians in efforts to remove unnecessary costs from health care delivery systems and improve the quality of care delivered. The program combines an ideas contest, in which providers and staff identify areas that could be targeted to reduce inefficiencies and health care costs, followed by a selective full proposal stage, in which intervention strategies are vetted. A final implementation component entails the partnership of a small number of innovators with testable ideas and an implementation science team, including health systems leaders in quality, operations, finance, and information technology. Initial results show notable improvements in value related to blood transfusions, inpatient respiratory care, operating room supply costs, postoperative opiate use, length of stay for colorectal surgery and gynecology-oncology surgical patients, and overuse of antibiotics.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

The CHV Measuring Value Initiative, in partnership with the UCSF Clinical Innovation Center, began in 2016 and represents a multidisciplinary internal analysis and consultation service aimed at supporting and aiding improvement work throughout UCSF Health. The program’s early efforts include: 1) Leveraging the health care cost-accounting system to define patterns of clinical care and opportunities for improvement; 2) Designing a cost-of-care calculator—a method for measuring and understanding the impacts of clinical initiatives; 3) Linking frontline clinical improvement work to the financial processes of the health care system, including forecasting, budgeting, purchasing, and supply chain management; and 4) Developing methods to better link clinical and financial data, using novel big data approaches.

CHV has also begun to work with employers, labor unions, and other purchasers, as well as consumers, patients, and other groups, to establish payment policies that support organizations that try to improve price, quality, and other aspects of value (https://healthvalue.ucsf.edu/).

These programs, which incorporate a multidisciplinary team of innovators, implementors, health services researchers, health care financing experts, informatics, and implementation scientists, represent efforts to rigorously test and learn valuable local lessons within smaller laboratories—for example, a department or unit, where the experimentation can take into consideration local culture. This testing is crucial as health care delivery is beginning to shift and respond to both public and private payers who are pursuing significant changes in the financial incentives for care delivery. This transformation, from revenue that is based on fee-for-service to one that promotes value within a budget and changes in reimbursement, including shared savings, bundled payments, and capitation (Bindman, Pronovost, Asch, 2018), will require substantial system capacity to be successful.

The types of needed “bold experiments” will likely not occur at a time when leaders of health care organizations continue to be concerned about jeopardizing profit margins. Developing capacity and the confidence to implement evidence-based, locally tested and evaluated change represents such a building block. Additional building blocks will consist of institutional replications that will also draw upon the skills of additional team members from throughout the health care system, clinicians, administrators, information system levers, legal counsel, and intellectual property and privacy officers (Bindman, Pronovost, and Asch, 2018). Furthermore, federal, state, and private foundation support for additional experiments—for example, those aimed at incorporating a variety of quality improvement methods, such as reducing hospital-acquired infections and readmissions for heart failure—could substantially reduce some of that financial risk to health care organizations (Bindman, Pronovost, and Asch, 2018).

Social Determinants of Health (SDHs) and Inequity

The increased consciousness regarding the impacts of social determinants of health (SDH) and growing inequity on health outcomes, as well as a shift to patient management of chronic health conditions, will also require the medical community to play an activist role that goes beyond clinic walls. SDH include early life experiences; socioeconomic conditions (income and poverty); quality and level of education; access to employment, WWW.SFMMS.ORG

work/life balance, and work environment; social and physical infrastructure and living conditions; social networks; and public safety (Braveman, Egerter, Williams, 2011). Evidence indicates that many social determinants are associated with chronic stress, resulting in biologic and physiologic influencers on the regulatory systems, including the metabolic, cardiovascular, and peripheral nervous systems. Addressing socioeconomic factors that exacerbate, and in some cases cause, health issues has become an imperative whether you are a payer or provider, a nonprofit or for-profit entity. National, state, and foundation initiatives are increasingly supporting developing wraparound services to foster health and reduce unnecessary medical costs, including stable housing paid for by Medicaid, support for transportation, and access to healthier foods and safer environments. Yet, clearly, more investments will need to be made in the years ahead, as Accountable Care Organizations and Accountable Care Communities, among others, recognize the importance of multi-sectoral, partnership approaches that close this vital chasm. Other relevant testing, in terms of taxes on sugar-sweetened beverages, tobacco, and marijuana, represent not only public health efforts to decrease consumption but also important pools of funding for additional community investments.

As is true of learning health care communities, further testing and innovation, as well as rigorous evaluations that incorporate social determinant variables along with a wide array of relevant data sets (e.g., education, employment, juvenile justice, etc.), will play a significant role in demonstrating the vital “return on investments” both in the short and long run.

Given the diversity and economic strength of our state, California is at an important crossroads. Will California continue to play a leadership role in advancing improvements in our health and well-being? Based upon our history, the answer is likely to be yes, but it will require an extensive and ongoing commitment from all of us.

Claire D. Brindis, PhD, is professor and director of the Philip R. Lee Institute for Health Policy Studies and co-director of the Adolescent and Young Adult Health National Resource Center at the University of California, San Francisco.

Her research focuses on health care access and utilization by adolescents and young adults, as well as the translation of research into policy and programs.

References: 1. Bindman AB, Pronovost PJ, Asch DA. Funding innovation in a learning health care system. JAMA. 2018 Jan 9; 319(2):119–120.

2. Braveman P, Egerter S, Williams D. The social determinants of health: Coming of age. Annu Rev Public Health. 2011(32):381–98.

3. The Center for Health Care Value, UCSF. https://healthvalue.ucsf.edu/ (downloaded February 2, 2018).

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

11

150 Years of Advocacy

THE FUTURE OF THE ACA AANHPIs in the Center of the Storm Winston F. Wong, MD, MS, FAAFP The Affordable Care Act, aka the Patient Protection and Affordable Care Act (ACA), or, alternatively, “Obamacare,” grabbed national headlines for the better part of 2017. Specifically, the new Trump administra-

tion took on as its legislative and political priority the dismantling of the ACA. Subsequently, as the 115th Session of Congress convened, the Republican party set upon a strategy to garner the necessary votes to rescind the ACA. In one of the most dramatic moments in Congressional history, Senator John McCain, the Republican opponent of Barack Obama in 2008, literally turned his thumb down in a nationally televised session, denying the Trump Administration and leaders of his own political party the necessary votes to effectively kill the ACA. Arguably, no other ethnic or racial group had more at stake in this political drama than Asian-Americans, Native Hawaiians, and Pacific Islanders (AANHPI).

AANHPIs are often characterized as a “unique” population group with characteristics that are different than that of mainstream populations. Indeed, the AANHPI category lumps multiple cultures and nationalities into one group, sublimating important demographic and socio-economic variations across dozens of subgroups. In fact, this very heterogeneity within the AANHPI population underscores the central importance of the ACA to the future of health care access for this group and all Americans.

Indeed, America is beginning to look like the AANHPI demographic, or conversely, AANHPIs are a representative slice of the American pie. For within this group, there is considerable income variation; wide differences in educational attainment; and representation of both recent immigrant status and nativity, of refugees, and of indigenous people. Thus, it is telling that no other group had more proportional increase in health insurance coverage under ACA than AANHPIs, with a drop of the uninsured rate among AAs from 15.1% to 6.5%, and NHPIs from 14.5 to 7.7% between 2010 and 2016. Effectively, the uninsured rate among AANHPIs has been cut by more than one-half since ACA reforms were adopted.

Moreover, the ACA provision to provide extension of a guardian’s employer-based health coverage to their dependent children age 26 and younger had arguably more impact on AANHPIs than on any other group. This key component of ACA allowed adult children, who are often part of the extended household of AANHPIs, to maintain health coverage as they continued through higher education or contributed to family income as young working adults.

The establishment of state-based (and, in some cases, federally supported multistate) insurance marketplaces has enabled individuals to get health insurance when their employers 12

or economic situation have no provision for coverage, as is often the case with AANHPIs. These individuals may run their familyowned business or work for small business operations. For example, among Korean Americans, the rate of self-employment is approximately 28%. Thousands of AANHPIs, because of this situation, were previously priced out of health insurance. Under the ACA marketplaces, not only are uninsured individuals able to shop for coverage as though they were part of a larger employee group but they often qualified for subsidy assistance based on their income levels. Within the AANHPI group, there are groups with significant income deprivation (e.g., Hmong, Khmer, Pakistani) that undoubtedly qualified for subsidized health coverage or Medicaid, the state-federal health coverage program for individuals who have incomes of 133%, or lower, of the Federal Poverty Level.

Indeed, Medicaid expansion under the ACA was a significant factor in health care coverage gains made by AANHPIs. In 2016, 11% of AAs and 23% of NHPI families lived under the poverty line, reflected by a Medicaid coverage rate of 16.9% among AAs and 34% among NHPIs. Thus, nearly 1 of every 6 AANHPIs look to Medicaid as their health care coverage under the ACA. The largest gains in Medicaid coverage occurred in California, representing about one-quarter of all Americans who got coverage via Medicaid expansion. Prior to the full implementation of ACA, California had 35% of the nation’s uninsured AANHPIs. The direct impact of the state with the most AsianAmericans in the country in Medicaid expansion should not be underestimated. Moreover, the nation’s most successful health insurance marketplace, Covered California, provided insurance to 1.4 million, of whom 1.2 million received federal subsidies.

While California’s percentage of eligible Asian-Americans is roughly 15%, they comprised more than 22% of Covered California consumers. In San Francisco, where 33% of the population is Asian-American, with the implementation of both Healthy SF, the county’s health coverage program for low-income people, and the reforms of ACA, the uninsured rate hovers at 5%.

Despite the failure of Congress to pass a bill that would have resulted in the wholesale destruction of the ACA, its existence is still tenuous. In the comprehensive tax bill passed by Congress and signed into law by President Trump, one of the less publicized components included the removal of the mandated “tax penalty” for individuals who decline or fail to report individual health coverage on their tax return. Consequently, as of 2018 there is no incentive to purchase health insurance, nor any immediate financial consequence for refusing or declining coverage. The removal of the tax penalty portends an exodus of individuals who see no benefit to health insurance, the majority

(Continued on page 15)

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

Connecting practices to

EMERGING TRENDS. We’re taking the mal out of malpractice insurance.

In an ever-evolving healthcare environment, we stay on top of the latest risks, regulations, and advancements.

From digital health innovations to new models of care and everything in between, we keep you covered. And it’s more than a trend. It’s our vision for delivering malpractice insurance without the mal. Join us at thedoctors.com

150 Years of Advocacy

OUTLANDISH NEW REALITIES The SFMMS as Public Policy Catalyst Steve Heilig, MPH A century and a half ago, the average American lifespan was around 50 years, with very high infant mortality. Transportation was by foot, coal-fueled train,

horse, and maybe bicycle. In San Francisco the Gold Rush had built a town of chaotic frenzy, with few physicians, no real hospitals, many fires, and regular epidemics of all types.

A small group of local physicians, all trained “back East," banded together mid-century to form the San Francisco Medical Society to improve things, mainly by starting some local medical education and setting standards to weed out the many “quacks” hanging out shingles. They also began building hospitals and medical schools—among others, UCSF, San Francisco General, and Stanford Medical Centers can all be traced to these early efforts.

The SFMS evolved through the decades, with fires destroying many early records. Local media archives do show the group being asked by the mayor to help with the problem of opium dens in Chinatown in the 1890s as well as various smallpox and plague outbreaks, and helping with blood drives during the World Wars. By the 1950s, they had helped found the local blood bank and shared offices with it on Masonic Avenue. There they hosted a 1966 debate about the new Medicare program (where the AMA president called it “communism”); in 1967 they saved the new Haight-Ashbury Free Clinic when its medical liability coverage was canceled due to the “hippie” patient population, thus preserving a growing clinic movement. Prepaid health plans such as Kaiser, also termed “socialist” by some medical organizations, were welcomed into the SFMS before many others did so. SFMS leaders were among the first Latino and Asian medical association presidents. There was an SFMS symphony orchestra for decades, too.

Then, in the early 1980s, AIDS hit in San Francisco. The SFMS hosted a citywide task force with the health department, UCSF, and others to respond. It was a heady time. Heated policy debates were the rule regarding viral testing, needle exchange, quarantine, occupational risk, funding, and more. SFMS policies on these issues often prevailed at the state and national levels.

The SFMS hosted the first large AIDS conference in San Francisco, as well as a very active research consortium, and was part of many other educational efforts, including the mayoral HIV summits. Many CMA and AMA policies on these issues originated from the SFMS. The peak HIV era spurred a renewed SFMS focus on public advocacy and partnerships with the local health department and other health groups. Some notable contributions followed:

14

Tobacco: The SFMS was a loud voice for cracking down on tobacco promotion and use, advocating for the early-1990s ban on smoking in restaurants and other businesses. This landmark policy has spread nationwide. Our policy on regulation of electronic cigarettes/vaping has also been widely cited and emulated. Now a ban on menthol products adopted here is being hard fought but has the potential to likewise proliferate, for the benefit of all—other than the tobacco industry.

Health care access: SFMS was strongly in favor of seeking universal coverage for San Franciscans, including the Healthy San Francisco program. This fight went all the way to the United States Supreme Court, but San Francisco prevailed.

SFMS also consistently supported efforts such as rebuilding San Francisco General Hospital, funding our health care safety net, and more.

Reproductive choice: In 1991, the SFMS convinced the AMA to support bringing the new “abortion pill” RU486 to the U.S. A group of SFMS ob-gyns and others began meeting to plan public advocacy and helped stage an importation of the pill from Europe, wherein a pregnant woman was busted at the airport in front of mass media. The story landed on the cover of The New York Times and all other media, and presidential candidate Bill Clinton pledged to bring the medication to American women. That took years, but since then countless patients have been offered this option. It should also be added that women physicians were admitted to the SFMS before many other medical associations did so.

Ethics issues: As medical and public opinion evolved, the

SFMS became “neutral” on the option of physician-assisted dying. A member survey indicated widely split opinions but overall “pro-choice” support. Guidelines developed at the SFMS again were featured as a New York Times cover story. Numerous efforts to convince the CMA to “go neutral” failed until 2016, when that change occurred and a state bill was finally able to go forward. Ten state medical associations have since followed suit, most citing the CMA. The SFMS also convinced the CMA that allowing nurse practitioners to “POLST” patients was good policy. And our guidelines on “medical futility” or nonbeneficial treatment have been widely adppted, even by entire health systems.

Sugar taxation: An SFMS resolution adopted by the CMA

signaled that organized medicine would support increased taxes to decrease consumption and help pay for associated costs. This remains a hard-fought battle, but progress is being

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

made. Similar proposals are supported regarding alcohol taxation as well, but without movement on that topic yet.

Drug policy: The SFMS board unanimously endorsed 1996’s Proposition 215, legalizing “medical” use of cannabis, after informal surveys showed many physicians favored this choice and the United States “drug czar,” a general, came to a board meeting and ordered the SFMS to oppose it. We were the only such association to do so. Since then SFMS leaders have been instrumental in CMA policy formation on this and the broader issues of evidence-based drug policy. SFMS pushed for addiction medicine to become an official specialty and presents large educational forums in the field, including at the San Francisco Addiction Summit in 2017 (and upcoming in 2018).

Antibiotic resistance: An invitational conference at SFMS sparked not only AMA policy on reducing the resistance-breeding agricultural overuse of antibiotics but an ongoing coalition working to minimize such use via stronger regulation. Both state and local improvements have resulted, with more to come.

Environmental heath: An SFMS conference marked the

founding of the Collaborative on Health and the Environment, a large network of professionals working on many aspects of toxics and other concerns. That organization thrives and has given birth to a leading institute for women’s environmental health at UCSF, numerous educational offerings, and many other contributions.

Partner violence guidelines: Recognizing that existing

clinical guidelines on intimate partner/domestic violence were too long for many physicians to easily use, SFMS condensed the best practices into one concise guideline that was recognized in a JAMA review as one of the best in existence.

Through all this, the SFMS has steadily published its journal San Francisco Marin Medicine, now in its 91st year and of unsurpassed quality for similar publications—when national awards were given in its category, we won so often we became disqualified. Our journal remains superb due to the continuing excellent contributions of authors both local and nationwide. The SFMS has also been referred to as the “conscience” of organized medicine, sometimes bringing uncomfortable realities to the broader state and national levels. To give a most recent example, in 2017 SFMS wrote to the AMA protesting their quick endorsement of Dr. Tom Price as Donald Trump’s nominee to head the U.S. Department of Health Services, as we perceived too many problems with Price’s positions and history. As it turned out, he indeed was not the best candidate for this very important position.

Thus the SFMS—now SFMMS—has long served as a relatively small spark of local, state, and national health improvement. It is likely that more SFMMS proposals have become CMA and AMA policy than those of any other county association. The commonalities of these efforts include a commitment to evidence-based proposals and to compassion even when the evidence is not conclusive, working with other committed experts of all stripes, and use of the credibility of committed physicians to advance good ideas via government, the CMA and AMA, our journal, and the media.

WWW.SFMMS.ORG

The Future of the Affordable Care Act (Continued from page 12) of whom are skeptical that a regular monthly premium charge provides them any commensurate security that they would not be burdened by a catastrophic health condition and its incumbent financial cost. This scenario undermines a sound, financially viable insurance market that requires maximal distribution of actuarial costs.

In addition, the liberalized criteria that enabled ACA’s Medicaid expansion is under constant scrutiny and subject to radical redesign. Medicaid “reform,” such as the recently approved Kentucky state provision that Medicaid recipients demonstrate fitness for work, results in additional burden to individuals who rely on this much-maligned program for the poor and underserved. Recent attempts to move Medicaid to a block grant or a federally imposed population-based ceiling cap would likewise reduce enrollment among AANHPIs. Thus, as the political winds prevail, so will ACA be squarely facing the headwind. The AANHPI population has many needs in accessing high-quality, affordable, and person-centered care and epitomizes both the challenges and opportunity to provide health care as a basic human right. As a group, the choices and opinions they express to the industry and our policy makers will be a harbinger of the expectations of America as a whole. As individuals who make up the tapestry of America, they will help shape the future of how our health care system becomes more responsive and equitable.

Winston F. Wong, MD, MS, FAAFP, is chairperson of the National Council of Asian Pacific Islander Physicians.

Over and again, even proposals that initially could be seen as outlandish have eventually, with time and effort, become mainstream, or at least accepted enough for impact. Many innovations that begin in our city and in California as a whole eventually spread far and wide—which is one reason those who oppose healthy efforts often fight us so ferociously (and, often, deceptively). San Francisco has been called “49 square miles surrounded by reality,” but sometimes we make our reality spread far and wide, for the benefit of all. Countless members have volunteered their valuable time and expertise to these ends. And we shall continue!

Steve Heilig, MPH, is director of public health and education at the SFMMS and managing editor of San Francisco Marin Medicine. He is also co-editor of the Cambridge Quarterly for Healthcare Ethics, a senior staff member at Commonweal in Marin, guest editor of the Journal of Psychoactive Drugs, consultant to numerous health organizations, and a widely published author.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

15

150 Years of Advocacy

TAX CODE OVERHAUL IMPACTS The Tax Bill Threatens Our Health and Our Democracy Sandra R. Hernández, MD, MPH Just before Christmas, Congress passed legislation that would overhaul the tax code, make dramatic changes to federal health care policy, and undermine the budgets of Medicaid and Medicare, two pillars of the American health care system. The legis-

lation passed on a narrow party-line vote, with 12 Republicans in the House and one Republican in the Senate voting against the bill.

The final tax bill will have a profound effect on the health and well-being of Americans for a generation. No one should forget that, to get this close, both the House and Senate rushed to approve a deeply unpopular proposal with little transparency or due diligence. Left unchecked, these actions will harm millions of Americans—and American democracy itself.

Even though the legislation has been framed as a tax bill, it is very much a health care bill. It eliminates the Affordable Care Act’s individual health insurance mandate, which will serve to destabilize the individual health insurance market.

The Congressional Budget Office (CBO) projects that this change alone would increase individual premiums by 10% per year and cause as many as 13 million Americans to join the ranks of the uninsured by the end of the next decade. At the time of the tax bill’s passage, the UC Berkeley Labor Center projected that eliminating the individual mandate would cause the uninsured population in California to grow by 1.7 million people by 2027.

Congress may still pass separate legislation to restore some stability to the individual market, but the leading proposals are too modest to prevent much damage.

Seismic Impact

If the language in the final tax bills amount to a major earthquake in the health care system, the aftershocks might be just as dangerous. By eliminating more than $1 trillion in federal revenue, the administration and congressional leaders are manufacturing a budget crisis. Republican leaders have indicated that they intend to use the revenue shortfall that they are engineering with this tax bill to seek deep cuts in safety-net programs, starting with Medicaid. Whether or not those efforts materialize this year, the threat still looms large.

This isn’t merely about what the legislation will do to health care, because it also would exacerbate inequality and worsen health disparities in this country. Under the final tax bill, lowand middle-income families are projected to pay more in taxes over the next decade. That means they will have a harder time paying not just for health care but also for food, housing, child care, education, and other basic needs. When people struggle so much to make ends meet, they suffer more from illness and die younger. And if inequality keeps getting worse, it will under16

mine the economic, social, and political stability upon which our nation depends.

The burden on Californians is particularly heavy. Before the tax bill, Californians were able to deduct the full amount they pay in state and local taxes on their federal tax returns. Now that deduction will be capped at $10,000. The fact that millions of Californians will pay more in federal taxes could put new pressure on our state and municipal governments to reduce their taxes. Under that scenario, it is not hard to imagine a new wave of painful state and local budget cuts.

The irony is that California actually had the power to stop this runaway train. If the entire California congressional delegation had worked together to protect their constituents, and if they had been united and strong, they could have prevented many—if not all—of the worst provisions in the tax bills from becoming law.

The tax bill was a test of leadership. Too many of our public servants failed that test. I worry that the health of our people— and our democracy—will pay the price.

Dr. Sandra R. Hernández is president and CEO of the California Health Care Foundation. She is a former CEO of the San Francisco Foundation and former director of public health for the City and County of San Francisco.

She is an assistant clinical professor at the UCSF School of Medicine. After practicing at San Francisco General in the AIDS clinic from 1984 to 2016, she served on numerous health advisory and educational boards for the City and County of San Francisco, at the Stanford Center for Population Health Sciences, at U.C. Davis, and with the U.C. Regents Committee on Health Services. She is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

150 Years of Advocacy

ADVOCACY UPDATE Physicians Launch New Coalition to Protect Access to Care Shannon Udovic-Constant, MD, and the California Medical Association A note from SFMMS Past-President and CMA Trustee Shannon Udovic-Constant, MD:

Protecting Access to Care As California gears up for a gubernatorial election this year, it is important that our politicians understand the issues that are facing physicians and patients in our current health care environment and move beyond platitudes to really set forth policy that will make a difference. There are many areas of opportunity. California still has 3 million who are uninsured. Many with an insurance card struggle to have true access to the care that they need. Physicians are burdened with increasing regulatory demands that are interfering with time spent with our patients. The CMA saw an opportunity to broaden the health care conversation beyond SB 562 in order to set forth a realistic framework to provide universal access to care in California. In order to accomplish this, a coalition was formed and principles identified. The next step will be for the coalition to identify some ways to accomplish the goals outlined. Please share your thoughts on the SFMMS blog at www.sfmms.org.

January 17 — Today, the California Medical Association (CMA) launched a new coalition of more than 100,000 California physicians, dentists, nurse practitioners, community clinics, and pharmacists to protect the gains California has made under the Affordable Care Act (ACA) and improve California’s health care system.

The Coalition to Protect Access to Care will actively oppose efforts in Washington, D.C., to repeal and replace the ACA, as well as provide a more realistic and responsible solution to California’s SB 562—flawed legislation that would dismantle the health care marketplace and destabilize the state’s economy. The Coalition also seeks to tie the current federal and state health care debate to practical realities that health care providers experience throughout the state.

The Golden State has made great strides under the ACA, expanding care to more than 5 million Californians who were previously without health coverage. According to the Public Policy Institute of California, nearly 60 percent of Californians view the ACA favorably, and only 18 percent want the law repealed. The Coalition will work with policymakers to protect and expand coverage to the remaining 2–3 million without access to care.

The Coalition also believes that with so much uncertainty in our nation’s politics, now is not the time to walk away from the ACA in favor of establishing a new and undefined health care system.

“We believe that every Californian deserves access to timely, quality health care and affordable coverage,” said CMA President Theodore M. Mazer, MD. “Unfortunately, SB 562

WWW.SFMMS.ORG

would wreak havoc on the market, forcing existing successful models aside while destabilizing the state budget—it’s simply unaffordable and fails to recognize real-world access and market dynamics.”

SB 562 would eliminate Medi-Cal, Medicare, all private insurance, and the Covered California exchange for a singular health care insurance product provided by the state, without offering any way to pay for it. This measure threatens the health care marketplace for millions of Californians and is based on erroneous assumptions regarding how California can use health care funds provided by the federal government. It also ignores the fact that the state does not have the same powers as the federal government to effectuate a single-payer system.

What’s more, the Legislative Analyst’s Office (LAO) found that the proposal could “require new state tax revenues in the low hundreds of billions of dollars” and “could result in a lower minimum funding requirement for schools and community colleges” under Proposition 98. In other words, SB 562 would pit health care groups against public education advocates in an annual battle for state budget dollars, forcing Californians to choose between quality education and quality health care—an unfair, irresponsible, and unnecessary request. The Coalition is committed to the following principles: • Aggressively protect and expand access to health care by building upon the successes of the Affordable Care Act. • Work to expand access to care to the remaining 2–3 million Californians who are still without coverage.

• Oppose efforts to repeal or undermine the Affordable Care Act. • Oppose Senate Bill 562 and any other health care proposal that destabilizes California’s health care system by calling for unrealistic revenue increases that could destabilize our state budget.

• Commit to improving and expanding care for all Californians through an approach that builds on California’s existing health care delivery system.

California needs pragmatic and implementable solutions that benefit patients instead of scoring political points.

“A pluralistic health care delivery system can work, and we are committed to real solutions that improve and expand the current system without hurting patients or the economy of California,” said Dr. Mazer.

In addition to CMA, Coalition members include the American College of Obstetricians and Gynecologists (District IX), California Association of Nurse Practitioners, California Dental Association, California Pharmacists Association, the Central California Partnership for Health, and Kaiser Permanente.

For more information, please visit ProtectAccessCA.org.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

17

150 Years of Advocacy

SAN FRANCISCO DRUG POLICY Adult Use of Cannabis and Safe Injection Services Barbara A. Garcia, MPA; Israel Nieves-Rivera; and Tomás J. Aragón, MD, DrPH Like all urban centers in the United States, San Francisco faces its challenges with legal and illegal substance use. In a recent issue of SFMMS Medicine, we cov-

ered the economic impact of alcohol consumption in San Francisco. In this issue, we discuss the legalization of adult use cannabis and the proposed pilot testing of safe injection services.

Our public health approach is based on the principles of harm reduction and prevention, and the universal values of dignity, equity, and compassion.

Legalization of adult use cannabis

On November 8, 2016, California voters passed Proposition 64, the Adult Use of Marijuana Act. This proposition legalized cultivation, production, manufacturing, sale, and consumption of cannabis products for persons of ages 21 years or older. Legalization closes one chapter of a history of mass incarceration for using or selling cannabis. This alone is an enormous public health benefit to families and communities impacted by the “war on drugs.”

We recently completed a health impact assessment (HIA) to anticipate and prepare for the public health impacts of legalization. The HIA supports our goals to (a) prevent youth access and exposure to cannabis, (b) minimize potential harms to communities from cannabis use, (c) prevent the renormalization of tobacco product use, and (d) ensure that perceptions of cannabis recognize risks associated with use.

Although the disease and injury profile of cannabis use is much lower than that of tobacco and alcohol (450,000 and 88,000 annual deaths, respectively), cannabis still has adverse health harms. For psychoactive substances we categorize consumption effects due to acute intoxication (including overdosing), end-organ toxicity (especially the brain), and problematic use (also called substance use disorder; formerly called dependence and abuse under DSM-IV). Consuming cannabis edibles can be tricky, because the psychoactive effects are delayed until 30 minutes to 2 hours after starting consumption. A novice user may intentionally consume more to achieve a desired effect and accidently overdose. Regardless of route of consumption, persons who become intoxicated must not operate any vehicle. In Colorado, authorities recommend waiting until a user returns to full alertness and motor function and at least six hours after smoking, or at least eight hours after eating or drinking marijuana, before driving, biking, or performing other safety sensitive activities.

Our biggest concern and priority is youth protection. Brain neurodevelopment continues into the mid-twenties. Cannabis exposure is based on age at initiation, potency, quantity used, and frequency and duration of use. Early age of initiation, am18

plified by these exposure factors, confers the greatest risk for the development of cannabis use disorder or for other adverse consequences: cognitive deficits (learning, memory, attention), lack of motivation, or psychosis (including schizophrenia). Unfortunately, youth perceive cannabis to be “safe and natural,” and their parents’ knowledge of cannabis health effects may be outdated.

Closing racial inequities is also a priority. In 2013–2015, among San Francisco high school students, current cannabis use for African-Americans was 42.9%, whites 33.6%, Latinos 28.1%, and Chinese 2.8%. In 2011–2015, African-Americans had 5.8 times the age-adjusted cannabis-related hospitalization rate and 5.2 times the cannabis-related emergency department visit rate as the overall population. From other data, we know that African-Americans have the lowest academic achievement and the lowest rates of high school graduation, and adults have the highest rates of disease, injury, and premature deaths. Because education is a strong determinant of socioeconomic and health inequities, preventing youth cannabis use is our highest health and equity priority. We are working closely with the schools and youth organizations to strengthen our alcohol and substance use prevention programs. For providers: Because each legal substance (tobacco, alcohol, cannabis) has a unique risk profile, it is better not to compare them. However, they do share the following in common: First, early age at initiation, amplified by potency, quantity used, and frequency, increase the risk of harm and addiction. Second, the substance use industries promote overconsumption (e.g., the side effect of the “designated driver” is that other passengers can overconsume). And third, harm reduction principles can apply to all addictive substances and have a role.

For example, the American Journal of Public Health (PubMed ID: 28700290) published evidence-graded “Lower-Risk Cannabis Use Guidelines” so providers can counsel cannabis-using patients how to reduce risks of harm.

For the latest health information, visit the California Department of Public Health site “Let’s Talk Cannabis” at https://www.cdph. ca.gov/Programs/DO/letstalkcannabis/Pages/LetsTalkCannabis. aspx.

Public health supports safe injection services

Two million Americans suffer from substance use disorders related to prescription opioids, heroin, and synthetics such as fentanyl, and the availability of fentanyl and its poisoning of drug supplies, in particular, poses additional concern due to its ability to heighten the potency and toxic influences of heroin and cocaine when mixed.

(Continued on page 23)

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

You face plenty of challenges today.

Banking shouldn’t be one of them.

We’re here to help make your life easier with highly personalized financial solutions tailored specifically to the needs of you and your practice.

Call us today!

Your Dedicated Banking Team

John Osborn

Chris Angle

Vice President & Assistant Regional Trust Manager, Vice President, Commercial Banking Wealth Management

415.249.8318 MechanicsBank.com MEMBER FDIC

Martha Cifuentes Vice President & Branch Manager, San Francisco

Tools and solutions built around your needs • • • •

• • • •

Remote Deposit Payment and Merchant Card Services Cash Management Financing for: o Buy-outs/Buy-ins o Acquisitions/Expansions o Equipment Financing o Commercial Mortgages o Existing Loan Refinancing Personal banking for your employees Private Banking for you and your family Investment Management Trust and Estate Services

150 Years of Advocacy

A TALE OF TWO POLICIES Turning Around Vaccination Rates in Three Years Matthew Willis, MD, MPH In late 2014, some visitors to Disneyland, the “happiest place on earth,” left with an unwanted souvenir—measles, which they shared with family, friends, and neighbors. Over several months, measles spread across California, fueled by low vaccination rates.

Most cases were people who had not been fully vaccinated. The outbreak eventually sickened at least 159 people in six states, Canada, and Mexico.

What followed was a lesson in the role of legislation in protecting public health, and in supporting science as a basis for policy change. Today, California childhood vaccination rates are the highest ever recorded, with steady increases since 2014. This success can be traced to two pieces of legislation: Assembly Bill 2109 and Senate Bill 277—both sponsored by state senator/pediatrician Richard Pan and strongly supported by our medical societies.

In Marin County, the debates around vaccine policy have been particularly intense—and the gains more dramatic. This school year, 94% of Marin kindergartners are fully vaccinated. While slightly below state averages, this represents a leap forward for this historically vaccine-hesitant community.

In 2013, only 80% of incoming Marin kindergartens were fully vaccinated—the lowest rate in the Bay Area and among the lowest in the state (Figure). At the same time, Marin County also registered among the highest rates of pertussis statewide.

Marin County Childhood Vaccination Rates

As a new Public Health Officer in 2013, low vaccination uptake in this affluent and highly educated community was perplexing to me.

Two years earlier, I had been deployed to Haiti after the earthquake, where death from vaccine-preventable disease was a sign of lack of access to vaccines. In Marin we were vulnerable to the same diseases, but for a very different reason. Our risk of outbreaks was by choice.

Even more concerning, the steady downward trend in vaccination rates was being mirrored across the state.

20

Fortunately, Senator Richard Pan, a pediatrician, and colleagues in the medical society were organizing to address low vaccination rates as a policy problem. In 2013, California had among the weakest vaccination laws in the nation.

In 2013, the power of persuasion, on a case-by-case basis with parents, was the primary tool available to us to boost childhood vaccination rates. Yes, children entering school were “required” to be vaccinated against serious and preventable diseases. Unless—and this was the flaw—the child’s parent or guardian cited a personal belief against required vaccinations. Children with Personal Belief Exemptions (PBEs) could legally enter school completely unvaccinated. Over time, more and more parents were opting out, and outbreak risk increased.

In 2014, prior to the measles outbreak, Assembly Bill 2109 passed, requiring parents to have a conversation covering the risks of leaving children unvaccinated with a physician prior to obtaining a PBE. This law sponsored by Dr. Pan was the beginning of the solution to under-vaccination in California. In Marin, the rate of fully vaccinated children increased 4% in 2014, the year AB 2109 passed. Parents were making new decisions based on new information. This success also highlights the value of strong partnership between public health advocates and clinicians serving a given community.

In anticipation of AB 2109, Marin Public Health partnered with the Marin County Office of Education to survey parents to better understand their vaccination beliefs. Our goal was to optimize newly required conversations and to support pediatricians to address concerns held by vaccine-hesitant parents. Through this process we learned that most children with PBEs were partially vaccinated, and that their parents often had focused concerns about specific vaccines.

We also found an underappreciation of the community-wide benefit of vaccination. The term “Personal Belief Exemption” misleadingly suggested that parental vaccine decisions are purely personal, with only personal implications.

Working with pediatricians, we developed messaging to address common themes of parental concern and to frame vaccination as a matter of community welfare. These better-informed conversations led more Marin parents to choose vaccinations.

Passing AB 2109 was a positive sign that California lawmakers were willing to take legislative action to support vaccinations. However, the measles outbreak of 2014–2015 proved that these gains were too little, too late.

The Disneyland measles outbreak gained national media coverage and stimulated important dialogue in California and across the nation about vaccinations. Near the center of this was a seven-year-old boy from Tiburon. Rhett Krawitt was in treatment for leukemia and was too immune suppressed to be vaccinated. Rhett and his family stepped forward to fight for stronger vaccination policy. Rhett spoke to this as a matter of survival. He put a face on that child who is actu-

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

ally threatened by another parent’s choice not to vaccinate their child.

When two unvaccinated Marin children contracted measles in the Disneyland outbreak, the national media spotlight shone brightly locally for a few days. Crews from the major networks visited the Krawitts; local health officials, including vaccination champions in the medical society; and Senator Pan. Even Jon Stewart and Jimmy Kimmel featured the story. (On the resurgence of diseases due to high opt-out rates, Kimmel joked that we seem “more afraid of gluten than smallpox.” Stewart accused us of practicing “mindful stupidity.”) This high-profile debate raised the visibility and urgency of SB 277 and allowed Rhett’s compelling voice to powerfully pair with Dr. Pan’s messages. Rhett is now healthy and fully vaccinated, and at age 10 already holds a legacy of protecting generations of Californians.

A recent New York Times article entitled “After a Debacle, How California Became a Role Model on Measles” concludes, “One law changed the behavior of impassioned resisters more effectively than a thousand public service announcements might have. . . . Maybe changing minds isn’t so important. People may not have altered their attitudes about vaccination, but the fact is that these laws actually changed behavior.”

However, a closer analysis of the data paints a slightly more nuanced picture. In fact, increases in uptake of childhood vaccinations preceded the legislation that eliminated Personal Belief Exemptions (SB 277). The increases in vaccination rates that followed AB 2109 were primarily attributable to changing beliefs. Instead of public service announcements, AB 2109 placed the locus of these important conversations into the context of the pediatrician’s office. This validates the role of the clinician as a trusted advocate in the particular context of each family.

Ultimately, eliminating the exemption loophole in vaccination law was necessary to achieve the rates required to protect Californians from preventable outbreaks. However, challenges still remain.

SB 277 eliminated new PBEs, but children with current PBEs remain exempt and continue “grandfathered” through their schooling. Some schools remain at high risk due to unvaccinated children in higher grades. Eventually, as new cohorts of fully vaccinated children enter as kindergarteners, campus-wide vaccination rates will increase.

Additionally, medical exemptions, reserved for children with contraindications to vaccination, have increased after new Personal Belief Exemptions were eliminated. If this trend emerges as a threat to overall vaccination rates, there may be a role for medical societies to advocate for additional legislation.

In 1868, the newly formed San Francisco Medical Society advocated to increase the availability of small pox vaccine in San Francisco. These founders could hardly have known that 150 years later vaccinations would still be threatened, and that we would still be fighting. California’s recent vaccine policy success was driven by physicians, who played vital roles at every stage—in describing need and crafting strategies, as elected leaders sponsoring legislation, as spokespersons in public dialogue and media, and as trusted partners in dialogue with parents. As we face new challenges, including the opioid crisis, threats to health care access, and epidemics of chronic disease, we can look to this recent demonstration of what organized medicine and public health can achieve.

Matthew Willis, MD, MPH, is the Public Health Officer for the County of Marin.

WWW.SFMMS.ORG

San Francisco Drug Policy Update (Continued from page 18) In San Francisco, an estimated 22,500 people inject drugs and approximately 160 to 200 people die in the city each year from drug overdoses. Unlike other parts of the United States, where overdose deaths have dramatically increased, overdose deaths in San Francisco have remained constant. We believe this is because of a long-standing and successful Drug Overdose Prevention and Education (DOPE) Program that distributes naloxone and trains on its use. However, the injection drug use landscape has changed in recent years. The proportion of overdose deaths caused by fentanyl contamination and adulteration are increasing. There is increasing concern about people injecting drugs in public and about discarded needles. In public health, we are committed to protecting and improving health for all, including people who inject drugs. We focus on a continuum of services, including preventing overdoses, reducing soft tissue infections, preventing transmission of blood-borne pathogens (HIV, hepatitis C), and providing access to high-quality substance use treatment and physical and mental health care. Safe injection services (SIS) extend this care continuum to include an evidence-based strategy based on the principles of harm reduction and prevention and the values of dignity, equity, and compassion. Approximately 100 safe injection sites now operate in more than 65 cities around the world. More than 100 studies have reported evidence that SISes reduce overdoses and deaths, improve injection safety, and increase access to substance use treatment. Also, SISes do not increase public disorder, attract drug-related crime, or increase relapse rates.

For San Francisco, a 2017 cost-benefit study found that a single 13-booth safe injection services site would result in the following each year: Each dollar spent would generate $2.33 in savings, for total annual net savings of $3.5 million; 415 fewer hospital stays; 3.3 fewer HIV cases; 19 fewer hepatitis C cases; 110 more people who inject drugs entering treatment; and 1 life saved every four years.

SIS is supported by the American Medical Association, SFMMS, and San Francisco political leaders. On February 2, 2018, the San Francisco Health Commission passed a resolution endorsing “the Safe Injection Services Task Force’s recommendations for operating safe injection services in San Francisco.”

What can providers do? Through your professional networks, please support Assembly Bill 186, currently pending in the California Legislature, which would allow designated counties, including San Francisco, to operate safe injection services according to specific requirements and prohibit those involved with the programs from being charged with drug-related crimes.

Barbara A. Garcia is the director of Health, San Francisco Department of Public Health.

Israel Nieves-Rivera is director of the Office of Health Equity and Policy, Population Health Division, San Francisco Department of Public Health.

Tomás J. Aragón is the health officer of San Francisco and director, Population Health Division, San Francisco Department of Public Health.

A full list of references can be found at www.sfmms.org.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

21

Advocacy Case Study: San Francisco's Menthol-Flavored Tobacco Ban

MENTHOL-FLAVORED TOBACCO Bans on Sales Increase Efforts to Protect Vulnerable Populations John Maa, MD, and Man-Kit Leung, MD Menthol is an additive that poses population level harm to the U.S. public, as it increases smoking initiation and targets vulnerable populations such as African-Americans, women, and youth. Adolescents who

start smoking menthol cigarettes are more likely to become regular smokers than those who begin with non-mentholated cigarettes.

Prohibiting the sale of flavored tobacco, including menthol cigarettes, is an important step in protecting San Francisco children from the unrelenting efforts of the tobacco industry to addict them to lifelong smoking. For decades, tobacco companies have used flavorings to enhance the taste and reduce the harshness of their products to make them more enticing.

In recent years, there has been an explosion of sweet-flavored tobacco products, especially e-cigarettes and cigars. These products are available in a wide assortment of flavors that belong in a candy store or ice cream parlor, such as gummy bear, cotton candy, peanut butter cup, and cookies ’n’ cream. A 2014 study identified more than 7,700 unique e-cigarette flavors, with an average of more than 240 new flavors being added per month.i Sales of flavored cigars, meanwhile, have increased by nearly 50 percent since 2008, and flavored cigars made up more than half (52.1%) of the U.S. cigar market in 2015, according to Nielsen convenience store data.ii These sweet products have fueled the popularity of e-cigarettes and cigars among youth. A government study found that 81% of kids who have ever used tobacco products started with a flavored product. Youth also cite flavors as a major reason for their current use of non-cigarette tobacco products, with 81.5% of youth e-cigarette users and 73.8% of youth cigar users saying they used the product “because they come in flavors I like.”iii Across all tobacco products, the evidence is clear: Menthol cigarettes and flavored tobacco products are specifically targeted to youth and overwhelmingly used by youth as a starter product, making it easier for them to become addicted to smoking, with the preference for flavors declining with age.

Tobacco industry marketing, often targeted at minority communities, has been instrumental in increasing the use of menthol tobacco products, especially among minority groups and youth. As a result, 85% of African-American smokers smoke menthol cigarettes like Newport and Kool, compared to 29% of white smokers. Menthol cigarettes are particularly popular among youth: More than half of youth smokers use menthol cigarettes, including seven out of ten African-American youth smokers.iv RJ Reynolds and Lorillard (now owned by RJ Reynolds) dominate menthol production, with Newport holding a 57% market share, followed by Kool, Salon, and Ebony cigarettes. The FDA’s Tobacco Products Scientific Advisory Committee (TPSAC) estimates that by 2020, 4,700 excess deaths in the AfricanAmerican community will be attributable to menthol cigarettes, and over 460,000 African-Americans will have started smoking because of menthol in cigarettes. TPSAC further concluded that “Removal of menthol cigarettes from the marketplace would benefit public health 22

in the United States.”v In 2009, the Family Smoking Prevention and Tobacco Control Act (FSPTCA) was signed into federal law, making it illegal to manufacture cigarettes that contained “characterizing flavors” other than that of tobacco. However, the ban exempted menthol cigarettes, which include menthol as a masking agent and sweetener to disguise the health harms and soothe the mouth pain causing by smoking tobacco (as with mentholated cough drops). The TPSAC later issued a report calling on the federal government to ban the sales of menthol cigarettes in America.

An end to the use of menthol cigarettes has been identified as a key part of the overarching endgame strategy to bring the tobacco epidemic in America under control. Tobacco use has caused 20 million deaths in America since the Surgeon General’s report in 1964, which is more than all of the American lives lost in all of our nation’s wars, multiplied by 10. Menthol cigarettes account for an estimated 50% of all tobacco product sales to the age groups 18 to 24 and account for 30% of the total market for cigarette sales in America, which explains why Big Tobacco is nervously monitoring the trend of menthol bans that is sweeping across America.

The scientific evidence leaves no doubt that flavored tobacco products—including menthol—have a profound adverse impact on public health in the United States, resulting in more smoking and subsequently more death and disease from tobacco use. The research also demonstrates that the tobacco industry is responsible for the harm caused by menthol cigarettes because of its targeted marketing to children and African-American communities and its manipulation of menthol cigarettes to appeal to specific target markets. Prohibiting the sale of flavored tobacco products, including menthol cigarettes, will help counter these industry tactics.

Menthol cigarettes were first banned in Brazil in 2012, then in Canada in 2017; they will be banned in the United Kingdom in 2020, to be followed by the European Union, to curb youth smoking. On August 26, 2017, five U.S. Senators (Elizabeth Warren and Ed Markey of Massachusetts, Jack Reed and Sheldon Whitehouse of Rhode Island, and Richard Blumenthal of Connecticut) introduced legislation that would ban the sales of menthol cigarettes in America. For the first time, the NAACP was not opposed to the legislation. The TPSAC and FDA are also monitoring closely for federal action, which makes the visionary efforts of the late Mayor Ed Lee in San Francisco even more critical to uphold. Big Tobacco has portrayed the public health legislation as a job killer, though it has created positions for law firms, communications teams, and lobbyists who work for Big Tobacco.

In 2013, the San Francisco Medical Society delegation led the way in California with the successful CMA HOD resolution “Ban on Menthol Tobacco Additives” and catalyzed the May 2016 CMA white paper entitled “Flavored and Mentholated Tobacco Products: Enticing a New Generation of Users.” This report was approved by the CMA Board of Trustees and summarized the existing evidence on the impact of fla-

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

150 Years ofCase Advocacy Advocacy Study: San Francisco's Menthol-Flavored Tobacco Ban

BAN ON ADDITIVES A Proposed Full Ban on Menthol Additives in Tobacco Products John Maa, MD; Gordon Fung, MD; Leslie Lopato, MD Whereas, tobacco remains the leading preventable cause of morbidity and mortality among Californians and Americans; and Whereas, smoking has decreased significantly in the past decades due to concerted efforts on many fronts, but the tobacco industry continues to market its products to youth with a significant percentage of adolescents becoming addicted to smoking each generation; and Whereas, menthol is an additive long present in many if not most cigarettes, and it has been well established that menthol cigarettes pose a population-level harm to the U.S. public as they increase smoking initiation and target vulnerable populations including African-Americans, women, and youth, with adolescents who started smoking menthol cigarettes being more likely to become regular smokers than those who start with non-mentholated cigarettes; and Whereas, as all flavorings other than menthol have long been banned in tobacco, and the FDA has long considered banning menthol from tobacco products, as urged by many health authorities and its own Tobacco Products Scientific Advisory Committee, and has just issued a report concluding it is “likely that menthol cigarettes pose a public health risk above that seen with non-menthol cigarettes” but by failing to ban menthol cigarettes, the FDA has not taken all steps possible to lower youth and young adult smoking initiation rates; and Whereas, two former United States Secretaries of Health, from the Carter and first Bush administrations, recently wrote to The New York Times that menthol is “the most deadly tobacco flavoring” that not only lures children to start smoking but also vored and mentholated tobacco products on public health, especially among priority populations with higher rates of tobacco use than the general population.

The San Francisco Marin Medical Society is a proud member of a strong coalition of health organizations (San Francisco vs. Big Tobacco) working to uphold the ordinance originally passed by the San Francisco Board of Supervisors. We are joined by the American Academy of Pediatrics, the American Association for Cancer Research, American Cancer Society, American Heart Association, American Legacy Foundation, American Public Health Association, and American Lung Association. By supporting this ordinance, voters will put the health of San Francisco’s youth and minority communities before tobacco industry profits. Please vote yes to defend the flavored tobacco products ban on June 5, and ask family, colleagues, friends and other healthcare professionals to do the same.

WWW.SFMMS.ORG

makes it harder for menthol smokers to quit; and Whereas, the American Academy of Pediatrics, American Association for Cancer Research, The American Cancer Society—Cancer Action Network, American Heart Association, American Legacy Foundation, American Lung Association, and American Public Health Association have all joined in urging a ban on menthol, with the AMA conspicuously absent on this important issue; and Whereas, the collective European Health Ministers and Brazil agreed this year to ban menthol to curb youth smoking; now be it Resolved: That CMA supports a full ban on menthol additives in tobacco products in order to curb smoking; and be it further Resolved: That this be referred for national action.

John Maa, MD, is chief of the Division of General and Acute Care Surgery at Marin General Hospital and is on the medical staff of Dignity Health – St. Francis.

Gordon Fung, MD, is editor of San Francisco Marin Medicine and is a cardiologist at UCSF. Leslie Lopato, MD, is a neurologist and psychiatrist who practices in San Francisco and treats a variety of mental illnesses.

California Medical Association Policy, Submitted by SFMS and Adopted, 2013. A full list of references can be found at www. sfmms.org.

Dr. John Maa is a graduate of U.C. Berkeley and Harvard Medical School. He served as captain in the U.S. Army and completed his general surgery residency at UCSF. He is currently chief of the Division of General and Acute Care Surgery at Marin General Hospital and is on the medical staff of Dignity Health – St. Francis.

Man-Kit Leung, MD, is an otolaryngologist—head and neck surgeon—in private practice and past president of the San Francisco Marin Medical Society.

A full list of references can be found at www.sfmms.org.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

23

Advocacy Case Study: San Francisco's Menthol-Flavored Tobacco Ban

SF TAKES ON BIG TOBACCO The Battle over San Francisco’s Ban on Candy-Flavored Tobacco Larry Tramutola Big Tobacco (aka RJ Reynolds) is breaking political spending records in San Francisco in a repugnant effort to overturn the city’s ban on candyflavored tobacco products. Most observers believe RJ

Reynolds will spend millions to defeat the legislation that seeks to stop Big Tobacco from marketing flavored tobacco products to children and targeting certain minority groups.

Shortly before his death, San Francisco Mayor Ed Lee signed into law an ordinance to restrict the sale of flavored tobacco products in the city. This followed weeks of lobbying and education by major health organizations and health leaders, who argued that restricting sales of these products would make it more difficult for youth to become addicted to tobacco.

The unprecedented amount of money the tobacco companies are spending in San Francisco reveals the importance of the youth market to them. Studies show that flavored tobacco products are undermining efforts to reduce smoking among children.

In fact, these products are specifically intended to attract a new generation of smokers because candy flavors improve the taste and reduce the harshness of tobacco products. This makes them more appealing and easier for youth to become addicted to. Since most tobacco users start before age 18, flavored tobacco products play a critical role in the industry’s marketing efforts.

A report authored by the American Academy of Pediatrics, the Cancer Action Network, the American Heart Association, the American Lung Association, and the Campaign for Tobacco Free Kids found that in recent years, tobacco companies have significantly stepped up the introduction and marketing of flavored noncigarette tobacco products. The report found: In recent years, there has been an explosion of sweet-flavored tobacco products, especially e-cigarettes and cigars. These products are available in a wide assortment of flavors that seem like they belong in a candy store or ice cream parlor—like gummy bear, cotton candy, peanut butter cup, cookies ’n’ cream, and pop rocks for e-cigarettes and chocolate, wild berry, watermelon, lemonade, and cherry dynamite for cigars. A 2014 study identified more than 7,700 unique e-cigarette flavors, with an average of more than 240 new flavors being added per month. Sales of flavored cigars have increased by nearly 50 percent since 2008, and flavored cigars made up more than half (52.1 percent) of the U.S. cigar market in 2015, according to Nielsen convenience store market scanner data.

The report documented the widespread availability of flavored tobacco products and their popularity among youth.

These sweet products have fueled the popularity of e-cigarettes and cigars among youth. While there has been a steep drop in youth use of traditional cigarettes, overall youth use of any tobacco product has remained steady in recent years due to the popularity of to-

24

bacco products like cigars and e-cigarettes—products that are predominantly flavored. From 2011 to 2015, current use of e-cigarettes among high school students increased more than tenfold—from 1.5 percent to 16 percent—according to the National Youth Tobacco Survey.

While health leaders, parents, education leaders, elected officials, and many others standing up for our kids will be far outspent by the tobacco companies, the truth is on the side of public health, and the campaign outcome is a toss-up. If you would like to help the campaign as a volunteer via SFMMS, please contact Steve Heilig at heilig@sfmms.org.

Larry Tramutola is recognized as one the country’s top experts on getting difficult tax measures passed. He led the nation’s first successful Soda Tax campaign in Berkeley, California, and the subsequent successful Soda Tax measures in San Francisco and Oakland. His clients include elected officials, hospitals, school districts, community colleges, cities, counties, and numerous public and private organizations. He is a graduate of Stanford University and is the author of several books about election strategy.

SFMMS

ADDICTION SUMMIT Annual David E. Smith, MD Symposium

Friday, June 1, 2018 8:30am - 5:30pm UCSF Mission Bay Conference Center 1675 Owens Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • Opiates • Psychedelic Medicine • Legal Marijuana

• Advances in addiction medicine and primary care • Marin & San Francisco problems and responses

To register, or for more information, please visit www.drsmithsymposium.com Event co-sponsored by SFMMS, SFDPH, CAFP, UCSF CME provided by CAFP

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

Advocacy Case Study: San Francisco's Menthol-Flavored Tobacco Ban

TIME TO TALK AGAINST TOBACCO Physicians Need to Speak Out Against Big Tobacco in the June Referendum Nisha Parikh, MD After decades, the tobacco wars continue with the latest skirmish breaking out over a measure on the June 2018 ballot in San Francisco. Big Tobacco is

fighting to overturn an innovative anti-tobacco policy protection for youth, particularly those from underserved communities.

Last summer, the SF Board of Supervisors unanimously approved the nation's strongest ban on flavored tobacco products. The late Mayor Ed Lee, a champion for public health, gave his full support to the flavored tobacco product restriction as he stood on the steps of City Hall in 2017, and he signed the law a few months later. Big Tobacco reacted by spending hundreds of thousands of dollars to fund a petition drive for a referendum of this measure to be placed on the June 2018 ballot. Their next goal is to misinform and persuade voters to repeal this landmark public health policy. We can expect an expensive fight in which tobacco companies will be flooding SF media to protect their profits.

As physicians, we have the trust of our patients, particularly those who are parents of school-aged children. The latest public policy battle with Big Tobacco is a prime opportunity to inform and educate parents of the new and dangerous tobacco products to which their children are the core marketing target.

Limiting the sales of flavored tobacco products is one way we can reduce the number of youth who take up this deadly habit.

In December, Salon cited the following trends: “alternative products such as e-cigarettes and small cigars, which have become increasingly popular with young smokers. E-cigarettes are still being marketed in such flavors as ‘Berry Cobbler,’ ‘Caramel Cafe,’ and ‘I Love Watermelon Candy.’” As physicians, we must take a stand to prevent another generation from becoming addicted to tobacco products.

Salon also reported that menthol cigarettes account for a significant portion of U.S. cigarette sales (30%)—and research shows much higher percentages among smokers under age 18, particularly African-Americans—and so billions of dollars could be riding on the outcome of the SF flavored tobacco referendum. RJ Reynolds (maker of the most popular menthol cigarettes, Newports) has mounted an all-out assault and has already spent more than $1.3 million to overturn the San Francisco ordinance, according to a campaign finance report for January through September 2017.

According to the Centers for Disease Control and Prevention, nearly three-quarters of U.S. high school students who reported smoking in the prior month report using a flavored to-

WWW.SFMMS.ORG

bacco product. Sales of flavored tobacco products have increased by 50% since 2008 in the U.S., including an increase in youth use of e-cigarettes (vaping). The majority of youth tobacco users cite taste as a primary reason for their current use of non-cigarette products. In fact, from 2011 to 2015, use of e-cigarettes among high school students increased more than tenfold, from 1.5% to 16% percent, according to the National Youth Tobacco Survey. Big Tobacco encourages youth to falsely believe vaping is safe and free of addictive chemicals. Adolescents view e-cigarettes or vape pens as the latest technology gadget, not recognizing them as the latest method of spreading nicotine addiction.

Both the U.S. Food and Drug Administration and the Surgeon General have warned that flavored tobacco products increase the odds that new users will develop a long-term addiction. However, with each warning and every ruling, the tobacco industry seeks to circumvent the tobacco cessation agenda and hook new users as more of their long-time customers suffer from premature death.

Flavors mask tobacco's taste and reduce the harsh smoke, so they are more appealing and easier for beginners to experiment with—and ultimately become addicted to. Tobacco products come in flavors such as Cotton Candy, PB&J Sandwich, Berry Blast, and Gummy Bear; and in many forms, such as menthol cigarettes, candy-flavored cigars and cigarillos, smokeless tobacco (dip, snuff, chewing tobacco), hookah tobacco, and liquid nicotine solution for e-cigarettes (“vape” juice).

Menthol is appealing for its cool, minty flavor and masking of the harshness of tobacco smoke. It allows smokers to inhale more deeply, and it makes it harder for them to quit. In fact, menthol smokers show greater dependence on nicotine, and their failure rate at quitting smoking is higher than that of other smokers.

The ban on flavored tobacco is a crucial protection for our children. We want our kids to live long, healthy lives free of addiction, preventable disease, and premature death. A “yes” vote in June 2018 will uphold the Board of Supervisors’ restriction on the sale of flavored tobacco in San Francisco. Consider sharing this information with your patients. The need for this public health protection could not be timelier nor more vital. We urge you to talk, as part of the effort to stand against Big Tobacco and protect San Franciscans’ health.

Nisha Parikh, MD, is a cardiologist at UCSF.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

25

LEADERSHIP PROFILE: BOBBY BARON, MD Associate Dean and Innovator of the Academic Clinician Educator Lawrence Cheung, MD, and John Maa, MD

Editor's note: Robert B. Baron, MD, MS, is professor of medicine, associate dean for Graduate and Continuing Medical Education, and Designated Institutional Official (DIO), UCSF School of Medicine.

What led you to medicine?

In high school, I was always interested in math and science, but during college at Princeton in the late 1960s and early 1970s, my interests evolved to more social and political topics. I graduated with a degree in sociology and anthropology. I was considering living in a rural community (after having grown up in the suburbs) but knew I didn’t want to be a farmer, so I decided to try veterinary medicine.

I went to the University of Wisconsin, Madison, to complete prerequisite courses for veterinary school, and I studied nutrition and obtained a master’s degree. I ultimately found mentors in the medical school and began to think that I could succeed in medicine. Experiencing serious illness in my family also motivated me to become a physician. So I applied to medical school instead. As a graduate student, I did not have a standard medical school advisor, and I applied to 23 different schools. Fortunately, one was UCSF. I was initially placed on the waiting list but was accepted in August! I think an interview I had with a senior faculty member who was very interested in nutrition made the difference.

Why internal medicine?

Back in the 1970s, I was interested in working with the underserved, and from the beginning I assumed I would work in primary care via family medicine. During my third year of medical school, I also learned about primary care general internal medicine. Dr. Steve Schroeder was creating a new Division of General Internal Medicine (DGIM) and integrated the innovative residency in primary care internal medicine into the division. Dr. Schroeder was my ward attending for senior medicine and that, along with some remarkable medicine residents, did the trick. Dr. Holly Smith was the department chair of medicine at the time.

After residency, I joined the faculty and began working at the Screening and Acute Care Clinic (SAC) at Parnassus. After two years, I became the director of SAC. The SAC was a terrific learning and teaching environment for me. My clinical skills dramatically matured, and I had the opportunity to teach medical students and residents in a very busy ambulatory setting. It also gave me a unique experience with interprofessional collaboration, as I worked very closely with nurses and nurse practitioners to make SAC work, and the opportunity to work closely with clinicians in virtually every specialty at UCSF. Although all of the DGIM faculty were outstanding teachers and clinicians, they were all also very focused on research. My role was different, more focused on clinical medicine and teaching. I think the experiences I had in SAC, caring for a very diverse patient population 26

at the very start of the HIV epidemic in San Francisco, are a major part of my continued love of clinical medicine. I was most fortunate to be able to share my passion for patient care with students and residents.

Can you describe the birth of the clinician educator?

When DGIM and the Primary Care Internal Medicine Residency Program were created, Dr. Schroeder hired a number of remarkable faculty, including Drs. Al Martin, Steve McPhee, Bernie Lo, Steve Cummings, and Eliseo Perez-Stable. Dr. Schroeder’s vision was to build a core group of independently funded clinician investigators who were also outstanding teachers and clinicians. I had not done a research fellowship and the formal clinician educator pathway did not yet exist.

But in practice, I was one of the first internal medicine faculty to try to develop a career based on excellent clinical and teaching skills and useful administrative and leadership skills. It was later in my career that I learned how to also contribute with educational scholarship.

When Dr. Perez-Stable stepped down as the Residency Program Director, I assumed the lead. I directed the program from 1989 to 2006. This work, training future primary care physicians, became the essence of my role at UCSF. We obtained training grants and additional funding from the Robert Wood Johnson Foundation and the Department of Health and Human Services. This enabled us to innovate as we developed new initiatives in primary care practice, preventive medicine, chronic disease management, evidence-based medicine, diversity, care of the underserved, behavioral medicine, interprofessional collaboration, quality improvement, and resident research. We were early adopters of the primary care home, interdisciplinary work, and population health. We were also early adopters of the electronic health record (EHR). Despite its limitations, it allowed us to innovate in several domains, particularly preventive medicine.

How did you develop companion professional roles at UCSF?

In 1990, UCSF acquired Mount Zion Hospital, which had a separate, long-standing internal medicine residency program led by Dr. Kenneth Woeber. Several years after the merger, our department chair, Dr. Lee Goldman, asked me to direct the Mount Zion residency (along with the Parnassus Primary Care Program). As part of a sabbatical year and after, I worked with Dr. Woeber and others to better integrate the Mount Zion program with the other residency programs at UCSF. Over a three-year period, we transformed the program into another unique UCSF primary care residency program. We built a new faculty-resident primary care practice (still functioning at 1701 Divisadero Street) and started a small teaching hospitalist program in conjunction with the hospitalist program that was starting at Parnassus. Unfortunately, the inpatient service at Mount Zion was closed in the final days of the UCSF-Stanford merger. With full support of the

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

UCSF Department of Medicine, we were able to integrate the Mount Zion residents with the other UCSF primary care internal medicine residents and create new positions for the newly hired faculty.

Because of my time at Madison, I came to UCSF with an interest in nutrition. Another student a year ahead of me was also interested in nutrition, and we quickly discovered that there was little nutrition in our curriculum. Various faculty committees had made the same observation, and this eventually led to the creation of a new position as medical school curriculum coordinator for nutrition. To the school’s good fortune, they recruited Dr. Marion Nestle to come to UCSF. Dr. Nestle taught nutrition in biochemistry, and together we were able to increase nutrition in the Introduction to Clinical Medicine course as well. As junior faculty, I spent over a decade working with Dr. Nestle and teaching nutrition to medical students.

I was also able to help create a nutrition support service to make regular nutrition rounds in the hospital, working with pharmacists and dietitians. As my ambulatory practice grew, I quickly realized that many of the chronic diseases we were caring for were related to obesity. I was able to started the UCSF Adult Weight Management Program, which continues to this day. We were one of the first academic weight management programs to incorporate medically supervised, very low-calorie diets (less than 1,000 calories per day) into our treatment options.

I have always been interested in lifelong learning, and this also lead to some interesting career twists. One day, Dr. McPhee showed me a flyer for a continuing medical education (CME) course in primary care being taught elsewhere and asked why we couldn’t do the same. So we did. To this day, UCSF continues to offer one of the largest series of CME offerings in primary care of any medical school.

The UCSF CME program also offers outstanding CMEs is virtually every specialty. After helping to lead this work in the DGIM and later the Department of Medicine, I became Associate Dean for the School of Medicine in 2000. My work in CME has led to fascinating collaborations training physicians in Nicaragua, Tanzania, and Vietnam.

Around this time, the Accreditation Council of Graduate Medical Education (ACGME) created a position in each teaching hospital for an institutional GME leader titled the Designated Institutional Official (DIO). The DIO is responsible for oversight of all GME programs at the institution. In the early 2000s, Dr. Susan Wall held this position and led UCSF into institutional accreditation and the modern era of GME. Dr. Wall was DIO when the first duty hour limitations were implemented in 2003. When Dr. Wall stepped down in 2006, I became Associate Dean for GME and DIO. Working closely with Vice Dean for Education Dave Irby, we were able to fully conceptualize and unify the continuum of medical education at UCSF with close coordination between undergraduate medical education (UME), GME, and CME. We were able to think more broadly about GME curriculum, well-being, diversity, and quality and safety, and we hired outstanding faculty to help lead these efforts.

What is your philosophy regarding graduate medical education?

We have more than 1,500 residents and fellows in our clinical learning environments, and we quickly realized that they could be part of the solution to improve patient care at each of our major clinical sites.

First and foremost, residents and fellows are an essential part of the clinical care team, and patients always come first. We are equally committed, though, to the patients that the residents will WWW.SFMMS.ORG

care for the rest of their career. We know from several studies that one of the key predictors of the care that physicians provide during their careers is the outcomes of the care in the environment in which they train. Thus we pay a lot of attention to the nature of our clinical learning environments, insuring that patients receive care that is high in quality, safe, equitable, and high in value. We have a strong focus on professionalism and careful supervision, ensuring that residents and fellows have the appropriate amount of progressive independence.

What about medical student indebtedness and primary care career choices?

I don’t think that indebtedness is the whole story to career choice in primary care. At least some evidence suggests that the relationship between indebtedness and primary care career choice is a U-shaped curve, with people at either extreme (both low and high indebtedness) tending to choose careers other than primary care. Clearly, though, for many lower-income students and others with high debt, future incomes do predict specialty choice. It has long concerned me that U.S. doctors have such variation in salaries. With less of a range in physician compensation, we would have a more balanced mix of specialists and primary care physicians. Of course, there are many other factors, including prestige, perceived quality of life, etc., that also have made primary care a hard choice for many graduates. The good news is that primary care practice is much better than it ever has been. In my opinion, changes to primary care homes, interprofessional care, and even electronic health records have made primary care much more satisfying than ever. The EHR has allowed us to work much more collaboratively with colleagues in different specialties.

What do you see as challenges to graduate medical education?

There is a need for greater and more meaningful workforce planning in the U.S. The U.S. health system should have the ability to better estimate the public’s health care needs and train physicians to meet those needs. Currently, we allow hospitals to create new training programs as long as they fulfill the program requirements, but no one is carefully analyzing whether there is really a need for more physicians in that specialty. I anticipate that in the next decade there will be a greater emphasis on accountability of GME programs, requiring outcome measures in learner competence, the learning environment, and workforce needs, to receive federal GME dollars.

Any advice for students interested in your career path and becoming a DIO?

I think there are many roads to follow to become a DIO. Of course, there are only 800 DIOs at teaching hospitals across America! Some of us come from education backgrounds, others from management backgrounds, and some from clinical backgrounds. We, the community of DIOs, have developed a set of core competencies for DIOs that include skills in emotional intelligence, communication, adaptability, systems thinking, leadership, team work, operational planning, and courage. However, I do think that the experience of having been a program director is probably the best training for the DIO position.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

27

NEW LAWS Significant New California Laws of Interest to Physicians, From the California Medical Association

The California Legislature had an active year, passing many new laws affecting health care. On the following pages you will find highlights of the most significant health laws of interest to physicians.

Allied Health Professionals AB 89 (Levine) – Psychologists: Suicide prevention training.

Requires, effective January 1, 2020, an applicant for licensure or license renewal as a psychologist to complete a minimum of six hours of coursework or applied experience under supervision in suicide risk assessment and intervention.

SB 554 (Stone) – Nurse practitioners: Physician assistants: Buprenorphine. Prohibits construing the Nursing Practice Act, the Physician Assistant Practice Act, or any provision of state law from prohibiting a nurse practitioner or physician assistant from furnishing or ordering buprenorphine to a patient when done in compliance with the provisions of the federal Comprehensive Addiction Recovery Act.

Confidential Information

AB 210 (Santiago) – Homeless multidisciplinary personnel team. CMA position: Support. Authorizes counties to establish a homeless adult and family multidisciplinary personnel team, with the goal of facilitating the expedited identification, assessment, and linkage of homeless individuals to housing and supportive services and to allow provider agencies, including those providing health, mental health, and substance abuse services, to share confidential information for the purpose of coordinating housing and supportive services to ensure continuity of care.

AB 1119 (Limón) – Developmental and mental health services: Confidentiality. CMA position: Support. Existing law requires all information and records obtained in the course of providing specified developmental and mental services to be confidential and authorizes disclosure only in specified cases. This bill additionally authorizes, during the provision of emergency services and care, the communication of patient information and records between specified individuals, including physicians and surgeons.

SB 241 (Monning) – Medical records: Access. CMA position: Support. Revises provisions of law governing the right of patients to access and copy their medical records by conforming these requirements to federal Health Information Portability and Accountability Act of 1996 (HIPAA) requirements, including conforming state law regarding charges for clerical costs and requiring health care providers to provide the records in an electronic format if they are maintained electronically and if the patient requests the records in an electronic format.

SB 575 (Leyva) – Patient access to health records. Expands a provision of law that entitles a patient to a copy, at no charge, of the relevant portion of the patient’s records that are needed to 28

support an appeal regarding eligibility for certain public benefit programs, by including initial applications in addition to appeals, and by expanding the list of public benefit programs to include InHome Supportive Services, the California Work Opportunity and Responsibility to Kids program, CalFresh, and certain veteransrelated benefits.

Drug Prescribing and Dispensing

AB 40 (Santiago) – CURES database: Health information technology system. CMA position: Support. Requires the California Department of Justice (DOJ) to make electronic prescription drug records contained in its Controlled Substance Utilization Review and Evaluation System (CURES) accessible through integration with a health information technology system no later than October 1, 2018, if that system meets certain information security and patient privacy requirements.

AB 265 (Wood) – Prescription drugs: Prohibition on price discount. CMA position: Support. Prohibits, with specified exceptions, a person who manufactures a prescription drug from offering in California any discount, repayment, product voucher, or other reduction in an individual’s out-of-pocket expenses associated with his or her health insurance, health care service plan, or other health coverage, including, but not limited to, a co-payment, coinsurance, or deductible, for any prescription drug if a lowercost generic drug is covered under the individual’s health insurance, health care service plan, or other health coverage on a lower cost-sharing tier that is designated as therapeutically equivalent to the prescription drug manufactured by that person, or if the active ingredients of the drug are contained in products regulated by the federal Food and Drug Administration, and that generic drug is available without prescription at a lower cost and is not otherwise contraindicated for the condition for which the prescription drug is approved.

AB 1048 (Arambula) – Health care: Pain management and Schedule II drug prescriptions. CMA position: Sponsor. Beginning July 1, 2018, authorizes a pharmacist to dispense a Schedule II controlled substance as a partial fill if requested by the patient or the prescriber. Requires the pharmacy to retain the original prescription, with a notation of how much of the prescription has been filled, the date and amount of each partial fill, and the initials of the pharmacist dispensing each partial fill, until the prescription has been fully dispensed. Authorizes a pharmacist to charge a professional dispensing fee to cover the actual supply and labor costs associated with dispensing each partial fill associated with the original prescription.

SB 17 (Hernandez) – Health care: Prescription drug costs.

CMA position: Support. Requires health plans and insurers that report rate information through the existing large and small group rate review process to also report specified information related to prescription drug pricing to Department of Managed Health Care

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

(DMHC) and California Department of Insurance (CDI). Requires DMHC and CDI to compile specified information into a consumer-friendly report that demonstrates the overall impact of drug costs on health care premiums. Requires drug manufacturers to notify specified purchasers in writing at least 90 days prior to the planned effective date, if it is increasing the wholesale acquisition cost (WAC) of a prescription drug by specified amounts.

End-of-Life Issues

AB 242 (Arambula) – Certificates of death: Veterans. CMA position: Support. Requires a person completing a certificate of death to indicate whether the deceased person was ever in the Armed Forces of the United States. Requires the Department of Public Health to access data in the electronic death registration system to compile data on veteran suicides and to provide an annual report to the Legislature and the Department of Veterans Affairs.

Health Care Coverage

SB 133 (Hernandez) – Health care coverage: Continuity of care. Requires a health care service plan to include notice of the process to obtain continuity of care in any evidence of coverage issued after January 1, 2018. Requires a health plan to provide a written copy of this information to its contracting providers and provider groups, and a copy to its enrollees upon request. Extends existing continuity of care protections in the Health & Safety Code and Insurance Code to health plan enrollees and insureds whose prior coverage was terminated because the health plan or insurer withdrew from any portion of a market. Requires a health plan or insurer to include notice of the availability of the right to request completion of covered services as part of, to accompany, or to be sent simultaneously with any termination of coverage notice sent under specified circumstances.

SB 223 (Atkins) – Health care language assistance services.

Requires a health care service plan and a health insurer to notify enrollees or insureds upon initial enrollment and in the annual renewal materials of the availability of language assistance services and of certain nondiscrimination protections, and would require this information to be included in the evidence of coverage, on other materials disseminated to enrollees or insureds, and to be posted on the plan or insurer’s website. Requires this written notice to be made available in the top 15 languages spoken by limited–English-proficient (LEP) individuals in California as determined by the State Department of Health Care Services (DHCS).

Establishes minimum qualifications for interpreters providing interpretation services to enrollees and insureds and prohibits the plan or health insurer from requiring an LEP enrollee or insured to provide his or her own interpreter or rely on a staff member who is not a qualified interpreter to communicate directly with the enrollee or insured. Applies to Medi-Cal managed care plans, mental health plans, and DHCS in addition to health care service plans and insurers.

Health Care Facilities and Financing

AB 395 (Bocanegra) – Substance use treatment providers.

Adds the use of medication-assisted treatment as an authorized service by narcotic treatment programs licensed by the State Department of Health Care Services. Authorizes methadone, LAAM, WWW.SFMMS.ORG

buprenorphine, or any other medication approved by the FDA for the purpose of medication-assisted treatment to be used by a licensed narcotic treatment program. Authorizes the department to implement, interpret, or make specific this provision by means of plan or provider bulletins or similar instructions and requires the department to adopt regulations no later than January 1, 2021. Authorizes a physician to treat a number of patients specified under the DEA registration instead of a maximum of 20.

Specifies that bills for services under Drug Medi-Cal must be submitted within six months.

AB 658 (Waldron) – Clinical laboratories. CMA position: Support. Directs the California Department of Public Health to temporarily suspend the annual renewal fee for clinical laboratory licenses until January 1, 2020.

AB 1102 (Rodriguez) – Health facilities: Whistle-blower protections. Increases the maximum criminal fine from $20,000 to $75,000 for violations of whistle-blower protection laws that apply to patients, employees, and other health care workers of hospitals.

Medi-Cal

AB 205 (Wood) – Medi-Cal: Medi-Cal managed care plans.

CMA position: Support. Requires Medi-Cal managed care plans (MCMC) to maintain a network of providers that meet specified time and distance standards, specific to county and provider type. Requires plans that cannot meet the standards to submit a request for alternative access standards. Permits the use of clinically appropriate telecommunications technology as a means of determining annual compliance with the time and distance standards or in approving alternative access to care. Sunsets these requirements on January 1, 2022. Implements changes required by the federal Medicaid managed care rule related to state fair hearings involving MCMC beneficiaries as well as to beneficiary grievances and appeals to MCMC plans.

SB 171 (Hernandez) – Medi-Cal: Medi-Cal managed care plans. CMA position: Support. Implements federal Medicaid managed care regulations. Commencing July 1, 2019, requires a MediCal managed care plan to comply with a minimum 85% Medical Loss Ratio (MLR) and to report the MLR for each MLR reporting year as specified. Requires, effective for contract rating periods commencing on or after July 1, 2023, a Medi-Cal managed care plan to provide a remittance to the state if the MLR does not meet the minimum ratio of 85% for that reporting year and specifies how any remittance will be transferred. Requires the Department of Health Care Services (DHCS) to ensure that all covered mental health and substance use disorder benefits comply with federal regulations. Directs DHCS to require Medi-Cal managed care plans to increase certain payments to designated public hospitals, as specified, and to establish a program under which such hospitals may earn performance-based quality incentive payments.

Medical Cannabis

SB 94 (Committee on Budget and Fiscal Review) – Cannabis: Medicinal and adult use. CMA position: Support. Establishes a single system of administration for cannabis laws in California.

Contains changes to the Budget Act of 2017 that are necessary for Continued on page 30...

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

29

NEW LAWS Continued from page 29 . . . state licensing entities to implement a regulatory framework pursuant to the Medical Cannabis Regulation and Safety Act (MCRSA) and the Adult Use of Marijuana Act (AUMA) of 2016 (Proposition 64). Conforms MCRSA and AUMA into a single system that prioritizes consumer safety, public safety, and tax compliance. Creates agricultural cooperatives, a method for collecting and remitting taxes, a process for testing and packaging, and a process for collecting data related to driving under the influence.

Mental Health

AB 1315 (Mullin) – Mental health: Early psychosis and mood disorder detection and intervention. Establishes the Early Psychosis Intervention Competitive Selection Process Plus Program and an advisory committee to the Mental Health Services Oversight and Accountability Commission to expand the provision of high-quality, evidence-based early psychosis and mood disorder detection and intervention. Establishes the Early Psychosis Detection and Intervention Fund and provides that moneys in the fund shall be available, upon appropriation by the Legislature, to the commission for the purposes of the bill.

SB 565 (Portantino) – Mental health: Involuntary commitment. Requires mental health facilities, upon a patient’s completion of a 14-day period of intensive treatment for mental disorder or impairment by chronic alcoholism, to make reasonable attempts to notify family members or any other person designated by the patient at least 36 hours prior to any certification review hearing for an additional 30 days of treatment.

Professional Licensing and Discipline

AB 508 (Santiago) – Health care practitioners: Student loans.

CMA position: Support. Repeals provisions of law authorizing boards to cite and fine, or deny licensure or licensure renewal, to a health care practitioner if he or she is in default on a United States Department of Health and Human Services education loan.

AB 1340 (Maienschein) – Continuing medical education: Mental and physical health care integration. Requires the Medical Board of California to consider including in its continuing education requirements a course in integrating mental and physical health care in primary care settings, especially as it pertains to early identification of mental health issues and exposure to trauma in children and young adults and their appropriate care and treatment.

SB 798 (Hill) – Healing arts: Boards. Extends the operation of the Medical Board of California until 2022 and makes various changes to the Medical Practice Act. Includes, among other provisions, elimination of the medical board’s authority to approve ABMS equivalent boards, establishes a post-graduate training license for physicians, requires additional residency training, makes the Board of Podiatric Medicine independent of the Medical Board of California, changes the adverse event reporting requirements for outpatient surgery settings, changes the require30

ments for use of an expert witness in disciplinary cases.

Public Health

AB 841 (Weber) – Pupil nutrition: Food and beverages: Advertising. CMA position: Support. Prohibits, except as provided, a school, school district, or charter school from advertising food or beverages during the school day, and from participating in a corporate incentive program that rewards pupils with free or discounted foods or beverages that do not comply with specified nutritional standards when the pupils reach certain academic goals.

AB 1221 (Gonzalez Fletcher) – Responsible Beverage Service Training Program Act of 2017. CMA position: Sponsor. Establishes the Responsible Beverage Service (RBS) Training Program Act of 2017 and requires the Department of Alcoholic Beverage Control, on or before January 1, 2020, to develop, implement, and administer a curriculum for an RBS training program. Beginning July 1, 2021, requires an alcohol server to successfully complete an RBS training course offered or authorized by the department.

Authorizes the department to charge a fee, not to exceed $15, for any RBS training course provided by the department and require the fee to be deposited in the Alcohol Beverage Control Fund.

SB 239 (Wiener) – HIV and AIDS: criminal penalties. CMA position: Support. Modifies criminal penalties related specifically to human immunodeficiency virus (HIV) that imposed stricter criminal penalties to individuals infected with HIV in comparison to other communicable diseases. Repeals provisions making the intentional exposure to another person by a person who has tested positive for HIV a felony. Eliminates criminal penalties specific to HIV-infected individuals and instead makes the intentional transmission of an infectious or communicable disease a misdemeanor if specified circumstances apply.

SB 536 (Pan) – Firearm Violence Research Center: Gun violence restraining orders. CMA position: Support. Requires the state Department of Justice (DOJ) to make information related to gun-violence restraining orders that is maintained in the California Restraining Order and Protective Order System or any similar database maintained by DOJ available to researchers affiliated with the University of California’s Firearm Violence Research Center, or, at the discretion of DOJ, any other entity that is concerned with the study and prevention of violence, for academic and research purposes.

These are just a sampling of the new laws impacting health care in 2018 and beyond. For a comprehensive list, see “Significant New California Laws of Interest to Physicians for 2018” in the California Medical Association’s online resource library at www. cmanet.org/resource-library. CMA members can access On-Call documents free at www.cmanet.org/cma-on-call.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

FIREARM VIOLENCE PREVENTION A Public Health Approach California Medical Association The United States continues to struggle with an epidemic of firearm violence. Not only are physicians in a unique position to assess risk, provide education and change behaviors related to gun violence, they may also address this issue more broadly as a consumer safety and public health issue.

In 2017, CMA convened an ad hoc Firearm Violence Prevention Committee (“Committee”) to perform a comprehensive review and analysis of the following materials as it relates to prevention of gun violence: (1) existing CMA policy, (2) other medical and health organization policy statements, (3) epidemiological data, and (4) current scientific research. The following position statement on the prevention of firearm violence, as recommended by the Committee was officially adopted by the CMA Board of Trustees on July 28, 2017.

1. CMA recognizes that fundamentally, firearm violence is a human and civil rights matter; it violates the fundamental human right to life, liberty, and security of person - the right to live safely without fear in a free society. In heavily impacted communities, the

ordinary activities of daily life are contorted as people seek to avoid victimization. Involvement is broader than is commonly recognized. While interpersonal violence involves primarily young men, with persons of color at highest risk, self-directed violence involves primarily older men, and risk is higher among white men than others. Violence against women is important, particularly where domestic violence is concerned. Mass shootings, though uncommon, are changing the character of American public life. There are important structural and cultural determinants of risk; not all risk is at the individual level. The consequences of firearm violence - for individuals directly affected, those around them, affected communities, and California at large are substantial. a. CMA declares firearm violence to be a public health and public safety problem with major direct and indirect negative effects at individual and community levels. b. CMA recognizes there are disproportionately high rates of firearm violence in low-income communities and communities of color, and supports efforts to decrease this by mitigating the structural causes of disparities in firearm violence. c. CMA supports decreasing the frequent depiction of violence in the media as it may contribute to desensitization towards violence and to a culture of violence in our society.

2. California physicians have a responsibility to take action on the prevention of firearm-related injuries and deaths. a. As with other public health issues, physicians have a WWW.SFMMS.ORG

unique responsibility as trusted public health figures to respond to the harms associated with firearm violence, both as individual clinicians and as community advocates. b. Through their role in routine screening and assessment, physicians are able to counsel and educate patients about firearm safety and storage, including best practices to reduce injuries, deaths, and psychological trauma related to firearm use.

Particular care should be given to individuals in risk categories such as a history of alcohol or substance abuse, history of violence, and risk of harm to self or others. c. CMA opposes any policies, regulations or legislation that restricts physicians’ ability to initiate discussions about firearm safety issues with patients. d. Expanded education and training are needed to improve clinician familiarity with the benefits and risks of firearm ownership, safety practices, and communication with patients about firearm violence. Medical schools and residency programs should incorporate firearm violence prevention into their academic curricula. California-specific resources such as continuing medical education modules, toolkits, patient education handouts, and clinical intervention information would help to address this practice gap.

American Academy of Pediatrics Gun Policy The American Academy of Pediatrics calls for legislative and regulatory actions to reduce the incidence of firearm-related violence: • Reinstatement of the ban on the sale of assault weapons to the general public • A ban on the sale of high-capacity ammunition magazines to the public • A ban on Internet sales of firearms • Action against unregulated sales by dealers who sell large quantities of firearms to individuals • Implementation of a mandatory waiting period before receipt of a purchased firearm • Closure of the gun show loophole (ie, requiring background checks and waiting periods for firearm sales at gun shows as at permanent retailers) • Restoration of funding to the Centers for Disease Control and Prevention to conduct firearm-related research Continued on page 32...

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

31

Continued from page 31 . . .

3. CMA opposes the suppression of firearm research that has stripped federal and state funding for data surveillance, research and analysis, which has prevented the advancement of evidence-based policies as benefitting other major public health issues. a. CMA supports restoration of funding for firearm research and data surveillance proportional to its public health impact which will, in turn, help support and drive evidence-based policy solutions. b. CMA supports the systematic collection of firearm-related morbidity and mortality data using comprehensive national and state databases, and supports elimination of barriers to access of this data for research purposes.

4. CMA is concerned that the focus on people with mental illness as perpetrators of interpersonal and community violence distracts from the fact that their mental illness is a much stronger risk factor for suicide than for violence against others, and that people with mental illness are much more likely to be victims of violence than perpetrators of violence.

a. Greater attention and resources should be spent upon reducing the risk of suicide by improving access to mental health treatment and addressing the subset of individuals with mental illness who may be at risk of harming themselves or others. b. Physicians should be trained to recognize warning signs and respond to patients who may present with a mental illness, and may be at risk of harming themselves or others. This includes being aware of the laws that may necessitate reporting obligations as well as understanding which clinical interventions might lead to a patient becoming prohibited from owning a firearm or having a firearm in their possession being temporarily removed.

5. CMA recognizes that California has been a state leader in addressing federal statutory and regulatory gaps in firearm policy. CMA supports California’s

strong legal and regulatory protections related to firearms, and commits to working with the American Medical Association and others to improve federal policy in that regard. a. CMA recognizes that gun ownership is valued by many members of the public, and agrees that laws and regulations related to firearm violence should be consistent with the constitutional right establishing individual ownership of firearms under the Second Amendment of the Bill of Rights. b. CMA supports the appropriate regulation and taxation of firearm and ammunition purchases, and that such items be subject to legal and regulatory protections in regard to design, sale or transfer, possession and storage. c. CMA supports the establishment of a universal background check system and the successful completion of a use and safety course for all persons buying or otherwise taking ownership of a firearm or purchasing ammunition. d. CMA supports a requirement for firearm owners to report the theft or loss of a firearm within 72 hours of becoming aware of the loss. e. CMA acknowledges evidence indicating that individuals 32

with a history of alcohol or substance abuse, domestic violence, suicidal ideation or other physical harm to self or others are at increased risk for firearm violence, and supports appropriate restriction of access to firearms for such individuals. f. CMA supports appropriate limitation or ban on possession of firearms and ammunition with features designed to increase their rapid killing capacity, or are particularly lethal. g. CMA acknowledges that waiting periods prior to firearm purchases may be effective in reducing suicide deaths attributable to firearms. h. CMA supports local authority for cities and counties to enact laws more restrictive than those at state or federal levels as they relate to the sale, possession, taxation, transfer and other aspects of commerce related to firearms and ammunition. i. CMA specifically recommends firearm safety practices including: storing firearms unloaded and in locked position in a separate location from ammunition, as a means of reducing unintentional and self-inflicted firearm injuries, in particular among children and teenagers. j. CMA acknowledges a constantly changing landscape related to firearm violence, and recommends revisiting the issue at appropriate, frequent intervals over the next decade.

6. CMA supports targeted public education campaigns on firearm violence and its prevention as a way to make positive impacts on public opinion, and cost-effectively provide key information to important audiences. The targeted outcome of a public educa-

tion campaign is to improve public understanding of the risks associated with firearms and to enlist community partners in the effort to reduce morbidity and mortality from firearms.

7. CMA supports a population-based, public health approach directed towards firearm violence, with emphasis on forms of firearm violence that have disproportionate societal impact, including the following: higher incidence of firearm violence in lowincome communities and communities of color; firearm violence by and against law enforcement, in particular the use of lethal force; firearm violence by and against individuals with mental illness; and public mass shootings.

Full report at: http://www.cmanet.org/files/pdf/cmafirearm-violence-position-statement.pdf. Members of the CMA Firearm Violence Prevention Committee included Shannon Udovic-Constant, MD (Chair), Amy Barnhorst, MD, Catherine Gutfreund, MD, Eric Hansen, MD, Donald Lyman, MD, John Maa, MD, Paul Phinney, MD, Andrew Fenton, MD, Zachary Wettstein, and Garen Wintemute, MD. Staff: Samantha Pellon, MPH, and Elishah Thompson.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

GUN VIOLENCE: COMPENSATION FOR HEALTHCARE EXPENDITURES Draft Resolution endorsed by SFMMS delegation to CMA, February 2018 Whereas, the ongoing tragedy of gun violence in the United States has been labeled a public health crisis by the AMA, with huge attendant financial costs to hospitals, health systems, insurers, and many others; and Whereas, it has been well established that the gun industry and the gun advocacy groups such as the National Rifle Association has fought any safety features, regulatory proposals, or other measure that could demonstrably or probably lessen gun-related carnage; and Whereas, the gun lobby has hobbled gun-related research to avoid increasing evidence of the impacts of gun violence; and Whereas, when “big tobacco” was shown to have known of and promoted harmful products, eventual legal action compelled large financial settlements to be distributed to those negatively impacted by their products; now be it Resolved: That the gun industries should be held financially responsible for the healthcare and other economic costs related to their marketing of and advocacy for guns sold in our nation, in a manner similar to successful class action lawsuits against “big tobacco”, with the funds distributed to healthcare providers so impacted and survivors of gun violence.

Tracy Zweig Associates INC.

A

REGISTRY

&

PLACEMENT

FIRM

~ Physicians ~ Nurse Practitioners Physician Assistants

Voice: 800-919-9141 or 805-641-9141 FAX: 805-641-9143 tzweig@tracyzweig.com www.tracyzweig.com

MARIN WEIGHT LOSS & WELLNESS MEDICALLY SUPERVISED WEIGHT LOSS PROGRAMS, LED BY DR. GAIL ALTSCHULER We welcome Cassale Sherriff, Nutritionist, as we expand our options for personalized and whole food plans for weight loss and optimal health.

GAIL ALTSCHULER, MD MEDICAL DIRECTOR

CASSALE SHERRIFF

NUTRITIONIST S.F. Medicine Visit our new website and sign up to receive 02-20-14 our weekly health & nutrition emails:

WWW.MARINWEIGHTLOSS.COM

415-897-9800 | info@marinweightloss.com SUITE 411, 400 PROFESSIONAL CENTER DRIVE • NOVATO, CA 94947 SUITE 1, 350 BON AIR ROAD • GREENBRAE, CA 94904

WWW.SFMMS.ORG

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

33

SFMMS ADVOCACY ACTIVITIES A HISTORY OF ADVOCATING FOR COMMUNITY HEALTH As the only medical association to represent the entire spectrum of medical specialties, modes of practice, and interests of physicians in San Francisco and Marin, the San Francisco Marin Medical Society (SFMMS) has been a champion for community health issues since its formation in 1868. Our policymaking efforts through collaborations with state and national medical societies and political leaders, as well as articles in our award-winning journal, San Francisco Marin Medicine, have given us a reputation for being influential far beyond the Bay Area. The SFMMS advocacy agenda continues to focus on public health and the following areas:

ENSURING ACCESS TO CARE: With ongoing vigilant efforts

to preserve programs and prevent cuts in Medi-Cal reimbursement, SFMMS leaders have long advocated that everyone should have access to quality medical care. SFMMS joined in the lawsuits to preserve the Healthy San Francisco program, an ultimately successful battle that went all the way to U.S. Supreme Court. SFMMS advocated for, and has provided assistance to, community-based organizations including the Haight-Ashbury Free Medical Clinics, San Francisco Free Clinic, Marin Community Clinics, Operation Access, and many others where members have donated medical care and treatment for the uninsured and underserved.

ANTI-TOBACCO ADVOCACY: SFMMS was a loud voice for

cracking down on tobacco promotion and use and supported the early 1990s ban on smoking in San Francisco restaurants, a landmark policy that spread nationwide. SFMMS has also advocated for stronger protections from secondhand smoke, higher taxes on tobacco products to provide additional funding to Medi-Cal, and the removal of tobacco products from pharmacies. In 2017, SFMMS supported a ban on flavored tobacco products adopted in San Francisco that is now being fought hard by the tobacco industry.

HIV PREVENTION AND TREATMENT/HEPATITIS B:

Having been among the first to push for legalized syringe exchange programs, appropriate tracking and reporting processes for clinical data, optimal funding, and more, SFMMS has been at the center of advocacy for responses to the AIDS epidemic since the 1980s, including drafting several resolutions that would evolve into CMA and AMA policies as well as statewide ballot initiatives. SFMMS continues to be a partner in the Hep B Free program in San Francisco.

SUGAR-SWEETENED BEVERAGES: SFMMS has long been

on record combatting overconsumption and marketing of sugar and soda, especially to young people. To help prevent and battle obesity, diabetes, heart disease, and other associated diseases, SFMMS endorsed the SF vs. Big Soda coalition and supported the landmark local tax on sugar-sweetened beverages, approved by voters, with revenue slated to help fund programs to prevent or reduce the consequences of consumption of sugar-sweetened beverages.

34

ANTIBIOTIC RESISTANCE: SFMMS leaders have presented at national meetings and contributed to policy on antibiotic resistance, including the AMA’s first statement on antibiotic overuse and agriculture.

SCHOOL AND TEEN HEALTH: SFMMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, and has worked on improving school nutritional standards.

VACCINATION ADVOCACY AND EDUCATION: In re-

sponse to increased outbreaks of vaccine-preventable diseases in the Bay Area and across the state, the medical society emerged as a leader in supporting policy to increase school vaccination rates. Through education about the safety and efficacy of vaccines and support of legislation that eliminated personal belief exemptions from required childhood vaccines, vaccination rates have increased significantly since 2012. SFMMS has authored several resolutions for the CMA, including a resolution allowing minors to receive vaccines to prevent STIs without parental consent.

END-OF-LIFE CARE: SFMMS leaders have developed numer-

ous policies and educational efforts to improve care toward the end of life, including publishing guidelines on medical futility or non-beneficial treatments that have been widely adopted by regional health systems. SFMMS was one of the early adopters of Physician Orders for Life-Sustaining Treatment (POLST) in California and has been active in the local community coalition to ensure successful use of the form and the important conversation that goes along with completing the medical orders contained on the form. As medical and public opinion evolved, SFMMS became neutral on the option of physicianassisted dying and advocates for physicians and patients to exercise their own judgment as part of the patient-physician relationship.

REPRODUCTIVE HEALTH AND RIGHTS: SFMMS has been a champion of reproductive choice for women, including supporting the use of RU486 and the medical termination of pregnancy.

SFMMS continues to be a state and national leader in advocating for women’s reproductive health and choice, including access to all medical-indicated services.

ENVIRONMENTAL HEALTH: Among SFMMS’s many envi-

ronmental health efforts are establishing a nationwide educational network on scientific approaches to environmental factors in human health and advocating for reduced exposure to mercury, lead, and air pollution.

GUN SAFETY/DOMESTIC VIOLENCE INTERVENTION:

SFMMS has contributed to the national debate on gun safety, including ending censorship and allowing physicians to discuss gun safety with their patients. The medical society published

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

guidelines on domestic violence screening and intervention for physicians and other clinicians that were widely distributed and well received by clinicians citywide; the society was cited in the Journal of the American Medical Association as one of the best such resources.

ORGAN DONATION: SFMMS has been the vanguard in seeking

improved donation of organs to decrease waiting lists and deaths due to the shortage of organs through educating the public and proposing new policies regarding consent and incentives for organ donation.

DRUG POLICY AND OPIOID SAFETY: SFMMS has been a

leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, “treatment on demand” policy that supports immediate entry into drug treatment for those requesting it, and treatment instead of incarceration. SFMMS was integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis. In collaboration with the public health department, SFMMS has helped develop guidelines for safe opioid prescribing that have been adopted in primary care settings.

PRESERVING PHYSICIAN AUTONOMY: Working together with the CMA, SFMMS advocates for policies that protect physician autonomy and the patient/physician relationship, scope of practice, and reimbursement.

PARTNERSHIPS: SFMMS works closely with many local special-

ty and health organizations, such as the Chinese Community Health Care Association, Marin Community Clinics, Marin Department of Health and Human Services, RxSafe Marin, San Francisco Community Clinic Consortium, San Francisco Department of Public Health, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, West Bay Hospital Conference, and others.

1868

th

2018

Anniversary

EASE PHYSICIAN BURNOUT CMA URGES CONGRESS AND CMS TO PROVIDE REGULATORY RELIEF TO PHYSICIANS California physicians are overwhelmed by unnecessary, burdensome regulations that take time and resources away from providing quality patient care. These regulations are a major contributing factor to the disturbing trend in physician burnout.

The CMA is urging Congress and the Centers for Medicare and Medicaid Services (CMS) to reduce the regulatory burdens under the Medicare and Medicaid programs. CMA’s recommendations for reform will simplify the Medicare/Medicaid programs, reduce costs, improve quality, increase access to physicians, and allow physicians to spend more time with their patients.

CMA’s top 10 priorities for regulatory relief:

1. Reduce the quality and EHR reporting burdens of MACRA.

2. Enforce electronic health record (EHR) vendor compliance and interoperability, and limit add-on fees.

3. Reform the Medicare physician audit programs: Recovery Audit Contractor (RAC) program and the pre- and post-payment review audits.

WWW.SFMMS.ORG

4. Require State Medicaid programs and Medicaid managed care plans, rather than physician offices, to arrange and pay for interpreter services.

5. Reduce the voluminous Medicare Advantage (MA) health plan medical record requests of physicians related to MA risk-adjustment scores.

6. Further delay and simplify the new Medicare imaging appropriate-use criteria program.

7. Remove lab certification requirements for physicians who use waived tests or physician-performed microscopy.

8. Rescind the Medicare Two-Midnight/Observation Care rule.

9. Exempt physician in-office drug compounding from the new FDA rule.

10. Change the Stark anti-kickback restrictions to allow more coordinated care alternative payment models.

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

35

SAVE THE DATE APRIL 18, 2018

CALIFORNIA MEDICAL ASSOCIATION

44TH ANNUAL LEGISLATIVE ADVOCACY DAY Wednesday, April 18, 2018 • Sheraton Grand Sacramento

Activities include: • CMA’s Legislative Advocacy Day Webinar Training Wednesday, March 28, 2018 • 7:00 - 8:00PM • Put your training into ACTION and visit your legislator!

Please note: Scholarships may be available to medical students for travel and accommodations through their county medical societies.

REGISTRATION IS FREE

Reserve your spot today at cmanet.org/events 36

For more information, please contact Yna Shimabukuro at (916) 444-5532 or yshimabukuro@cmanet.org.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

SAINT FRANCIS MEMORIAL HOSPITAL 115 YEARS AND COUNTING James Macho, MD, and Kathleen Jordan, MD Long before becoming the official health care provider of the San Francisco Giants in 1999, Saint Francis Hospital (SFMH) has been part of the fabric of the San Francisco community, serving the needs of its evolving community. In 1905, five physicians joined efforts to establish “the most up-to-date, modern hospital west of Chicago.” On April 18, 1906, at 5:12 a.m., disaster struck: Fire resulting from the Great San Francisco Earthquake burned the newly constructed hospital to the ground. The hospital quickly relocated to the home of Dr. Redmond Payne. Dr. Payne’s home served as the temporary location until a new 100-bed hospital could be built at the intersection of Bush and Hyde Streets (which remains its location today). The hospital’s 100 beds were full within 10 days. By 1921, the post-war baby boom led SFMH to construct a 200-bed obstetrics wing, the largest in San Francisco. It continued to serve the community’s obstetrics needs for many decades and was the place of delivery for many San Francisco natives, including current members of the SFMH medical staff and many members of the San Francisco Marin Medical Society.

Over time, its leadership in plastic and reconstructive surgery brought the establishment of its Plastic and Reconstructive Surgery Clinic and Residency program in 1952 and, later, a four-bed burn unit in 1955. By 1967, the burn center expanded to a 10-bed unit, and in 2016 to a 16-bed unit; today it continues to serve San Francisco and the surrounding counties as the renamed Bothin Burn Center. The 2017 medical staff includes 29 plastic and reconstructive surgeons.

The Bothin Burn Center serves patients from San Francisco and the surrounding counties, including victims of the San Bruno PG&E pipeline explosion and the more recent Sonoma and Napa County fires.

In 1965, Saint Francis broke ground for the 12-story tower, which remains today as the main hospital. After a major renovation in 1984, Saint Francis joined the Dignity system in 1993. This nonprofit hospital continues to serve the health care needs of San Francisco’s most ethnically diverse and densely populated neighborhoods. It serves the urgent health care needs of downtown, Chinatown, Nob Hill, and the Tenderloin, as well as an array of tourists’ needs from hotels within its neighborhood. The Emergency Department (ED) sees more than 36,000 visits annually and is the second-busiest ambulance destination in San Francisco (behind only the County’s trauma ED at SF General). In 2004, the hospital opened an inpatient Behavioral Health Unit to address a growing need in the community.

By 2005, Saint Francis opened satellite clinic sites at the new AT&T Park and in Walnut Creek to address the expanding San Francisco community as well as the needs of the San Francisco Giants organization. And in 2015, it aligned with GoHealth to bring health care to local communities in San Francisco with GoHealth’s ever-expanding footprint of urgent care clinics in the Bay Area.

Since 2014, the Saint Francis Foundation has had a community leadership role in the Tenderloin Health Improvement Partnership (TLHIP), a multisector collective partnership to improve health and well-being in the Tenderloin with initiatives that have ranged from establishing safe parks and streets to collective efforts to address housing, education, and psychosocial issues.

With Bay Area firsts such as Dr. Sam Esterkyn bringing laparoscopic cholecystectomy to the region in 1990, the SFMH Department WWW.SFMMS.ORG

of Surgery has continued to grow and serve the community’s needs.

In 2017, the Gender Institute was established to ensure excellence in care for all in our community, with initial focus on comprehensive surgical and support services needed for transgender health.

Our Department of Surgery, led by orthopedic surgeon Dr. Victor Prieto, continues to bring excellence to the Saint Francis community. Gynecology surgeon Dr. Mona Orady, director of Minimally Invasive Surgery at SFMH, continues to lead excellence in patient care by expanding procedures that can be performed with robotic-assisted laparoscopy, allowing quicker recovery and, for some, making surgical cure possible.

Under the leadership of Hospital President Dr. David Klein, Saint Francis will continue to serve the community needs, incorporating all that is provided by the rapidly changing health care environment, with new technologies, new alignments, and advancing health care knowledge. 2018 will also realize what the Dignity Health/Catholic Health Initiatives (CHI) merger will bring to the SFMH community by creating the nation’s largest not-for-profit hospital system.

SFMMS

ADDICTION SUMMIT Annual David E. Smith, MD Symposium

Friday, June 1, 2018 8:30am - 5:30pm UCSF Mission Bay Conference Center 1675 Owens Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: • Opiates • Psychedelic Medicine • Legal Marijuana

• Advances in addiction medicine and primary care • Marin & San Francisco problems and responses

To register, or for more information, please visit www.drsmithsymposium.com Event co-sponsored by SFMMS, SFDPH, CAFP, UCSF CME provided by CAFP

MARCH 2018 SAN FRANCISCO MARIN MEDICINE

37

UPCOMING EVENTS MD Career Fair March 20, 2018 | 5:00 p.m.–8:00 p.m. | Mission Bay Conference Center, 1675 Owens Street, San Francisco Join SFMMS and attend this annual career-planning event to meet with representatives from leading health care organizations across the country when they travel to San Francisco to recruit residents and fellows training in the area. Residents and fellows in all years of training and all medical specialties are encouraged to attend. A complimentary buffet will be served. Visit http://bit. ly/2sfjCrg for more information, or to register.

CMA Legislative Advocacy Day Webinar March 28, 2018 | 7:00 p.m.–8:00 p.m.

On March 28, CMA will host a webinar for all registered attendees.

This webinar will review in detail CMA’s list of bills to be lobbied, effective advocacy tips, and other relevant program information.

Visit www.cmanet.org for more information or to register.

38

CMA Legislative Advocacy Day April 18, 2018 | Sheraton Grand, 1230 J Street, Sacramento, CA Join more than 400 physicians, medical students, and CMA Alliance members who will be coming to Sacramento to lobby their legislative leaders as champions for medicine and their patients during CMA’s 44th Annual Legislative Advocacy Day. Attendees will have the opportunity to go to the Capitol throughout the day to meet with legislators on health care issues. Meetings with Marin and San Francisco legislators will be scheduled and coordinated by SFMMS. This is a unique event for California physicians and is free of charge to all members. For more information, please contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 extension 268, or visit http://bit.ly/2nNRLd0.

SAN FRANCISCO MARIN MEDICINE MARCH 2018 WWW.SFMMS.ORG

Donate Blood. Save Lives.

To make an appointment, call us at 1-888-393-4483 or visit www.bloodcenters.org

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

You face plenty of challenges today.

Banking shouldn’t be one of them.

We’re here to help make your life easier with highly personalized financial solutions tailored specifically to the needs of you and your practice.

Call us today!

Your Dedicated Banking Team

John Osborn

Chris Angle

Vice President & Assistant Regional Trust Manager, Vice President, Commercial Banking Wealth Management

415.249.8318 MechanicsBank.com MEMBER FDIC

Martha Cifuentes Vice President & Branch Manager, San Francisco

Tools and solutions built around your needs • • • •

• • • •

Remote Deposit Payment and Merchant Card Services Cash Management Financing for: o Buy-outs/Buy-ins o Acquisitions/Expansions o Equipment Financing o Commercial Mortgages o Existing Loan Refinancing Personal banking for your employees Private Banking for you and your family Investment Management Trust and Estate Services