May 2016

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

PUBLIC HEALTH

THE COMMUNITY AS PATIENT Zika Virus Health Care Access for Uninsured

Chronic Pain Management Pre-Exposure Prophylaxis Getting to Zero

Eliminating Traffic-Related Fatalities by 2024 We’ve moved offices! See inside for details.

VOL.89 NO.4 May 2016

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IN THIS ISSUE

SAN FRANCISCO MEDICINE May 2016 Volume 89, Number 4

Public Health: Community as Patient FEATURE ARTICLES

MONTHLY COLUMNS

10 Serving San Francisco: From AIDS to the ACA—Reflections

of Three Former Directors of Health

Jeffrey Hom, MD, MPH, with David Werdegar, MD, MPH,

Sandra Hernandez, MD and Mitchell Katz, MD

4

Membership Matters

7

President’s Message Richard Podolin, MD

15 The ACA Environment: Providing Health Care Access

to the Uninsured

Alice Kurniadi, MPH, and Colleen Chawla, MPA

27 Classified Ads

14 Zika Virus: An Overview for San Francisco Physicians

Cora Hoover, MD, MPH

18 Chronic Pain Management: Primary Care Burden to Public

Health Crisis—The CDC Responds

Joseph Pace, MD 20 Pre-Exposure Prophylaxis: Getting to Zero in San Francisco

Stephanie E. Cohen, MD, MPH, Susan S. Philip, MD, MPH, and

Tomás J. Aragón, MD, DrPH 21 A New Place to Better Serve

Alice Chen, MD

22 Vision Zero San Francisco: Eliminating Traffic-Related

Fatalities by 2024

Megan Wier, MPH; Ana Validzic, MPH; Leilani Schwarcz, MPH 25 Healing the Healer: Changing the Way We Understand

and Respond to Trauma

Kenneth Epstein, PhD, LCSW, and Emily B. Gerber, PhD

OF INTEREST

26 CMS Update

Ashby Wolfe, MD, MPP, MPH

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

9

Guest Editorial Tomás J. Aragón, MD, DrPH

28 Medical Community News 30 Upcoming Events

Announcement: We’re moving!

Please note that after May 31, 2016, the SFMS office and mailing address will change to 2720 Taylor St, Ste 450, San Francisco, CA 94133.

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Physicians Champion Bills to Increase Access to Care at Legislative Leadership Day More than three hundred physicians, including SFMS members, participated in CMA’s Legislative Leadership Day on April 13 at the State Capitol. The SFMS group, represented by leadership as well as at-large members, met with Senator Mark Leno, Assemblymember David Chiu, and Assemblymember Phil Ting.

The SFMS delegation focused on advocating for a package of public health bills that puts the focus on issues like the tobacco tax, closing loopholes in California’s assault weapons ban, and expanding access to primary care providers through increased funding for Song-Brown program. Photos and details from the event can be found in the June issue of San Francisco Medicine and on sfms.org.

SFMS Advocates for Public Health Protections to Help Prevent Diabetes, Heart Disease, and Stroke

SFMS joined the American Heart Association and other public health experts in a press briefing in support of World Health Day and San Francisco’s sugar-sweetened beverage warning label for advertisements legislation. The City’s warning label ordinance, endorsed by SFMS, is widely recognized as a consumer-friendly tool to increase health awareness and information. Supervisor Scott Wiener and Dean Schillinger, MD, from the UCSF Diabetes Center highlighted the importance of educating communities and consumers most negatively impacted by sugary drinks. SFMS was represented by board member John Maa, MD, and first-year UCSF medical student Brooke Rice.

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SB 137 Provider Network Directory Compliance On July 1, 2016, a new law will take effect that requires plans to ensure that physician directories are accurate and up-to-date. SB 137 includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payors’ networks.

To accomplish this, payors are required to contact providers in writing, electronically and by telephone. The payor must document the outcome of each attempt. If the payor is unable to verify the provider’s information, it may remove the provider from the directory and delay payment, but must first provide at least ten business days advance notice. The new law also requires physicians to do their part in keeping the information up-to-date. Specifically, the law requires providers to notify payors within five business days if they are no longer accepting new patients or, alternatively, if they were previously not accepting new patients and are now open to new patients. If a provider is not accepting new patients and is contacted by a new patient based on information found in the payor’s provider directory, the new law requires provider to direct the patient to the plan/insurer to find a provider or to the regulator to report a directory inaccuracy.

SB 137 requires physicians to respond to plan and insurer notifications regarding the accuracy of their provider directory information, either by confirming the information is correct or by updating demographic information as appropriate. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a provider group may terminate a contract with a provider for a pattern of repeated failure to update the required information in the directories.

CMS Announces Second Cycle of Medicare Revalidation

All Medicare providers and suppliers are required to revalidate their Medicare enrollment information under new Affordable Care Act enrollment screening criteria in an effort to prevent fraud within the Medicare system. Once a Medicare enrollment application is validated, it goes on a five-year revalidation cycle. Now that five years have passed since the ACA’s revalidation requirement took effect, the Centers for Medicare and Medicaid Services (CMS) is initiating a second cycle of revalidation requests. According to CMS, Noridian (Medicare Administrative Contractors for California) will continue to send revalidation notices two or three months prior to each provider’s revalidation due date.

SAN FRANCISCO MEDICINE MAY 2016 WWW.SFMS.ORG

What providers need to know: • If you have multiple reassignments/billing structures, you must coordinate the revalidation application submission with each entity.

• Noridian will send revalidation notices (either by email or mail) two or three months prior to the revalidation due date. When responding to revalidation requests, be sure to revalidate your entire Medicare enrollment record, including all reassignment and practice locations.

• If a revalidation application is received but incomplete, Noridian will contact you for the missing information. If the missing information is not received within thirty days of the request, the Medicare Administrative Contractor (MAC) will deactivate your billing privileges.

• If billing privileges are deactivated, a reactivation will result in the same Provider Transaction Access Number, but there will be an interruption in billing during the period of deactivation. This will result in a gap in the provider’s enrollment status with Medicare.

• If the revalidation application is approved, the provider will be revalidated and no further action is needed.

CMA and AMA Urge DOI to Oppose Anthem and Cigna Merger

In early April, the California Medical Association (CMA) testified before the California Department of Insurance (DOI), urging it to oppose the proposed merger of Anthem and Cigna.

“We are concerned with the impact of this merger on physicians and patients,” said Francisco Silva, CMA general counsel and senior vice president.

“We are concerned that this merger would compromise access to health care, health care quality and patient affordability.”

The American Medical Association (AMA) also sent representatives to the hearing to testify against the merger. “We oppose Anthem’s goal of dominating the California health insurance market by purchasing Cigna—the state’s sixth largest insurer,” said Henry Allen, AMA’s top antitrust attorney. At the hearing, CMA presented DOI with the results of a physician survey showing that eightyfive percent of California’s physicians are opposed to the merger of health insurance giants Anthem and Cigna. AMA noted that health insurer consolidation compromises the ability of physicians to advocate for their patients. In practice, market power allows insurers to exert control over clinical decisions, which undermines the patient-physician relationship and eliminates crucial patient care safeguards. Competition among health insurers, on the other hand, can lower premiums, enhance customer service, and spur innovative ways to improve quality while lowering costs. Patients benefit when they can choose from an array of insurers who compete for their business by offering desirable coverage at competitive prices. AMA also presented state regulators with an analysis that found the proposed Anthem-Cigna merger would run afoul of federal antitrust guidelines in highly-populated metropolitan areas across California.

Senate Passes Opioid Addiction Treatment Measure

In March, the U.S. Senate voted 94 - 1 to fund opioid addiction treatment for prisoners, to increase opioid abuse prevention efforts and to expand the availability of the anti-overdose drug naloxone (Narcan).The bill, known as the Comprehensive Addiction and Recovery Act (CARA), would increase opioid abuse and prevention education efforts, expand the availability of Narcan to law enforcement, identify and treat incarcerated individuals, expand drug take-back efforts, strengthen prescription monitoring drug programs, and create prescription opioid and heroin treatment intervention programs. The U.S. House of Representatives is also considering similar legislation. The House version of the legislation, which was introduced in February 2015, currently has ninety-two cosponsors (seventy-five Democrats and thirty-two Republicans). The House bill is still in committee, and none of the three committees to which it has been assigned has voted on it yet.

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May 2016 Volume 89, Number 4 Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Payal Bhandari, MD Arthur Lyons, MD Toni Brayer, MD John Maa, MD Chunbo Cai, MD David Pating, MD Linda Hawes Clever, MD SFMS OFFICERS President Richard A. Podolin, MD President-Elect Man-Kit Leung, MD Secretary John Maa, MD Treasurer Kimberly L. Newell, MD Immediate Past President Roger S. Eng, MD SFMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Director of Administration Posi Lyon Membership Coordinator Ariel Young

BOARD OF DIRECTORS Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Katherine E. Herz, MD Todd A. LeVine, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term: Jan 2014-Dec 2016 Benjamin L. Franc, MD Benjamin C.K. Lau, MD Ingrid T. Lim, MD Keith E. Loring, MD Ryan Padrez, MD Rachel H.C. Shu, MD Paul J. Turek, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Brian Grady, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

MAY 2016 SAN FRANCISCO MEDICINE

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PRESIDENT’S MESSAGE Richard Podolin, MD

Sugar As A Public Health Hazard On March 7, the Board of the San Francisco Medical Society voted unanimously to support a ballot initiative championed by Supervisor Malia Cohen that would levy a 1 cent per ounce tax on the distributors of sugar-sweetened beverages.

The revenue would go into the city’s general fund, so the measure can pass with a simple majority, but the measure mandates the establishment of an advisory committee that would make recommendations to the mayor and supervisors to fund programs aimed at reducing the consumption of these beverages in San Francisco and addressing their effects. A previous attempt to pass a 2 cent per ounce soda tax with the funds directed to support physical education and nutritional programs, sponsored by Supervisors Cohen, Mar, and Weiner, failed to get the 2/3 majority needed when tax revenues are targeted to a specific purpose but did receive 55.6% of the vote.

Two-thirds of adults and one-third of children in the United States are overweight or obese. One study found that for each 12-ounce soda children consumed daily, their odds of becoming obese increased by 60 %. Observational studies have associated the consumption of sugar-sweetened beverages with an increased risk of developing type II diabetes.

Approximately 40% of US adults already have some degree of insulin resistance, and it is projected that the same percentage will eventually develop frank diabetes. In California, patients with diabetes accounted for a third of all hospitalizations in 2011, and the average hospital stay for a patient with diabetes cost $2,200 more than for a patient without diabetes. The total cost for hospitalization of diabetic patients in California in 2011 was $17.3 billion - the majority paid by public insurance.

Representatives of the beverage industry assert that obesity and diabetes are the result caloric intake exceeding energy expenditure. Thus, they argue, it is unjust to single out sugar- sweetened beverages among other caloric sources for either taxation or warning labels. Sugar-sweetened beverages are the single largest contributor to both caloric intake and added sugar the American diet. But as two recent reviews document, the contention that calories from sugar are equivalent to calories from other sources is wrong. 1,2 A 20-ounce bottle of soda contains the equivalent of approximately 16 teaspoons of sugar. The average American drinks nearly 42 gallons of sweetened beverages a year, the equivalent 39 pounds of extra sugar annually. These beverages are sweetened with either sucrose, which is 50 % fructose (and 50 % glucose), or with high fructose corn syrup, which may contain up to 65% fructose, and there is considerable evidence from both basic science and clinical trials that fructose is particularly culpable in the development of type II diabetes and its complications.

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After absorption, fructose is nearly completely extracted by the liver in a first pass process. Hepatic glucose metabolism is catalyzed by phosphofructokinase, an enzyme inhibited by ATP and citrate. This allows regulation of the reaction according to the energy status of the cell. Fructose metabolism, in contrast, is rapid and relatively unregulated. This poorly regulated metabolism depletes hepatic ATP stores which may contribute to insulin resistance by decreasing the cellular binding of insulin and reducing the number of insulin receptors. In addition, fructose metabolism triggers hepatic de novo lipogenesis, increasing triglycerides and VLDL, and inhibiting hepatic fatty acid oxidation. These actions promote hepatic accumulation of fat, leading to hepatic inflammation and further insulin resistance. Free fatty acid release from the fructose derived VLDL can cause lipid accumulation in skeletal muscle cells, inducing insulin resistance in skeletal muscle as well. In response, pancreatic beta-cells increase insulin secretion and, over time, this can result in beta-cell dysfunction.

Fructose stimulates storage of calories in abdominal fat.

Compared to glucose, it causes less suppression of the appetite-stimulating hormone ghrelin, and both less stimulation of and greater resistance to the satiety hormone leptin. As a result, the calories consumed in sugar-sweetened beverages are usually in addition to, rather than in replacement of, other caloric intake.

The city of Berkeley led the way, passing a 1 cent per ounce tax on sodas in 2014. With this ballot initiative, San Francisco, (and Oakland, which is putting a similar measure before voters), could be the first major cities in the nation to proactively address this public health crisis.

Dr. Podolin is a cardiologist at St. Mary’s Medical Center where he has been chief of the medical staff and currently serves as vicechair of the Community Board. Connect with Dr. Podolin via the SFMS LinkedIn Group or send him an email at podolin@sfms.org.

References 1. Tappy, L., Lê, KA. Physiol Rev. 2010 Jan;90(1):23-46. doi: 10.1152/physrev.00019.2009.

2. DiNicolantonio, J.J., O’Keefe, J.H., Lucan, S.C. Mayo Clin Proc. March 2015;90(3):372-381. doi: 10.1016/j. mayocp.2014.12.019.

MAY 2016 SAN FRANCISCO MEDICINE

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GUEST EDITORIAL Tomás J. Aragón, MD, DrPH, Health Officer, City & County

Transforming Population Health Editor’s Note: The SFMS and the San Francisco Department of Public Health have worked together productively for over a century. This partnership became especially close during the tragic explosion of the HIV epidemic here a couple decades ago, and has continued regarding many health concerns and efforts.

For this public health theme edition, we asked our highest-ranking local public health physician to serve as a guest editor—for the first time in the 89 years of this journal. Dr. Tomas Aragon— our “local surgeon general’ as he aptly puts it—graciously and gladly agreed, and this is especially well-timed with the addition of a large cohort of new SFMS members from the health department’s widely-varied staff. So, thanks to Dr. Aragon, welcome to all new SFDPH members, and we hope all enjoy and learn from this issue! —Gordon Fung, MD and Steve Heilig, MPH

Welcome to the San Francisco Medicine issue on public health!

I am the health officer of San Francisco and director of the Population Health Division (public health services) of the Department of Public Health. By California law all counties have a physician health officer to exercise leadership and legal authority to protect and promote health. For each county, we are the appointed community doctor—your local “surgeon general.”

The Institute of Medicine defines public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.”1 More than the health of populations, population health is “a systems framework for studying and improving the health of populations through collective action and learning.”2 By systems framework we mean socioecological, complex adaptive systems. Transforming complex systems requires multilevel, cross-sectoral, and transdisciplinary efforts that are coordinated and aligned—what we call “collective impact.” We see this population health approach in the articles in this issue. The best in our City—all of us collectively—are “mobilizing people, organizations, and communities to effectively tackle tough public health challenges.”3 In this issue we cover emerging epidemic threats and challenges (Zika virus, chronic pain management with opioids), new approaches to old problems (Getting to Zero, Vision Zero, Trauma-Informed Systems), and updating our innovative health care access program (San Francisco’s Health Care Security Ordinance). Most of them use collective impact as an organizing principle. Collective impact is a framework to tackle deeply entrenched and complex social problems.

Organizations from different sectors come together to solve a problem using a common agenda, aligning and improving their efforts, and using common measures of success to WWW.SFMS.ORG

achieve significant and lasting change.

“Getting to Zero” (G2Z) is a citywide collaborative committed to getting HIV infections, deaths, and stigma to zero.

One new tool is pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. “Vision Zero” is a citywide collaborative mobilized to reduce pedestrian deaths to zero by 2024. Responding to the Zika virus epidemic will require a sustained local and global effort involving public health, health care, laboratories, vector control, and community-based organizations. Responding to the U.S. opioid epidemic will require a collective change in the prescribing of opioid medications for chronic pain management. The success and national recognition of San Francisco’s Health Care Security Ordinance has been possible by the commitment and collective action of our health care and political systems.

San Francisco is leading the nation in transforming health and human services agencies and organizations into “healing organizations” by providing training in “Trauma Informed System’s Principles and Competencies” (described in this issue). The trauma-informed lens not only recognizes the direct and indirect effects of trauma on communities, families and children, but also on our diverse staff that come from and serve these communities and clients. Trauma includes structural trauma from poverty, racism, and discrimination.

For children ages 0 to 5, we call the effects of trauma “toxic stress.” Toxic stress in children results in lasting changes in the brain, body, and behaviors into adult life resulting in decreased executive function (memory, judgment, selfawareness, and self control), higher risk behaviors (alcohol, drugs, sex, violence), and chronic diseases.4 Not only are the effects of toxic stress socially transmitted across generations, but recent research confirm that chronic stress causes chromosomal abnormalities that are transmitted from mother to child. Because of the national and global population health significance of childhood toxic stress, the White House, Bill & Melinda Gates Foundation, and UC San Francisco is convening a national conference on June 6th and 7th entitled “Precision Medicine and Public Health: Harnessing big data to improve health and health equity during the first 1000 days of life.”

The population health framework provides public health and health care practitioners a unifying framework for partnering to protect and improve the health of our patients, our communities, and our staff. The San Francisco Medical Society is a national leader in promoting population health strategies to transform our communities and health systems. We look forward to bringing more of these inspiring stories in future issues.

A full list of references is available online at www.sfms.org.

MAY 2016 SAN FRANCISCO MEDICINE

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Public Health

SERVING SAN FRANCISCO From AIDS to the ACA: Reflections of Three Former Directors of Health Jeffrey Hom, MD, MPH, with David Werdegar, MD, MPH; Sandra Hernandez, MD; and Mitchell Katz, MD “San Francisco has had a culture of using science and using evidence, making good policy decisions and continuing to try to get everybody into care. You work with great people who have a commitment to the public good. You do it under the spotlight of everybody and everything, and you’re trying to allocate limited resources to the best and highest need. It was a great job.”

– Sandra Hernandez, MD

While support from elected officials is important, the success of health departments depends greatly on their leadership, and the vision, agenda and tone set by their directors.

Over the last several decades, the San Francisco Department of Public Health, often looked to from across the country as a pioneer in public health initiatives, has been led by courageous and dedicated health directors. Three of them generously contributed their thoughts to this article.

David Werdegar, MD, MPH

What attracted you to public health and public service?

I was attracted to public service as an undergraduate at Deep Springs College, a remarkable school in eastern California.

The school’s mission is to educate students for a lifetime of service. It was a formative experience that influenced all my subsequent career directions.

I entered medical school with a sense that Medicine embodied the social sciences as much as the physical sciences, and that health services would have to call on both. Residency training at UCSF oriented me toward interest in primary care, and later, as a faculty member, to an increasingly broad conception of health care. An early sabbatical spent at the School of Public Health in Berkeley gave valuable perspectives. Eventually, I wound up serving as the founding chair of a new Department of Family and Community Medicine at UCSF, whose academic responsibilities concern health care in context of family, culture, and community.

Continuing development of that department would have fulfilled many of my long-held career aspirations. However, in late 1984, I was asked by then-Mayor Diane Feinstein to serve as head of the Public Health Department in San Francisco, which is what I did for the next six years. Those were the earlier years of AIDS, and organizing an effective community-wide response to the epidemic was the dominant public health imperative.

What are you most proud of accomplishing during your tenure at SFDPH? 10

Looking back, I am pleased that I was able to serve in a leadership role in public health at a time of great need. I knew the community well—at least I thought I did—and I felt I could use all my training and experience, familiarity with local health care institutions, and many professional relationships to special advantage. To an extent that was true, but I underestimated the magnitude of the task. A lot of on-the-job learning was necessary.

These were some of the most important accomplishments: We were able to involve all sectors of the health care community, and really the community at large, in a massive collective endeavor to care for those with HIV and contain the epidemic.

The work was accomplished in a close collaboration with the gay community, and with significant, creative involvement of a myriad of community-based organizations.

A network of community-based primary care health centers was needed to help reach many in the city who lacked access to care. An important accomplishment was the conversion of antiquated public health clinics into comprehensive primary care centers, with linkage to San Francisco General.

I should mention one important political accomplishment: As the consequence of a long overdue ballot measure, in late 1984, the Health Department became a department reporting to the Mayor, with a Commission, similar to the Police Department, Fire Department and other key units of the city’s operations. Previously, the Health Department reported to the city’s Chief Administrative Officer, where it was largely hidden from view. Mayor Feinstein appointed a distinguished Commission, whose members reflected the diversity of the city. I was appointed Director at that same time. Thereafter, all of the Health Department’s activities would be reviewed in public, by a very knowledgeable Health Commission, and with opportunity for public comment. I take no credit for this, except that one of my first responsibilities was to help launch the new Commission and present its first Director’s report.

What lessons did the position teach you and how did you apply them after leaving the department?

I learned that public health is not easy work. There are a lot of forces at play. When immersed in it, one becomes more aware of all the social factors that impinge on the health and wellbeing of the community—many of which, of course, lie beyond the immediate province of public health. But I found that the voice of public health carries great weight. It is a respected voice in the community, and can promote constructive change beyond its borders.

I developed great admiration for those who work in public health, in all categories, and for their sense of commitment to its mission. I developed enhanced appreciation for the contri-

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butions of community-based non-profits, without whose help public health could not effectively reach all sectors and all the populations it must serve.

I became much more fully aware that public health work occurs in the public arena. While we seek and hope for enlightened government policies for benefit of the public’s health, there is no substitute for the political savvy and skills necessary, in the process, to move the body politic in that direction.

What’s next for public health in SF and California?

I foresee a “golden era” for public health in San Francisco.

I believe the accomplishments of the Health Department, over the years, have gained widespread community support for its work. I believe it will be a pacesetter in urban public health looking forward. But it will have always to guard against attitudes that are unfriendly to public sector involvement in the affairs of the community.

We have a world-class Health Department in San Francisco.

Few local departments of health can match its size, scope of responsibilities, range of services, facilities, experience, or depth of staffing. It has a remarkably close, mutually beneficial affiliation with a leading health science university. All told, it has enormous firepower for benefit of the commonweal. The challenges for SF Public Health will be to cope successfully, and take leadership in dealing with the many new stresses, dislocations, and disparities of an intensive urban environment.

David Werdegar, MD, MPH, was the Director of Health from 1985 to 1991. Now semi-retired, he continues to serve on the boards and committees of health organizations across California.

Sandra Hernandez, MD What attracted you to public health and public service?

We’re all a product of our time in history. I’d always had this interest in public health, and when I got out of my residency at UCSF in 1987, I had this incredible opportunity. Dr. George Rutherford, then the Director of the AIDS office in the health department, asked me to work with him. Our goal was to fund community clinics and think about what an optimal care delivery system would be for HIV infected patients. It was a unique time in the history of medicine. The health department had an AIDS office that had an extraordinary esprit de corps. A lot of the work there was to educate clinics to think about screening people, to think about high-risk behavior, and to begin to put in place protocols for early intervention, disease surveillance, and reporting. That got me interested in designing community-based programs like needle exchange. At that time, needles could only be legally available via prescription. Yet, we knew that needle exchanges could significantly reduce HIV and Hepatitis. We had the opportunity to prevent HIV from spreading in injection drug users, their sexual partners, and their children.

My early days in public health were in the midst of an epiWWW.SFMS.ORG

demic that wasn’t theoretical. They weren’t just numbers. That very much influenced my view of the role of the public sector.

We would go to the Board of Supervisors every Friday and report on all data we had from our surveillance unit in the office, and based on that data, they declared a public health state of emergency. Under that state of emergency we were able to provide a legal means of funding and distributing needles into the community. If you think about data, the role of government, how to use rules and regulations to do the right thing, that single act, I think, probably saved thousands and thousands of HIV infections in women and children. We had the data. We put the data together in reports that were compelling. We used the rules and regulations of a public health officer to declare a state of emergency. And then we did something that was edgy and important and risky to do, but that saved lives and reduced incidence of liver disease and other injecting drug user (IDU) related conditions. We had a lot of support from all kinds of folks, but that is as good an example of public health that I could ever really describe from a first-hand perspective. We did a lot of things, but this is one that exemplifies for me how important the nexus of public service and public health is to maintaining health of populations.

What are some of the things you’re proud of accomplishing during your tenure at SFDPH?

When Pete Wilson was governor, he had a very anti-immigrant agenda. Early on when I was Director, he issued an emergency regulation that would have discontinued prenatal care for undocumented women in California. I remember going to the mayor’s office and saying, “The governor has issued this emergency declaration. I want to meet with the OB/GYN docs and pediatricians, and I think we should try to stop the state from doing this.” And so we did. We organized a statewide coalition, compiled a large body of science and evidence that argued for prenatal care, and stopped the governor’s attempt to eliminate prenatal care for undocumented women. That was an amazing experience.

At that time, the state was also in the very early years of moving the Medi-Cal population into managed care. One of the important bodies of work that I spent much of my time and energy as Director was creating the San Francisco Health Plan, the Medi-Cal local initiative for San Francisco, and putting together its governance and financing. That health plan became the backbone for Healthy San Francisco. It was important because the county hospital had a very large Medi-Cal population, but also a very large uncompensated care population. The creation of that health plan and getting it qualified to be able to take on the Medi-Cal population for San Francisco was a very important for low-income patients, as well as for the safety-net system of care in SF. Lastly, we as a county had been spending an exorbitant amount of money to house seriously mentally ill adults in out-ofcounty facilities. A bond initiative was passed that enabled us to build a state-of-the-art mental health facility right next to Ward 86 at San Francisco General Hospital. That was really one of those extraordinary opportunities, because there was an “out of county, out of mind” mentality, and we brought those patients back. The facility got built on budget, on time, was state-of-the-art, and to-

Continued on the following page . . .

MAY 2016 SAN FRANCISCO MEDICINE

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Serving San Francisco Continued from previous page . . . day continues to provide a significant amount of access for seriously mental ill patients when they need acute hospitalization.

What lessons did the position teach you and how did you apply them after leaving the department?

Public service created for me, being in philanthropy for close to eighteen years, a real appreciation for how important the public sector role is in health and health care. In philanthropy, you are using what would have been tax dollars to try to make government more accountable, improve services, innovate and evaluate new programs, and make meaningful changes in the use of public resources. It’s highly valuable to have worked inside the system and to understand all the levers there are for change, but also all of the constraints that people who are doing public service are trying to manage day-to-day.

The move to philanthropy and to the San Francisco Foundation was influenced in many ways because of the work that we did with Ryan White. Quite a bit of what we did there was to regrant federal dollars to not-for-profits that were serving people with HIV disease, whether it was mental health, peer support, food programs, or housing programs. That was really where I learned about the role of different sectors in solving problems: nonprofit, government and investments, financial models—all were very helpful for moving into the philanthropic sector.

What’s next for health care in California?

The passage of the ACA two years ago was another extraordinary moment in the history of medicine and health policy. The opportunity to come to the California HealthCare Foundation—a statewide foundation which had been so integral to California’s effort to ready the State for the expansion of MediCal, and for the launch of our statewide exchange Covered California—seemed one not to miss. In some ways, I have been working my entire career on making the MediCal program a mainstream, high quality, high value program. Ok, we’ve got all these people now who are newly insured. How do they become advocates for the care they are entitled to receive, how well does the system manage and meet their needs holistically, how good is their access to primary/specialty care, and how do we improve quality and reduce cost now that we have almost everybody in the coverage tent?

Finally, we get national health care reform, and now we need to make it affordable to use and sustainable financially. We need to leverage technology, we need to make sure that every licensed clinician is working at the top of their license; we must break down access and language barriers. This is a time of immense change within the healthcare delivery system, as payment methods change from reimbursing by volume to reimbursement for value. There is a lot yet to do to make the care delivery system work for everyone, especially for low-income families throughout California. The California Healthcare Foundation team and I look forward with urgency to the journey ahead.

Mitchell Katz, MD What attracted you to public health and public service?

I was attracted to the SFDPH initially because of the amazing response of the Department to the AIDS crisis. I began in 1991, which was among the darkest years of the epidemic in terms of the numbers of deaths, but the AIDS office, where I began as the head of research under Sandra Hernandez, was an amazing place filled with people who were working all hours of the day and night to make a difference.

What are you most proud of accomplishing during your tenure at SFDPH?

I am most proud of the creation of Healthy San Francisco.

What really distinguishes the program from others is that it enrolled people regardless of income, immigration status or preexisting conditions. It pulled the public and the private sector together. I used to get fan mail from parents across the country who were so happy that their children were covered because they lived in San Francisco.

What lessons did the position teach you and how did you apply them after leaving the department?

The strongest lesson I learned was that just because someone tells you that what you want to do will not stand up in court—if it is the right thing—push forward anyway. There were people who believed that the public funding of needle exchange, the employer spending requirement of Healthy San Francisco, and the prohibition of sale of tobacco in pharmacies would not stand up to legal review. We were never challenged on the funding of needle exchange, and California has since removed its anti-paraphernalia laws. In the case of the employer spending requirement and the ban of the sale of tobacco, we were challenged in court but we ultimately prevailed.

What’s next for public health in SF and California?

There has been excellent work elucidating the tremendous disparities in health outcomes across SF, California, and the U.S. There needs to be more work on how to eliminate those disparities.

Mitchell Katz, MD, was the Director of Health from 1997 to 2010. He is currently the Director of the Los Angeles County Department of Health Services. ***** Jeffrey Hom is a fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at the University of Pennsylvania. A native San Franciscan, he completed his internal medicine-primary care residency at UCSF in 2014.

Sandra Hernandez, MD, was the Director of Health from 1994 to 1997. She is currently the President and CEO of the California HealthCare Foundation.

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MAY 2016 SAN FRANCISCO MEDICINE

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Public Health

ZIKA VIRUS An Overview for San Francisco Physicians Cora Hoover, MD, MPH Zika virus is an arbovirus of the genus flavivirus that was first discovered in Africa in the 1940s, and likely

circulated at low levels in Africa and Southeast Asia for decades before emerging to cause significant outbreaks beginning in 2007. Zika virus has spread rapidly in Latin America since 2015, affecting thirty-three countries and U.S. territories as of March 22, 2016. Several Pacific Islands and Cape Verde are also currently experiencing local transmission. Zika is spread to people primarily by the bite of an insect: the Aedes mosquito. Sexual transmission by men to their partners and intrauterine transmission are additional mechanisms of concern for Zika virus. Zika virus disease is generally mild, involving fever, rash, conjunctivitis, and joint pain.

The majority of infected individuals are asymptomatic.

As of April 13th, 2016, three hundred fifty-eight travel-associated cases of Zika virus infection have been diagnosed in the United States, and as of April 15, thirty-four cases have been diagnosed in California. Most of these cases involved travelers returning from Zika-affected countries who tested positive for the Zika virus, but a small proportion of these cases resulted from transmission by a returning male traveler to a sex partner.

In late 2015, Brazil noted an increase in microcephaly cases associated in time and place with the Zika epidemic. Zika virus has been identified in fetal and placental tissues of affected fetuses and neonates, and abnormal ultrasound findings were noted in twenty-nine percent of women known to have symptomatic Zika virus infection during pregnancy in a small Brazilian study.

Besides microcephaly, Zika virus infection during pregnancy has been associated with ocular malformations, intracranial calcifications, intrauterine growth retardation, spontaneous abortion, and stillbirth. A high quality retrospective study of microcephaly in French Polynesia, where Zika virus transmission was widespread during 2013-14, posited an approximate risk of one in one hundred for microcephaly if the mother was infected prenatally. Much remains to be understood concerning the epidemiology and biological mechanisms of birth defects associated with Zika virus.

Zika virus infection has also been associated with GuillainBarré syndrome, with a case-control study of the French Polynesia Zika epidemic revealing a risk of 2.4 per ten thousand infected individuals. Although Guillain-Barré syndrome appears to be an uncommon sequela of Zika virus infection, the widespread transmission of Zika currently occurring in Latin America has led to large numbers of Guillain-Barré diagnoses in Zika affected countries.

The Aedes mosquito that transmits Zika virus is currently found in limited areas of the United States, especially in southern states with year-round warm weather, and has been detected in several communities in California. There has been no local transmission of Zika virus by mosquitoes in the United States thus far, though health officials anticipate that sporadic locally transmit14

ted cases may occur, especially in areas such as Texas, Hawaii, and Florida that have previously experienced limited local outbreaks of dengue virus transmitted by Aedes mosquitoes. Although the potential range of the Aedes mosquito in the United States is extensive, the United States is likely not at risk for large Zika virus outbreaks.

In light of birth defects associated with maternal Zika virus infection, the Centers for Disease Control (CDC) has issued travel advisories for pregnant women and guidance to prevent sexual transmission. Currently, pregnant women are advised not to travel to countries or territories where Zika virus is circulating. If travel is unavoidable, pregnant women are advised to take strict precautions to avoid mosquito bites. Men who have traveled to Zika-affected countries and who have pregnant partners are advised to use condoms or abstain from sex during the entire pregnancy. Because virus may persist in semen for weeks to months after symptomatic infection, returning male travelers who have had symptoms consistent with Zika are advised to use condoms or abstain from sex for six months before attempting conception. Men who have not had symptoms of Zika virus infection and all women (symptomatic or asymptomatic) are advised to wait for eight weeks after returning from a Zika-affected country before attempting conception.

Prenatal care providers should offer Zika virus testing to their pregnant patients who have traveled from Zika-affected countries. Testing is recommended for pregnant women who have had a clinical illness consistent with Zika disease within two weeks of potential Zika exposure. Zika testing can be offered to asymptomatic pregnant women who have traveled from a Zika transmission area or who had unprotected sex with a male partner who had Zika symptoms during travel or within two weeks of return. Zika testing may also be requested for symptomatic nonpregnant patients with potential exposure to Zika virus. Depending on the timing of testing and the clinical scenario, Zika testing may include polymerase chain reaction (PCR) and/or immunoglobulin M (IgM) serology. These tests are run at the California Department of Public Health Laboratory in Richmond, CA. Detailed instructions for specimen submission for San Francisco providers are found here: http://www.sfcdcp.org/zika_providers.

Cora Hoover, MD, is the Director of Communicable Disease Control and Prevention at the San Francisco Department of Public Health. She is a Preventive Medicine/Family Practice physician. A full list of references is available at www.sfms.org.

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Public Health

THE ACA ENVIRONMENT Providing Health Care Access to the Uninsured Alice Kurniadi, MPH, and Colleen Chawla, MPA In 2006, San Francisco passed the Health Care Security Ordinance (HCSO), which requires covered employ-

ers to make healthcare expenditures on behalf of their eligible employees. Employers could meet the HCSO expenditure by offering health insurance, providing employees with a Health Reimbursement Account (HRA; this option was later eliminated by the implementation of the Affordable Care Act), or contributing to the City Option Program. San Francisco’s innovative health access program, Healthy San Francisco (HSF), was formed as part of the City Option Program, providing access to coordinated health care regardless of employment, pre-existing conditions, or immigration status, and at low cost to participants. This pioneering approach to providing care to the uninsured and indigent helped put San Francisco ahead of the curve when the Affordable Care Act (ACA) passed in 2010 and implemented in 2014. For employees whose employers comply with the HCSO by contributing to the City Option, HSF-eligible employees are enrolled into HSF at a discount and non HSF-eligible employees (e.g., non-SF residents or those who have insurance through other means) are provided with a Medical Reimbursement Account (MRA), which employees can use to be reimbursed for a variety of eligible expenses.

Healthy San Francisco Program Updates

Since HSF’s launch on July 2007, 144,330 unique individuals have enrolled with the program, including 14,632 who were enrolled as of 12/31/2015. By empaneling uninsured patients through enrollment into a coordinated care delivery program, the program utilized a medical home model that focused on patients to engage in preventative and primary care to decrease avoidable emergency department usage, where many uninsured patients had become accustomed to seeking care. In FY 2014-2015, fortyfour percent of participants had an outpatient visit. This was a great achievement for individuals who had no other options for affordable access to health care services.

HSF reached a peak enrollment of almost fifty-three thousand participants in July 2013, shortly before implementation of the ACA’s Medi-Cal expansion and Covered California availability.

This high enrollment enabled San Francisco to effectively outreach to participants who were becoming eligible for Medi-Cal expansion and individual coverage through Covered California.

Since October 2013, the HSF program enrollment has decreased WWW.SFMS.ORG

by seventy percent to just over 14,600 through 2015. This represents a tremendous success of the program, as most disenrollments were due to individuals enrolling into either Medi-Cal or Covered California. This successful transition of patients to ACA coverage has changed the demographics of the HSF population.

The percentage of Hispanic participants has increased from twenty-eight percent in October 2013 to seventy-four percent in December 2015. Unlike ethnicity, income of those enrolled in the HSF program has remained relatively similar; fifty-six percent and sixty percent of all participants were under one hundred percent of the Federal Poverty Level (FPL) in October 2013 and December 2015, respectively. At the same time, the population who were in the twenty-five to forty-four age category has increased from forty-four percent to fifty-eight percent, respectively.

Several steps have been taken to address the challenges faced by the residually uninsured in San Francisco. Beginning in 2015, the program removed the age sixty-five limit so that seniors are now able to enroll if they meet all other eligibility criteria. The program also streamlined and simplified the process for employees to access their employer contributions. Currently, the five eligibility criteria are: • San Francisco Residency • At least eighteen years of age • Not enrolled in insurance for the last ninety days • Not eligible for any public full scope insurance programs • Living on a combined family income at or below five hundred percent FPL

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MAY 2016 SAN FRANCISCO MEDICINE

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The ACA Environment Continued from page 15 . . .

City Option Program Updates and new Bridge to Coverage Program At the same time, the HCSO continues to work in concert with the ACA to reduce barriers to participation in the ACA insurance options for covered employees. With the elimination of the standalone HRA under the ACA, employers have increased the use of the City Option program to satisfy the HCSO, with over 202,000 individuals receiving employer contributions from the program initiation through 2015. This has led to a dramatic increase of employees with active MRA accounts that can be used to cover costs such as insurance premiums and copays.

However, there continue to be many San Franciscans who are residually uninsured, either due to ineligibility for ACA coverage or unaffordability, even with the federal subsidies, due to the high cost of living in San Francisco. To improve affordability, in August 2015, the San Francisco Health Commission approved a San Francisco Department of Public Health (SFDPH) proposal to modernize the City Option to ensure that all low- and moderate-income San Franciscans have access to affordable health care.

The City Option Modernization includes two components: 1) allows uninsured residents who do not have affordable coverage options to remain in HSF despite their potential eligibility for Covered California insurance programs, and 2) creates the Bridge to Coverage Medical Reimbursement Account (Bridge to Coverage MRA) program, which is premium and cost-sharing assistance for eligible employees receiving employer contributions to the City Option.

The Bridge to Coverage MRA is expected to launch in late 2016, and will offer a benefit based on the eligible employee’s estimated cost of a Silver level plan on Covered California, as follows: • Premium assistance equal to sixty percent of their costs for premiums for the second-lowest cost Silver plan on Covered California, after federal subsidies are applied; plus • Out-of-pocket health care cost-sharing assistance that ensures that their Silver plan deductible is no more than five percent of their income.

Bridge to Coverage MRA eligibility is as follows: • Uninsured San Francisco resident • Receiving contribution to City Option under the HCSO • Eligible to purchase insurance on Covered California • Annual income <500% FPL

The modernization of the City Option is expected to increase the affordability of Covered California for approximately three thousand eligible city residents, and maintain the HSF safety net for those who are not eligible for the ACA or do not have affordable insurance options. These programmatic adjustments were informed by extensive research and planning, made possible by a generous grant from the California Health Care Foundation, through which SFDPH engaged the UC Berkeley Labor Center and Health Management Associates to identify the target population and to assess benefit design and administrative options.

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Alice Kurniadi, MPH, is a Manager in the Office of Managed Care overseeing the Healthy San Francisco Program at the San Francisco Department of Public Health. Colleen Chawla is Deputy Director of Health and Director of Policy and Planning for the San Francisco Department of Public Health.

SFMS Vaccination Public Service Announcement Featuring Musical Icon Graham Nash “Teach your children” is the title of rock legend Graham Nash’s most-loved song, and also of the new SFMS video wherein he urges parents to fully vaccinate their children. Mr. Nash, of “America’s Beatles” Crosby, Stills, Nash and Young, graciously offers his words and classic music for this 45-second public message, “I vaccinated my kids and they’re all brilliant!” he says.

Please enjoy and share this important message. See the video here: http://goo.gl/SKFd5D.

Antivaccine Film’s Real Scandals

This letter appeared in the San Francisco Chronicle, May 2: Regarding “Vaccine critics take case to film” (April 29): Mick LaSalle provides a carefully neutral review of the new film “Vaxxed” but potential viewers should have an informed view of who is behind this antivaccine effort. Director Andrew Wakefield not only had his fraudulent research supposedly linking autism to vaccines withdrawn, but was shown to be heavily invested in profiting from so-called alternative “cures” for autism and thus had his medical license revoked.

Another researcher in the film, Brian Hooker, also had his research withdrawn for both scientific and ethical reasons. So these are wholly discredited people playing on emotional reactions to the undeniable parental pain that comes with autism. As for the so-called government “whistle-blower” they feature, he actually said “I want to be absolutely clear that I believe vaccines have saved and continue to save countless lives. I would never suggest that any parent avoid vaccinating children of any race. Vaccines prevent serious diseases, and the risks associated with their administration are vastly outweighed by their individual and societal benefits.” So all should be aware that this film is not about science but science fiction. —Steve Heilig, San Francisco Medical Society MAY 2016 SAN FRANCISCO MEDICINE

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Public Health

CHRONIC PAIN MANAGEMENT Primary Care Burden to Public Health Crisis—The CDC Responds Joseph Pace, MD From 1999-2014, more than one hundred sixty five thousand people have died from prescription opioid overdose in the US—outstripping deaths from illicit substance

use. This trend mirrors the increased prescribing of opioid medications at high doses over long periods of time to treat chronic, noncancer pain (CNCP). Contributing factors include concerted efforts to answer concerns about the undertreatment of pain; aggressive marketing by pharmaceutical companies attesting to the safety of prescription opioids for long term use; escalating drug doses to address perceived tolerance to the drugs’ analgesic effect; lack of awareness of effective, non-opioid based pharmacologic treatments (e.g., select anticonvulsants and anti-depressants); and lack of access to effective non-pharmacologic treatments (e.g., cognitive-behavioral therapy (CBT)).

In March of this year, the Centers for Disease Control (CDC) responded to this crisis with a set of Guidelines for Prescribing Opioids for Chronic Pain.1 The document assesses the evidence regarding the risks and benefits of using opioids in the treatment of CNCP in the primary care setting (outside of the setting of end of life). The authors acknowledge that there is insufficient evidence in many areas to guide practice, and, where there is evidence, it is often only of fair quality. Yet the sense of urgency to reverse the trend in prescription opioid-related deaths, the authors believe, outweighs the desire for higher quality data to guide practice at this time.

So what does the CDC conclude from the available science when it comes to the use of opioids in treating CNCP (defined as pain lasting greater than three months or past the time of normal tissue healing)? The document assesses the clinical evidence in five areas:

1. Effectiveness: There is no evidence to support the effectiveness of opioids for long-term therapy (> 1 year) of CNCP when it comes to impact on pain level, function or quality of life.

2. Risk: Long-term opioid therapy is associated with a dose-de-

pendent risk of abuse and overdose. Overdose risk seems to increase dramatically at doses as low as 50 mg morphine equivalents (MME)/day with a hazard ratio as high as 3.73 in some studies compared to doses less than 20 MME/day. Additionally, there is some evidence pointing to increased risk of cardiovascular events when using opioids.

3. Dosing: There is inconsistent evidence about the risk of using extended release/long acting (ER/LA) formulations compared with immediate release (IR) dosing. When compared to extended release morphine, this uncertainty extends to the use of methadone for CNCP therapy with evidence pointing to increased overdose risk, lower overall risk of mortality and no risk difference.

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4. Risk Prediction and Mitigation: Available tools to as-

sess opioid abuse and misuse tools at the initiation of therapy (e.g., Opioid Risk Tool and Screener and Opioid Assessment for Patients with Pain-Revised) have low specificity and sensitivity. No evidence exists to guide the use of Prescription Drug Monitoring Programs (PDMP), opiate management plans, urine drug testing (UDT), pill counts or abuse-deterrent formulations in mitigating the risk of misuse, abuse or overdose.

5. Acute Pain: There is evidence to suggest that the use of opioids in treating acute surgical pain or pain related to trauma increases the likelihood of ongoing use at one year.

Ultimately, the document’s final recommendations are based on “contextual evidence” in the following areas:

Nonpharmacologic and Nonopioid Pharmacologic Treatments: In studies lasting up to six months, CBT, exercise,

and combined movement and behavioral treatments (compared to single modality therapy) reduced pain and improved function. In addition, the document refers to several other guidelines that indicate non-opioid analgesics (acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), COX-2 inhibitors); select anticonvulsants (gabapentin and pregabalin); and select antidepressants (tricyclics and serotonin norepinephrine reuptake inhibitors) as first or second line treatments. The potential harm of these medications (specifically, acetaminophen and NSAIDs) is considered to be substantially less than the risk of opioids.

Additional Data On Opioid Risk and Risk Mitigation:

Based on the review of additional studies not included in the clinical review, the authors take a firmer position on the disproportionate association of methadone in up to one third of opioid related deaths despite representing <2% of opioid prescriptions outside of opioid treatment programs. They also point to time-scheduled as opposed to as needed dosing of opioids leading to higher daily doses over time. Some additional risk factors for harm or overdose highlighted include: co-prescription of benzodiazepines, sleep apnea, renal or hepatic insufficiency, age > 65, depression, and substance abuse/ dependence.

When it comes to risk stratification, the authors suggest that PDMP and UDT, while not supported by clinical evidence, may help identify situations that are high risk for harm or overdose. They do, however, acknowledge the limitations of these tools including the cumbersome nature of using PDMPs and the potential for misinterpretation of UDT results potentially leading to inappropriate clinical decisions.

SAN FRANCISCO MEDICINE MAY 2016 WWW.SFMS.ORG

When it comes to risk mitigation, the authors extrapolate from the successes of naloxone distribution in community-based overdose prevention programs targeted to substance users in lowering overdose deaths as a potential strategy for decreasing overdose from prescription opioids. Finally, the authors found little to no evidence at this point to substantiate the concern that changes in opioid prescribing practices may lead to unintended increases in the use of heroin or illicitly obtained opioids.

Provider and Patient Perspective: Faced with the dilemma

of trying to address the increase in prescription opioid-related deaths in a setting of little to no high quality data, the authors review provider and patient perceptions about opioid therapy for CNCP. Providers are worried, frustrated, and lack confidence in addressing concerns about opioid risk with their patients. In turn, patients are concerned about “addiction,” report high levels of side effects, and are unsure about the overall benefit of opioid therapy when there is little else is available to treat their symptoms.

Cost: The authors point to the high direct and indirect costs of

prescription opioids including prescription expenses; costs of opioid-related overdose; and costs related to abuse, dependence and misuse compared with costs of non-pharmacologic and non-opioid based pharmacologic therapies.

Recommendations

When it comes to distilling the evidence into recommendations for clinical practice, here, too, the authors feel that the crisis regarding prescription opioid related deaths outweighs the lack of compelling, gold-standard level evidence.

Here is my take on the extensive recommendations:

Providers should have a systematic approach to opioid prescribing: proceeding with caution; identifying a clear and compelling indication to prescribe opioids; and being frank with patients about what we know about the risks and benefits of these treatments. After all, they are worried about the risks of opioids as well.

When providers choose opioids, they should be used at the lowest effective dose. While the guidelines stop short of naming a dose ceiling, the increase in overdose risk at > 50 MME/day is repeatedly mentioned. Furthermore, the recommendation is to avoid increasing dosage > 90 MME/day without clear and compelling justification. IR opioids are favored over ER/LA formulations at the start of therapy.

Methadone and transdermal fentanyl should not be first line choices.

The guidelines raise questions about the use of both ER/LA formulations along with as-needed IR dosing for so called “breakthrough pain.”

For those patients already at high doses, the recommendation is to review the evidence of increased risk and discuss tapering to a safer dose. When tapering, go slow, about ten percent per week, and allow for pauses in the taper if patients are experiencing withdrawal symptoms. Tapers may be accelerated if there is very high risk for overdose. Tapers are not necessary if there is compelling evidence of total diversion. Opioids should be used as part of a multimodal treatment strategy that includes evidence-based non-pharmacologic and non-opioid medications. Clear goals should be established at the outset for assessing risk and benefit of ongoing treatment, along with an “exit strategy” if risk outweighs benefit or if there is no benefit.

As risk of opioid misuse or overdose is hard to predict, providers should take a “universal precautions” approach to monitoring WWW.SFMS.ORG

and mitigation strategies that involve frequent and regular followup. Here the guidelines recommend follow-up within the first four weeks of start of therapy and at least every three months thereafter. In addition, the guidelines recommend checking the PDMP before the start of therapy and at least every three months thereafter.

UDT should be obtained before the initiation of therapy and at least annually thereafter. One final mitigation approach is the risk based co-prescribing of naloxone (e.g., history of overdose, history of substance use disorder, high opioid dosage (> 50 MME/day), concurrent benzodiazepine use, which should be avoided whenever possible).

When treating acute pain, the recommendation is limit opioids to three days or less, and not more than seven days in rare circumstances. If during the course of therapy, opioid use disorder is diagnosed, providers should offer or arrange for patients to access medication-assisted treatment with buprenorphine or methadone.

Commentary

Depending on one’s clinical setting, these guidelines may align to varying degrees with already established standards. More likely, though, is that current clinician practice varies greatly from these guidelines. As such, greater provider and patient education, awareness, and technical assistance may be needed to successfully transform the use of opioid therapy in CNCP treatment. As overwhelming as continuing to treat CNCP as we have been as a medical community is, changing practice may feel more overwhelming. This will take time.

After all, it took us almost twenty years to come to this point. Whatever you may think of the strength of the arguments for change in opioid prescribing practice, it is clear that change is here. In closing, I offer these thoughts and calls to action as a way to guide our way forward in a process that will overhaul the way we treat CNCP in the years to come—hopefully to the benefit of our patients and communities: • We want to advocate for payors and other stakeholders to support the creation of payment models to support evidence-based non-pharmacologic therapies.

• When we make a change in our practice, we want to be transparent with our patients about why we are making the recommendations we’re making.

• We want to reach out to our colleagues within our practices; acute, specialty and tertiary care settings; and other community stakeholders to craft a consistent, compassionate and comprehensive approach to pain management that focuses on safety and well-being.

• We don’t want to refuse to write another opioid prescription.

Despite the risks, there are still compelling indications for the use of opioids in treating CNCP. • We don’t want to make sudden changes in the treatment plan that leave patients feeling judged, blamed, abandoned, or mistrusted. After all, they didn’t create this problem. We need their trust and they need to know our commitment is steadfast in order for us to back out of this crisis together with the least harm possible.

Joseph Pace, MD, is San Francisco Health Network Director of Primary Care Homeless Services and Medical Director, Tom Waddell Urban Health. He is co-chair of the San Francisco Safety Net Pain Management Work Group. He also co-hosts City Visions, a “thinking person’s talk show” on KALW-FM public radio.

Reference Dowell, D.; Haegerich, T.; Chou, R. “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.” MMWR 65(1):1-49 MAY 2016 SAN FRANCISCO MEDICINE

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Public Health

PRE-EXPOSURE PROPHYLAXIS (PREP) Getting to Zero in San Francisco Stephanie E. Cohen, MD, MPH, Susan S. Philip, MD, MPH and Tomás J. Aragón, MD, DrPH The City and County of San Francisco (SF) was one of the first and hardest hit epicenters of the HIV epidemic. As of December 31, 2014, SF had 15,979 residents living with

HIV—thirteen percent of California’s living HIV cases. The good news is that new HIV infections are decreasing in San Francisco.

In 2014, multiple individuals and organizations, including the San Francisco Department of Public Health (SFDPH), established the multi-sector, independent Getting to Zero Consortium (G2Z), with the long-term goal of Zero HIV infections, Zero HIV Deaths, and Zero HIV stigma.1 The G2Z consortium is structured into four committees, each with representation from SFDPH, public and private medical care providers, the University of California San Francisco, communitybased organizations, other San Francisco government agencies, and persons from affected populations: 1. The rapid antiretroviral treatment (ART) committee focuses on initiation of antiretroviral therapy (ART) for newly infected persons as soon as possible after diagnosis. Treating individuals early in infection improves health outcomes and reduces onward HIV transmission.

2. The pre-exposure prophylaxis (PrEP) committee targets expanding and monitoring PrEP use. PrEP can reduce the risk of HIV infection by over ninety-five percent when taken daily.

3. The retention and re-engagement committee aims to ensure uninterrupted and sustained receipt of HIV medical care for all HIVinfected persons. Continuous engagement in medical care includes treatment for patients to achieve and maintain viral suppression, thereby improving health outcomes and survival for people living with HIV and reducing their risk of onward HIV transmission.

4. The committee on stigma and discrimination against people living with and at risk for HIV addresses the challenges faced by vulnerable populations with a focus on reducing barriers to HIV prevention, treatment and care.2 PrEP is an important new HIV prevention tool and a critical component of the G2Z strategy for ending the HIV epidemic in San Francisco. PrEP is an intervention in which HIV-uninfected persons at risk for HIV take one pill a day to prevent acquiring HIV. The medication currently approved by the federal Food and Drug Administration for PrEP is co-formulated emtricitabine/tenofovir (Truvada®). PrEP complements other proven HIV prevention options, such as reducing the number of partners, consistent use of condoms, needle and syringe exchange, and suppressing viral load through use of HIV medication among those who are HIV infected.

PrEP is a critical first-line intervention for individuals at greatest risk of HIV, including gay men and other men who have sex with men, transgender persons, persons who inject drugs, and others at high risk for infection. The experience of San Francisco clinicians who are already providing PrEP confirms that it is feasible for PrEP 20

to be provided by all health care providers as part of primary care.2,3 PrEP medication and clinical monitoring are covered by major private insurance programs, as well as Medicare, Medi-Cal and Covered California, though cost-sharing varies. Financial assistance may be available to individuals seeking PrEP, whether they have insurance or not. The Fair Pricing Coalition website has a concise summary of PrEP assistance programs.4 In February 2016, the first reported case of a breakthrough HIV infection in a patient consistently taking oral Truvada® as PrEP to prevent HIV was reported at the Conference on Retroviruses and Opportunistic Infections in Boston.5 The patient was infected with a strain of HIV that had several resistance mutations to multiple classes of antiretroviral medications. While such viruses are extremely rare, the case demonstrates that PrEP, like other preventive medications and behavioral interventions, does not provide one hundred percent protection against HIV infection. Nevertheless, the body of scientific and clinical data previously presented about the efficacy of PrEP confirms the game-changing role of this intervention in reducing new HIV infections.

Individuals taking PrEP should be tested for HIV at least every three months.6,7 Because rates of sexually transmitted diseases (STDs) are high among individuals taking PrEP, we recommend STD screening every three months for individuals who are using PrEP. This includes screening for urethral, pharyngeal and rectal gonorrhea and chlamydia (if the patient reports exposure at these sites) and for syphilis. All individuals who are being evaluated for PrEP should be asked if they have been exposed to HIV in the prior seventy-two hours, and if so, should be offered immediate post-exposure prophylaxis (PEP).

There are several resources available to San Francisco clinicians prescribing or considering prescribing PrEP

The SFDPH’s PrEP Navigation Program at SF City Clinic offers free technical assistance to providers and clients who have clinical or logistical questions about PrEP, and can provide training to individual providers or clinics in San Francisco.

For information and assistance, visit our website

www.sfcityclinic.org/services/prep.asp.

Contact Us E-mail: Robert.blue@sfdph.org or telephone: (415) 487-5537.

The national PrEP Clinician Consultation Line (855) 448-7737 or (855) HIV-PrEP is available Monday through Friday, 8 a.m. to 3 p.m. PST.

The Pacific AIDS Education & Training Center (PAETC) offers free technical assistance and training related to

PrEP and clinical practice: www.PAETC.org, e-mail: paetcmail@ucsf. edu or telephone (415) 476-6153.

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Stephanie Cohen MD, MPH is the Medical Director of San Francisco City Clinic and an Assistant Clinical Professor of Medicine in the Division of Infectious Diseases at the University of California, San Francisco. Susan Philip MD, MPH is the Director of the Disease Prevention and Control Branch of the Population Health Division of the San Francisco Department of Public Health, and an Assistant Clinical Professor of Medicine in the Division of Infectious Diseases at the University of California, San Francisco. Dr. Aragón is the health officer of San Francisco; director of the Population Health Division, Department of Public Health; and adjunct faculty at the UC Berkeley School of Public Health.

References 1. www.gettingtozerosf.org.

2. SFDPH, “HIV Annual Epidemiology Report 2014”. Available online at: https://www.sfdph.org/dph/comupg/oprograms/HIVepiSec/HIVepiSecReports.asp.

3. Volk JE, Marcus JL, Phengrasamy T et al. “No new HIV infections with increasing use of HIV pre-exposure prophylaxis in a clinical practice setting”. CID 2015; epub ahead of print Sept 1, 2015.

4. Marcus JL, Volk JE, Pinder J et al. “Successful implementation of HIV preexposure prophylaxis: lessons learned from three clinical settings”. Curr HIV/AIDS Reports 2015; in press.

5. www.fairpricingcoalition.org.

6. Knox, et al. CROI 2016, abstract 169aLB. 7. US Public Health Service. Pre-exposure prophylaxis for the prevention of HIV infection in the United States-2014: A clinical practice guideline. Available at: www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf 8. Pre-exposure prophylaxis: A primer for primary care providers. Available at: www.sfcityclinic.org/services/prep.asp#Providers.

Tracy Zweig Associates INC.

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REGISTRY

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A New Place to Better Serve Alice Chen, MD Early one fine May morning in San Francisco, beds (and the patients in them) will start rolling, a few at first, then more, then wave after wave of them. The staff of Zuckerberg San Francisco General (ZSFG) has come to appreciate what it takes to build a new hospital and open it for patient care. The city’s voters approved Proposition A in 2008, authorizing $887.4 million in bonds to pay for a new inpatient hospital.

Construction began, placing the new building in the center of a dense urban campus. A daunting task indeed. But what a thrill it has been to see the progress and keep the promise to our city. The beautiful, state-of-the-art facility is a breathtaking nine stories, seven above ground, of steel, glass and brick.

Licensed for 284 acute care beds, it offers interventional radiology, fourteen operating suites, emergency and trauma services, birthing, intensive care and acute care for everyone from neonatal to geriatric patients.

Ambulatory care—including primary, specialty, and diagnostic services—will remain in the existing main hospital building. Our new and improved campus will continue to serve the patients of the San Francisco Health Network, of the San Francisco Community Clinic Consortium, and of our Healthy San Francisco partners, as well as provide trauma care for anyone who is injured in the city.

While the voters paid for the building itself, the cost of the furniture, equipment and technology, approximately $170 million, was paid by a combination of private donations and additional city funds. The ZSFG staff is ready to welcome and treat San Franciscans in an extraordinary environment for generations to come.

Alice Chen is a primary care internist at Zuckerberg San Francisco General and the Chief Medical Officer for the San Francisco Health Network.

~ Physicians ~ Nurse Practitioners Physician Assistants Current Addiction Issues from Legalization to Medicalization DAVID E. SMITH, MD SYMPOSIUM | Friday, June 10, UCSF Mission Bay

Voice: 800- 919-9141 o r 805-641-9141 FAX: 805-641-9143 t zw eig @tracyzweig .co m w ww.tracyzweig .co m

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Learn from David E. Smith, MD and Other Leaders in the Addiction Treatment Community! Join David E. Smith, MD and other industry leaders for a one-day symposium on “Current Addiction Issues from Legalization to Medicalization.” Taking place on Friday, June 10th at the UCSF Mission Bay Conference Center, speakers will discuss an update on marijuana legalization initiatives in California, and an integrated health care approach to the opioid epidemic. Continuing Education Credits will be available. For information see: http://www.drsmithsymposium.com or email lmaguire@dominiondiagnostics.com.

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Public Health

VISION ZERO SAN FRANCISCO Eliminating Traffic-Related Fatalities by 2024 Megan Wier, MPH; Ana Validzic, MPH; Leilani Schwarcz, MPH

San Francisco, at just forty-nine square miles, is home to almost one million residents, a major employ-

ment center, and an international destination with world-class attractions. Every day over one million people travel throughout the city to work, attend school, shop or socialize with family and friends by foot, bike, transit, and car. San Francisco is one of the nation’s most walkable and bikeable cities, with the accompanying health benefits from physical activity.

However, approximately thirty people lose their lives every year in a transportation collision, and over two hundred people are seriously injured on San Francisco’s streets.1 Among these traffic fatalities, more than fifty percent are to people walking compared to fourteen percent nationally, and cyclist deaths have increased in recent years. Among comparable California cities, San Francisco ranks first (worst) for pedestrian, bicyclist, and motorcyclist collisions resulting in injury or death.2

Just twelve percent (one hundred twenty-five miles) of city streets account for over seventy percent of severe and fatal injuries.

The built environment, including the design of our transportation system, plays a major role in severe and fatal traffic injuries. High traffic volumes, high densities of people living and working, and wider, higher speed streets called “arterials” are established environmental risk factors for traffic injury collisions.3 Increased vehicle speeds kill—with a pedestrian five times more likely to die when hit by a vehicle traveling at forty mph compared to twenty-five mph. In neighborhoods like the Tenderloin, South of Market, and Chinatown, all of these factors in one area contribute to geographic disparities in injury concentrations, particularly to pedestrians.

These communities also have higher concentrations of lowincome, disabled, non-English speaking, and immigrant populations that rely on walking and transit for transportation. In San Francisco, seniors are five times more likely than younger adults to be fatally injured in a pedestrian injury. Children are also at risk for pedestrian injury due to their physical, developmental, and cognitive attributes depending on age. The annual medical costs alone of pedestrian injuries seen at Zuckerberg San Francisco General Hospital (ZSFGH) are $15 million, with the total pedestrian injury health-related economic costs estimated at a much higher $564 million a year.4 As San Francisco’s only Level I Trauma Center, ZSFGH is a critical partner in advancing Vision Zero on multiple levels, from providing the immediate clinical response to these incidents, to sharing important hospital data, as well as reporting on the bur22

den and health consequences of these crashes.

San Francisco needs safer streets for all people—including the most vulnerable, who are reliant on walking. While thirty percent of San Francisco’s streets are located in areas defined as Communities of Concern, half of the City’s high injury corridors are located in these communities. Communities of Concern include low-income communities, communities of color, seniors, and people who rely on walking and transit as their primary means of transportation.

A Common Agenda and Strategic Action

Vision Zero SF is a policy initiative adopted by the City to create a culture in which city residents, workers and visitors prioritize traffic safety, and ensure that people do not die or suffer serious injuries while using our streets. Vision Zero SF strengthens the City’s long-standing commitment to create a thriving, safe, and healthy city by implementing engineering, enforcement and education initiatives to prioritize safety— with a goal of eliminating all traffic deaths in San Francisco by 2024. This “safe systems” approach seeks to protect people from serious injury or death when a crash occurs by creating safe roads, slowing speeds, improving vehicle design, educating people, and enforcing laws to support safer road user behaviors. This multi-pronged approach has been effective in Sweden, where Vision Zero originated in 1997, and where traffic deaths have been cut in half since its adoption.

Interagency collaboration is at the core of Vision Zero SF. Agencies, departments, and elected officials across the city are working together to develop, fund, and implement effective strategies to save lives. San Francisco Municipal Transportation Agency (SFMTA) and the San Francisco Department of Public Health (SFDPH) co-chair the Citywide Vision Zero Task Force, with quarterly public meetings to support accountability attended by representatives from over a dozen city agencies, as well as community stakeholders such as the Vision Zero Coalition—led by Walk San Francisco and comprised of over forty community-based organizations from the most impacted communities. Eleven city agencies, councils, commissions (including the Health Commission), and the San Francisco Unified School District have adopted resolutions in support of Vision Zero.

Utilizing a data-driven process and following international best practices, Vision Zero SF is working to ensure that city resources are spent where they will have the greatest impact in creating safer streets. City Agencies are working to complete the actions detailed in the Vision Zero Two-Year Action Strategy, released in February 2015 and organized by traffic

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safety best practices focused on the “5 Es” of Engineering, Enforcement, Education, Encouragement, and Evaluation, as well as Policy. City staff report on progress on a quarterly basis to the Citywide Vision Zero Task Force, as well as to the SF Transportation Authority Board’s Vision Zero Committee, comprised of members of the Board of Supervisors. Progress to date on the focus areas include:

Engineering: The SFMTA, with its partners, including SF Department of Public Works (SFDPW) and SF Planning Department, is prioritizing safety improvements on the high injury network. Thirty projects were completed in twenty-four months and twenty miles of safety treatments were installed on the high injury network.

Enforcement: The San Francisco Police Department (SFPD) has implemented Focus on the Five, a citywide enforcement initiative that targets the five most dangerous traffic violations that contribute to traffic injuries and deaths. One third of total issued traffic citations were for these top five violations.

Education, Engagement: SFMTA and SFDPH are partnering on multiple traffic safety media campaigns, including an upcoming one on reducing speed. SFDPH leads the Safe Routes to Schools Program, educating schoolchildren and their families WWW.SFMS.ORG

about safe and active walking and biking, and recently launched Safe Streets for Seniors, a new program to reduce traffic fatalities and injuries to seniors and people with disabilities.

Evaluation and Analysis: SFDPH partners with other city agencies, including the SFMTA and the SFPD, to monitor progress regarding injury reduction targets, to evaluate effectiveness of efforts, and to conduct analyses to inform data-driven, evidence-based investments. SFDPH has deployed a data-driven approach to targeting traffic safety investments via an online, open-source analytics database called TransBASESF.org.

SFDPH’s identified the Vision Zero High Injury Network for targeted safety improvements, which is now being used by SFMTA, SFDPW, San Francisco Planning Department, and San Francisco Figure 1: Vision Zero County Transportation High Injury Network Authority (Figure 1).

12% of street miles* SFDPH and ZSFGH are Severe/Fatal Injuries: working with multiple • 70% People in Vehicles city agencies to de• 76% People on Motorcycles velop a comprehensive • 72% People Walking Transportation-related • 74% People Riding Bikes Injury Surveillance * non-freeway System to monitor

Continued on the following page . . .

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Vision Zero Continued from the previous page . . . transportation-related injuries and deaths in support of improving the City’s Vision Zero policy. This system will gather and link existing transportation-related injury and fatality data collected by city agencies, including police reports, hospitalization, emergency medical service, and Medical Examiner’s Office data into a comprehensive database, providing a more complete picture of transportation-related injuries occurring in the city.

This data system will vastly expand the City’s capacity to understand the geographic distribution, causes, costs, and consequences of transportation-related injuries in San Francisco.

Policy: In 2015, efforts were advanced in coordination with pedestrian and bicycle advocates, along with other interested cities, to seek a legislative sponsor for a state bill that would authorize a pilot for the use automated speed enforcement (ASE).

Draft legislation was developed, twenty-two letters of support/ resolutions from Boards and community groups in San Francisco have been received to date, and an ASE website was launched as part of communication efforts on this initiative.

In the coming years, the City will continue to coordinate to implement local strategic actions in partnership with local stakeholders, as well as increase its engagement with state agencies and other California cities to advance initiatives to save lives as Vision Zero initiatives gain momentum in California and the United States.5

Megan Wier, MPH, is Director of the Program on Health, Equity and Sustainability in the Environmental Health Branch at SFDPH, where she and her team develop and apply innovative approaches to using health data and evidence to inform safe, sustainable and equitable transportation and land use planning and policy in collaboration with local communities and government agencies. Ms. Wier co-chairs the San Francisco Citywide Vision Zero Task Force, and oversees comprehensive, collaborative data systems in support of evaluation, surveillance, monitoring and analysis of San Francisco’s data-driven, evidence-based transportation injury prevention initiatives.

Ana Validzic, MPH, has managed several active transportation and traffic safety programs at the San Francisco Department of Public Health since 2002. In this capacity, she coordinates various educational programs and encouragement activities focused on safe and active walking and bicycling, including Vision Zero and Safe Routes to School.

Leilani Schwarcz, MPH, is an epidemiologist in the Program on Health, Equity and Sustainability in the Environmental Health Branch at SFDPH, where she is spearheading efforts to develop a citywide comprehensive Transportation-related Injury Surveillance System to support the City’s Vision Zero policy. Leilani is also stationed part-time at the Trauma Center at Zuckerberg San Francisco General Hospital to utilize hospital and trauma registry data to analyze the burden of traffic injuries, factoring in cost and healthcare resources.

Reaching the goal of zero traffic fatalities requires strong partnerships between the clinical and public health worlds. Relationships between ZSFGH trauma surgeons and SFDPH epidemiologists provide Vision Zero with a unique foundation to assess patterns of injury severity to inform transportation-related prevention efforts.

For more information, please visit www.VisionZeroSF.org.

References 1. Vision Zero San Francisco. “Vision Zero San Francisco Two-Year Action Strategy” (2015). Online: http://www.joomag.com/magazine/ vision-zero-san-francisco/0685197001423594455?short.

2. California Office of Traffic Safety. “2012 OTS Rankings”. Online: http://www.ots.ca.gov/Media_and_Research/Rankings.

3. Wier M., Weintraub J., Humphreys E.H., Seto E., Bhatia R. “An area-level model of vehicle-pedestrian injury collisions with implications for land use and transportation planning”. Accident Analysis & Prevention. Jan;41(1):137-45 (2009). doi: 10.1016/j.aap.2008.10.001.

Epub 2008 Nov 4.

4. San Francisco Planning Department. “Walk First: Pedestrian Safety in San Francisco”. Online: http://walkfirst.sfplanning.org.

5. Vision Zero Network. Online: http://visionzeronetwork.org.

Cannabis in California: Science, Policy, Prevention, Profits, and Perils A new issue of the San Francisco-based Journal of Psychoactive Drugs has just been published, edited by David Smith, MD and Steve Heilig, MPH of the SFMS. It is most timely given this year’s likelihood of the legalization of cannabis in our state. For information, contents, and copies, see: http:// www.tandfonline.com/toc/ujpd20/current.

Public Health

HEALING THE HEALER Changing the Way We Understand and Respond to Trauma Kenneth Epstein, PhD, LCSW, and Emily B. Gerber, PhD As health professionals, we live during a time and in a place with unparalleled access to evidence about what is required for healthy development and well-being across the life span. And yet even with this understanding, the

gap between the science of healing and practice remains. Why is it so difficult for patients, practitioners, and service systems alike to make changes that improve our ability to prevent or ameliorate diseases that continue to disproportionately impact so many? It turns out that trauma is a likely barrier that can impede our ability to heal and be healed.

While the idea that something that happens in our minds may also impact our bodies is as old as civilization, a watershed study published in 1998 by Drs. Vincent Felitti and Robert Anda and their colleagues drew a clear empirical connection between childhood adversity (Adverse Childhood Experiences, ACEs) and long-term health consequences in adulthood (e.g., heart disease, cancer, stroke; Felitti et al., 1998). Most surprising was the high prevalence of ACEs in study participants (middle to upper-middle class patients), with nearly two-thirds reporting at least one ACE, and more than 12 percent of participants reporting four or more. We now know that the more ACEs experienced, the higher the risk for social, emotional and behavioral problems in childhood and adolescence and poor psychological and health outcomes in adulthood.

Clearly, childhood adversity is not only a “mental health” problem, but also a complex mind-body problem that needs to be addressed by multiple fields including medicine. Trauma is a pervasive part of human experience and histories, one that we all share. It’s something that can happen to a soldier in Afghanistan and to a family walking to a corner store in San Francisco. About 90 percent of us will experience a trauma at some point during our lifetimes, with exposure to multiple traumas as the norm. Clearly then, the prevalence and the lifelong consequences of trauma throughout the lifespan, is a clarion call-to-action to assure the conditions in which individuals can be healthy (Blodgett, 2012, citing IOM, 1988, 2002).

In San Francisco, we recognize that a new response is needed —a comprehensive, multi-level public health approach to the devastating effects of trauma on individuals, families, communities and service organizations. This includes tertiary, intensive, trauma-informed care for those who need it, as well as primary and secondary interventions that prevent trauma from occurring, promote health and well-being, and facilitate early recognition for at-risk populations. These interventions must then be translated to family and community level interventions that increase capacity and resilience.

However, similar to individuals, trauma also imperils the health of the systems providing this care. Ultimately, the effectiveness of our trauma interventions with families and communities may hinge in large part on our ability to counter its impact on our healthcare organizations and workforce.

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By infusing trauma-informed principles and understanding into day-to-day leadership and staff practices, policies and operations, the City of San Francisco is leading the nation by developing a traumainformed public health system that fosters wellness and resilience for everyone in the system. The Initiative has based its change efforts on the Trauma Informed System’s Principles and Competencies including: • Trauma Understanding • Cultural Humility & Responsiveness • Safety & Stability • Compassion & Dependability • Collaboration & Empowerment • Resilience & Recovery These six principles provide the framework for the foundational training curriculum as well as the starting place for considering our programs and policies, staff-to-staff and staff-patient relationships. Training is now underway with the entire DPH workforce (approximately nine thousand DPH employees), from clerks to providers to administrators, with the goals of creating a shared understanding and language about stress and trauma, as well as providing guiding principles and practical tools to support the DPH staff in working more effectively within the context of a chronically stressed and traumatized system. This “101” training is an important first step in a relationship-based systems change process that is being informed by implementation science.

However tempting it is to embrace training as the solution, it is never enough. Our initiative uses a multi-pronged approach to develop and sustain learning and change by utilizing the principles of implementation science to insure that knowledge is transferred into and sustained within actual structures, practices and supports. These include baseline and continuous evaluation of trauma’s impact on organizational and staff work life, commitment to change, embedded program champions to lead change efforts, development of growth and healing plans, policy alignment and regular consultation with subject matter experts, and those with lived-experience.

To improve care, implement practices that rely on evidence and achieve sustainable improvements in healthcare, we must make these critical investments in a healthy workforce and organization.

By actively counteracting the “dis-integrating” effects of trauma on our systems and services, we will more effectively meet the needs of our families and communities by developing healing organizations that support reflection in place of reaction, curiosity in lieu of numbing, self-care instead of self-sacrifice, aligned rather than competing initiatives and collective impact rather than siloed structures.

Kenneth Epstein is the Children’s System of Care Director for San Francisco County Community Behavioral Health Services. Dr. Emily Gerber is Assistant Director of the Children, Youth and Families System of Care and a Licensed Clinical Child Psychologist.

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CMS UPDATE Ashby Wolfe, MD, MPP, MPH

Here at the California Medical Society (CMS), we’ve been working for several months on some of the new programs and initiatives created by the Medicare Access and CHIP Reauthorization Act signed of 2015. Additionally, we are now seven years in to the concerted launch of a truly national health information technology platform. A lot of important steps have been made in this effort, but we’re still at a stage where technology often hurts, rather than helps, physicians provide better patient care. CMS is committed to taking a user-centered approach to designing policy.

Understanding what we want from technology means first understanding how we provide and receive care today in America, where the patient is more diverse, more mobile, and more demanding than ever before. The consumers CMS serves are a good representation of all of our care needs—140 million Americans, most on fixed or low incomes—in every type of care situation: the Medicare patient leaving the hospital with five prescriptions to fill and two appointments to book; the Marketplace customer who will have coverage for the first time and finally be able to have his wife’s chronic fatigue looked at; the daughter who has made the difficult decision to move her father in a nursing home and wants to know staffing ratios and quality ratings; or the family with a child with disabilities on Medicaid that requires 24-hour care and is watching every dollar and interviewing every home care worker.

The way people get care today—on the go, on their own terms, often not anchored in the system—means their information needs are ever more vital, and yet so basic. People ask: “Am I recognized when I show up? Are my needs, preferences, and history available?” Today’s technology at its best is ideally suited to meet these needs: the cloud, social media, one-click purchases, information at our fingertips, everything wired, convenient devices, expert systems, intelligent agents. We know what we need to do and the technology is available.

To address these issues, our agency is charged with implementing the new bipartisan Medicare Access and CHIP Reauthorization Act (MACRA)—legislation intended to bring valuebased care to the everyday physician practice. We have created a new playbook at CMS by making our most concerted effort ever at listening to front-line physician and patient input upfront. After first collecting feedback from across the health care sector, we launched our work with a four-day session with physicians and technology companies, and sought more comment through a public Request for Information. But the bulk of our work has been directly with front-line physicians. In coordination with our Central Office in Baltimore, we have completed eight focus groups with front-line physicians in four separate markets, and have many more coming. I’ve been on the road meeting with a number of physicians to learn more specifically how they interact with technology and what their day-to-day 26

challenges are. My colleagues and I have received powerful feedback, including comments that current Electronic Health Record (EHR) platforms and systems put too much of a burden on physicians and their teams, taking time away from caring for patients.

Many physicians report challenges with needing information from a different EHR that doesn’t communicate well with their practice EHR, so there remains a heavy reliance on faxing or “snail mail” to coordinate care and follow-up. One person pointed out that it takes eight clicks on a computer to order aspirin for a patient. Many physicians see fewer patients each day because they are spending more time doing data entry into their EHR. At times, there is too much information, but it is still very difficult to find on a busy EHR screen.

Three themes have emerged that are shaping CMS’ agenda moving forward:

• Physicians are hampered and frustrated by the lack of interoperability. Simple issues such as needing to simply track a patient referral, or review a hospital discharge summary to ensure proper follow-up, can be terribly difficult and onerous in a busy practice.

• Regulations in their current form slow down physician practice, create documentation burdens, and often distract from patient care.

• Physicians find their EHR technology hard to use and cumbersome. It slows them down, and doesn’t speed their path to answers.

CMS will be addressing these themes in very specific ways, as we work to implement the new MACRA legislation. We will be issuing our first proposed regulation on MACRA in the spring of 2016, but we can share the concepts of our approach and how our agency views the work moving forward.

The first area we are addressing is the documentation overhead associated with the Meaningful Use program. Since we are still pulling together details on the proposed MACRA rule that will soon be open for public comment, the following represents the vision for the approach to this work. We have been working to try to close the gulf between our public policy work and what is happening in the reality of patient care. From a number of focus groups and listening sessions, we are hearing the message loud and clear: “Stop measuring clicks, focus instead on allowing technology to become a tool and on the results technology can create. Give us more flexibility to suit our practice needs and ultimately more control.”

Where possible, we favor letting outcomes rather than activities drive the agenda. We can take advantage of how the landscape has changed over the last five years with the proliferation of programs that depend on care coordination and population health.

Interoperability is the second area of our focus. It is an essential ingredient not only for better patient care, but, as President Obama mentioned in early March, it is also a key part of the preci-

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sion medicine initiative that will unlock an entirely new future of better health. We are making a concrete effort to commit to this work; on February 29, Health and Human Services Secretary Burwell announced that companies representing ninety percent of EHRs are committing to three vital steps to work towards true interoperability and to prevent data blocking or firewalls from getting in the way of coordinating patient care. Our agency has also recently announced funding to connect many of the remaining parts of the system that are not part of the EHR incentive program but serve our neediest Medicaid patients every day—long-term care, behavioral health, and substance abuse providers. Ultimately, clear communication pathways between electronic systems will give physicians and patients what they want from their technology, so-called bottom-up interoperability. Our agency will help facilitate two goals that practicing physicians have identified: closing the referral loop and patient engagement.

That leads to the third area CMS is focused on: to give the physician better tools that help him or her with patient care. It’s not only Meaningful Use (MU) regulations that concern physicians, they want better technology. It is time to finally create the improved workflows and the apps that physicians are looking for. Shifting from MU-oriented design to developing certified technology that is user-centered is a big opportunity. Flexible EHR incentives should give tech companies new products to develop. As part of this effort, our sister agency, the Office of the National Coordinator, is launching an App Discovery Site as an EHR-neutral place for new apps that can securely move data in and out of an EHR. CMS is working to ensure that our policies communicate what is important—improved patient care, better spending, and healthier people. A challenging goal, but one made easier by talking about it publicly and listening to physician and clinician input. The implementation of the MACRA legislation is an ongoing process, and our agency is committed to closing the gap between on-the-ground care delivery and policies that promote the tools for better care. Connecting to what happens in daily patient care is vital to our policy-making as we seek a better, smarter healthier system and better patient outcomes. To that end, please do not hesitate to contact me with questions or concerns at ashby.wolfe1@cms.hhs.gov.

We would also welcome comments on our first proposed regulation on MACRA when it is released this spring. You can keep track of new developments at: https://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/ Value-Based-Programs/MACRA-MIPS-and-APMs/MACRAMIPS-and-APMs.html

Classified Ads Cosmetic Surgery Practice for Sale - Fairfield, CA. Long established. Revenue $805,000 ($200k of revenue from Fillers and Botox, $100k of revenue from Obagi) Office Surgical Suite certified by AAAHC and IMQ. 2,000 sq ft with free parking. Photos available. Offered at only $205,000. Real estate also available for purchase. info@practiceconsultants.com.

800-576-6935. www.PracticeConsultants.com.

Sublet: SF Financial Disctict Medical Office - 22 Battery St at Bush and Market. 2 exam rooms, 1 or 2 days a week. J Binstock, MD. (415) 956-8686.

Occupational Medicine Practice for sale. East San Francisco Bay, CA. Revenue $663,000 in 5,000 square feet facility near hospital; 6 exam rooms plus procedure and treadmill rooms. Outstanding reputation draws patients and contracts from throughout the San Francisco Bay Area. Existing transferable contracts assure steady revenue stream. Independent appraisal available. Offered for $312,000. Contact info@medicalpracticesusa.com 800-576-6935. www.medicalpracticesusa.com.

Large, dynamic, fast-paced medical group with multiple locations is seeking an experienced in-house Senior Revenue Cycle Manager who knows how to deliver results. If you have more than five years experience with a proven history of success in this area, please email brotter@goldengateurology.com.

Fall In Love With Practicing Medicine Again. For Sale: Well Established Medical Weight Loss Practice In Marin County.

Enjoy work-life balance and financial freedom. This all cash practice offers a flexible schedule and provides multiple income streams. In addition, this practice presents a significant growth opportunity. This is and will continue to be and active ongoing practice. The seller will enable a smooth transition.

Email now drgail@marinweightloss.com.

Ashby Wolfe, MD, MPP, MPH, is the Chief Medical Officer, CMS Region 9, San Francisco, CA.

WWW.SFMS.ORG

MAY 2016 SAN FRANCISCO MEDICINE

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MEDICAL COMMUNITY NEWS Saint Francis Robert Harvey, MD, MBA

Dignity Health Saint Francis Memorial Hospital has been helping service the health care needs of the Tenderloin neighborhood for generations. With widespread obesity and rising rates of chronic illness among this mostly low-income urban population, the need for accessible public health programs is bigger than ever. Through our community benefit efforts, we’re leveraging our resources and strengths to help create a healthier community.

The Tenderloin Health Improvement Partnership, an initiative of Saint Francis Memorial Hospital and the Saint Francis Foundation, helps nonprofits, businesses, government agencies, and funders within the Tenderloin neighborhood work together in more coordinated ways for a greater collective impact on public health.

This partnership is committed to improving community health, safety, and well-being for more than thirty-three thousand residents of the Tenderloin, one of San Francisco’s most densely populated and neediest neighborhoods.

One example of this partnership in action is the Green Mobile Kitchen Health Education Project.

For the second consecutive year, Saint Francis has awarded a $103,000 community grant to this project to further aid its efforts to promote healthy living among some of the most vulnerable residents of the Tenderloin. The Green Mobile Kitchen Health Education Project addresses health needs by teaching skills to prevent obesity, diabetes, and other health problems to Tenderloin residents—a vast majority of whom lack access to affordable, fresh, and healthy food. The project is a joint venture of From the Garden to the Table and San Francisco Recovery Theatre.

From the Garden to the Table is a health education organization that teaches low-income youth and their communities to improve their health through better food options. San Francisco Recovery Theatre helps residents of the Tenderloin neighborhood who are battling substance abuse, mental health, or housing problems work through their challenges using positive theater experiences. Together, the organizations bring a series of demonstrations, classes, and theater experiences directly to residents to help shift health outcomes in a positive direction.

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St. Mary’s

Robert Weber, MD

The saying “It takes a village” can certainly be applied when addressing the health care needs in our large and diverse community. At a time when resources are scarce, Dignity Health St. Mary’s Medical Center is committed to working with and supporting community organizations that share a goal to reduce health disparities in San Francisco.

Through our Community Grants Program, St. Mary’s recently awarded funding to two local nonprofits—San Francisco Care and Justice Alliance and The Asian Health Collaborative. These nonprofits pool the efforts of several organizations to help maximize and catalyze their impact in the community.

San Francisco Care and Justice Alliance is a collaborative project comprised of three community-based organizations: Shanti, The Justice and Diversity Center of the Bar Association, and the AIDS Legal Referral Panel.

The Alliance provides medical treatment referral and legal services to underserved populations living with HIV/AIDS, hepatitis C, or other chronic health conditions. The Alliance will use the grant to help its clients address urgent issues such as housing security, safety net economic benefits, navigating complex systems of care, and maintaining ongoing relationships with medical providers.

The Asian Health Collaborative (AHC) also consists of three community-based organizations, Self Help for the Elderly, Kimochi, and the Asian Women Resource Center/Gum Moon Women’s Residence, working together to improve the health of the communities in which they serve, primarily the monolingual Asian population throughout San Francisco.

The AHC focuses on addressing unhealthy eating habits in the Asian community that can often lead to diabetes and obesity, particularly among low-income seniors and children.

The AHC will use the grant from St. Mary’s to expand its partnerships throughout the City’s Asian communities, providing additional education workshops and health screening in its fight against diabetes and obesity.

SPMF

Robert Osorio, MD, FACS

Our physicians and staff have long been committed to battling liver disease, a serious health disparity affecting Asians and Pacific Islanders. Asian Pacific Islanders constitute less than five percent of the country’s population but more than fifty percent of Americans with chronic hepatitis B (CHB).

Hepatitis B, caused by the hepatitis B virus, is transmitted through blood, intercourse and during childbirth. Untreated, it commonly leads to cirrhosis and/or primary liver cancer, which afflict thousands of people in the United States each year including here in the Bay area. Our program combines public education, screening, treatment (including liver transplantation), and clinical and basic research. Stewart Cooper, MD, Chief of General and Transplant Hepatology and Liver Research, is a champion of several initiatives.

He and his colleagues also conduct various clinical studies including groundbreaking nationally recognized research to find new finite therapies to eradicate CHB. Since 2007, as part of a citywide, SF Hep B Free, program, our physicians and staff have screened more than 5,000 at-risk San Francisco residents and vaccinated those not already immune. Dr. Cooper and his group treat patients with liver disease at clinics in communities with a high occurrence of CHB, including clinics in San Francisco’s Sunset neighborhood and in Oakland. The team delivers more community-based care than any other liver specialist group in the entire nation. In 2015, they initiated a dedicated Center for Asian Liver Health in Oakland, staffed by accultured specialists including Chanda Ho, MD, and Tammy Lee NP They also opened a liver clinic this year at North East Medical Services in downtown San Francisco.

To continue raising awareness, our SPMF team, SF Hep B Free and the American Liver Foundation are sponsoring a contest at San Francisco high schools to design posters encouraging screening and vaccination. The winning poster will be displayed this fall at the Asian Art Museum.

SAN FRANCISCO MEDICINE MAY 2016 WWW.SFMS.ORG

MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Congratulations to our nationally recognized stroke experts at California Pacific Medical Center Research Institute (CPMCRI) and CPMC’s clinical stroke team for their new research being published in the Journal of Stroke and Cerebrovascular Diseases. CPMC research determined that current criteria are unnecessarily complex, and their SMART (Simplified Management of Acute Stroke using Revised Treatment Criteria) approach is enabling physicians to quickly determine which patients will benefit from thrombolytic treatment. Nationally, fewer than five percent of patients with acute ishchemic stroke (AIS) receive lifesaving thrombolysis (clot-busting drugs), the most effective known treatment.

At CPMC, that rate averages over twenty-five percent, one of the highest rates nationwide.

Dr. Michael Rowbotham, Senior Scientist and Scientific Director of the CPMCRI, will be honored at the American Academy of Neurology (AAN)’s Annual Scientific Meeting in April with the 2016 Mitchell B. Max Award for Neuropathic Pain, in recognition of his outstanding research and clinical achievements. With findings published over the course of his thirty-year career, Dr. Rowbotham is well-known for his clinical trials innovations and pioneering mechanismsoriented clinical studies. A new approach to treating ovarian cancer provides similar benefits with less toxicity compared to a standard taxanebased chemotherapy dosing regimen, according to results published online in the New England Journal of Medicine. The open-label, phase 3 randomized study was conducted by researchers at Sutter Health’s California Pacific Medical Center (CPMC) and leading cancer centers across the U.S., and suggests new strategies for personalized treatments. Encouraging clinical results from previous studies showed improved survival with a ‘dose dense’ administration of the chemotherapy drug paclitaxel, and increased progression-free survival (PFS) with the addition of the monoclonal (or, ‘biologic’) antibody bevacizumab (Avastin®). The findings prompted lead study author John Chan, MD, scientist and gynecologic oncologist at CPMC, and colleagues to determine if less frequent dosing of paclitaxel could provide the same PFS benefits.

WWW.SFMS.ORG

Kaiser

Maria Ansari, MD

As part of Kaiser Permanente’s commitment to caring for the communities it serves, we continue to support through our myriad outreach programs and physician involvement initiatives the public health of all San Franciscans. Currently, Kaiser Permanente San Francisco (KPSF) cares for over 200,000 City residents, almost twenty-five percent of the City’s population. By partnering with both the SFDPH and the extensive network of safety net community clinics, we’re able to provide innovative and effective care through programs that address chronic disease management, heart disease and stroke, and HIV/AIDS prevention. Examples of these programs include our technical expertise training, Preventing Heart Attacks and Strokes Everyday (PHASE) for public health and community clinics. Our PHASE program has led to a sixty-two percent reduction of heart attack risk in our members, and by sharing this with partners in our community clinics, non-members are receiving the benefits as well.

The amount of KPSF funding toward alleviating the county’s burden of providing health care to the uninsured, MediCal, and vulnerable populations through our charity care programs totaled $5 million in 2014. Additionally, we provide a comprehensive medical home to the uninsured through Healthy San Francisco, and have maintained our commitment to serve three thousand of the patients that use this health care access program. Our outreach and care for over nine hundred patients at-risk for HIV through an innovative medication program involving the prophylactic Truvada (or PrEP) minimizes the burden of HIV/AIDS treatment on City systems, as well as our own. In addition, we are active members of the City’s bold initiative, “Getting to Zero,” which aims to reduce HIV transmission and HIV related deaths in San Francisco by ninety percent before 2020. Finally, through our Community Benefit partnership with San Francisco General Hospital (SFGH) & Trauma Center and SFDPH, we provide grants for quality improvement, specialty care, and capital improvements. A recent example is a five million dollar donation to help fully equip the new acute care and trauma center at SFGH.

SFDPH

Alice Chen, MD

The San Francisco Health Network is the City’s only complete system of care, providing primary care, specialty, hospital, rehabilitation, skilled nursing, mental health and substance abuse services to San Francisco’s Medi-Cal and uninsured population. We also run the only trauma center and psychiatric emergency services for everyone in the City, at Zuckerberg San Francisco General Hospital and Trauma Center.

Operated by the Department of Public Health, the Network is deeply connected to the public health mission to protect and promote the health of all San Franciscans. Network staff and programs contribute to many citywide initiatives—tackling HIV, food insecurity, health disparities, homelessness, traffic safety and the hazards of cigarette smoking.

The Network’s patient population is made up of higher percentages of African Americans and Latinos than the City overall, and lower percentages of white and Asian people. Our patients face health disparities and challenges that we have expertise in treating. We are proud to offer them integrated primary and mental health services in our community clinics, top-rated birth services at Zuckerberg San Francisco General and fourstar rehabilitation and skilled nursing care at Laguna Honda Hospital.

Our goals are simple: improved patient experience, timely access to care and lower per capita costs. That is why we are investing in our primary care system, improving patient flow between our various levels of service, developing a universal electronic health record and creating models of care to meet the needs of our most vulnerable and highestutilizing patients.

Check out our progress on the San Francisco Performance Scorecard, which monitors how the City is doing in key policy areas: http://www.sfgov.org/scorecards.

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MEDICAL COMMUNITY NEWS UCSF

Wade Smith

The UCSF clinical enterprise has evolved in significant ways in the last three years, largely in response to national and regional trends, supported by the Affordable Care Act, that require increasing access to care, improving the health of populations, and increasing the value of care provided. The most significant change has been the formation of UCSF Health, an integrated health care delivery system.

UCSF Health encompasses UCSF Medical Center, UCSF Benioff Children’s Hospitals in San Francisco and Oakland, the UCSF Faculty practice, Langley Porter Psychiatric Hospital and Clinics, Benioff Children’s Physicians foundation and joint ventures with John Muir Health, including an accountable care network set to begin enrolling patients in 2017. In addition, UCSF Health includes an affiliation with Hospice by the Bay, and a number of physician groups and hospitals throughout the Bay Area.

The primary goal of UCSF Health is to deliver innovative, accessible, and high value care to a large population of patients in the Bay Area while continuing to provide tertiary and quaternary care to patients in the Western United States and beyond. The combination of these many entities within UCSF Health will facilitate improvements in coordination of care across the continuum and allow for novel care approaches that can reduce the total cost of care for patients. Among the most important long term initiatives is the integration of electronic health records across UCSF Health. In addition, UCSF Health will prioritize patients being cared for in their local communities.

UCSF Health remains a core component of the UCSF campus and continues to share the mission to train the next generation of health professionals and to pursue scientific discovery that can contribute to improvements in human health.

New Podcast on End-of-Life Care The California Academy of Family Physicians is pleased to announce the availability of a new podcast focused on end-oflife care and conversations: The Talk. The Talk features family physicians, palliative care specialists, an ethicist (Steve Heilig of the SFMS) and others describing their experiences with patients at the end-of-life. The series delves into the meaning of palliative care, the need to mobilize the primary care workforce to offer palliative care services, approaches to advance care planning and patient/family communication. The Talk also explores California’s new End-of-Life Option Act, which authorizes a terminally ill adult with certain qualifications to request and receive a prescription for “aid-in-dying” drugs. The Act is scheduled to go into effect on June 9. http://www.familydocs.org/eol/podcast 30

UPCOMING EVENTS 5/13-15: Western Leadership Academy | Hilton San Francisco Union Square | Save the date for the 2016 Western Health Care Leadership Academy. Confirmed keynote speakers include renowned surgeon, writer and public health researcher, Atul Gawande, MD; Karl Rove, former Deputy Chief of Staff and Senior Advisor to President George W. Bush; and comedian, internist and founder of Turntable Health, ZDoggMD (also known as Zubin Damania, MD). The 2016 Leadership Academy continues its mission of providing information and tools needed to succeed in today’s rapidly changing health care environment.

The conference will examine the most significant challenges facing health care today and present proven models and innovative approaches to transform your organization’s care delivery and business practices. For more information, visit www.westernleadershipacademy.com.

5/18 Webinar: Reimbursement 101 | 12:15 p.m. to

1:15 p.m., CMA webinar | This webinar is intended for physicians, medical group practice administrators, and physician executives to learn ways to maximize reimbursement in the face of declining payor and government reimbursement and increased regulatory scrutiny. This webinar will provide managed care and payor contracting tips, as well as what to do when you aren’t getting paid. In addition, it will help you prepare for and defend against government and payor reimbursement audits. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit.ly/1Vsxiqg.

5/25 Webinar: California Healthcare Performance Initiative Physician Quality Rating Program | 12:15

p.m. to 1:15 p.m., CMA webinar | Last year, through commercial and Medicare claims data, CHPI issued clinical quality ratings for fifteen thousand California physicians. California Health Performance Information System (CHPI) is gearing up to publish its second cycle of physician quality scores later this year.

Physicians will soon begin receiving notices advising of their quality scores along with information on how to access the review and corrections portal to confirm or correct their data.

This webinar will provide an overview of the CHPI quality rating project, along with step-by-step instructions on how physicians can review their data for accuracy before the quality scores are published. SFMS members receive complimentary access to this webinar ($99 for non-members) and can register at http://bit. ly/1T7u9Iv.

6/4: Annual Summer Workshop in Clinical Ethics

8:30 a.m. to 4:30 p.m. | The Program in Medicine & Human Values at California Pacific Medical Center is organizing a skills workshop on resolving conflicts in the clinical setting, as well as an update on common ethical issues encountered in patient care. The workshop is geared to bioethicists, physicians, nurses, legal counsel, risk managers, chaplains, social workers, administrators, ethics committee members, patient advocates, attorneys, security staff, and interested others. CME and CEUs will be offered. For more information, please call (415) 600-1647 or visit www.cpmc.org/ethics/.

SAN FRANCISCO MEDICINE MAY 2016 WWW.SFMS.ORG

A financial safety net for you—

AND THE ONES YOU LOVE 10- AND 20-YEAR LEVEL TERM LIFE No matter where you are in life, SFMS Group Level Term Life Insurance benefits can be an affordable solution to help meet your family’s financial protection needs.

Mercer and SFMS leveraged the buying power of your fellow members to secure dependable and affordable life insurance benefits at competitive premiums from ReliaStar Life Insurance Company, a member of the Voya® family of companies.

With quality life insurance benefits extended at competitive rates, you’ll rest easy knowing you’ve provided coverage for your loved ones through the Group 10-Year and 20-Year Level Term Life Plans.

As a member, you can conveniently help protect your family’s financial future with the Group 10-Year and 20-Year Level Term Life Plan.

It features: • Benefits up to $1,000,000 • Rates that are designed to remain level for 10 or 20 full years* • Benefit amounts that never change during the level term period provided premiums are paid when due

See For Yourself: Get more information about your Group 10-Year and 20-Year Level Term Life Plans, including eligibility, benefits, premium rates, exclusions and limitations, and termination provisions by visiting www.CountyCMAMemberInsurance.com or by calling 800-842-3761.

Sponsored by:

Administered by:

Underwritten by: ReliaStar Life Insurance Company, a member of the Voya® family of companies 75534 (5/16) Copyright 2016 Mercer LLC. All rights reserved.

Mercer Health & Benefits Insurance Services LLC • CA Insurance License #0G39709 777 S. Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.insurance.service@mercer.com • www.CountyCMAMemberInsurance.com * The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the group policy with 60 days’ advance written notice.

The County Medical Associations & Societies receive sponsorship fees for insurance programs that offset the cost of program oversight and support member benefits and services.

San Francisco Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Return Service Requested

Find the best specialist for your patient with one call.

We make it easy to transfer and refer your patients to specialists at CPMC, part of the Sutter Health network. One call allows you to match your patients’ needs with the right specialist, notify admissions, get authorizations and more.

And we’re available 24/7, so you never have to wait to find the best possible care for your patients. It’s another way we plus you.

Referrals and Transfers 24/7 888-637-2762 cpmc.org