SAN FRANCISCO 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 E D I CA L S O C I E T Y
the future of primary care Cost Consciousness: Physician Responsibility? The Primacy of Prevention: Interview with Anthony Iton, MD
Photos from the Sfms annual dinner
VOL. 85 NO. 2 March 2012
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IN THIS ISSUE
SAN FRANCISCO MEDICINE March 2012 Volume 85, Number 2
Primary Care FEATURE ARTICLES
MONTHLY COLUMNS
12 Primary Care in America: An Uncertain Future John Maa, MD
4 Membership Matters
14 Considering Cost: Modern Medicine and Appropriate Care Toni Brayer, MD 15 The Primacy of Prevention: Anthony Iton, MD, on Communities, Quality, and Cost Steve Heilig, MPH 18 After Hours Clinic: Filling a Need for Care Jessica Kuo, MBA 19 The Changing Face of Medicine: A Primary Care Physician’s Perspective Sashi Amara, MD 20 A New Model: Creating Health Care Experiences for Patients and Practicioners Katherine K. Sulzer 22 Pre-Op Appointments: Where Do They Fit in an Already Busy PCP Schedule? Cynthia Point, MD 23 A View to the Future: Combining the Haight-Ashbury Clinics and Walden House Dave E. Smith, MD, FASAM, FAACT
Editorial and Advertising Offices: 1003 A O’Reilly Ave., San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.
7 SFMS Advocacy Activities 9 President’s Message Peter J. Curran, MD 11 Editorial Gordon Fung, MD, PhD 32 Hospital News 33 In Memoriam Nancy Thomson, MD 34 In the News 34 Classified Ad
OF INTEREST 25 SFMS Annual Dinner 29 SFMS Honors Two Local Organizations 31 Health Policy Perspective: Scarier than Socialism? Steve Heilig, MPH
MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members SFMS at California Cancer Research Initiative Campaign Launch
The morning includes speeches from a number of key legislative leaders. Attendees will go to the Capitol in the afternoon to meet with legislators on health care issues. The meetings will be scheduled and coordinated by local county medical societies.
This event is offered at no cost to SFMS members.
Please email SFMS at info@sfms.org or call (415) 561-0850 if you would like to attend.
SFMS Member Receives AAP Martin Gershman Child Advocacy Award
Shannon Udovic-Constant, MD, SFMS president-elect, and pediatrician at Kaiser Permanente San Francisco, was selected as the recipient of the 2012 Martin Gershman, MD, FAAP Child Advocacy Award. This prestigious award is given annually by District IX (California) of the American Academy of Pediatrics (AAP) to honor a California pediatrician whose long-established commitment to advocacy for children has been demonstrated through community, state, or private sector activities. Please join SFMS in congratulating Dr. Udovic-Constant for her achievements. She will be presented with the award at the annual AAP Joint District Meeting in June. Join SFMS to support Proposition 29, formerly known as the California Cancer Research Act, a ballot initiative that will be on the June 5 primary ballot. Prop. 29 will increase the cost of a pack of cigarettes by $1 and dedicate those new funds to cancer research and smoking cessation efforts. The SFMS carried a resolution to the CMA annual meeting last year urging support of CRCA and the CMA endorsed the initiative in January. SFMS President Peter Curran, MD, was one of five speakers at the Prop. 29 campaign launch in San Francisco. Dr. Curran is pictured above (far left) at a rally in support of Prop. 29.
4/12 SFMS Networking Mixer
Networking is ranked as one of the most valuable services provided by SFMS. Join SFMS at our upcoming physicianstudent mixer to help UCSF medical students connect with physicians in a relaxed, no-agenda format aimed only at networking. Event details and RSVP information will be posted on the SFMS blog at http://sfmedicalsociety.wordpress. com/.
Become a Champion of Medicine, Participate in 4/17 Legislative Leadership Conference
Join SFMS for the CMA Legislative Leadership Conference on April 17 at the Sacramento Convention Center. Members have the unique opportunity to gain advocacy training and network with colleagues throughout California at this annual event. 4 5
San Francisco Medicine March 2012
Final Ruling Blocks 10% Medi-Cal Rate Cuts to Providers
Due to the efforts of a coalition led by the California Medical Association, a final ruling was issued by Judge Christina Snyder of the California Central Federal District Court, which blocks a 10-percent Medi-Cal reimbursement rate reduction. Her decision is a huge win for physicians in California and for the patients they treat. We thank our members for helping us accomplish this important outcome, preventing deterioration of access to care. Our hope is that this achievement will serve as a reminder to those who are not yet members and encourage them to join SFMS/CMA today. To have continued success winning these battles for all California physicians and patients, it is crucial that we gain the support of those who benefit. For more information or to read the full statement issued by the coalition of plaintiffs in CMA et al. v. Douglas, please go to http://wp.me/pBDEx-zp.
Short-Term Payment Delays for Medi-Cal Providers
The state of California announced that it will institute short-term payment delays to Medi-Cal institutional providers due to a severe cash flow shortage. Implementation of the delays is effective March 1, 2012. For detailed information about the payment schedule and affected providers, please go to http://wp.me/pBDEx-A3. www.sfms.org
2012 NHSC Loan Repayment Now Accepting Applications The National Health Service Corps (NHSC) Loan Repayment Program (LRP) announced the opening of the 2012 application cycle. With two levels of funding, the NHSC LRP offers primary health care providers loan repayment assistance in exchange for working in rural, urban, and frontier communities. Full-time and half-time options are available for primary care physicians to provide culturally competent, interdisciplinary primary health care services to underserved populations located in selected Health Professional Shortage Areas. Visit http://nhsc.hrsa.gov/ loanrepayment/index.html to apply.
New Medicare Patient Preventive and Wellness Services Resource
Medicare reimburses physicians $70 for a typical patient visit. However, doctors can earn more than twice that—$166—for conducting a patient’s initial wellness visit. The Centers for Disease Control and Prevention developed “Team Up to Stay Healthy” to help physicians encourage their Medicare patients to take full advantage of the preventive and wellness services available to them. The free guide spells out exactly what patients need to know about their preventive and wellness benefits and can be found at http:// wp.me/pBDEx-zz.
SFMS On-Site Seminar
March 22, 12:00 p.m.–1:45 p.m.: Strategies to Survive and
Thrive in Private Practice Private practice is not dead! Many physicians continue to have successful private practices by offering additional services to increase revenue and by tightening operating expenses. This seminar will provide you with the tools necessary to reduce overhead expenses and increase revenue. $109 each for SFMS/CMA members and their staff ($99 for each additional attendee from the same office); $159 each for nonmembers. Lunch is included. Contact Posi Lyon, plyon@sfms.org or (415) 5610850 extension 260, for more information.
Complimentary Webinars for SFMS Members
CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events. March 21: HIPAA Update 2012 • 12:15 p.m. to 1:15 p.m. April 4: Guide to Managing Upset and/or Difficult Patients • 12:15 p.m. to 1:15 p.m. April 18: Best Practices for Managing Your Accounts Receivable • 12:15 p.m. to 1:15 p.m. SFMS members also have complimentary access to the webinars offered by SFMS/ACCMA. Members can register at https://www.accma.org/ Learning/UpcomingPrograms.aspx or contact Dennis Scott at (510) 6545383. March 14: Health Care Social Media: Considerations for Policy Development • 12:30 p.m. to 1:45 p.m. March 22: Surviving the Stress of Being Sued • 12:30 p.m. to 1:45 p.m. April 11: Avoiding Embezzlement: Strategies to Protect Your Practice • 12:30 p.m. to 1:45 p.m.
www.sfms.org
March 2012 Volume 85, Number 2 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay
EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD Peter J. Curran, MD Stephen Walsh, MD
SFMS OFFICERS President Peter J. Curran, MD President-Elect Shannon Udovic-Constant, MD Secretary Jeffrey Beane, MD Treasurer Lawrence Cheung, MD Immediate Past President George A. Fouras, MD SFMS EXECUTIVE STAFF Executive Director Mary Lou Licwinko, JD, MHSA Assistant Executive Director Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon Membership Assistant Lauren Estrada
BOARD OF DIRECTORS Term: Jan 2012-Dec 2014 Andrew F. Calman, MD Arti D. Desai, MD Roger S. Eng, MD Jennifer Gunter, MD John Maa, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Man-Kit Leung, MD Keith E. Loring, MD Terri-Diann Pickering, MD Marc D. Rothman, MD Rachel H.C. Shu, MD
Term: Jan 2010 -Dec 2012 Gary L. Chan, MD Donald C. Kitt, MD Cynthia A. Point, MD Adam Rosenblatt, MD Lily M. Tan, MD Shannon UdovicConstant, MD Joseph Woo, MD
CMA Trustee Robert J. Margolin, MD AMA Representatives H. Hugh Vincent, MD, Delegate Robert J. Margolin, MD, Alternate Delegate
March 2012 San Francisco Medicine
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San Francisco Medicine March 2012
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SFMS Advocacy Activities A PROFESSIONAL VOICE FOR COMMUNITY HEALTH SINCE 1868 The San Francisco Medical Society (SFMS) has been involved in community health issues since the 1800s. As the only medical association in San Francisco representing the full range of medical specialties and interests, SFMS health advocacy has been broad. Via policy-making efforts with state and national medical and political leaders and an award-winning journal, SFMS has often been influential far beyond the city. The SFMS agenda and activities continue to focus on the community and the following areas of involvement: • Forming HealthShare Bay Area (see below) to improve patient care and reduce costs • Working with the physician community to promote the adoption of electronic health records to better serve patients • Advocating against cuts to Medi-Cal and Medicare reimbursement to provide continued access to care for all San Franciscans • Preserving the health care safety net and public health programs in times of severe budget cuts • Supporting antitobacco legislation and San Francisco’s law banning the sale of tobacco in pharmacies, and smoking in restaurants and other businesses, and eliminating tax credits for films showing smoking • Supporting the Healthy San Francisco program and participating in legal defenses to preserve the program, while helping to monitor the program’s progress • Providing physicians for medical consultation for San Francisco schools and for volunteer care at community clinics • Working on legislation to allow minors, without parental consent, to receive vaccines to prevent STIs; to prevent bans on medical procedures such as circumcision; and more • Cosponsorship of the Hep B Free program in San Francisco • Advocacy for improving end-of-life care in the Bay Area via new policies, use of new advance directives (such as POLST), and educational outreach to physicians and patients
HOW SFMS SERVES THE COMMUNITY
HEALTHSHARE BAY AREA Working under the auspices of
the SFMS Community Service Foundation and guided by a diverse board of San Francisco and Bay Area health care industry professionals, the SFMS worked to develop HealthShare Bay Area to provide the infrastructure for a unified electronic health record system. The project originally targeted San Francisco but now includes partners from the East Bay. This service allows providers to have access to secure community-wide patient data. It also permits patients to gain a complete view of their medical records, irrespective of where individual records may reside. HSBA will launch in 2012.
UNIVERSAL ACCESS TO CARE SFMS leaders have long advocated that every San Franciscan should have access to quality medical care. Recent SFMS participation in this effort has included the Mayor’s Health Care Reform Task Force, the San Francisco Health Care Services Master Plan Task Force, and the Mayoral Task Force, which designed the Healthy San Francisco program. SFMS also joined in the lawsuits to preserve that program. SFMS advocates www.sfms.org
have advocated for community clinics since the founding of the original Haight-Ashbury Free Clinics in the 1960s.
MEDICAL LIABILITY PROTECTION The CMA and SFMS were
instrumental in passing MICRA, which saves virtually every doctor many thousands of dollars in liability premiums annually and saves hospitals and health systems much more. We have successfully defeated repeated attacks on MICRA by trial lawyers through the years.
REBUILDING/PRESERVING SAN FRANCISCO GENERAL HOSPITAL SFMS spokespersons took a lead in advocating for full
funding of the seismic rebuild and in advising, as members of the Mayoral committee, where and how that would occur.
HIV PREVENTION AND TREATMENT The SFMS was at the center of medical advocacy for solid responses to the AIDS epidemic, being among the first to push for legalized syringe exchange programs, adequate funding, and more.
SCHOOL AND TEEN HEALTH SFMS helped establish and staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the SFUSD school health service.
ENVIRONMENTAL HEALTH SFMS established a nationwide educational network on scientific approaches to environmental factors in human health; has advocated on reducing mercury, lead, and air pollution exposures; and much more. REPRODUCTIVE HEALTH AND RIGHTS SFMS has been a state and national advocate for reproductive health and choice.
BLOOD SUPPLY SFMS has long been a partner of the Blood Centers of the Pacific and seeks to help increase donations.
ORGAN DONATION SFMS has been a leader in seeking improved
donation of organs to decrease waiting lists, via education and new polices regarding consent and incentives for organ donation.
OPERATION ACCESS SFMS is a founding sponsor of this local organization providing free surgical services to the uninsured and has provided office space, volunteers, and funds. DRUG POLICY SFMS 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, and treatment instead of incarceration. MEDICAL ETHICS SFMS has developed and promulgated for-
ward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policy makers, and the general public. March 2012 San Francisco Medicine
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PRESIDENT’S MESSAGE Peter J. Curran, MD
O Brother, Where Art Thou? Physician Solidarity in a Changing Health Care Climate Last fall, an emergency resolution was submitted to the CMA House of Delegates. Physicians were outraged about a large hospital nonprofit organization deciding to raise professional liability insurance requirements and adding a contract clause to indemnify the hospital against acts of physician “negligence.” The CEO of the hospital corporation justified this decision because of the current medical malpractice climate impacting hospitals in specific patient areas such as emergency medicine, anesthesiology, and radiology. In a letter to Dustin Corcoran, CEO of the CMA, the chief executive said the insurance requirements will be a part of contract negotiations between the hospital and medical groups, “many of which are business operations with significant assets and operations.” The center of the tempest is Dominican Hospital in Santa Cruz, a community hospital that has a large indigent population base. At the time the liability insurance requirements were being added to contract negotiations, Dominican’s emergency department contract was being put up for bid. Due to the patient-payer mix, a staff hospitalist referred to the hospital as being “essentially a county facility,” many of the hospital-based physicians were receiving directorships from the hospital, and the decision to open the ED contract to bid may have been largely financial. However, hospital administration was in favor of the new limits on liability insurance from $1 million to $2 million per individual; the hospital president was heard to say, “(We) can no longer pay for sponges being left in patients.” The emergency department contract subsequently went to California Emergency Physicians America, a large physician partnership with emergency coverage in several California hospitals. It is difficult to know exactly what the motivation is behind a hospital corporation deciding to increase liability insurance requirements for physicians. The obvious explanation is that awards for malpractice claims are increasing. The truth depends on whom you ask. Hospital administrators state that, because of the legal provision of “ostensible agency,” hospitals are usually held at least partly responsible for injuries to patients in the hospital setting, even when the injury is the result of negligence by the physician. Although most California insurers would agree that the number of claims against physicians is down, the prevalence of larger awards has increased by some accounts. However, the average malpractice award in California is less than $200,000, well below the accepted limit of $1 million per individual for insurance coverage. In the case of Dominican Hospital, there are reports of physicians on the medical staff being involved in claims while “naked,” or unprowww.sfms.org
tected, due to lapsed policies. The impact of higher insurance limits is clear. For the hospital-based specialties involved, the average liability coverage premiums will increase 30 to 40 percent. Smaller-group practices likely will not be able to compete with large physician organizations for hospital contracts. Perhaps most daunting is a picture of trial lawyers grinning from ear to ear over the prospect of taking malpractice cases with higher payouts. The CMA recognizes it as a back-door attack on the protections of the Malpractice Injury Compensation Reform Act (MICRA), which has protected physicians from rising malpractice insurance premiums since the 1970s by limiting awards for pain and suffering and has adopted policy objecting to liability insurance limits above those mandated by the medical staff bylaws and to the particularly onerous clause to indemnify the hospital. When I called Peter Sokolove, president of Cal ACEP, to ask him how the Dominican ER contract turned out, he took the call while hiking in Yosemite. He had written a letter to the CEO of the hospital corporation to argue against the raised limits, but he admitted that he didn’t know the final terms of the deal. Donaldo Hernandez, president of the local county medical society, learned that the hospital anesthesia group had agreed to a new contract; the group felt that “they had little choice but to sign.” The Cohen brothers’ comic film O Brother Where Art Thou? (2000), starring George Clooney, references an earlier film called Sullivan’s Travels, in which a director sets out on a journey to experience the human suffering of the common man while attempting to make a movie based on Homer’s Odyssey. O Brother is what the Cohen brothers imagine would have been the resulting movie. Perhaps the lesson learned from the Dominican Hospital story is, ultimately, the importance of physician solidarity to protect each other from ourselves. March 2012 San Francisco Medicine
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EDITORIAL Gordon Fung, MD, PhD
What Is Primary Care? Defining this month’s theme seems easy on the surface. Primary care is a timely and pertinent issue, since the Health Care Reform Act depends on primary care medicine to play a significant role. The problem is that you get a different definition of it from whomever you ask. And even after you get a sense of what it is, you get the feeling that it’s the broken spoke in the wheel of health care. How is it broken? There are many ideas, but I’m not sure any of them explain the whole picture. What we usually read are well-articulated anecdotes of how one’s personal experience in the field, or view as an economist or engineer looking at the practice, sees a group of practitioners slogging away at an enormous and growing number of tasks that seem ever more onerous and less satisfying. As a recently elected leader into one of the largest and most respected professional organizations, the American College of Physicians, I found it surprising that one of the group’s most pressing tasks is to come up with a definition of an internist—those who are considered the exemplars of primary care physicians. At a recent strategic planning retreat, we worked on such a statement. Our guidelines were that the definition needed to be simple and understandable to patients and the public; practical for payors, legislators, and regulators; and demonstrate respect for the practitioners’ education, intelligence, and wisdom. A group of us felt that we would need the help of trained marketers for this task. One of the problems of defining primary care is that some definitions are physician-centric and others are system-centric. For the physician-centric, we look at the different groups of physicians who are categorized in primary care. For the system-centric, we see a team of providers led by physicians but with a role for everyone to perform to not just manage the patient’s disease but also to prevent problems and promote healthy living. Wikipedia defines a primary care physician, or PCP, as a physician/medical doctor who provides the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. Such a definition seems simple enough to understand. So what’s the problem? I suspect that part of the problem for patients, payors, and regulators is the number and kinds of practice models that primary care physicians find themselves in: the solo private practice physician (the oldest model), the mega-group multispecialty practice (such as Kaiser or Cleveland Clinic), the new team-based approach of patient-centered medical home models (PCMH) with the PCP as leader of a team, the concierge practices of solo and small groups that try to limit the size of practice. For patients, the limited numbers of PCPs create an www.sfms.org
access problem; reimbursement systems encourage them to go directly to a specialist if they feel that’s appropriate. Shortages of primary care physicians are an additional and increasing problem in many developed countries. In the U.S., the number of medical students entering family practice training dropped by 50 percent between 1997 and 2005. Research by the University of Missouri-Columbia (UMC) and the U.S. Department of Health and Human Services predicts that by 2025, the U.S. will be short 35,000 to 44,000 adult care primary care physicians. To discuss the state of primary care medicine in this issue, Cynthia Point, a practicing internist, expresses her frustrations but demonstrates how patients can work with their physicians to make the situation more efficient and workable. Sashi Amara, another practicing internist, writes about using a more systems-based approach to organize work flow and function better as a team. David Smith, former medical director of the Haight-Ashbury Free Medical Clinic and now a consultant, shows how merging two clinics effectively can keep difficult disease management issues safely in the outpatient community setting, not in the hospital. Internist Toni Brayer discusses appropriate care and the need for physician leadership to direct this discussion. Anthony Iton talks about retraining physicians to include population health in their thinking, to manage individual patients while thinking outside the box to make an impact on the health of the community. He also points out the need for physicians to speak up to be part of the solution. John Maa, a UCSF surgeon who recently took a sabbatical and researched the Health Care Reform Act, states that primary care is an integral part of the HCR—but not in its current form: Physicians need to lead the transformation of primary care into a more exciting and attractive option for medical students. March 2012 San Francisco Medicine
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Primary Care
Primary Care in America An Uncertain Future John Maa, MD After witnessing the health reform debate in Washington, D.C., firsthand during my sabbatical in 2010, I was struck by some of the misunderstandings on Capitol Hill about the current state of primary care in America. Physicians themselves have
generated these misperceptions. At a House Ways and Means hearing in February of 2011, then CMS Administrator Dr. Donald Berwick was quoted as saying, “One overdemanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early.” Dr. Berwick’s comments led a member of Congress to question whether “preventive care is in too high a demand.” Another national trend that may be sending a wrong message to Congress is “concierge medicine,” which raises questions about the motivations of a career in primary care. The field of primary care has been under intense pressure for decades. In the 1990s, the intent of the managed care movement was to transform the role of the primary care provider (PCP) as a gatekeeper to specialty care and hope to attract the best medical students to an intellectually stimulating career that would involve mastery of a broad body of medical information. But that mission has at best met with mixed success, as PCPs are in short supply across the nation. Persistent and unresolved concerns raised by primary care faculty about inadequate compensation and the overall future of the field may be having the adverse effect of discouraging medical students from pursuing career paths in primary care. The introduction of the 80-hour workweek may have created a further disincentive for students to choose primary care, because it offers students the option to train for only two additional years at 80 hours a week in order to become either a medical or surgical specialist. Clearly, physicians must help reframe the national dialogue to decrease the negative perceptions of primary care and increase the positive attributes, to attract more medical students to the field and resolve the national workforce shortages of primary care providers. What are other trends affecting the delivery of primary care? In my capacity as a surgeon at UCSF Medical Center, I recently received a survey from a local health network, asking me to rate up to fifteen primary care physicians for the thoroughness of their medical histories and reasons for referring a patient for consultation over the past year. The goal of these efforts is to reward PCPs who perform particularly well, which, though laudable, is under strain as time pressure for patient visits in clinics continues to mount. Consider the fact that in some Asian countries (Japan and Taiwan) that have universal health care access, outpatient visits with health providers average as little as five minutes or less to accommodate the enor12 13
San Francisco Medicine March 2012
mous volume of patients seeking care. To maintain a high quality of care, it may be necessary to place a cap on the number of patients in a PCPs practice. Another challenge is to assure a high-quality training experience to attract students to careers in primary care. The obstacles are highlighted by the following testimony from MEDPAC Commissioner Gene Hackbarth before the House Energy and Commerce Committee in 2010: “And one of the reasons that young physicians in training don’t go into primary care is they have that experience, ambulatory experience, and it is not a good one. It is in a clinic that is not well managed. They don’t have time to deal with their patients, and so they are turned off by primary care. Fixing that problem, as you say, is not something that is going to happen overnight—finding new settings, rich settings for people to train in.” Over the past decade, the increasing role of the medical hospitalist in the inpatient setting, and nurse practitioners in the outpatient setting, may have encroached upon the roles for PCPs to play and reduced their visibility within the hospital. Transforming the daily work environment of PCPs will not be easy, but the success that other fields of medicine have had can be instructive. In the late 1990s, perceptions of an oversupply of anesthesiologists and a loss of scope of practice as the numbers of nurse anesthetists expanded led to declines in applications to anesthesia residency. In response, the field of anesthesia was redefined to make the field more attractive to medical students by highlighting the satisfactions of a career as an anesthesiologist and a renewed emphasis on education over service. Medical school clerkships could be reformed to increase student experiences in outpatient settings where longitudinal relationships with patients could be emphasized as a benefit of outpatient care. The satisfaction of providing such continuity of care is usually not experienced during a brief elective. An expanded role for PCPs as educators in the inpatient setting (the ED, OR, and ICU) could prove extraordinarily helpful in defining a brighter future for students to envision. Incentivizing teaching roles, and limiting the traditional use of the volunteer clinical faculty (who are already overworked as medical student preceptors), would likely strengthen and revitalize student perceptions of a career in primary care. Another essential step to secure the future of primary care is to support the increasing numbers of primary care providers who are women. Fields with higher numbers of women will inevitably experience temporary workforce shortages as a result of maternity leave, and appropriate arrangements for physician colleagues (both men and women) to provide coverage in their absence will be invaluable. Additionally, finding ways to support women as they take time off for maternity leave, by sharwww.sfms.org
ing a job or residency, may encourage more applicants. Other financial solutions to support medical students should be considered. Existing federal loan repayment or tuition support programs mandate practice in an underserved area after finishing residency as payback. Legislative changes should be made to disconnect this link and offer unrestricted medical school tuition support for students who practice primary care after finishing residency, regardless of location. Another alternative is to redefine “underserved areas” in primary care to include urban areas, as the shortage of PCPs exists across the entire country, not just in rural areas. Other solutions to the shortage of primary care providers may come from unexpected places—there may be ways to incentivize those trainees who leave other specialty residencies to consider training in primary care. Another opportunity is for primary care providers to provide new answers to the national emergency care crisis. The commitment of the Obama Administration in the Affordable Care Act to the creation of patient-centered medical homes does reflect the willingness of the federal government to invest resources for the field of primary care to succeed. Some authors www.sfms.org
have suggested that medical homes could be open after hours, on holidays, and on weekends, to alleviate ED overcrowding and boarding. The Sacramento Bee recently reported on alternative primary care options, including urgent care clinics and satellite facilities that are open outside of traditional business hours, signaling a vital new role that PCP’s may come to play in a coordinated continuum of primary care, urgent care, and emergency room care. The greatest source of hope for the future of primary care may rest in the four PCPs currently elected to Congress: Paul Broun, (R-GA), John Fleming (R-LA), Donna Christensen (D-Virgin Islands), and Scott Desjarlais (R-TN). Their leadership may provide inspiration to medical students and residents across America about the opportunities that arise from choosing a career in primary care. John Maa, MD, is an assistant professor of surgery at UCSF and is director of its surgical hospitalist program. He is also a member of the U.C. Office of the President’s Tobacco-Related Disease Research Program Scientific Advisory Committee. Maa is an active member of the SFMS.
March 2012 San Francisco Medicine
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Primary Care
Considering Cost Modern Medicine and Appropriate Care Toni Brayer, MD Looking back at the history of medicine, the doctor-patient relationship appears to be so pure and simple. There was no such thing as a “primary care physician.” Everyone practiced
primary care, and there were no confusing payment mechanisms to interfere in this relationship. One way or another, the doctor delivered his (always “his”) best care to the patient and the patient paid for the service in cash, eggs, or barter. There were no high-price drugs. Diagnostics consisted of smelling the urine or looking at blood cells under a microscope. Even a stay at the hospital was affordable to the average man. How things have changed in the past fifty years! We have so much more to offer, and yet there is tremendous dissatisfaction and angst among both doctors and patients—now known as consumers—regarding our modern health care system. Much of this boils down to two things: resources and money. Medicine as we practice it now just plain costs too much. Dr. Victor Fuchs, PhD, wrote an op-ed in the New England Journal of Medicine about “The Doctor’s Dilemma—Delivering Appropriate Care.” He asks, “How can a commitment to cost-effective care be reconciled with a fundamental principle of primacy of patient welfare?” Physicians are trained to deal with each patient one at a time and to make decisions based on that patient alone. Our obligation and focus on the patient first has not changed. But we now have obligations to society that challenge our role as the patient’s advocate. What was once simple is now filled with complexities that add moral stress to primary care doctors. We are in an era when the high cost of treatment can actually bankrupt the system. Rising health care costs are everyone’s problem. Employers are shifting insurance costs to workers, and health costs are reported to be the biggest cause of bankruptcy. Since the primary driver of health expenditure is the doctor’s pen, we can no longer think it is someone else’s problem to solve. Adcetris, a new Seattle Genetics cancer drug, will cost $121,000 for a course of treatment to treat Hodgkin’s lymphoma. A new prostate cancer vaccine, Provenge, will cost $93,000. When the FDA approves new drugs, it doesn’t look at cost or cost-benefit ratios. Most of the new drugs approved by the FDA offer marginal improvement over what is already available. The same is true for new medical devices (artificial joints, heart valves, robotics, new scanners). Is it worth $121,000 to live an extra three months? What 14 15
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about an extra six months? What about living an extra six months but spending most of that time in the hospital with serious complications? If the hospital down the street has a new $10 million MRI scanner, to be competitive every other hospital has to buy one just to keep the patients coming. Does that raise the standard of health in society? It gets even more complex. On one hand we are seeing a nationwide shortage of common drugs that are widely used, because they are generic and the profit margin has disappeared for the pharmaceutical manufacturers. The number of drug shortages has quadrupled since 2005 and is putting a major stress on hospital pharmacies and doctors as they scramble to find safe and effective alternatives. As I write this, injectible diazepam, metaclopromide, bupivacaine, and atropine are impossible to find. A common cancer drug, Doxil, cannot be found and similar shortages of common antibiotics and anesthesia drugs are in short supply. This is happening at the same time that the new $121,000 cancer drug is being announced. Make no mistake: We have a fixed health care budget. The Medicare bank is broken, and the wave of baby boomers hitting Medicare age is just beginning. Tough as it is, we need to develop policies that will allow everyone to live long and be healthy. We need to look out for the common good and society as a whole, because that will ultimately affect the patient in front of us. Determining appropriate care based on our best science and evidence is a critical first step. None of these are easy questions, and there are no easy answers. What is “appropriate care” and who should be responsible for making cost-effective decisions? The newly published American College of Physicians Ethics Manual states that physicians have a responsibility to use health care resources responsibly to help ensure that resources are equitably available. That makes us part of the solution. Doctors, patients, and policy makers need to pull their ostrich heads out of the sand. Patients need to quit demanding the “new, new thing” that they read about or saw on TV. Everyone needs to know what treatments, tests, and drugs actually cost. Just because someone else is “paying for them” doesn’t mean the cost is zero. As more patients are assuming first-dollar payment, they are asking the question, “Is this really worth it?” It is a question the physician should also ask. Patients and doctors need to tackle this one together, and neither patients nor physicians any longer have the luxury of unlimited health care resources without also assuming the responsibility of considering who will pay for them.
Toni Brayer, MD, is an internal medicine physician, former president of the SFMS, and current member of the San Francisco Medicine editorial board. Her widely read blog, http://www. everythinghealth.net, covers exactly that: everything health. www.sfms.org
Primary Care
The Primacy of Prevention Anthony Iton, MD, on Communities, Quality, and Cost Steve Heilig, MPH Anthony Iton, MD, JD, MPH, seems compelled to take on dauntingly big problems, and many people might well be thankful for that. Issues such as violence, obesity, diabetes, and health disparities are daunting for anyone to consider, but Iton remains both practicalminded and guardedly optimistic. At his talk at the SFMS annual dinner in January, he received multiple ovations even when imparting some difficult, even damning, information. In this interview, he tells of his journey from aspiring surgeon to law student to practicing internist to consumer advocate to director of public health for Alameda County—and now, senior vice president at the California Endowment (calendow.org), a major foundation he had hand in creating. He and his colleagues analyze virtually all the factors that are creating the ongoing crisis in personal and public health in our nation. SFMS: You began your career as an internist—how did you get into public health issues? Iton: I think the original sense that there was something larger at play in producing the illnesses I was seeing came to me at John Hopkins when I was a medical student in the 1980s. I intended to become a surgeon, and I saw a thirten-year-old kid who’d been shot in the abdomen, with a temporary ostomy placed. Rather than a real ostomy bag he had a Ziploc kitchen bag, and it was a mess. I asked to speak to his mother, and he told me she was in jail, and he had come by himself. He lived with his grandmother, who he said was strung out on crack. I was just stunned and did not know what to do—do I send him home, admit him, or what? The realization hit me that I was being asked to treat what were largely social ills with pills. And it didn’t seem appropriate, and certainly not effective. A series of such encounters launched me on a quest to better understand the health care system and factors at play in neighborhoods like East Baltimore. I decided I would work on Capitol Hill while still in school, and I learned that there was good understanding about things like universal health coverage, and after medical school I went to law school. I also did a preventive medicine residency externship for a master’s in public health at Berkeley, and eventually I wound up director of public health for Alameda County. So apparently you still believe that we have to do much more than try to deal with public health issues with a one-on-one clinical approach. www.sfms.org
Yes, I think the key to this work is to stop looking for silver bullets. We have to recognize that there are layers of influence that shape people’s health, and construct positive interventions there. For example, behaviors do matter, but there’s a context for those that is largely man-made. While we want to help people make better choices, we need to look at what shapes those choices. The narrower the range of choices, the less likely you’ll make good ones. For example, with eating well, it of course requires willpower and knowledge, but it also requires access to healthy food—which does not exist in East Baltimore, or East Oakland, or Bayview Hunters Point. We all need access to healthy food, parks, clean air and water, but we also know that in many communities those are not there. So, knowing that, how do you advise a patient and community on how to change that reality? One of the striking tools you use is graphic “mapping” of health and socioeconomic factors. Yes, I fell in love with geographic information systems that present data in ways laypeople can understand—medicine and public health people tend to present data in complex ways that regular people and policy makers don’t “get.” But most people can read a map and identify where they live on it. In Alameda County we had access to roughly half a million death certificates, and we decided to map it and found this startling fact that there was a cluster of neighborhoods with an average life expectancy of about 65 years—which is basically the life expectancy of Pakistan. There were other neighborhoods with an average of 95 years—the highest in the world—and you could walk from one to the other. So we had to explain that, and we found that conventional rationales for differences in disease rates did not hold up. There had to be other factors at play. We ended up publishing quite a bit of this information, in journals and the newspapers and in a PBS documentary. It drove a different kind of conversation, and it got more attention when people saw the unfairness of actually losing ten to fifteen years of life due to these factors and social policies. You’ve used the analogy of needing not only to put out “fires” but to look upstream and see what is causing the fires, and prevent them. Yes, we argue that this work requires both the clinical work of putting out fires and understanding the policies that lead to the damage, and how do we correct those. Health is larger than health care and choices; it’s a product of how we design our communities, and how we provide access to basic opportunities. Many societies around the world have recognized this and improved their access to education, health care, fresh food, childcare, and the like. For whatever reasons, we have largely ignored that.
Continued on the following page . . .
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The Primacy of Prevention Continued from the previous page . . . You used a striking term for this: “medical apartheid.” I don’t think you can get away from the reality of how rigidly segmented opportunity is in our society. This work really starts with data, and with seeing people living within a half mile of one another having life expectancies that differ by twenty years. I don’t see any real way to describe that other than some form of apartheid, rigidly segmented such that neighboring communities can have such radically different life experiences. I’ve been to South Africa and I studied the health of blacks there in the 1980s, and I was struck by how much of what I saw there reminded me of East Baltimore. In fact, I found in some ways that there was more hope to be found in South Africa than here—you had folks there who at least saw the potential for change, whereas in parts of Baltimore or Oakland hope often seemed to be extinguished in the eyes of people walking around. I used to take my staff on walking tours through East Oakland and ask them to look in the eyes of thirteen- or fourteen-year-old children and talk about what they saw, and they saw how adolescents would undergo a diminution of the hope that they had in childhood. They aren’t making this up; they’re describing what they see before them. And that’s man-made. So when you talk with clinicians, how do you advise them on how they might really help? My sense is that are a couple of things clinicians can do directly. The first is to avoid our tendency to sort of blame the victim, to go beyond just saying, “You need to eat better, and please read this brochure.” We need to assess things like where they might go to get better food, and how they might get outside—to enlist them in finding better options. Sometimes a group approach works: get people together to find farmer’s markets, to educate themselves, and so forth; physicians can be very impactful in that regard. The second thing is to be spokespeople in education and policy, to write op-eds, to talk about getting physical activity back into people’s lives, engineering traffic calming to make walking safer, to protect open recreational space. The CMA Foundation has been a great partner to us in this kind of work, particularly around chronic disease, diabetes, and obesity. Physicians, for good or bad, have a lot of power in these policy debates, and we don’t necessarily use that power as effectively as we could to get at some of the root causes of diseases we’re seeing in our practices. There is a real ongoing struggle to refocus the health system on primary care. Do you agree with that general goal? I went into primary internal medicine in the late 1980s when those residency tracks were being developed, with the realization that we need to not only improve quality and reduce cost but to get somebody to sort of “quarterback” the care people get. That seemed appropriate to me, and at the time people felt there was a big movement in that direction. But I’m surprised that now, more than twenty years later, we haven’t made much progress in that regard, in terms of the numbers of people going into primary care and the degree to which it drives the system. I’m surprised and troubled by that. But I also think we need to train our primary care physicians 16 17
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differently, to show them how to engage in population health. They need to become the leaders in our system. There was a resentment of managed care, at least as it seemed to be corporate-driven, with a focus on cost control above all else. I think that in part that was due to a lack of physician leadership. I think the next round of this, “Managed Care 2.0,” is going to have much greater physician leadership, with a focus on managing care on the front end with highquality primary care. That I look forward to participating in. It’s why I went into medicine, to help keep people healthy rather than just managing their diseases. Cost matters, but what matters more is what patients experience, and only physicians, nurses, and others can effectively manage care to keep people out of fragmented, cascading bad experiences that might have been avoided if only somebody had seen the whole picture. Are there examples of systems you admire in this respect? Kaiser and Group Health of Puget Sound are two physicianand consumer-led organizations focused on ensuring high-quality care and managing cost, but also in making an investment in prevention without looking for quick cost savings from that. Federal health reform is rolling out now, amid great controversy and conflict. What’s your overall take on that? I’m hopeful. I think there’s going to be a lot of push in the initial years to contain costs. Again, if the leadership is from those who are mostly concerned about the bottom line, we’re in for some rough sailing. But if we can get some leadership that understands that high-quality care can generally cost less than poor-quality care, and who are sophisticated enough to know how to provide that care and “message” about it, then we’ll start to see much bigger improvements in the integration and provision of care. But it’s not clear to me that we are yet at the point where we recognize that quality and costs are aligned—people are still arguing that quality comes at the expense of costs, or vice versa. And that’s unfortunate. How did you get involved with the California Endowment? I worked for Consumer’s Union, the publisher of Consumer Reports, which has been pushing for more patient-friendly health care for a century. In the mid-1990s, when the first wave of managed care was taking hold in California, there was this creation of HMOs without walls, essentially; creatures of Wall Street buying up contracts with doctors and hospitals, Health Net and all of that era. The “Blues” that were chartered as nonprofits long ago saw their business models turned upside down by these profit-making entities with lots of capital, and they could crowd out the not-forprofits—who also wanted access to that capital and wanted to convert to for-profit status. California Blue Cross was the biggest of all of them. They’d never paid taxes, and their assets belonged to the people of California. So when they tried to convert, we at Consumer Reports wanted to make sure those assets weren’t essentially stolen to wind up in private hands. We argued, successfully, that they had to convert at least some of those assets into public charities. They said they guessed they were worth about 100 million dollars, and the insurance commissioner at the time agreed, but we said no, you have to disgorge 100 percent of your value into a charitable foundation. In short, we won and created two foundations’ worth, starting with www.sfms.org
$1 billion dollars. Now it’s about $4 billion dedicated to improving the quality of life and health of Californians. Did you at the time imagine you were creating an eventual job for yourself? I really had no idea [laughing]. I was a doctor and didn’t know what a foundation was or did and didn’t imagine that doctors would work there. For more than a decade I had really nothing to do with the California Endowment, until I got into public health and these partnerships to improve public health practice. So what is the Endowment’s focus in this regard now? Our focus now is on trying to prove the value of prevention, including in communities. It’s more than rhetoric. Preventing obesity, for example, will reduce costs, and there are strategies at the community level that are proven to be effective. And there are other issues, like violence, that are really chewing up a lot of costs, and in some of our communities neighborhood safety and youth violence is what people say is their number-one concern. We know we can reduce the number of kids caught up in the juvenile justice system, to keep them in school, and these things have been demonstrated to reduce health costs and other costs. Plus we’re trying to remind everyone that access to primary care is critical, and that we can provide such services that will benefit us in terms of both cost and quality. Health care reform rests heavily on expansion of Medicaid, or Medi-Cal here, and the long-standing problem that there is low reimbursement.
It’s a big problem, particularly in California where the reimbursement rates are ridiculously low. But the bottom line even now is that putting people with no insurance onto Medi-Cal will at least mean that a system used to getting nothing will at least get something. This can reshape the health care system over time. You’ll never have the pressing need to pass the hot potato of the uninsured patients. Taking the demand off the emergency rooms and other tertiary services will dramatically improve quality and save money. It just won’t happen overnight. I am cognizant of the reimbursement rate issue and the fact that inducing primary care practitioners to accept more Medi-Cal is not a winning proposition at this point, so for at least several years we’ll have to look at Federally Qualified Health Centers, which get cost-based reimbursement, as our primary vehicle for expanding care for these underserved populations. I’m a physician first, and that is still my primary identity. It’s long been frustrating to me that physicians have not been as actively engaged in these conversations as they might be. I know a lot of physicians want to be involved; the question is how do we bring them into advocacy for better health. So many of us are frustrated with trying to manage these problems in fifteen-minute encounters in our offices. It takes not just that, but much, much more. Steve Heilig, MPH, is assistant executive director at the SFMS and is editor of the Cambridge Quarterly for Health Care Ethics.
The clock is running on implementation of federal health reform. Health care providers and payers are jockeying to position themselves for the impending changes in health care coverage, delivery and reimbursement. Who will survive the demands of the new marketplace? Who will prosper?
Follow the Money…The Transformation of Medical Practice 15th Annual California Health Care Leadership Academy April 27-29, 2012 • Disneyland Hotel • Anaheim, California
Featured speakers include John Chiang, California State Controller and Peter V. Lee, Executive Director, California Health Benefit Exchange Plus: practice management and leadership skills workshops to improve your bottom line and enhance your effectiveness in the new marketplace
www.sfms.org
Multiple Registration & Early-Bird Discounts Save up to $200 per person • Register by March 30th
To Register: 800.795.2262 • caleadershipacademy.com
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After Hours Clinic Filling a Need for Care Jessica Kuo, MBA Americans work longer hours than workers in most other developed countries. The typical American middle-income family put in an average of 11 more hours a week in 2006 than it did in 1979. Although
more than 805,000 people reside in San Francisco, there were no after-hours clinics available to accommodate busy families until the establishment of the After Hours Medical Clinic this month. Staffed by the Pacific Family Practice Medical Group, the clinic provides much-needed nonoffice, after-hours medical care at reduced cost for both patients and insurers. The clinic operates from 5:00 p.m. to 9:00 p.m. on weekdays and from 10:00 a.m. to 4:00 p.m. on Saturdays. An after-hours clinic provides walk-in care that focuses on acute conditions and exacerbations of chronic conditions. In a study done by the California HealthCare Foundation, the most common diagnoses seen in nonemergent and nonprimary care settings are upper respiratory infections (60.6 percent); preventive care, such as vaccinations and preventive exams (21.6 percent); other minor conditions such as allergies, insect bites, rashes, and conjunctivitis (9.5 percent); and urinary tract infections (3.7 percent). These four groups of diagnoses accounted for more than 95 percent of all visits to acute care clinic sites.
According to “Health Matters in San Francisco” and the California Office of Statewide Health Planning and Development, 18,000 emergency department visits were preventable.
Dr. Robin Weinick of RAND Health, one of the largest private health research groups in the world, estimates that 13.7 to 27.1 percent of all emergency room (ER) visits could occur in less intensive, walk-in-based care facilities. A combination of increased working hours for patients and diminished primary care access result in unnecessary use of emergency departments. Delays in care and additional costs incurred in ER visits are a drain on health care resources. Several studies have estimated that costs of care in nonemergency, nonprimary care clinics are $279 to $460 less per visit than ER costs for similar cases. “Extended hours have become a big concept of how to bring our practice to the people, to make it more available to the people,” explained Sophia Mirviss, MD. “It’s for existing patients, and also for people who come home and find themselves sick and really want to be seen but had to work all day. And for people who do not have insurance but want to get their strep throat checked but cannot go to the ER because it’s prohibitively expensive.” The clinic does not provide ongoing primary care services. It transmits all medical encounters to patients’ primary care physicians via an electronic medical records system so that the pri18 19
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mary care physicians retain control of all referrals and follow-up. AHMC is contracted with Brown and Tolland Medical Group to provide after hours care to all BTMG patients and are committed to maintaining the patients relationship with their primary care physicians. AHMC also provides travel vaccines and sees children. The community has embraced this concept; many physicians have been strongly positive in their responses. It has garnered support from insurers as it has the potential for reducing inappropriate ER and hospital use rates. Jessica Kuo, MBA, is the associate executive director for membership development at the SFMS.
References Scott MK. Health care in the express lane; the emergence of retail clinics. Oakland (CA): California HealthCare Foundation. 2006. Weinick, RM, and Betancourt, RM. No appointments needed: The resurgence of urgent care centers in the United States, Oakland (CA): California HealthCare Foundation. 2007. Building a Healthier San Francisco. Health matters in San Francisco. California Office of Statewide Health Planning and Development. Gill JM and Riley AW. Nonurgent use of hospital emergency departments: Urgency from the patient’s perspective. Journal of Family Practice. 1996; 42(5):491-6. Thygeson M, Van Vorst KA, Maciosek MV, Solberg L. Use and costs of care in retail clinics versus traditional care sites. Health Affairs. 2008; 27(5):1283-92.
Patient Resource: Free Science-Based Class on Childhood Immunizations This free class is designed to teach parents about what childhood vaccines do and don’t do, what diseases childhood vaccines are designed to prevent, and the risks and benefits of immunization. This science-based course is presented by the San Francisco Immunization Coalition A practicing pediatrician will also be present at each session for Q & A. Class Dates (all sessions cover the same material. Choose one date): Tuesday, May 22, 2012; Thursday, July 26, 2012; Tuesday, October 16, 2012. Sessions are from 6:00 p.m. to 8:00 p.m at the CPMC California Campus, 3700 California St. (at Spruce), San Francisco. Class takes place in the First Floor Conference Room A-B-C (near the cafeteria). Sessions are free, seating is limited. To attend please RSVP to Andrew J. Resignato at (415) 554-2567 or andrew@sfimmunize.org.
www.sfms.org
Primary Care
The Changing Face of Medicine A Primary Care Physician’s Perspective Sashi Amara, MD Primary care in the U.S. is in a fragile state. There is an increasing amount of pressure on primary care physicians to care for an increasing number of patients, with an increasing list of chronic medical conditions, in a decreasing amount of time and with less compensation. The big question is: How can we
be more efficient and practice safe and fulfilling medicine? Over the last seven years of my practice I’ve tried to find the answer to this question. During part of that time I was fortunate to be part of the Virginia Mason Production system, a management method that embraces a path of continual improvement and a goal of zero defects. Below are the take-home messages I have learned during this journey, and they have helped me evolve to be a better internist. In today’s collaborative medicine, effective communication among physicians, nurses, and MA’s is key in delivering quality care. This has become essential as we move forward to create a platform from which we can deliver “safe and effective medicine.” With this in mind, we designed work flows that help streamline the processes and I’ve included some examples here.
Electronic messages are all handled the same way. They include clear subject lines.
The descriptions of duties for the MA are clear.
It is important to have these duties defined both for clarity and to avoid conflicts. Also, cross-training MA’s throughout the organization (particularly section-wide, such as in internal medicine, general surgery, etc.) proved useful, as we could rotate them at any of our satellites and open a bigger pool of MA’s to rely on.
Work flow when a provider is on vacation continues. Many of us in a group practice probably have encoun-
tered piles of work waiting for us on our return, and we wonder whether taking a vacation was worth it! At our practice, we agreed to send out letters for both urgent and nonurgent labs, radiology, and all medication refills if a provider was away for more than three days. There was a fair amount of going back and forth about this, but we went ahead as we noted improved patient satisfaction associated with prompt relay of results. MA’s were also aware that the inboxes of the providers on vacation should be monitored and redirected appropriately.
Work flow is designed to monitor surveillance CT’s, US, etc. We designed a work flow with a clear distribu-
tion of responsibilities. There was an electronic group box to which all the surveillance was posted, and the MA on call for www.sfms.org
that day was assigned to monitor it. This meant that if a provider was on extended leave or moved, practices wouldn’t be lost.
Removing waste was a key component. It involved a process of identifying waste and figuring out an efficient method of eliminating it. Waste could be anything, including: • Waste of overproduction (lab results) • Waste of inventory (drugs and supplies) • Waste of poor quality (professional liability) • Waste of motion (searching for charts, patient supplies)
At the clinic level we implemented Kaizen, or continuous improvement techniques, to streamline the process. Some of the changes that resulted were
identical patient rooms for all providers, and this meant any provider or MA knew where supplies were and made the flow of the visit easy. We incorporated the Kanban system and tried to stock our patient rooms with the goal that everyone would have an idea of the inventory and not run short or over-order. We replaced the traditional doctor’s offices with a flow station, where the doctor and MA sit next to each other. Needless to say, there was some pushback, but post-transition we saw tremendous improvement in efficiency.
We had a system designed to detect errors and defects in work flow. If any member of the staff detected
or perceived a defect as affecting patient safety, this was communicated to the patient-safety office by phone or via e-mail. This team would respond immediately and determine what needs to be done. Based on the severity of the problem, either the entire process would be stopped immediately or the issue was investigated in a rapid manner to find a fix. Once the fix was implemented, we would follow up on the results to see if the defect was rectified. These alerts could be from patient complaints, bad outcomes, or any staff member recognizing a potential hazard. Though these processes were stressful for the parties involved, it ultimately created a safe environment and won patients’ trust. As a profession, physicians need to band together and change the way we are practicing medicine right now. The reality of the economics of health care—decreasing Medicare and Medicaid reimbursements and increasing labor costs and patient visits—will, hopefully, drive us to rethink ways of delivering safe and effective care. Sashi Amara, MD, practices internal medicine at the Saint Francis/St. Mary’s Medical Group. She recently relocated to San Francisco and joined the SFMS in 2011. March 2012 San Francisco Medicine
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A New Model Creating Health Care Experiences for Patients and Practitioners Katherine K. Sulzer
One Medical Group, founded by San Francisco physician Tom Lee, MD, MBA, is based on a new model for primary care. The model is building a care
system that strives to engage both patients and physicians through patient-centered care management. “There is no one magic bullet to how this all works,” says Lee. “It’s an orchestration of people, process, and technology.” Founded with the intention to reduce economic waste in health care spending and simultaneously improve the patient experience, the primary care model uses information technology wherever appropriate in an attempt to deliver high-quality services at a lower cost. In 2011, groups including Maverick Capital, Benchmark, Oak Investment Partners, and DAG Ventures invested a total of $20 million into the practice, allowing them to expand and serve patients nationally. There are seven offices in the Bay Area, with additional sites in New York City and Washington, D.C., totaling thirteen primary care offices. It is a membersupported practice; the annual fee, depending on location, ranges from $149 to $199 and pays for services that are not traditionally covered by health insurance, such as the time physicians spend e-mailing with patients. The practice accepts most major insurance plans (including PPOs, HMOs, and Medicare), and while the annual membership fee is not a requirement for care, Lee believes it helps members assess the market value of the service they receive. “People end up saving money,” says Lee. “For every visit you can deal with in a virtual sense, that’s one less co-pay, one less deductible that you’re paying through the system. Ultimately, we think it saves not only the patient money, but also the system money because it’s one less claim that’s run through the system.” One Medical Group’s business model attempts to reduce overhead costs and instead shifts focus toward the intangible 20 San 21 SanFrancisco FranciscoMedicine Medicine March March2012 2012
details that enhance customer service. The aim is for members to have same-day appointments, more extended time with their providers, and the option of consulting with the practice by way of multiple channels, including a comprehensive website, e-mail consultations, and a mobile phone application (which members may use, given the right clinical guidelines, to get prescriptions filled). Patients are encouraged to use the most convenient form of communication that’s supported by providers, given their respective clinical needs. The internal support systems and infrastructure appear to cultivate “good people systems and people cultures,” says Lee. One Medical Group’s patient base has grown steadily, a dynamic that’s based in large part on word of mouth from other members. The strong emphasis on enhancing patient access in an affordable fashion is built into the infrastructure of One Medical through the ethos of systematic reductionism and effective management of overhead structure. One Medical’s primary care model has used initial investments from venture capitalists to develop novel delivery methods for health care. It is yet to be proven if this model will not only be sustainable but able to provide economic gain for the investors. The implementation of technological advancements at One Medical attends to many systematic complexities that practices face in their efforts to increase organizational capacity for care management. “I think the difference with us is that we’ve tried to manage the technology piece a little bit more aggressively than traditional practices,” Lee explains. In 2011, 39 percent of primary care physicians had electronic medical record (EMR) technology, according to the Centers for Disease Control and Prevention (Cash, amednews, January 30, 2012). One Medical Group developed its own enterprise system for EMR technology that focuses not only on visits and code-captures but also on supporting a team-based approach for care. Lee believes information technology to be critical for this model of care in order to support a fluid, insync work flow between providers and administrative personnel. In a 2011 New York Times profile of One Medical Group, the publication noted that the practice generally sees sixteen patients a day, while the nationwide average for primary-care physicians is twenty-five (Hafner, New York Times, January 31, 2011). Doctors are paid salaries and serve as members of a team-based primary care model. The average staffing per doctor is nearly 1.5 employees. Zina Moukhelber, a contributing health IT writer for Forbes, notes that the typical staffing per doctor is 3.5 employees (Moukhelber, Forbes, September 7, 2011). www.sfms.org
One Medical’s Spear Street Office in San Francisco. Waiting room pictured above, exam room on facing page. While the organization continues to grow and expand to new cities, reaching new demographics, only time will tell if this model can sustain equity and balance between its growth and maintenance of its current infrastructure practices. In the Bay Area, One Medical group has more than thirty practitioners working throughout the seven office locations. Patients have access to allopathic care in addition to alternative and complementary medicine and therapies, including (but not limited to) naturopathy, Chinese herbal medicine, nutritionists, lifestyle management for stress and anxiety, and mind-body practitioners—all under one roof. The integrative methods seek to meet the patient’s health needs, support wellness behavior, and address specific aliments by, as Lee says, “being open-minded and giving patients choice about certain types of modalities that may be more effective than others.” That means discussing pharmaceuticals and natural remedies in one conversation, investigating alternative modalities to perhaps avoid surgery, and blending information so that it is accessible. As Lee says, “It’s truly an integrative approach.” San Francisco resident Victoria Thomas has been a member at One Medical Group for over a year and half. Thomas notes, “The model addresses the importance of physical, mental, and financial well-being. It’s painless to make, change, or cancel an appointment. Also, their administration always takes the time to explain how their practices align with my health insurance, which helps me have a better understandwww.sfms.org
ing of health-related costs.” One Medical’s offices are designed to be in tune with a distinct ascetic healing quality, filled with artwork, soft lighting, and calming, warm colors. The patient is met by administrative personnel seated behind urban-chic desks, and then greeted by his or her personal physician for an appointment. Lee’s vision of highly orchestrated people, process, and technology enables One Medical Group to continue adding services (both virtualized and physical) to manage populations’ health risks and to promote engagement with healthy behaviors and heath care data. The integration of cost-saving technology and people practices, in addition to members’ access to an expansive array of medicines, continues to drive One Medical Group’s success to date. While the long-term success and survival of One Medical Group’s model remains unknown, as with other experimental models (including Essence Group and GreenField Health), it has thrived under current conditions. Across the country, practitioners, patients, and the public await with anticipation as the development of this unique practice moves forward. Katherine Sulzer attends the California Institute of Integral Studies, where she is a candidate for her master’s degree in integrative health studies. She is also a medical journalist.
March 2012 San Francisco Medicine
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Primary Care
Pre-Op Appointments Where Do They Fit in an Already Busy PCP Schedule? Cynthia Point, MD “I am so, so sorry.” Sheila, my receptionist said as she handed me a stack of papers. She was distraught,
and I felt my heart sink. What was this about? Were these biopsy reports of cancer, which meant my patients were in for difficult times? Were they notices about formulary changes, requiring time to appeal patients’ medication needs? Were they notices of patients who have not had services done? Thankfully, none of these guesses were right. But what turned out to be in this stack of papers was a symptom of a larger issue in medicine today. The stack consisted of several letters from colleagues and messages from patients informing me of six surgeries scheduled in the next week to ten days, all requiring a pre-op appointment urgently. So what, exactly, is the problem with this? As an internist with a busy schedule my issue is in finding time to fit them in within their needed time period or finding another physician who could carry out the exam. ***** Many of my fellow internists, family doctors, and pediatricians have retired or left the area. Some have opted to change to concierge practice models, taking care of 250 to 500 patients instead of 1,500 to 2,000. This has left thousands of patients scrambling to find doctors.
I accept as many patients as possible, as do my colleagues, but still the gap is not filled.
My daily schedule is crammed with four to six annual exams, plus Pap tests and breast exams. I also see patients with uncontrolled diabetes or hypertension for scheduled follow-up. Patients discharged from the hospital need to be seen within the week. There are visits for sore joints, urinary tract infections, rashes, abdominal pains, and more. I save forty-five to sixty minutes daily in fifteen-minute isolated intervals for acutely sick patients, but these are usually filled by late morning daily. I generally use the early morning, noon break, and very end of the day to review tests, return patient calls, or see patients in the hospital. ***** Returning to the stack of papers, I look at my schedule and try to figure out which appointments to cancel to fit in the preop patients. We all dread making these calls, telling patients we have to cancel their appointment, or asking surgery patients to postpone surgery to give us some breathing room. People are already upset with us, and canceling appointments doesn’t fix anything as those appointments need to be rescheduled and tomorrow may bring many more pre-op demands. Some of 22 23
San Francisco Medicine March 2012
these patients have had an annual evaluation in the past three to four months, but it has to be done again. Or the patient had one cataract removed four weeks ago, but the exam has to be done again because more than thirty days have elapsed. Many patients are young and healthy, perhaps only taking thyroid medication or needing antidepressant medication. Many of the surgeries are minor, being done under local anesthesia, or are arthroscopic same-day procedures, or lithotripsy. Many more patients are having surgeries at a younger age. A small number of surgeries are done for complicated and/or elderly patients or are for complex procedures such as joint replacements, and we could accommodate these patients without too much distress, but accommodating all of the preop patients is what makes it overwhelming. The appointments are time consuming as some surgeons have their own specific lab requests, not dictated by medical requirements but by their preference, and often I find myself hunting through records to determine if and where an EKG or other test has been done recently. I can’t fill out orders before the visit, because insurance changes and I don’t know what lab the patient needs to use. Additionally, I don’t know in advance at which facility the surgery will be done. Inevitably, patients ask me questions about the procedure, which I can’t answer. So what can be done to remedy this? Many of my patients schedule elective surgery around their annual visits. We thank them profusely. Some ophthalmologists follow guidelines in place in other areas and schedule the second surgery to be done two weeks after the first if all goes well. This bypasses the second pre-op and repeated lab tests. The Anesthesia Society guidelines recommend that minor procedures done on basically healthy patients have the pre-op clearance done by the anesthesiologist. This was the norm until recently. In the past, otolaryngologists, orthopedists, and urologists did their own notes for minor procedures. This could be done again. Finally, except for emergencies, contacting my office before scheduling the procedure will avoid having to reschedule it, and it will give me time to work something out for the patient. The more notice I have, the more likely I will be able to see the patients for the pre-op. Having only a few days is not enough. If we work together, we can ensure timely and safe surgeries and improve patient care and satisfaction. Cynthia Point, MD, is an internist who has been in private practice for more than twenty years in San Francisco. She has been a member of the San Francisco Medical Society since 1988 and is currently serving on the Board of Directors. She did her residency at Children’s Hospital, which is now part of CPMC.
www.sfms.org
Primary Care
A View to the Future Combining the Haight-Ashbury Free Clinics and Walden House Dave E. Smith, MD, FASAM, FAACT In July 2011 the Haight Ashbury Free Clinics and Walden House, two iconic 1960s nonprofit health care agencies, merged into a single organization to provide primary medical care and addiction treatment services to the most vulnerable members of society. The combined organization, led by Dr.
Vitka Eisen, CEO of the new Haight Ashbury Free Clinics, emphasized that this collaboration “will give our clients a seamless integration of care, allowing them multiple entry points to access primary and mental health care. We now have the expanded capacity to provide comprehensive medical, substance abuse, and mental health care to the community we serve.” The Original Haight Ashbury Free Medical Clinic was founded in June of 1967 during the Summer of Love, with the founding philosophy that “health care is a right, not a privilege.” The Free Clinics have long been innovators in delivering integrated health care services to the many people who can least afford them. Like Walden House, the Clinics have served the uninsured, the homeless, and the socioeconomically disenfranchised, including those with HIV/AIDS, a vast majority of whom have incomes well below the federal poverty line. In 2010, the primary care clinic provided primary medical care to approximately 8,000 individuals at its original location on Clayton Street in the Haight Ashbury and at its integrated care center in the Mission District (where the central administration of the combined enterprise is now located). Walden House is a therapeutic community, also founded in the Haight Ashbury at the beginning of the nationwide drug epidemic to help homeless adolescents and young adults with substance abuse problems. Since 1969, it has been nationally known in recovery services, and last year it provided services to more than 9,000 clients with mental health and substance abuse problems in its various residential and outpatient centers throughout California. Walden House has been in the forefront of developing prison treatment programs and interacting with the criminal justice system. Walden has also provided addiction treatment services with vocational housing services for those leaving the criminal justice system and transitioning back into their communities. Research on therapeutic communities has found their treatment to be successful up to eighteen years after release from prison, reducing new arrests and the health consequences of addictive disease, including HIV risk (Martin et al 2011).
A Marriage Made in Haight
The combined organizations create one of the largest private nonprofit health care and addiction treatment facilities www.sfms.org
in the United States, springing from two very different backgrounds. The Haight Ashbury Free Clinics began as a medical practice designed to deliver health services to the flower children who believed in “better living through chemistry” and flocked to the Haight Ashbury during the Summer of Love (Smith and Luce 1971). An early supporter of the Free Clinics was the legendary rock concert promoter Bill Graham of the Fillmore Auditorium, who organized benefits by legendary San Francisco rock groups including the Grateful Dead, Janis Joplin, Grace Slick and the Jefferson Airplane, and John Fogerty with Creedence Clearwater Revival. A 1969 benefit helped establish the Haight Ashbury Free Clinics drug detox program, which was the first community-based outpatient, non-methadone drug detox. Methadone maintenance was available in California beginning in 1968, but medication-assisted detoxification on an outpatient basis in a primary care medical setting was a violation of the law, leading to the arrests of some targeted physicians. The development of the phenobarbitol detox technique by Smith and Wesson (1971) served as the basis of the Clinics’ outpatient detox program (Wesson 2011). The Free Clinics Detoxification, Rehabilitation, and Aftercare Program was a forerunner of the modern field of addiction medicine, which forty years later includes 2,500 diplomates of the American Board of Addiction Medicine, forty-five residency training programs in addiction psychiatry certified by the Accreditation Council on Graduate Medical Education, and ten residency training programs certified by the ABAM Foundation. In 1969 the phenobarbital method was supplemented with opiate withdrawal symptom relief medications and adapted to outpatient detox for heroin in association with psychosocial counseling, serving as the precursor of the integration of pharmacotherapy and psychosocial treatment as a model for the treatment for addictive disease (Gay et al 1971). This method was particularly useful for polydrug abusers addicted to both opiates and sedative-hypnotics with comorbid psychiatric disorders (Sheppard 1971, Smith and Gay 1972, Wellisch et al 1971, Wesson et al 1972). This link to rock and roll continues today as the Rock Medicine section of the Haight Ashbury Free Clinics provides medical services at more than 650 major public events annually, using an all-volunteer medical staff that treats more than 4,000 individuals each year. The Free Clinics also provide more than 67,000 mental health, substance abuse, and aftercare services to more than 6,000 clients in the San Francisco county jail, providing parole aftercare through individual and group therapy, medical planning case management, and com-
Continued on the following page . . .
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Haight Ashbury/Walden House Continued from the previous page . . . munity placements. This latter service integrates well with the criminal justice-related services that are the bedrock of Walden House. However, Walden House began with a very different culture than the medically-oriented Haight Ashbury Free Clinics, basing its classic residential therapeutic community on Synanon, a behavioral-change model using confrontational group process and work therapy. The early Walden House model was a rigorous residential program with harsh administrative responses to infractions, seeking to create a sense of unity, community, and structure. With the recognition of dual diagnosis patients who exhibit both comorbid addiction and psychiatric disorders requiring medication, Walden House adapted to changing times and integrated more fully with the medical system. Walden has accepted patients on methadone maintenance for the past twenty years. As reported by Sorensen (2009), patients on methadone maintenance accepted into the Walden House therapeutic community, with drug problems other than opiates, participated equally well in its psychosocial program as patients not on methadone. This mixed-modality, integrated approach was innovative in that methadone maintenance programs and therapeutic communities traditionally have been antagonistic to each other, as therapeutic communities for the most part do not accept patients on methadone maintenance (Bonetta 2010).
The trend in addiction treatment in California is based on research that has confirmed the effectiveness of medication used in conjunction with ongoing counseling to treat substance abuse disorders. Despite mounting clinical evidence that medication-assisted treatment (MAT) is an important and effective part of comprehensive care options for clients who are chronically ill with alcohol and other drug disorders, overall rates of implementation and sustained adoption of medication to treat addiction remain limited, particularly in treatment programs based on psychosocial recovery models and medically based primary care services (Rieckmann et al., 2010). The innovative merger of Haight Ashbury Free Clinics and Walden House will serve as a model for integrating the medical culture and the addiction treatment culture in order to provide improved services in the era of health care reform (Roy and Miller 2010).
A New Proving Ground
San Francisco is an excellent proving ground for such integration in Healthy San Francisco, a capitated program that mandates parity with mainstream medicine for addictive disease and mental health disorders. San Francisco continues to be a model for overcoming what Jean Merwin, RN, vice president of Healthcare Services at HAFC – Walden House, calls the “patient silo” approach, where the patient with multiple disorders is compartmentalized into different systems rather than treated with an integrated approach. For example, David Hersh at San Francisco Department of Public Health has been using new tools available to addiction medicine such as Suboxone, a Schedule III drug that can be prescribed by an appropriately trained medical professional, to address the growINC. ing prescription opiate problems surfacA REGISTRY & PLACEMENT FIRM ing in primary care medical facilities in San Francisco (Hersh et al 2011). These and other innovations in addiction treatment will need to be integrated into the health care system of the future, given Nurse Practitioners ~ Physician Assistants that substance abuse in all of its manifestations represents our country’s numberone public health problem. The merger of the Haight Ashbury Free Clinics and Walden House demonstrates that San Francisco remains on the cutting edge of innovation and integration of medical substance abuse and mental health services, serving as a model for the health care system of the future in the United States. Locum Tenens ~ Permanent Placement
Tracy Zweig Associates Physicians
V oi c e: 800-919-9141 or 80 5 - 6 4 1 - 9 1 4 1 FA X : 805-641-914 3
tzweig@tracyzweig . c o m www.tracyzweig.c o m
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San Francisco Medicine March 2012
David E. Smith, MD, a graduate of UCSF Medical School, was founder of the HaightAshbury Free Clinics in 1967, is a past-president of the American Society of Addiction Medicine, a clinical professor at UCSF, and a long-time member of the SFMS. A full list of references is available online at www.sfms.org/archives. www.sfms.org
SFMS Annual Dinner More than 160 attendees participated in the SFMS Annual Dinner at the Concordia Argonaut Club on January 19. Peter Curran, MD, board-certified cardiologist from St. Mary’s Medical Center, was installed as the 2012 SFMS President. SFMS would like to thank our members, sponsors, and special guests Supervisor David Chiu and Dr. Anthony Iton of the California Endowment for their support of this event and the medical society.
2012 Officers left to right: Lawrence Cheung, MD (treasurer); George Fouras, MD (immediate past president); Peter Curran, MD (president); Jeffrey Beane, MD (secretary); Gordon Fung, MD (editor), and Shannon Udovic-Constant, MD (president-elect)
Judy Silverman, George Fouras, and Anne Fouras
Amy Whittle, Arti Desai, and Jennifer Do
Hugh Vincent, Ed Chow, and Roger Eng
Janice Lee and Peter Curran
www.sfms.org
March 2012 San Francisco Medicine
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SFMS Annual Dinner Left: St. Mary’s physicians and staff with St. Mary’s President Anna Cheung
Below: Kristen Razecca and Steve Walsh
Dexter Louie, Joan Vincent, Rob Margolin, Hugh Vincent, and Eric Tabas
Supervisor David Chiu with SFMS Executive Director/CEO Mary Lou Licwinko 26 27
San Francisco Medicine March 2012
Dr. Mark Edmunds and his wife
From left to right: Mark Kono, Bill Kapla, David Hyman, Chuck Wibbelsman, and Michael Rokeach www.sfms.org
George Fouras (right) passes the gavel to newly installed 2012 President Pete Curran (left)
UCSF medical students with their sponsors
Supervisor David Chiu addressing the event attendees
SFMS President Peter Curran with Richard Podolin, Frank Charlton, John Umekubo
Keynote Speaker Anthony Iton, MD, JD, MPH
Perlman Award recipient David Pating, MD (right) and Editor Gordon Fung (left) www.sfms.org
Our thanks to the following corporate sponsors who helped make the 2012 SFMS Annual Dinner possible: Brown & Toland Physicians California Pacific Medical Center Chinese Hospital Chinese Hospital Medical Staff First Republic Bank Hill Physicians Medical Group Kaiser Permanente San Francisco Marsh Medical Insurance Exchange of California Northwestern Mutual Saint Francis Memorial Hospital St. Mary’s Medical Center UCSF Medical Center Special thanks to Saint Francis Memorial Hospital for providing meeting space and parking for the 2012 SFMS board meetings. March 2012 San Francisco Medicine
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Dr. David Young, MD reconstructive plastic surgeon
The san Fr ancisco Wound care and reconsTrucTive surgery cenTer aT s T. M a r y ’ s More than 152 years ago, eight Sisters of Mercy sailed to San Francisco with a few medical supplies and a plan: To cure suffering. Today, our plastic and reconstructive surgeons still use the same tools our founders used: The most advanced tools available in modern medicine. Their hands.
The MosT sophisTicaTed surgery. For more inFormaTion or To schedule an appoinTmenT, call 415-750-5535.
pressure ulcers • venous stasis & diabetic ulcers • radiation wounds • abdominal hernia & ostomy wounds • varicose veins • lymphedema • osteomyelitis • neuropathic pain and ulcers • post surgical wounds •
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San Francisco Medicine March 2012
www.sfms.org
SFMS Honors Two Local Organizations Receive Grant through the SFMS The San-Cop Foundation is a Danish family fund established by a wealthy man who, decades ago, had a positive experience with medical care while visiting San Francisco. For many years the foundation has provided grants to physicians and health organizations doing good work in our city and has asked the SFMS to nominate such worthy awardees. This year’s awardees each received $10,000. Financial Fitness Clinic at San Francisco General Hospital Forty-three million Americans—approximately the population of the 50 most populous U.S. cities combined—live in poverty. This number is climbing rapidly, up 11.1 million, or more than 30 percent, since the year 2000. Financial stress and economic determinants of health rival widely known risk factors for increased morbidity and mortality, such as poor diet, limited physical activity, and environmental toxins. Those living in poverty have a higher risk of hypertension, elevated lipid levels, hyperglycemia, obesity, chronic illness, and overall mortality, and an estimated 880,000 lives could be saved each year in this country by reducing income inequity. Yet physicians rarely have the tools or time to address financial hardship and poverty as root causes of poor health among their patients. In February of 2011, a handful of physicians from San Francisco General Hospital (SFGH) partnered with financial counselors to address this problem and provide their patients the economic resources they needed. The result was the Financial Fitness Clinic (FFC), a referral-based clinic at SFGH that provides patients in financial need the tools to address economic challenges that impact their health. The FFC includes one-on-one financial counseling, referral to dozens of money-saving services, and financial education to promote each patient’s financial and physical health. Each patient who attends the FFC creates a budget and develops a concrete financial action plan (similar to a written medical action plan, such as an asthma action plan) with the help of a personal financial counselor and trained FFC clinicians. Patients are encouraged to design their plan with a desired health outcome in mind. The FFC didactic curriculum teaches financial skills: effective budgeting, debt management, building credit, tax advice, and strategies for long-term savings. The FFC also provides each patient a list of tailored economic referral resources, and each patient is contacted for longitudinal follow-up. Since the first FFC session in February of 2011, patient attendance at the Financial Fitness Clinic has tripled, and most FFC patients report that they are learning what they’d hoped. For clinicians at SFGH, the FFC provides patients key financial tools and skills that address the economic root causes of poor health. The San-Cop Award from the San Francisco Medical Society has made it possible for the FFC to take on new roles and better serve patients and providers at SFGH. With the help of the award, the FFC will be hiring new staff to more closely folwww.sfms.org
low up with patients from session to session and help them stay on track toward their financial goals. The award will help the FFC develop a portable medical-financial curriculum and tool kit for interested medical centers to use to help build their own financial health clinics. Finally, the San-Cop Award will help the FFC expand to build capacity and serve new sites.
Curry Senior Center
In the heart of the City, Curry Senior Center has been a leader and a lifeline to seniors for nearly forty years. Right in their own neighborhood, seniors can easily access a wide range of integrated services through Curry, from health care to housing to everything in between: It is comprehensive care in a single setting. Through its unique partnerships and personal approach, Curry creates a welcoming environment for a diverse group of people. Here, seniors can feel comfortable choosing the services they individually need and remain confident that their right to self-determination is respected. A dedicated team of geriatric experts partners with them as needed to navigate the route to the most appropriate care. At the center of Curry is its primary health care clinic— easily the envy of anyone. For those who cannot leave home, Curry’s medical staff even makes house calls—a kind of “high-touch” care that’s virtually unheard of in today’s hightech world. Another central part of Curry’s offerings is its homelike meals, served 365 days a year. And, just as at home, if someone is missing from the table, the absence is noticed. More than a medical provider or a meal site, Curry is a community—a place for those who long to belong. For individuals at a stage of life when isolation is all too common, Curry helps create social connections, so essential for healthy aging. Committed to serving all those who walk through its doors, Curry continues, undaunted, to tackle the complex challenges of aging. Each year, Curry offers services such as the following, serving 2,000 seniors in eight different languages: a primary health care clinic that sees patients by appointment, on a drop-in basis, or through house calls; breakfast and lunch for seniors every day of the year, plus meal delivery for the homebound; permanent housing for formerly homeless seniors; case management and counseling to assist with housing, appointments, benefits, translations, recovery, life skills, and in-home support such as help with chores; health education and social programs such as cultural events, walking groups, bingo, movie nights, and field trips. March 2012 San Francisco Medicine
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Let Us Help You Find Your Way to Meaningful Use Bay area providers have the opportunity to receive subsidized technical services to implement and effectively use an EHR. Space is limited and joining CalHIPSO is free through 2014 if you enroll by February 29, 2012. What are you waiting for? CalHIPSO Member Benefits and Resources Receive technical assistance with your EHR Implementation from CalHIPSO and a network of skilled professionals who can help you make informed decisions Access to CalHIPSO’s EHR Vendor Partner Program, which includes reduced pricing and pre-negotiated contract terms FREE HIMSS membership - a $160 value! Educational webinars on Meaningful Use, Privacy and Security, EHR Incentive Programs, REC membership & more! Technology product bundles - access to reduced pricing on hundreds of hardware and software products through PC Connection or CDW Discounted HIPAA Privacy and Security Compliance Program Tools through PrivaPlan High-level project management services Assistance with demonstrating Stage 1 Meaningful Use in order to begin receiving EHR incentive payments
For more information contact Kent Waldsmith, (510) 285-5745 or Kent@CalHIPSO.org www.CalHIPSO.org
Health Policy Perspective Steve Heilig, MPH
Scarier than Socialism?
Following the Health Care Money “Health care is a right, not a privilege.”—Founding motto, Haight-Ashbury Free Clinics, 1967 “Health Care Reform: Show Me the Money” was an apt title for the packed seminar copresented in February by the SFMS, Hospital Council of Northern and Central California, San Francisco Community Clinic Consortium, and University of San Francisco. The room was full of health care movers and shakers, and the keynote speaker, Harold Miller of the Center for Healthcare Quality and Payment Reform, delivered an impressive outline of “Win-Win Approaches to Payment and Delivery System Reform.” His basic message: Higher quality and lower costs are not necessarily in conflict, and, in fact, we can and must “reduce costs by improving care.” But attaining both will require closer and “more trusting” collaboration than ever before. Miller provided case studies in how better outcomes and skillful pricing can result in a better bottom line—while satisfying new imperatives for quality measurement. And all of this attained without dreaded “rationing” or even “death panels.” “There is enormous waste in our system, which could be saved without rationing, and everybody in this room knows it,” said Terry Hill, MD, vice president of Hill Physicians, on the panel after Miller’s talk. Nobody contradicted him. An elephant in the room was how much financial incentives contribute to that. “We pay today for treatment, not care,” observed Miller. He noted that although Medicare is by far the biggest cost, nobody will cut that due to the AARP. With “Accountable Care Organizations” now the primary prescription, panelist Dr. Bill Fera of Ernst & Young noted that “you actually can’t have a fee-for-service system in an ACO, so we’ll have to call it something else.” It was notable that the day before, giant United Health announced it was moving away from fee-for-service; also that health policy guru Ezekiel Emanuel just predicted that “the American health insurance industry will be extinct” by 2020. Another panelist, Kristen Miranda, vice president of Blue Shield, worried aloud, “Will we end up with a single-payer scenario years from now because we weren’t able to get it together?” Miller’s prescriptions for “getting it together” could be seen as an attempt to prevent just that scenario. Beyond that, at least three other “elephants”: The coming chronic disease explosion. As SFMS President-Elect Shannon Udovic-Constant noted during the Q&A
session, “More and more kids are developing serious adult problems—obesity, diabetes, and so forth. As a pediatrician, the model of me talking to them for a few minutes in my office is just not enough.” But some of these problems are no accident. Tobacco, junk food, and alcohol are aggressively marketed, especially to youth. Yet any move to force payment for these external costs via taxes is defeated. What if a strong coalition of doctors, nurses, hospitals, insurers, and patients got together to demand of the relevant industries (and our legislators) that it was time they ponied up their fair share? How about an “AARP” for everybody else? Who will provide the care? Many people will be newly insured, mostly by Medicaid —two million in California alone. Most will need primary care, and projections are that the shortage of primary care physicians is bad and getting worse. The pressure to use other clinicians is already heightening, but even that might not suffice. How can the many financial incentives against going into primary care be lessened, even reversed? “End of life” care: Estimates are that at least 20 percent of all health care dollars are spent in our final year of life. Maybe that’s appropriate, but consider that in other modernized nations, people in hospice settings—vastly cheaper than hospitals—spend an average of two months there. Here, it’s more like two weeks. Beyond the human denial of mortality and “medical optimism” about curing late-stage problems, could payment incentives have something to do with that? It’s an uncomfortable question. It will take a huge clinical and cultural shift to back off from our overly intensive end-of-life cascades of care, but that might be an effective win-win goal—both efficient and humane, and not a “death panel” in sight. Well, one can dream, right? And this final observation: National health care reform remains controversial on many fronts. But those most knowledgeable and supportive—even guardedly so—have done a fairly bad job of educating the public. Presentations like Miller’s show that reform sets up a regulated market system where everybody competes on both quality and cost. Health care providers have rarely really had to do that before. Perhaps that scares some people even more than “socialism.” Does that seem ironic? Steve Heilig, MPH, is associate executive director of the SFMS.
Physician/Hospital Partnerships Needed to Control Total Costs: Opportunities for Health Care Cost Reduction Hospitals and Specialists Improved Inpatient Care
Use of Lower-Cost Treatments
Reduction in Adverse Events
Reduction in Preventable Readmissions
Improved Prevention and Early Diagnosis
Improved Practice Efficiency
Reduction in Unnecessary Testing and Referrals
Reduction in Preventable ER Visits and Admissions
Primary Care Practices
www.sfms.org
All Providers Improved Management of Complex Patients
Use of LowerCost Settings and Providers
Lower Total Health Care Cost
Chart courtesy of Harold Miller, Center for Healthcare Quality and Payment Reform
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HOSPITAL NEWS KAISER
Veteran’s
CPMC
Robert Mithun, MD
Diana Nicoll, MD, PhD, MPA
Michael Rokeach, MD
For the past decade and a half, we have been strong proponents of providing “medical homes” for our Kaiser Permanente members. We have more than 100 primary care providers (PCPs) in San Francisco, and we divide our Department of Medicine into “modules” to create more intimate medical homes. Each module contains PCPs as well as supportive allied health care professionals (such as physical therapists, behavioral therapists, diabetes nurses and/or pharmacologists, nurse case managers) to meet the majority of our members’ needs—including complex medical and social needs. Nearly all our members are linked to a PCP. Each PCP oversees the care of members on his or her panel and uses powerful databases to report which members may need more attention for specific medical needs. We support that process through our Chronic Conditions program, led by internists and staffed by a multitude of medical professionals from pharmacists to medical assistants. Our electronic medical record assists us in meeting our goals and the members’ needs, in that we have the most important information available to us immediately and longitudinally. Members can access results and directly send and receive secure e-mails to and from physicians as well as other health professionals and staff. Our members can receive same-day specialty consultation, as we have instituted “p-consults” whereby a PCP can call a specialist in real time during a member’s visit. The specialist can then give advice directly, without requiring the member to make another visit to the medical center. Given our proximity to one another, the specialist can even see that member in person. We are increasingly using videoconferencing to provide a face-to-face specialty consultation at the medical center or in the comfort of the member’s home. Our future holds the promise of continuing to strengthen the bond between each member and his or her PCP, in conjunction with providing excellent care at the member’s module/medical home.
In 2010, in support of the VA’s Universal Health Care Services Plan to redesign health care delivery, San Francisco VA Medical Center (SFVAMC) implemented Patient Aligned Care Teams (PACTs). PACTs provide accessible, coordinated, comprehensive, patientcentered care. The teams include the primary care provider, RN, LVN, and clerk. Extended team members include, but are not limited to, the clinical pharmacist, social worker, dietitian, and mental health provider. In 2011, SFVAMC was one of five VA sites in the country to receive a $5 million grant to become a Center of Excellence in Primary Care Education, to teach primary care residents, nurse-practitioner students, and associated health trainees together in the multidisciplinary PACT environment. One of the goals has been to reduce patient travel by increasing telephone care and by using online secure messaging (e-mail). Additional goals include provision of sameday access to care, better care coordination, and improved continuity of care. SFVAMC also offers patients with chronic conditions (such as diabetes and hypertension) group care sessions.
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CPMC signed a joint venture agreement with Lucile Packard Children’s Hospital (LPCH) in January, formalizing a new collaborative relationship to broaden the specialty care available through CPMC’s pediatric programs. CPMC and LPCH are now working side by side to deliver some of the nation’s leading inpatient pediatric specialty care at our California Campus. To date, LPCH physicians have performed approximately fifty surgical procedures in general surgery and urology at CPMC. Many of these cases were complex and unusual, and the outcomes have been excellent. Additional specialties will be added in the near future, including orthopaedics and neurology. On January 1, Mike Cohill assumed the role of president of Sutter Health’s West Bay Region, taking over for Dr. Martin Brotman, who is now Sutter’s new senior vice president of education, research, and philanthropy. Cohill has been a part of the Sutter Health family for more than thirty years, holding positions as vice president at Sutter Health and CEO of Sutter Pacific Medical Foundation as well as taking senior leadership roles at Sutter affiliates in Sonoma County, the Central Valley, and the Sacramento/Sierra regions. Dr. Julia Adler has been appointed as chair of the Physician Wellness Committee. The Physician Wellness Committee offers confidential assistance to members of the CPMC’s medical staff who have personal or professional concerns. Referrals can be made from medical staff members, their families, other health professionals, and support staff. The confidential phone line is (415) 600-2736. CPMC’s Medical Clown Project was recently featured in the San Francisco Chronicle. Designed to help lift the spirits of patients at CPMC, this project is a collaboration between an elite group of clowns and the Institute for Health & Healing. The program serves children on the inpatient pediatric units, adult patients in the skilled nursing units, and both resident and outpatient participants in the Alzheimer’s program.
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HOSPITAL NEWS
In Memoriam
Nancy Thomson, MD
St. Mary’s
UCSF
Francis Charlton, MD
Michael Gropper, MD
The patient-centered medical home (PCMH) is a concept that has evolved over the past forty-five years, since the introduction of the term by the American Academy of Pediatrics. Primary care providers (PCPs) have aspired to provide essentially that service to their patients from the days of the horse-andbuggy house call. Key elements start with a personal physician responsible for providing, coordinating, and arranging for all of a patient’s health care needs and services integrated across a continuum of providers, at varied sites, encompassing all levels of care, with enhanced access via expanded hours and electronic/telecommunications. No problem, right? Unfortunately, as the base of medical knowledge has expanded exponentially, the breadth of most of our skills (even that of PCPs) has shrunken in the face of ever-increasing specialization. How many PCPs stay with their patients from home to office to hospital to ICU to skilled nursing to rehab to assisted living to hospice to the grave? While physical continuity is lost, we are kept abreast of our patients now via fax, phone, mail, and e-mail. Our patients are still being cared for, but it is more often than not by someone other than ourselves. The electronic health record (EHR) and health information technology (HIT) domains are predicted to not only enable but also to ensure connectivity, enhance quality, improve efficiency, and provide continuity of optimal standardized yet personal care to all of our patients. I’m all for progress, and our health care delivery system definitely needs to change in many areas, but this pie-in-the-sky idea that the PCMH hinges on HIT is fundamentally wrongheaded. HIT use will preferentially welcome the young, the educated, and the wealthy while impeding access to the poor, elderly, and mentally deficient. Some of our neediest patients need a no-tech solution.
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Adopting electronic health records (EHRs) and integrating them into practice work flows can improve coordination of care and patient safety, reduce duplicate tests, and greatly enhance quality of care. We’ve found this to be true at UCSF, where the use of EHRs continues to roll out across the institution, transforming how providers, staff, and patients exchange information. The system, called APEX at UCSF, is proving especially useful for our primary care patients, who can now send messages to their physicians, request appointments and medication refills, and view test results—all through APEX’s patient portal, UCSF MyChart. Offered in our primary care practices since April 2011, MyChart has greatly enhanced the ability of our physicians to care for their patients by creating a truly integrated record that includes input from them, their staff, their patient’s various specialists, and the patients themselves. Since its launch, more than 10,000 patients have signed on to MyChart. In the coming years, we hope to offer our patients ways to integrate their health monitoring devices, such as oxygensaturation monitors, directly into the system. Soon we will no longer need to keep certain patients in the hospital for monitoring but rather monitor them from their homes, remotely and securely. This example perhaps best illustrates how technology is becoming key to personalized patient care. In addition to increasing the continuity of care, APEX is also helping our patients feel empowered to help manage their own care and become more active participants in their treatment and recovery.
Herman Noah Utley, MD Dr. Herman Utley was born to Jacob Ulevich and Dina Wasserman Ulevich in Milwaukee, Wisconsin, on October 17, 1926. He passed away on February 1, 2012, at the age of 85. As a youth he was fascinated by rockets, which led to correspondence with physicist Robert Goddard, father of modern rocketry. This sparked an interest in science and electronics. At age seventeen, Utley enlisted in the United States Navy, acquiring a special interest in research and the development of radar. Dr. Utley finished medical school at the University of Wisconsin in Madison in 1951 and began further training at Michael Reese Hospital in Chicago. He later completed a fellowship at Harvard’s Beth Israel Hospital, where he met his wife, Joyce Miller. The couple moved to San Francisco and in 1956 Dr. Utley began a fifty-year career as an internist specializing in cardiology at Mt. Zion Hospital. With his broad scientific background, Dr. Utley created many life-changing devices throughout his medical career. These included the development of a pacemaker in 1958 as well as ambulance-to-hospital telemetry, enabling EMTs to transmit EKGs of their patients directly to the hospital, saving time in diagnosing a problem and starting treatment. A simple toy with a “movable picture” inspired Herman to invent the widely distributed “ABC’s of CPR” card, which cleverly showed “Airway,” “Breathing,” and “Compression” directions for performing CPR. He made numerous contributions to the medical world, including more than 300 researchbased publications in peer-reviewed medical journals. Dr. Utley served as chief of staff at Mt. Zion Hospital from 1983 to 1984. During his tenure there he initiated the Mt. Zion Traditions Committee and the Mt. Zion Alumni Association. Dr. Utley received a lifetime award for research and teaching and was recently granted professor emeritus status from UCSF. He is survived by his wife of fifty-seven years, four children, and four grandchildren. Scholar, teacher, innovative researcher, and longtime fan of the Cal Bears and the San Francisco 49ers, he will be missed by many who benefited from his intelligence, creativity, kindness, compassion, and insight.
March 2012 San Francisco Medicine
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In the News Long-Time SFMS Member Honored by UC Berkeley School of Public Health Long-time SFMS member Marcus A. Conant, MD, will be honored with the 16th Annual Public Health Heroes Award from the University of California, Berkeley, School of Public Health along with former president of Ireland Mary Robinson. Dr. Conant is an honored and respected pioneer, lecturer, physician, and outspoken advocate for people with HIV and AIDS. Among the first physicians to identify AIDS in 1981, he helped create one of the largest private AIDS clinics, was a founder of the San Francisco AIDS Foundation, and his work contributed to development of some of today’s top HIV medications. In 1989 he created The Conant Foundation, a nonprofit education foundation that provides patients, their caregivers, and the community with educational tools and information regarding diagnosis, treatment, and management of HIV/AIDS and other sexually transmitted diseases. Dr. Conant and the foundation have contributed to more than two dozen clinical trials involving many of today’s leading HIV medications. He continues his strong, passionate and uncompromising demands to give hope to all people with AIDS through state-ofthe-art treatment and the assurance they can live with dignity and respect. Dr. Conant has been an SFMS member since 1971 and a contributing author to San Francisco Medicine. For information about this year’s Public Health Heroes Awards ceremony at Hotel Nikko on March 21, please visit http://www.publichealthheroes.org.
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SFMS Meets with Local Legislators SFMS, represented by Drs. Peter Curran, John Maa, Andy Calman, and Edward Melkun, attended a January social event honoring newly elected San Francisco Mayor Ed Lee. SFMS took this opportunity to introduce Mayor Lee to the medical society and our work on public health and access to care issues. Our physician members were able to meet with Assemblywoman Fiona Ma, with whom SFMS has partnered on several projects including Hep B Free, and Supervisor Malia Cohen, a collaborator on the AMA-approved SFMS resolution on “crisis pregnancy centers” and the (lack of) service they provided. Assessor Phil Ting was also in attendance in support of Mayor Lee. Dr. Curran is pictured above (left) with Ed Lee (right).
SFMS Urges Pelosi to Repeal Medicare SGR
SFMS sent a letter to Representative Nancy Pelosi on January 13, 2012, to urge her to advocate for the repeal of the Medicare SGR (sustainable growth rate) formula. Here is the SGR letter to Representative Pelosi. Dear Congresswoman Pelosi: On behalf of the San Francisco Medical Society and its more than 1,000 members, I want to thank you for your steadfast support over the years for a permanent fix to the Medicare SGR problem. We know you are aware that the longer we postpone a permanent fix for the SGRs, the more expensive the correction becomes. We now urge you to reaffirm this commitment when the House meets this month to work out a budget deal. With each short-term patch, the scheduled cuts get steeper and the cost of payment reform grows. In 2005, the formula could have been repealed for less than $50 billion over ten years. Today, the ten-year cost is nearly $300 billion. In five years, the combined cost of short‐term patches and accumulated SGR debt will reach $600 billion. It is irrational to invest more taxpayer money to support a policy that is a proven failure. A two-year patch will cost $39 billion and increase the cost of future efforts to repeal the SGR by an additional $56 billion. It will increase the projected cut in 2014 to 36 percent. Furthermore, if allowed to continue, the SGR will require rapidly escalating amounts of politically challenging “pay‐fors” in the future to prevent additional cuts. On behalf of San Francisco physicians and their Medicare patients, we appreciate your steadfast work in finding a permanent solution to this problem. Sincerely, Peter Curran, MD, President of the SFMS The SFMS received letters from Pelosi, Boxer, and Feinstein in response to the SGR letter and the full response is posted on the SFMS blog, http://sfmedicalsociety. wordpress.com.
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San Francisco Medicine March 2012
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2012
You still need to make important decisions now about rising health insurance premiums. So what can you do? • Enroll in a qualified High-Deductible Health Plan and open a Health Savings Account. This provides significant premium savings that can help fund your HSA account. With individualonly coverage, you are eligible to contribute up to $3,100 to your account or $6,250 with family coverage, on a tax-deductible* basis (members age 55–64 are eligible to contribute another $1,000). • Investigate RAF Sales Health plans offer incentives through discounts off their risk adjustment factors (RAFs) for you to change health
plans. Instead of your medical rates increasing this year, we might be able to help you offset some of that increase. • Mercer Select HRKnowHow If you play a role in your medical group’s health care and benefit plan decisions, stay current on challenging issues. Access is included at no charge for all members who purchase group health insurance through Marsh. Includes: • News and analysis of important benefit issues. • Compliance Link tool to assist with health care and group benefit plan administration.
* Marsh and the Society do not provide tax, investment or legal advice. Please consult with your professional advisors for guidance on these issues.
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