December 2018

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

THE BEST AND WORST OF TIMES: Acute and Chronic Hot Topics in Healthcare HEALTHCARE COSTS: Does Prevention Pay? Pricing: What you See isn't What you Get Bargaining for Billions

IMMIGRATION AND HEALTH Safe Injection Sites - Next Year?

Flavored Tobacco Bans: Preventing "Nico-Teen" Less Painful Opioid Policies Burnout and Empathy

Plus: Report from the CMA Annual Meeting Volume 91, Number 9 | December 2018

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SAN FRANCISCO MARIN MEDICINE

IN THIS ISSUE

December 2018 Volume 91, Number 9

THE BEST AND WORST OF TIMES: Acute and Chronic Hot Topics in Healthcare FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President’s Message: Year End Reflections John Maa, MD

The Cost Effectiveness of Prevention Ryan Guinness, MD, MPH & Eric Tang, MD, MPH

10 Beyond Savvy Shopping:

Price Transparency as Real-Time Value Tool

Logan Pierce, MD and Ari Hoffman, MD

12 How to Chop $20 Billion Off Our Drug Costs

Jack Lewin, MD

13 Building the Most Equitable, Inclusive Medical School Nationally

Catherine Lucey, MD

14 Second Opinion:

A Free But Invaluable Resource for Cancer Patients

Howard B. Kleckner, MD

26 CMA Applauds the Enactment of Federal Opioid Legislation

California Medical Association Staff 32 Community News: Kaiser Permanente

Maria Ansari, MD 32 Upcoming Events 32 Advertiser Index

OF INTEREST

16 Safe Injection Sites:

An Idea Whose Time Has Come

Michael Schrader, MD

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19 Burnout and Empathy

Peter N. Bretan, Jr., MD, FACS

28 SFMMS Community Health Agenda 2018

17 Physicians Talking About Immigration Policy and Health

Shelly B. Rodrigues, CAE, FACEHP and Conrad Amenta

CMA House of Delegates Meeting:

“It Was the Best of Years, it Was the…”

Michael Schrader, MD

20 Flavored Tobacco and Vaping Products Banned: Sale of Products Prohibited in Unincorporated Areas of Marin

22 Listening Post: Patients’ Health Outcomes Can Suffer When Providers Don’t Listen

Xenia Shih Bion, MPH 24 The Rise—and Fall?— of the Adolescent Vaping Epidemic Courtney Islam

1868 2018

Anniversary

SAN FRANCISCO

MARIN MEDICAL SOCIETY

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

MEMBERSHIP MATTERS CELEBRATING 150 YEARS OF SFMMS HISTORY— Protecting Patient & Physician Decisionmaking Working together with the California Medical Association (CMA), SFMMS has a long history of advocating for policies that protect physician autonomy and the ability to practice medicine without interference. We have provided a strong collective voice regarding scope of practice and reimbursement issues, and preserving the patient/physician relationship when it comes to medical decisionmaking, including reproductive choice for women, and care at the end of life.

Ensuring Access to Care

SFMMS has consistently supported efforts to improve access to care, including the rebuilding of Zuckerberg San Francisco General Hospital, and has provided assistance to the Haight Asbury Free Medical Clinic, San Francisco Free Clinic, Marin Community

Clinics, Operation Access, and many other community-based organizations where members have donated medical care and treatment for the uninsured and underserved.

Inspiring a Vision for the Future

SFMMS has had a progressive public policy agenda and constantly strives to stay ahead of current issues in health care. We are committed to developing future leaders in medicine, particularly as we see membership and engagement among residents, medical students and early-career physicians continue to grow.

We are grateful to have had the privilege of serving our members and their patients for the past 150 years!

Marin Supervisors Pass Ban on Flavored Tobacco Products

Grant Opportunity: Addiction Treatment in Primary Care

The Marin County Board of Supervisors unanimously passed a ban on flavored tobacco products in November. Flavored tobacco and vaping products will be banned from unincorporated Marin County when the ordinance takes effect in July 2019. Tobacco stores will have until 2020 to sell off their inventory. Lawmakers are hopeful it will curb the surge in teen use of these harmful products. SFMMS is grateful for the leadership of the Marin County BOS, SFMMS Board Member and Marin County Public Health Officer Matt Willis, MD, and SFMMS President John Maa, MD on this very important public health issue. The Food and Drug Administration recently announced its plan to ban sales of most flavored e-cigarettes in retail stores and gas stations around the country, in a similar effort to reduce the popularity of vaping among young people.

Read more at https://nyti.ms/2Dx4eKP.

The Center for Care Innovations, in partnership with the California Department of Health Care Services and CedarsSinai, is launching a new program titled Addiction Treatment Starts Here: Primary Care. The program’s goal is an increase in access to medication-assisted treatment (MAT) in primary care for patients with opioid use disorder. Up to 40 California health center sites will receive grants of up to $50,000 and a range of support to connect with peers and experts who are successfully implementing, scaling, and sustaining MAT in primary care settings. The 18-month program begins in February 2019. The application deadline is 5:00 PM (PT) on Friday, December 14. Read more or download application at http:// bit.ly/2BmWqtH.

Update: MBC Investigations Based on Death Certificate/CURES Data

Beginning in December 2017, CMA began receiving inquiries from physicians who received letters from the Medical Board of California (MBC) requesting a written summary of care and treatment rendered to a named deceased patient, as well as a copy of the physician’s curriculum vitae. CMA staff have been monitoring this issue to determine how physicians are being impacted by investigations based on death certificate data and whether the investigations are resulting in disciplinary actions. CMA continues to work with MBC on its disciplinary framework, track inquiries from members and work with the MBC staff to gather information about this project. CMA staff is assessing whether the reviews are being conducted appropriately and whether further legislative and regulatory advocacy is required at this time. Read more at http://bit. ly/2Kkd9AR.

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CMA Publishes Prop 56 Payment Monitoring Worksheet

The California Health Care, Research and Prevention Tobacco Tax Act of 2016 (Prop. 56) created new revenues dedicated to the Medi-Cal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. A total of $325 million was allocated for physician payments in the budget for 2017-18, with $488 million proposed for 2018-19. To help physician practices monitor their Prop 56 supplemental payments, the CMA has published a Prop.

56 Payment Monitoring Worksheet, which will automatically calculate the supplemental payment amount by CPT code so you can ensure that you are receiving your share of the supplemental tobacco tax money. The worksheet is available free to CMA members at https://cmadocs.org/prop56.

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SoFi Doubling Rate Discount for CMA/SFMMS Members SoFi offers CMA/SFMMS members student loan refinancing options that include low-variable and fixed rates with terms ranging from five to 20 years. For a limited time, SoFi is offering CMA members a special double rate discount. From now until December 20, 2018, you’ll pay 0.5 percent less in interest when you refinance at SoFi.com/CMA. Residents can refinance as well and pay as little as $100/month through the end of your residency. If you have questions about SoFi student loan refinancing, please visit https:// SoFi.com/CMA or contact SoFi directly at ask@sofi.com or (855) 456-7634.

CMA Launches New Mobile App for Members

The CMA has launched a new members-only mobile app. Free and available for Android and iOS, the CMAdocs app will keep you up to date and informed on issues critical to the practice of medicine in California. Some of the app features include access to your custom news and event feeds, discussion groups, grassroots action center, and webinar registration. To download the app, search “CMAdocs” in the Apple App Store or the Google Play Store. To log in, use your CMA/county website credentials.

Join us for the 2019 SFMMS

Please join us on Friday, January 25, 2019 at Cavallo Point in Sausalito to celebrate SFMMS' 151 years of advocating for physicians and patients, as well as the installation of Kimberly Newell Green, MD as the 2019 SFMMS President. We hope you will join us for an evening of festivities as we celebrate our rich history, our members, and their contributions to the local medical community. Purchase tickets at www.sfmms.org/events.aspx.

Sponsorship opportunities are available – contact Erin Henke at ehenke@ sfmms.org or (415) 561-0850 x268.

December 2018 Volume 91, Number 9

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

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DECEMBER 2018

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SAN FRANCISCO

Sutter’s ACE unit is one of a kind.

MARIN MEDICAL SOCIETY

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion healthcare initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes.

We cannot do this alone.

Join today to start receiving your benefits.

Visit www.sfmms.org/membership for more information about SFMMS membership and benefits, or to join online.

Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received by December 15, 2018. Renewing is easy: 1. Mail/fax your completed renewal form when you receive it in the mail; or 2. Renew online at www.sfmms.org with a credit card. *5% Early Bird Discount applies to 2018 full duespaying members only who are renewing at the same level for 2019; renewal form and payment must be received by December 15, 2018.

At Sutter, we know that part of healing means being in the hospital less. CPMC’s collaborative team in our Acute Care for the Elderly unit provides personalized care plans for older adults that help reduce patient stay and improve mobilization.

1868 2018

Anniversary

Call 415-527-0726 to refer a patient. sutterhealth.org/aceunit

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PRESIDENT’S MESSAGE John Maa, MD

YEAR END REFLECTIONS A vital lesson learned over the past decades has been that healthcare reform efforts that are not enlightened with the clinician’s perspective are less likely to be successful.

It has been an honor to serve as your President this year.

As I reflect upon the year and the many wonderful successes that we have jointly achieved, what shines brightest is the defense in June of the SF flavored tobacco products ban signed by Mayor Ed Lee that was then extended into Marin on Election Day under the leadership of Matt Willis. Shortly thereafter, on November 8th, the FDA announced the plan to ban the sales of most flavored e-cigarettes in retail stores and gas stations to reduce youth use.

SFMMS supported legislation to make water and milk the default beverages in children’s meals across California was also signed into law by Governor Brown. I would like to extend a special congratulations to CMA President-elect Peter Bretan (thank you to Lawrence Cheung for serving as his campaign manager) resulting in SFMMS now having 2 members on the CMA Executive Committee.

As we look to 2019, the debates on Capitol Hill and Sacramento will likely return to the healthcare reform—a process that will likely take decades to finish. A key challenge plaguing the current debate may be that we have yet to clearly understand the problems we are seeking to solve. The uniquely complex American healthcare system evolved over decades. It is unlikely that anyone would have ever intentionally designed it to function as it does today. Over the past decades, most healthcare reform attempts have been largely unsuccessful, and perhaps instead contributed to the challenges we now face. A key enduring legacy after the passage of Obamacare may be the revelation of how money and profit drive the healthcare delivery system, perhaps best illustrated by Steven Brill’s article about the chargemaster in TIME. In October of 2018, the CMA House of Delegates continued beyond a conversation from 2017 focused upon single payor healthcare, by adopting four CMA reports on 1) addressing utilization through improved care delivery, 2) addressing pharmaceutical costs, 3) enhancing competitiveness of the healthcare market, and 4) reducing the administrative burdens on physician practices. In the aftermath of the passage of AB 72, the key defeat of Prop 8, and the election of a new California Governor, these initial reports serve as a starting point for a larger agenda that must now become the primary focus of our organization.

We must first fill in the gaps of what the reports did not address, and then illuminate the discussion by harnessing the collective expertise, intelligence and experience from the nearly 40,000 CMA members statewide. A vital lesson learned over the past WWW.SFMMS.ORG

decades has been that healthcare reform efforts that are not enlightened with the clinician’s perspective are less likely to be successful. The central challenge is to be more intelligent and transparent about how and where our precious healthcare dollars are spent. Perhaps the key principle that will transform the existing money-driven medical delivery system is to reframe the conversation with the understanding that healthcare is a public good. In the end, we will likely identify ways to reform our society as a whole.

On November 6th, two SFMMS members were elected to the Marin Healthcare District Board. Three MDs were newly elected to Congress, including pediatrician Kim Schrier in Washington State. As we reflect upon American history, it is important to note that five of the 56 signers (nearly 10%) of the Declaration of Independence were physicians. I believe that meaningful progress in health reform will occur when ten percent of our Congressmembers are also physicians, as they can represent a powerful united force to caucus together and vote in unison. The ultimate goal someday is for the election of a physician as President of the United States, to provide a role model for America’s children, and reframe the healthcare debate. I believe that SFMMS is now uniquely positioned with President-elect Dr. Bretan to become the thought leader within the CMA in our State to lead the national health reform conversation forward. I look forward to the incoming Presidency of Kim Newell Green, under whom we can extend the SFMMS tradition of being a pioneer in innovation solutions to improve the health of the public.

Dr. John Maa attended UC Berkeley and Harvard Medical School, completing his surgery residency at UCSF, and also completed a fellowship at the UCSF Institute of Health Policy Studies and has been President of the Northern California chapter of the American College of Surgeons. He is the Chief of the Division of General and Acute Care Surgery at Marin General Hospital and on the medical staff of Dignity-St. Francis Hospital.

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CMA House of Delegates Meeting 2018: “IT WAS THE BEST OF YEARS, IT WAS THE….”

Michael Schrader, MD This year’s CMA House of Delegates meeting was contentious and sometimes confused but culminated in the amazing victory of our own Dr. Peter Bretan as President-Elect of the CMA. For us, that moment of elation was the high point of the weekend.

The election was between Dr. James Strebig, Dr. Kenneth Blumenfeld, and Dr. Peter Bretan for the presidency of the CMA. The candidates gave impassioned speeches promoting their respective visions for the CMA. A universal concern was physician well-being. All three candidates impressed the delegates. There was widespread feeling that there were only good choices for CMA president. The SFMMS delegation celebrated Dr. Bretan’s extraordinary and well-deserved victory.

Delegates representing each medical association and society in California gathered at the Sacramento Convention Center to hear evidence and make redactions to four CMA policy reports that had been drafted by CMA committees. The SFMMS resolution on Migrant Child Detention and Separation was evaluated and adopted by the CMA Board of Trustees. There was time to socialize and meet new people and reconnect with old friends.

The theme of the four reports was addressing the cost of healthcare. The impetus behind the focus on costs was that some kind of cost reform is inevitable and that physicians should have an active role in promoting positive and responsible change.

The four reports included: “Enhancing Competitiveness of the Healthcare Market,” “Addressing Utilization through Improved Care Delivery,” “Reducing Administrative Burdens on Physician Practices,” and “Addressing Increasing Pharmaceutical Costs.”

While the reports on reducing administrative burdens and enhancing competitiveness were generally well received there was more extensive debate on the other two reports. These reports were ambitious and far-reaching and, of course, contentious. Delegates were critical that the reports were overly ambitious, too broad, not specific enough, poorly framed. In addition delegates felt their contributions were more peripheral than substantive. At best, many felt that these reports were a starting point that addressed crucial issues.

There were several talks to inform the delegates about issues. The speakers included academics, a union leader, and an industry CEO. The highlight of the speakers was UCSF’s Dr. Jack Resneck, President of the AMA Board of Trustees and SFMMS member who inspired the delegates by presenting the tremendous leadership of the current AMA. He also joined WWW.SFMMS.ORG

SFMMS delegates for an informative collegial luncheon.

General criticisms of the talks were that they should be shorter and more focused on the issues being addressed.

Some delegates felt that it was not appropriate to include the Executive Director of the SEIU at the HOD when the SEIU has sponsored the statewide referendum Proposition 8 which is opposed by the CMA and potentially threatens the access to dialysis of patients and the livelihood of physicians. Another speaker was a CEO of a major health insurer and yet another was head of a nonprofit corporation wholly funded by healthcare corporations to generate cost benchmark data.

Many delegates voiced concerns that the HOD was not as well organized as perhaps it could have been. Over the past several years the format of the HOD has been changed to shorten the meeting and facilitate a year-round resolution process. This has created some new organizational problems. Some veteran delegates were wistful for the previous opportunities for social interaction in the longer sessions. One delegate was suspicious of the both the accuracy of oral vote tallies and the supervision of the electronic vote devices. There was confusion about the adoption of the Priority Consent Calendar with one delegation arguing for total deletion to allow more time for review. Debate was criticized for being chaotic with delegates failing to identify themselves before speaking and unclear order of delegate speakers.

Many delegates felt that their efforts were not meaningful and had been reduced to mere wordsmithing rather than substantive changes to the policy reports. We know CMA leadership is addressing these concerns.

Going forward the District VIII SFMMS Delegation is hopeful that the CMA will recognize the criticisms and address them.

We anticipate great things from the leadership of Dr. Bretan.

Dr. Schrader is Vice-Chair of the SFMMS delegation to the CMA House of Delegates.

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Acute and Chronic Hot Topics in Healthcare

THE COST EFFECTIVENESS OF PREVENTION

Ryan Guinness, MD, MPH & Eric Tang, MD, MPH

How can we prevent the most disease and deaths for every healthcare dollar spent? This question has been asked

multiple times in the longstanding debate on U.S. healthcare reform and continues to drive decision-making as funding for healthcare resources becomes increasingly constrained. It comes as the trend of rising healthcare costs—to individuals, the health sector, and wider society—becomes ever more significant. In such a financial and politically-charged atmosphere, demonstrating the cost-effectiveness of preventive health interventions is integral to ensuring the viability of these services now, and moving forward.

Cost-effectiveness ≠ cost-saving

While often used interchangeably, ‘cost-effectiveness’ does not equal ‘cost-saving.’ In the context of healthcare, for an intervention to be cost-effective, it generally means that the benefits are sufficiently large compared to the costs. On the other hand, cost-saving means an intervention costs less money when accounting for future costs saved. For example, if the benefits of a preventive health intervention are large enough compared to the costs, it may be considered cost-effective, even if it doesn’t necessarily save money in the long-term. If that same intervention were to decrease total cost and thus save money in the longterm, it would also be considered cost-saving.

Why is prevention often not cost-saving?

The amount of money spent on preventing illness is widely used on a population of people, regardless of whether or not they will acquire an illness. In contrast, the amount spent on treatment of an illness is only spent on people that become ill.

Generally, prevention is only cost-saving if (1) the cost of the preventive health intervention per patient is sufficiently small; (2) the cost of treatment for the illness per patient is sufficiently large; and (3) the disease is sufficiently common among the population targeted for prevention to make such a preventive health intervention worthwhile to implement on a large scale. However, since most diseases are rare, there can be a substantial amount of money spent on people that never would have become sick.

As such, designing targeted preventive health interventions to those at highest-risk is important to improve the overall costeffectiveness of the intervention.

In thinking about the reality of our healthcare system, very few health interventions actually save more money than they cost. However, there are some preventive health measures that are certainly known to be cost-saving, and include interventions such as childhood immunizations, counseling on the use of low-dose aspirin among middle-aged and older adults, as well as alcohol and tobacco use screening throughout the lifespan1.

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Factors that influence cost-effectiveness of prevention There are several considerations to make when determining the cost-effectiveness of a preventive health intervention: Target population: Includes those individuals in the population who are the highest-risk of acquiring disease without the preventive health intervention. For example, performing outreach to expand use of pre-exposure prophylaxis among men who have sex with men to prevent HIV transmission.

Technology: Some preventive health interventions may be more advanced than traditional interventions, but are just as effective.

For example, both FIT and colonoscopy are effective screening methods for colon cancer, but FIT incorporates newer technological features and is significantly lower in cost.

Screening frequency: The more often a preventive health intervention has to be performed, the more expensive it will be.

Proportion of the population already receiving the service: Some cost-saving or cost-effective preventive services already reach the vast majority of the target population (e.g. childhood immunizations). Providing the intervention to hard-to-reach populations not already receiving it may be expensive and make the cost-effectiveness of the intervention less favorable.

Cost-effectiveness on the national scale

Organizations such as the United States Preventive Services Task Force (USPSTF) will avoid considering costs in deciding which types of preventive services to recommend. Any recommendations that are put forth are based on both benefits and harms of services and an assessment of this balance, but does not consider costs of providing a service in an assessment. Costeffectiveness information is only later supplemented after the WWW.SFMMS.ORG

recommendation is made. Similarly, Medicare, Medicaid, and the FDA generally are not allowed to consider cost-effectiveness in deciding what types of procedures to cover and/or approve.

Thinking beyond individual preventive efforts

Medicine traditionally classifies preventive measures on the basis of disease course: primary prevention aims to prevent new cases of disease; secondary and tertiary prevention mitigate the effects of existing disease. Expanding our understanding of prevention to go beyond mitigating risk at the individual-level (e.g. cancer screening) to include risk within our surrounding environment (e.g. a ban on trans fats, stronger air quality regulation, etc.), may be a step to developing even more cost-effective preventive interventions that promote our overall health as a society2.

Most preventive interventions are not cost-saving, but many are cost-effective. Nevertheless, prevention health services should still be promoted because they are often the least expensive way to improve health. Targeting high-risk populations for particular preventive interventions will increase their cost-effectiveness. Moreover, thinking beyond individual clinical interventions and considering community-wide interventions

or ways to address environmental and social determinants of health may actually end up being more cost-effective (and even cost-saving) in the end.

Ryan Guinness MD MPH is a fourth-year resident in the Internal & Preventive Medicine Residency Program at Kaiser Permanente San Francisco and the University of California, San Francisco.

Eric Tang MD MPH is a graduate of the Internal & Preventive Medicine Residency Program at Kaiser Permanente San Francisco and the University of California, San Francisco.

References 1.

2.

Goodell S, Cohen J, and Neumann P. Cost savings and costeffectiveness of clinical preventive care. The Synthesis Project Policy Brief No. 18 [Internet]. Princeton, NJ: Robert Wood Johnson Foundation; 2009.

Chokshi D and Farley T. The cost-effectiveness of environmental approaches to disease prevention. NEJM 2012; 367:295-297.

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DECEMBER 2018

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Acute and Chronic Hot Topics in Healthcare

BEYOND SAVVY SHOPPING: PRICE TRANSPARENCY AS REAL-TIME VALUE TOOL Logan Pierce, MD and Ari Hoffman, MD

Three trillion dollars.

Eighteen percent of the economy. We all know the figures that reflect the astronomical costs of American healthcare, and the relatively poor quality we get in return. Graphs comparing healthcare expenditure to life expectancy clearly show the United States as an international outlier with a serious value shortfall, but they also fail to tell the story of the individual affordability crisis.

At a personal level, patients are suffering under the burden of mounting medical bills. At worst, this leads to personal bankruptcy and financial ruin. At best, it negatively impacts individual finances, and studies show that excessive financial burdens can have serious effects on people’s health1. The mounting financial burden of healthcare is partially due to growth in deductibles and other out of pocket expenses, which has outpaced rises in both wages and inflation. Yet, some of these costs can also be mitigated through thoughtful testing and prescribing on the part of providers.

As physicians, we can and should demand the long-term solutions to address the healthcare affordability crisis. In the meantime, we need to do right by the patients in front of us every day, even if the system is slow to change. That requires new tools to empower both providers and patients to make the best decisions for physical, mental, and financial wellbeing. Changing the underlying structure of our fragmented insurance system or systemic price regulation is beyond the scope of practice for most providers, but advocating for and implementing thoughtful price transparency tools can help patients find higher value care today.

Take a recent—and typical—patient experience. A middleaged man with chronic pain discovered during a hospital stay that dronabinol, a cannabis-like drug, controlled his nausea and allowed him to decrease his opioid use. He and his inpatient providers were ecstatic to find a non-opioid symptom management drug that worked for him. The doctors dutifully prescribed him the medication, and the patient dutifully marched to the pharmacy to pick it up. Then the price tag got in the way. The patient was both shocked and dismayed to find that the medication that worked so well for him was not covered by his insurance 10

SAN FRANCISCO MARIN MEDICINE DECEMBER 2018

plan, and would directly cost him hundreds of dollars per month. For that reason alone, he didn’t fill his prescription and remained stuck on the cheaper, but much more dangerous, opioids.

This is the new normal in U.S. healthcare, and variations on it play out countless times around the country.

In a national survey by the Kaiser Family Foundation and the New York Times 2, one in four non-elderly American adults had difficulty paying a medical bill in the past year, and 43% of that group avoided filling a prescription due to cost. It doesn’t have to be this way. Imagine a future state in which every clinician has access to accurate, personalized price information at the point of care. Not charges or costs to the medical center, but actual out of pocket expenses. Patients and their providers could weigh the costs and potential benefits of various treatment options to determine a course of action that optimizes their health while remaining within their budget.

Useful price information remains out of reach for most, but at its essence price transparency is a data-delivery problem, and we now live in a data world. To be sure, the data challenge is more complicated due to the complicated patchwork of insurance coverage and dizzying array of benefit designs, but historical context gives us reason for optimism. A conversation about price transparency was not even possible fifteen years ago. At that time, hospital charges were a black box, let alone reimbursement to hospitals from insurance companies, actual costs to the delivery system, or patient out-of-pocket expenses. Through a combination of legislation, regulation, digitization, and crowdsourcing, price information is increasingly available.

With available data, price transparency gained traction as a potential way to decrease wasteful spending. Price information has been variably added to the reams of data pushed to both patients and providers, but the optimal format is still very much up for debate. On the provider side, improvements in price transparency have been the subject of several recent pilot studies3,4, with interventions including price displays incorporated directly into the EHR, prices appended to order reports, and the effect of various educational initiatives. The results of these studies have WWW.SFMMS.ORG

been mixed with regard to whether or not they decrease ordering frequency. On the payor side, many insurers deploy patientfacing price transparency tools intended to turn patients into savvy shoppers for the most cost effective healthcare services.

These tools are not highly utilized by the general public and the jury is out on whether they can actually impact patient spending5. Even with perfect price information, unless a patient is using the tool while their provider is writing a prescription, the value cannot be fully assessed. One conclusion seems clear: people like price transparency, but we haven’t really figured out how to use it.

There are many different ways to accomplish price transparency, but we believe that the best way to deliver cost information is directly to the exam room, where healthcare decisions are made. Additionally, we believe that out of pocket costs are best delivered to the provider at the point of ordering, as opposed to the patient at the point of service acquisition. In an alternate version of the case above, the cost of dronabinol might have prompted a conversation about the value of the drug to the patient. While the provider has the medical knowledge to place the cost into context, only the patient can determine whether $200 a month is worth it for a nausea medicine.

For some, the out of pocket expense may be worth it. For others, it may be too high a price to pay, either because the marginal benefit isn’t worth the cost or because they just can’t afford it. What might come of such an open conversation with our patient? Perhaps he would have pursued other treatment options. Maybe a prior authorization would have fixed the problem, or documentation that other therapeutic options were tried and failed, depending on the patient’s insurance coverage. Price transparency is clearly not a panacea—our patient’s drug is still too expensive—but it is the critical denominator of the value equation for patients.

We are now at an inflection point. The data, technology, and desire all exist. Informatics will play an important role in developing and implementing the tools necessary to deliver price transparency to the exam room. Future initiatives focused on price transparency should strongly consider the ‘five rights’ of clinical decision support6: delivering the ‘right information’, to the ‘right person’, in the ‘right format’, through the ‘right channel’, at the ‘right time’.

We believe that the right information to operationalize the value equation in clinical practice is out-of-pocket cost to the patient. The right “person” is likely to be a team rather than an individual, with the same core dyad that remains the focal point of medical training: the patient and provider. And the right time is at the point-of-care, where healthcare decisions are being made.

The right format and channel are excellent informatics questions for future study. There are no silver bullets for the high costs of healthcare, but thoughtful application of technology to enable open and informed value conversations between patients and providers at the time of ordering is certainly a step in the right direction.

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Logan Pierce, MD is a Clinical Informatics Fellow, Division of Hospital Medicine, Dept of Medicine, UCSF.

Ari Hoffman, MD is Assistant Clinical Professor, Division of Hospital Medicine, Dept of Medicine, UCSF and Affiliated Faculty, Philip R. Lee Institute for Health Policy Studies.

References 1. de Souza, J. A., Yap, B. J., Wroblewski, K., Blinder, V., Araújo, F. S., Hlubocky, F. J., … Cella, D. (2017). Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the COmprehensive Score for financial Toxicity (COST). Cancer, 123(3), 476–484.

2. Data Note: Americans’ Challenges with Health Care Costs | The Henry J. Kaiser Family Foundation. (n.d.). Retrieved October 31, 2018, from https://www.kff.org/health-costs/ poll-finding/data-note-americans-challenges-with-healthcare-costs/ 3. Silvestri, M. T., Bongiovanni, T. R., Glover, J. G., & Gross, C. P. (2016). Impact of price display on provider ordering: A systematic review. Journal of Hospital Medicine, 11(1), 65–76.

4. Sedrak, M. S., Myers, J. S., Small, D. S., Nachamkin, I., Ziemba, J. B., Murray, D., … Patel, M. S. (2017). Effect of a Price Transparency Intervention in the Electronic Health Record on Clinician Ordering of Inpatient Laboratory Tests: The PRICE Randomized Clinical Trial. JAMA Internal Medicine, 177(7), 939–945.

5. Desai, S., Hatfield, L. A., Hicks, A. L., Chernew, M. E., & Mehrotra, A. (2016). Association Between Availability of a Price Transparency Tool and Outpatient Spending. JAMA, 315(17), 1874.

6. J.A. Osheroff. Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-step Guide. The Healthcare Information and Management Systems Society, Chicago, IL (2009).

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Acute and Chronic Hot Topics in Healthcare

HOW TO CHOP $20 BILLION OFF OUR DRUG COSTS A simple fix both Republicans and Democrats are missing Jack Lewin, MD Bernie Sanders and the progressive side of the Democratic

Party have been pushing lately all across the country, as we ramp up to the elections, for a "Medicare for all," for a single-payer system. And I don't think that's really politically too likely in the U.S. right now. But you know, there's another thing that we could do, that's an important big step, that is within, I think, political reach. And that would be to have our own federal government, the biggest purchaser of drugs in the world, actually be able to negotiate with pharmaceutical companies to get better prices.

When Tonya uttered these words in my exam room during a routine well child check in 2006, her twin boys, my patients, had just turned 8. The mother’s desperation became more and more apparent as the twins sat slumped in adult-sized chairs in my health clinic in the Bayview Hunters Point community of Southeast San Francisco. Tonya and I reviewed all the things that were being done: Individualized Education Plans (IEPs) for each boy at school (which took over a year to get in place), therapy appointments, consideration for ADHD medications, and efforts to get them into organized sports and choir.

That's what happens in every other country in the world. It is also happening with our own Veterans Administration [Department of Veterans Affairs] and military in this country.

They negotiate, so why can't Medicare Part D do that? Well, because our Congress is very, very nice to the pharmaceutical industry.

The pharmaceutical industry is a creative, wonderful part of our economy and the innovation in this country. I'm not antipharmaceutical industry, but it is one of the most profitable industries in the country and it gets all kinds of special favors from the federal government. The federal government allows the pharmaceutical industry now to have an extra five years beyond patent life for certain drugs in the marketplace.

That's powerful; that means no generics in that space— special market exclusivity we give to certain drugs and certain companies in certain situations. And once again, the FDA then can't put a generic in place of a drug because of these special privileges. So we give special privileges to the pharmaceutical industry, they're charging one-third as much in places like London and Paris and Berlin. These are expensive places just like the United States. So why are we letting that benefit go there and not here?

So, what should the federal government do? Let me just give you a quick background on one of my roles in life today, being Chairman of the National Coalition on Health Care in Washing12

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ton. It's the oldest, largest coalition on health policy. It's got 150 million Americans, if you put all the organizations it represents together. Groups like AARP and labor unions, the big business coalitions, professional societies, consumer groups, and so on.

You know what, that whole organization now thinks pharmaceutical costs are the number one priority. Getting them down. Our own President Trump campaigned around the country saying this was something he was going to do, right? He's not doing it.

We physicians and clinicians need to talk to our patients, talk to each other, because there is something we can do here.

I think the Board of the National Coalition isn't much different from all of us. We can get pharmaceutical prices down by asking the federal government to take a bigger role.

First, as the biggest purchaser, it ought to get the best price. Second, it can use leverage to stop excessive profiteering and monopoly environments. And it should. When a drug like the rarely used drug Daraprim for toxoplasmosis goes from $13 to $750 in a year, that's excessive profiteering. We could do something about that kind of excess. When EpiPens went through the roof, we could do something about that kind of thing.

But the most important single thing is this: Let Part D MediWWW.SFMMS.ORG

care, CMS [the Centers for Medicare & Medicaid Services], negotiate with the pharmaceutical industry for fair prices, and we could get a 20%—probably $20 billion—reduction in costs from that. We could get rid of the notorious donut hole in Medicare Part D, and we'd get drug prices down for our patients.

Look, we're faced as doctors with a value-based healthcare system. We're supposed to be getting better outcomes at lower costs, right? That's what we're all expected to do as clinicians.

We're worried because our own patients are not taking their meds and adherence is a complicated matter. But a very significant part of adherence is the cost of drugs for our patients. So let's let Medicare do everybody a favor, save $20 billion, get rid of the donut hole, cut the drug prices for senior citizens, improve adherence -- let's make that happen for people.

Remember this -- we're spending $500 billion a year on pharmaceutical costs and they're going up all the time. And there are a lot of wonderful things happening as a result of what's happening in innovation. But this is not because of the production costs

of drugs that pharma can't lower prices. It's not that. The actual production cost is up 10% of the selling price. It's not because of R&D [research and development]. R&D is a smaller amount of money than the pharmaceutical industry spends on advertising to people like you and me, and advertising direct to consumers. It's really about something else. It's just about a fair marketplace. And pharma has a special privileged place in the U.S. market.

It's time, really, to take this not-so-bold move, but very, very real move. Let Medicare and CMS negotiate for drug prices and get the cost down.

Jack Lewin, MD is chairman of the National Coalition on Health Care.

He has been CEO of the California Medical Association, the Cardiovascular Research Foundation, and the American College of Cardiology, and Director of Health for the Hawaii State Department of Health Services.

This piece was published in a previous form on MedPage in October, 2018.

BUILDING THE MOST EQUITABLE, INCLUSIVE MEDICAL SCHOOL NATIONALLY Catherine Lucey, MD At UCSF’s School of Medicine, diversity is a critical component of institutional success. But achieving the goal of advancing health worldwide and across our city requires continual work to ensure that the environments in which medical students learn, care, and discover are not only diverse but open, equitable, and inclusive.

"UCSF and its School of Medicine believe that equitable and inclusive environments are essential to high­quality patient care, effective learning, and cutting-edge discovery," said Catherine Lucey, MD, UCSF’s Executive Vice Dean, Vice Dean for Education, Professor of Medicine.

In 2015, that commitment was formalized at UCSF with the launch of Differences Matter, a five-year, multimillion dollar initiative supported by the School of Medicine Dean's Office.

The goal is to develop and implement strategies that will increase diversity in the academic community, train all learners to more effectively treat diverse patient populations, deliver more equitable care to our communities, design clinical research that is more inclusive of minorities and people from underserved groups, and eliminate disparities in accessing opportunities.

Differences Matter arose in response to White Coats for Black Lives, a national organization formed in 2014 by UCSF medical students driven to shed light on the impact of police brutality and increasing healthcare disparities.

UCSF Vice Chancellor of Diversity and Outreach J. Renee Navarro, PharmD, MD, likens the mission to changing the campus culture.

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"We have a 'culture of innovation' at UCSF and we accomplished that consciously by breaking down the walls between specific scientific disciplines to ask better scientific questions and to get the best and most creative solutions," Dr. Navarro said.

Collaborative work at UCSF is underway to address both structural racism and interpersonal biases that contribute to inequities in healthcare for patients and education for students.

These include: • Full-day training workshops on equity, inclusion, and bias • Updated UCSF MD competency milestones focused on diversity, equity, and inclusion • A committee to support educators to engage in equity pedagogy, created by the School’s Academy of Medical Educators • A new medical student orientation that challenges students to address healthcare disparities by individually and collectively learning about equity, inclusion, and bias.

Catherine Lucey, MD

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Acute and Chronic Hot Topics in Healthcare

SECOND OPINION:

A FREE BUT INVALUABLE RESOURCE FOR CANCER PATIENTS Howard B. Kleckner, MD The second opinion is a 501c3 non-profit which offers multidisciplinary second opinions to cancer patients at no cost in the State of California, provided by over 60 volunteer physicians specializing in cancer care. Thesecondopinion was founded in 1969 by several Bay Area cancer physicians utilizing a grant from Stanford and UCSF and at the time was called the Regional Cancer Foundation. The first Board included noted physicians such as Julius Krevans MD of UCSF, Henry Kaplan MD and William Rogers MD of Stanford.

The 1970’s was a time when oncology and cancer care were in their infancy and unavailable at most local facilities. The original purpose of the organization was to provide physicians access to a regional tumor board of cancer specialists not available at their facilities who could review their cases. Physicians would present their cases and obtain expert opinion from a panel of specialists.

Within a period of 20-30 years oncology specialists in medicine and surgery began practices all over the Bay Area and the Regional Cancer Foundation for physicians became unnecessary.

Cancer care was starting to be available all over the Bay Area.

However, the need for patients to confirm their diagnosis and treatment, the need for them to be reassured they were pursuing the correct course and the necessity to make peace with their disease remained. The Regional Cancer Foundation changed from an organization providing a service to physicians to an organization providing a service to patients directly and the name was changed to thesecondopinion.

We consist of over 60 Bay Area volunteer cancer sub specialty physicians in active practice and retired. We meet as a panel at our offices three times a month, usually on Fridays 12:15PM to about 2:30PM. We review three cases each session. We obtain all medical records in advance along with imaging studies on CD ROM and pathology slides. Information is sent to panel members, usually 3-5 physicians, in advance of the panel session.

On the day of the Tumor Panel, patients come with their families and we review their cases, answer their questions, give our opinion, and send a summary letter to providers and the patients along with a CD of the session. The sessions resemble a Tumor Board but with the patient and family present. What is unique is that all questions are directed by the patient and answers are focused to their questions and issues. Patients are incredibly grateful for our service.

All funding is through contributions and grants from foundations, organizations, and gracious individual donors. There 14

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is no cost to the patient, we do not bill insurance companies or Medicare. Many of our patients do have insurance; many do not.

Patients hear of us by word of mouth, their own physicians, referral from cancer coordinators, support groups, internet, American Cancer Society, and other sources. Patients may self-refer as well.

We get patients from all over California but mainly the Bay Area and strive to reach the most medically underserved. We even provide interpreters.

In 2017 we helped 350 individuals and family members during our panel sessions and by phone for those who cannot participate. Over our 49-year history, we have impacted the lives of thousands of cancer patients and their families by providing them with clarity, compassion and choice. At the heart of our program are the volunteer efforts of over sixty board certified physicians from multiple cancer related specialties. Their diverse experiences in cancer diagnosis and treatment allow us to provide a patient centered and compassionate service not duplicated by any other agency in California.

Our organization is bound by a shared commitment to helping adults diagnosed with cancer understand their disease and treatment options. Our Board of Directors and Staff work together to maintain financial and programmatic transparency. Our volunteer medical specialists ensure that patients and their families receive the clarity they need to make informed medical decisions through in-person dialogue. We help cancer patients and families by increasing understanding and alleviating uncertainty.

We are always looking for physicians to join us and if you as a physician have the time to participate even irregularly please contact me at our offices or through our website. We also welcome patient referrals. We are located at Geary Boulevard and Gough Street in San Francisco. You may read more about us at www.thesecondopinion.org.

Howard B. Kleckner, MD is a retired oncologist from Kaiser-Permanente where he was Chief of Hematology-Oncology at Hayward/Fremont and on staff at San Francisco. Currently he is Medical Director of thesecondopinion.

WWW.SFMMS.ORG

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Acute and Chronic Hot Topics in Healthcare

SAFE INJECTION SITES:

AN IDEA WHOSE TIME HAS COME Michael Schrader, MD I toured the safe injection site demonstration at Glide

Memorial Church recently, which sought to publicize the idea of safe injection sites, and demonstrate how such a facility would work.

Safe injection sites are not new: there are approximately 100 worldwide and the first opened in Europe in the 1980s. The sites do not supply drugs, only a supervised, hygienic place to inject drugs, with a goal to improve health and reduce public nuisance.

When I walk through the Tenderloin both at night and during the day, I see drug users injecting in doorways and on the sidewalk. They are disheveled, dirty, and often emaciated. The SF Department of Public Health estimates 22,500 people in SF inject drugs, and over 100 die every year from overdose. Injection drug users are at high risk for contracting HIV and hepatitis C. The demo was situated in a single room in the lower level of Glide that was partitioned into three areas: a reception area, an injection area, and a post-injection lounge. The injection area comprised seven stainless steel tables with chairs and a check-in desk, to be staffed by a healthcare worker who would dispense supply kits. The healthcare worker would be able to administer naloxone to reverse overdoses.

Each table was stocked with a sharps disposal container, disinfectant wipes, and hand sanitizer. Each injection station had a light and a mirror for the healthcare worker to monitor the user for signs of overdose. The tables had headphones playing the tragic stories of the ruined lives of drug users.

The final area was the “chill room,” a post-injection lounge with chairs and couches, books, and games. A list of services posted on the wall highlighted resources for food, healthcare, benefits, and treatment for addiction. My overall impression was, “This is so simple. Why can’t we do this?”

The key principle behind safe injection sites is of harm reduction. Harm reduction doesn’t necessarily solve a problem but it mitigates the damage. Injection drug use takes a devastating toll on drug users and the community. Interdiction, criminalization of users, and abstinence campaigns have not kept pace with worsening opioid epidemic. The benefits to the community include decreased open use, decreased needle litter, and an estimated savings of $3.5 million per year in healthcare, law enforcement, and other costs.

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The benefits to injection drug users include decreased transmission of disease, decreased death from overdose, access to social services, and treatment for drug addiction. These poor souls need our compassion. They are well past the point where they can help themselves.

The opioid crisis is an epidemic, and safe injection sites seek to mitigate the damage. The concept of safe injection sites has been endorsed by the San Francisco Marin Medical Society, the California Medical Society and the American Medical Association. A bill (AB 186) to authorize a pilot safe injection site program in SF was passed by the California state legislature but was vetoed by Governor Brown.

United States Deputy Attorney General Rod Rosenstein, in an opinion piece in the New York Times in August, 2018, called safe injection sites dangerous and illegal and threatened federal prosecution. Expert opinion disagrees, and the time for San Francisco Mayor London Breed and our City to act in the face of federal legal challenges has arrived.

In the 1980s when the spread of AIDS was epidemic among drug users, San Francisco made the bold move of promoting needle exchange, in part prompted by the SFMS. The practice began clandestinely. In 1992, Mayor Frank Jordan declared a public health emergency and authorized funding for needle exchange. The number of new HIV cases among injection drug users dropped from 212 in 1992 to 100 in 1998.

When I talk to people about SIS I found several misconceptions: Needle exchange is a failure, the Tenderloin is hopeless, and the principle of harm reduction is not well understood.

I counter: Needle exchange is a huge success, the Tenderloin can improve if we have the political and social will, and harm reduction is an important strategy to mitigate social ills. San Francisco needs to act to save our community, increase public health and safety, and show compassion to those who need our help desperately.

This movement to open a SIS in San Francisco has just begun. We can ultimately prevail with this lifesaving service.

Michael Sçhrader, MD is an internist in San Francisco, Vice Chair of the SFMMS delegation to the CMA, and Clinical Professor of Medicine and chair of the clinical faculty association at UCSF. WWW.SFMMS.ORG

PHYSICIANS TALKING ABOUT IMMIGRATION POLICY AND HEALTH Shelly B. Rodrigues, CAE, FACEHP and Conrad Amenta

Issues being raised by immigration actions, such as separation of families, ICE activities, changes to the Public Charge policies for Medicaid and CHIP, at the Federal level will have repercussions for all Californians, including physicians, their practice teams and their patients. While the depth of problems that may be created remains unclear today, increasing physician awareness about such issues will better prepare them and other clinicians if and when the actions are implemented. Working in collaboration with the Alameda Contra Costa Medical Association, San Francisco Marin Medical Society, American Academy of Pediatrics-California, Osteopathic Physicians and Surgeons of California and Sonoma County Medical Society, the California Academy of Family Physicians Foundation offers an opening salvo, so to speak, an information and awareness campaign to lay the groundwork for future political, advocacy and educational efforts aimed at protecting the health of California’s most vulnerable populations, especially children.

The six partners in this project have planned a multi-pronged information strategy, including identifying champions to speak at live events and to the media; a series of position papers and patient education pieces; webinars on a variety of topics and a web resource center for California physicians, culminating with a live panel presentation at CAFP’s All Member Advocacy Meeting, March 2019. Our thanks to the California Health Care Foundation for its support of this important project.

Four topic areas are top of the list, but given the rapidly changing policy landscape we will adapt, accelerate and sequence our activities to address time sensitive issues.

Public Charge: According to a policy briefing published by the Henry J. Kaiser Family Foundation, the Trump Administration is pursuing changes that, for the first time, would allow the federal government to consider the use of health, nutrition and other non-cash programs when making public charge determinations.

Under these changes, use of these programs, including Medicaid, CHIP, subsidies for Marketplace coverage, by an individual or family member, including a citizen child, could result in the federal government denying an individual a “green card” or adjustment to lawful permanent status or entry into the US. These changes would likely result in reduced participation in Medicaid, CHIP, Marketplace coverage, and other programs by immigrant WWW.SFMMS.ORG

families, including citizen children, even though they would remain eligible. Decreases in Medicaid and CHIP enrollment would increase the number of uninsured and reduce access to care, increase financial strains on families, and widen disparities in coverage.

In 2016, there were 10.4 million citizen children with at least one non-citizen parent.

Nearly nine in 10 of these children live in families with fulltime workers, but these workers often are in low-wage jobs, leading to lower family incomes and more limited access to health coverage. As such, more than half (56 percent) or 5.8 million, citizen children with a non-citizen parent had Medicaid or CHIP coverage in 2016. In California, 1.5 million citizen children with a non-citizen parent currently receive care via the Medi-Cal or CHIP programs – these children could leave the ranks of covered Californians, decreasing their access to care and increasing negative health outcomes – out of fear that one’s immigration status or application for citizenship could be adversely affected by use of such services.

Immigration Policy Issues: Georgetown University’s Health Policy Institute issued a study in June 2018 that delves into the issues surrounding undocumented immigrants in the US and the citizen children of these immigrants. Currently, 11.1 million undocumented immigrants reside in the US and debates have focused little on the 4.5 million citizen children of undocumented parents.

A new report highlights the damaging effects on the health of these children resulting from the precarious legal status of one or more of their parents. Children with undocumented parents live with anxiety about whether their families can stay together in the future. Many who experience the loss of a parent also suffer from poverty, reduced access to food and health care and limited educational opportunities. The report describes the behavioral and mental health problems that arise when a parent is actually arrested, detained or deported.

The authors predict that if policies resulting in arrest, detention and deportation do not change, more than 153,000 US citizen children could have a parent taken away from them each year. continued on page 18

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Acute and Chronic Hot Topics in Healthcare The projected effects on health include:

1. 43,000 US citizen children will experience a decline in their health status after a change in household income resulting from detention/deportation;

2. poorer health and shorter lifespans for remaining adult partners; and

3. absence of the primary household earner could result in more than 125,000 children living in food-insufficient

households.

Family Separation: It goes without saying that children need caretakers. As the scientists describe it, the long maturation rate for humans allows our brains to develop and do much more complex thinking. What happens when children don’t have a caretaker? The research is pretty clear, and UCLA Professors Juvonen and Silvers summarize it well in this Washington Post piece of May 15, 2018: “The strongest evidence for the importance of close caregivers comes from children who have experienced caregiver deprivation. Even when their physical needs are met, children raised in institutional orphanages commonly exhibit stunted growth, cognitive impairments, heightened anxiety and stress-related health problems that often persist even after being adopted into highly nurturing homes. Even mere instability of caregivers early in life is disruptive to children’s development. For example, youth in foster care who experience multiple transient placements are significantly more likely to drop out of high school, be unemployed as adults and develop mental and physical illnesses.”

ICE Actions: Physicians have expressed deep concern about their roles and responsibilities to protect their practices, staff and patients should US Immigration and Customs Enforcement (ICE) agents visit their offices or clinics. Medical societies and health care organizations can provide information to patients about the availability of legal and practice advice on their rights. Work has already been completed by groups including the National Immigration Law Center, California Primary Care Association and California Health+advocates. Physicians and their practice teams must be aware of their rights and have a plan in place to respond to ICE agents but also must be prepared to protect their staffs’ and patients’ rights in the process.

Shelly Rodrigues and Conrad Amenta are with the California Academy of Family Physicians and may be reached at: 415-345- 8667 For more on the effort described here, where SFMMS is a partner, including a fact sheet for clinicians, see: https://www.familydocs.org/f/2018-10/18.ImmigrationRightsandResponsibilities.

Final__0.pdf

SFMMS CONDEMNS USE OF TEAR GAS AT BORDER Tear gas is banned in warfare by international treaty, for various reasons but primarily as it is considered a chemical weapon. It can cause severe eye problems, even blindness, plus respiratory damage, and terror and emotional distress.

Children especially needed protection from such weapons. As the American Academy of Pediatrics recently stated, “Children are uniquely vulnerable to physiological effects of chemical agents. A child's smaller size, more frequent number of breaths per minute and limited cardiovascular stress response compared to adults magnifies the harm of agents such as tear gas...The use of tear gas on children— including infants and toddlers in diapers—goes against evidence-based recommendations, and threatens their short and long-term health." The AAP went on to condemn the use of tear gas at the US/Mexican border.

The San Francisco Marin Medical Society also strongly protests and condemns the use of chemical weapons, including tear gas, on anybody, including migrants and their families. As the AAP notes, "Children who are displaced and fleeing violence should be given special protection and humanitarian assistance and allowed to petition for asylum...

Immigrant children are still children, and they deserve our compassion and assistance."

Physicians take an oath of "Do no Harm". Even in contentious arenas, our elected leaders should consider this as well. The use of such weapons as tear gas on anybody, but especially children, makes our nation shameful in the eyes of the civilized world.

John Maa, MD, President Kimberly Newell, MD, President-Elect San Francisco Marin Medical Society

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BURNOUT AND EMPATHY Peter N. Bretan, Jr., M.D., FACS We have an epidemic in our profession of medicine as > 400 physicians commit suicide each year. While this number is staggering, it is not surprising as 11.2% of doctors have depression and 30-65% suffer from burnout. Burnout is a complete physical and emotional collapse. The process (Freudenberger) and metrics have long been established, but we as a profession are just beginning to approach this rampant malady. Burnout is an individual response to a systemic problem; thus it requires both individual and organizational strategies to deal with it. Currently studies support that organization interventions are more effective than individual ones, however, there are no published studies using both to solve the problem and that is a major dilemma.

Physicians need to have a greater awareness of burnout as it is not just bad for us, but also for our businesses and patients.

The many factors that contribute to burnout are actively being addressed through new initiatives. It was inspiring to hear at the 2018 NEPO meeting of the new effort by the CMA to reinvigorate clinicians with the joy of the practice of medicine. The American College of Surgeons also this year launched the campaign "Stop overregulating my OR" to reduce the administrative burden to surgeons and their practices.

As President of the California Urological Association, it was directly evident to me that as a specialty several years ago we were suffering the highest reported burnout rate of >60%.

My colleagues and I worked to ease the pressure from MOC by organizing to replace it with a more beneficial CME program called LLL (Life Long Learning). As a result, burnout has dropped almost 20%, supporting that just one organization change can significantly affect physician wellness. The APA, AMA, Stanford Medical Center, Permanente Medical Group, Oregon Med Centers Wellness, and Suicide Prevention have started needed programs, thus we must all work proactively to protect our profession from these organizational causes of burnout.

As these efforts evolve forward, it will be essential to address the rate of rising of the overall cost of healthcare delivery. We should be proud that California physicians provide outstanding care at one of the lowest healthcare delivery costs in the country.

Inadequate access to care for Medi-Cal patients remains a significant driver for inefficient primary care. This makes a compelling argument to continue to increase Medi-Cal reimbursements (as was accomplished through Prop 56) and to develop a structure for sustainable healthcare access.

My experiences in and out of CMA for the past 18 years in leadership have helped me forge relations to work closely with our Executive committee, the Board of Trustees, the component medical societies and the Presidents Forum to fulfil these goals.

My experiences directly with numerous State and federal legislators, as I have come to know them personally as my guest lecturers to the many pertinent parts of our healthcare policy course WWW.SFMMS.ORG

for medical students enables both students and colleagues to directly question our elected officials. But my humble beginnings have given me the most important asset of my leadership, that of empathy for my colleagues. With this brings an open mindedness and a commitment to be available at all times to discuss new issues that must be considered and vetted in this rapidly changing environment of healthcare for our profession of medicine.

Peter N. Bretan M.D., FACS is President-Elect of the CMA and a member of the SFMMS He wrote this piece for the CMA annual meeting in October.

HAVE YOUR PATIENTS BEEN IMPACTED BY WILDFIRE SMOKE? The American Lung Association will be highlighting lung disease patients impacted by wildfire smoke as part of our 20th anniversary State of the Air report to focus on the health effects of air pollution worsened by climate change. The report will be released in April 2019. If you have a patient who might be willing to share their story, please email Jenny.Bard@lung.org by January 1, 2019.

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(Note: The SFMMS actively supported this effort, modeled after the San Francisco policy previously adopted)

Flavored Tobacco and Vaping Products Banned

SALE OF PRODUCTS PROHIBITED IN UNINCORPORATED AREAS OF MARIN Starting January 1, 2020, specialty tobacco stores in unincorporated Marin County will be prohibited from selling flavored tobacco products, including vaping liquids and menthol cigarettes. For all other retailers and individuals, the ban goes into effect July 1, 2019.

With support from its Department of Health and Human Services (HHS) staff, the Marin County Board of Supervisors voted November 6 to add a chapter to the Marin County Code with the restriction on tobacco sales. The ordinance follows the lead of several Bay Area cities and towns that have acted against flavored tobacco and vaping products in the past year, including San Francisco, Novato, Fairfax and Sausalito.

Board President Damon Connolly said the Supervisors recognized that the tobacco products have a disproportionate impact on youth and people of color according to a presentation by Marin HHS at the October 30 Board meeting.

“This represents a crisis right now,” he said. “Big Tobacco is clearly doing targeted marketing strategies that in effect create a gateway to addiction. … So I think we’re doing the right thing today. It’s a positive for public health.”

The County’s Public Health Officer, Dr. Matt Willis, emphasized that tobacco use is the leading cause of preventable death and that flavoring of tobacco products is driving a concerning increase in tobacco and nicotine addiction.

“After decades of progress on the reduction of tobacco use, we’re losing ground,” Willis said prior to the Board’s vote. “It’s time for new policy. We have a choice to act now against flavored products or to wait longer. The cost of waiting will be measured in lives that should have been spared.”

New data show that e-cigarette usage, known as vaping, has more than doubled in the past two years among Marin County seventh, ninth, and 11th graders. The largest increase was seen in the number of 11th graders who reported vaping regularly, from 11 percent to 28 percent. Most regular tobacco users said they became addicted when they were young and that their first use of a tobacco product was flavored. Flavoring masks the harsh taste of regular tobacco and entices young people into regular smoking. Electronic smoking devices offer flavors such as cotton candy, bubble gum, vanilla and honey while introducing nicotine to younger users.

Smoking decreased in the United States between 2004 and 2014 but the use of menthol cigarettes increased. Statistics show that smoking menthol cigarettes reduces the likelihood of successfully quitting smoking. The change in County Code also will help address disparities in health between races in Marin, Willis said. More than 80 percent of African American smokers use the 20

SAN FRANCISCO MARIN MEDICINE DECEMBER 2018

Dr. Matt Willis, Marin County's Public Health Officer, speaks to the Board of Supervisors about the flavored tobacco ban.

menthol products that have been aggressively marketed in their communities.

Marin HHS’ Tobacco Prevention Services Office plans to support tobacco merchants with ordinance compliance efforts.

Senior HHS analyst Robert Curry said all tobacco retail merchants were visited by staff at their stores in August and informed about the pending policy that was adopted November 6 by the Board of Supervisors. Curry said local retailers such as United Markets, CVS, Mollie Stone’s and all independent pharmacies that discontinued the sale of tobacco products reported that overall profits had not been affected by halting sales of tobacco products.

“The Marin public prefers to support businesses that do not earn their profits from people's addiction or by finding young replacement customers for those who quit or died from tobaccorelated diseases,” Curry said.

The Tobacco Prevention Services Office partners with other counties throughout the state in a Healthy Stores Healthy Community[External] campaign that is a local collaboration with tobacco, alcohol and nutrition prevention programs that work toward healthy options.

The office allocates state and local dollars to deliver tobacco education programs to Marin residents and limit the harm of tobacco and related products. Marin HHS also is collaborating closely with law enforcement, the Marin County Office of Education, the Smoke Free Marin Coalition and other community groups on tobacco education.

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LISTENING POST:

PATIENTS' HEALTH OUTCOMES CAN SUFFER WHEN PROVIDERS DON'T LISTEN Xenia Shih Bion

“Ask the receptionist to schedule you for my last appointment of the day. That way I can spend as much time with you as it takes to answer all of your questions.”

These two sentences, spoken by my maxillofacial surgeon a

couple of years ago, may not have been significant for him. But for me, a terrified patient facing the prospect of jaw surgery, they were the most meaningful sentences any health care provider had ever said to me.

In general, doctors are admitted to the medical field based on their grades, test scores, and technical prowess. But soft skills, like the ability to listen or empathize with patients, can fundamentally shape a patient’s experience — whether she feels heard or ignored, cared for or belittled, understood or overwhelmed.

In the Journal of Participatory Medicine, researchers published a qualitative study based on open-ended interviews that found that 85% of respondents identified “having a doctor who listens to them” as being critical to their health care experiences, and that 71% felt the same way about “having a doctor who is caring and compassionate.”

The authors write, “The most striking finding of our study of what people want from their health care is that every participant answered this question as to what they wanted from the doctor.

This confirms anecdotal reports that people understand medical care as the interaction with their doctor, and with growing research on the importance of shared decisionmaking in medicine.” (Emphasis added.)

Listening to patients isn’t just important because it can make or break a patient’s experience with the health care system.

Patients’ health outcomes can suffer when health providers don’t or can’t dedicate time to making a personal connection with them.

Listening to Older Patients

In the New York Times, Paula Span writes about Marcia Levine, a retired family therapist who visited a gastroenterologist to examine the cause of her chronic fatigue. The doctor dismissed her complaints, saying, “At your age, you can’t expect to have much energy.” But when Levine eventually switched doctors, she was correctly diagnosed with a low-grade infection.

Stories like Levine’s are the impetus for medical schools to adopt anti-ageism curricula. Ronald Adelman, MD, cochief of geriatrics at Weill Cornell Medicine, developed an annual program for second-year medical students after he realized they were often basing care decisions on misperceptions of older adults. “If you’re

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only seeing the hospitalized elderly, you’re seeing the debilitated, the physically deteriorating, the demented,” Adelman says. “It’s easy to pick up ageist stereotypes.”

Span reports that at least 20 medical schools in the US have implemented anti-ageism programs to improve student attitudes toward older adults and improve elder care. This is crucial as the country’s demographics continue to change. The US Census Bureau projects that by 2035, older people will outnumber children for the first time in US history. At the same time, our supply of geriatricians is not meeting the demand. According to the American Geriatrics Society, the need for geriatricians will increase 45% by 2025.

Listening to Mothers

Too often, mothers also do not feel heard by their health providers. The Listening to Mothers in California survey, conducted by the National Partnership for Women & Families and funded by the Yellow Chair Foundation and CHCF, found that 74% of California mothers say natural childbirth should not be interfered with unless medically necessary, but only 5% gave birth with no medical intervention.

In Vox, Julia Belluz writes about the childbirth experience of Jill Arnold, a mother, maternity care patient advocate, and founder of CesareanRates.org. Arnold was repeatedly pressured WWW.SFMMS.ORG

by her doctor to have a c-section even though there was no indication it was medically necessary. With her husband and doula at her side, she refused a c-section again and again, eventually delivering a healthy baby girl after five hours of unremarkable labor. Arnold wants women to know that they can and should advocate for the maternity care they want: “It’s okay to say no [to a c-section] and to ask what their doctor, midwife, or nurse thinks will happen if they wait and watch,” she says.

Though California has been a leader in combating maternal mortality, in part by reducing unnecessary c-sections, the state is still struggling to provide mothers of color with better care.

In California Health Report, Caitlin Yoshiko Kandil interviews Allyson Brooks, MD, an ob/gyn and Ginny Ueberroth executive medical director endowed chair of the Women’s Health Institute at Hoag Memorial Hospital Presbyterian in Newport Beach, California. Brooks emphasizes the importance of listening to mothers of color, saying, “In the perfect world, the decision to have a c-section is based on shared decisionmaking. If an individual is feeling like [she doesn’t] have a voice or that [she’s] not participating in a conversation or the physician isn’t participating in that two-way dialogue and there’s more of a paternalistic approach, you see the c-section rates go up.”

Listening to Plus-Size Patients

When Corissa Enneking’s mother dragged her to the doctor, she had been on a near-starvation diet for six months. Enneking had struggled with her weight throughout her life and was regularly consuming only a few hundred calories per day. The diet left her hungry all the time and erratic much of the time.

But her doctor looked her up and down and, ignoring the clear and dangerous signs of an eating disorder, said, “Well, whatever you’re doing now, it’s working.”

In the Huffington Post, Michael Hobbes profiles Enneking and other patients who meet the clinical definition of overweight or obese. He writes, “Ask almost any fat person about her interactions with the health care system and you will hear a story, sometimes three, the same as Enneking’s: rolled eyes, skeptical questions, treatments denied or delayed or revoked. Doctors are supposed to be trusted authorities, a patient’s primary gateway to healing.” But instead, many plus-size patients feel traumatized by experiences with doctors who proselytize weight loss as the answer to their non-weight-related health issues. Take Emily, who went to a gynecological surgeon to have an ovarian cyst removed. Hobbes writes that “the physician pointed out her body fat on the MRI, then said, ‘Look at that skinny woman in there trying to get out.’”

Weight bias is pervasive in the health care industry even though studies have shown that people who are classified as clinically obese can be metabolically healthy and people who are thin can be unfit or diabetic. When doctors don’t listen to plus-size patients, they can miss opportunities to diagnose serious health problems and even exacerbate mental health issues stemming from the trauma of being fat in a fat-shaming world.

Ginette Lenham, a counselor who specializes in obesity, told Hobbes, “A lot of my job is helping people heal from the trauma of interacting with the medical system.”

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How Can Health Care Providers Be Better Listeners?

There are no shortcuts for getting the health care system to prioritize patients’ voices, but there are steps that the industry and its providers can take toward that end.

To listen to older patients, exposing medical students to antiageism programs like the one at Weill Cornell can help change the future health workforce’s perception of older adults. An evaluation published in the Journal of the American Geriatrics Society showed that 10 US medical schools with senior mentor programs demonstrated a positive effect on student attitudes toward older adults.

To listen to mothers, especially mothers of color, it helps to have culturally and linguistically competent doulas to advocate for women before and after birth. A study published in Birth found that women on Medicaid who received doula support had lower preterm and c-section birth rates than women on Medicaid who did not. The potential savings associated with doula support was, on average, $986 per birth.

To listen to plus-size patients will require a paradigm shift in the way doctors view and value weight. A new study published in the AMA Journal of Ethics confirms “the well-described phenomenon that medical students, like physicians, hold strong negative biases against obesity and patients with obesity.” These negative biases were consistent across six cohorts (2012 to 2017) of firstyear medical students “despite increased attention to the obesity epidemic in the literature and mass media.”

However, the researchers note that there is potential for using television and film depictions of negative weight bias to change students’ self-reported attitudes toward patients with obesity.

Since nutrition education is lacking in US medical schools, they recommend future research on combined nutrition and ethics curricula to mitigate weight bias among medical students.

Reprinted with permission of the California Health Care Foundation. Copyright 2018. All rights reserved.

Xenia Shih Bion is an engagement specialist at CHCF, where she oversees social media and analytics to amplify the programmatic work of the foundation. She is the author of CHCF Blog’s weekly Essential Coverage column. Prior to joining CHCF, Xenia was a research assistant at the Prevention Institute, where she wrote about nutrition policy. Xenia received a bachelor’s degree in journalism from the University of Missouri and a master’s degree in public health from the University of California, Berkeley.

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Anniversary

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NICO-TEEN The Rise - and Fall? - of the Adolescent Vaping Epidemic Courtney Islam Walking into the bathroom at school, I am met with a cloud of smoke. No, not smoke, vapor. It smells of mango, and I see three pairs of feet under the door to the wheelchair-accessible stall. I call out “Are you almost done?” I hear a smattering of giggles, a rustle of backpacks, a shuffle of feet. The girls pour out of the stall in a clump, one of them still exhaling white.

How, you ask, could high schoolers be smoking during school?

The answer lies in the recent invention of the e-cigarette.

E-cigarettes are electronic nicotine delivery systems used to inhale aerosol. Manufacturers target adolescents through flavorings and advertisements that appeal to unknowing teens. The most popular brand of e-cigarette is the JUUL. These devices are sleek, small, colorful, and fairly affordable, making them attractive to teens. Students feel sly and cool, as their teachers overlook these unfamiliar new devices lying on a desk or floor. JUUL is the most commonly used e-cigarette in Marin, with its headquarters located in San Francisco. JUULs have become wildly popular across the nation; the company currently owns 54% of the cigarette market.

These companies claim the goal of their products is to eliminate traditional smoking among adults. However, as e-cigarettes have gained traction, nicotine use among teens has increased astronomically. E-cigarettes have introduced a younger generation to nicotine, creating a new wave of addicts. JUUL differs from other e-cigarette brands because the “pod” inserted into the e-cigarette contains liquefied salts from the tobacco leaf, which is heated rather than burned. Inhaling this vapor, called vaping, is easier and smoother than smoking. Devices like Phix, Suorin, and JUUL are causing young adults, who previously would have never considered smoking, to become addicted to nicotine. The reality is that adults are not using these devices as frequently as adolescents.

So, are electronic cigarettes really healthier than traditional cigarettes? The FDA has not approved e-cigarettes as an effective method for smoking cessation. The NIH believes research should focus on adolescent users instead. They conducted surveys asking teens what they thought their devices contained, finding 66% of teens said they had only flavoring, while just 13.2% of teens were aware of the nicotine. These data bring a new, widespread concern, that e-cigarettes act as a gateway to smoking traditional cigarettes. Statistics support this scary realization: 30.7% of teenage e-cigarette users started using tobacco cigarettes within six months, while only 8.1% of non-users began smoking over the same period of time.

While e-cigarette awareness increases, frequent teen users continue to discover covert methods to vape in new locations.

These devices emit vapor instead of true smoke, allowing teens to avoid detection in class, exhaling into their sweatshirts or back24

SAN FRANCISCO MARIN MEDICINE DECEMBER 2018

packs. As a result, schools have begun taking drastic preventative measures. In Virginia, Yorktown High School has removed all main entrance doors to bathrooms, a common hiding place for teens vaping midday. Schools have banned flash drives to avoid confusion with similar looking e-cigarettes. Some have even added nicotine detectors alongside smoke detectors in bathrooms. Unfortunately, teens continue to evade these prevention systems through tactics such as using marijuana to dilute the nicotine concentration in JUUL pods.

While the medical field knows that the human brain does not fully develop until around the age of 25, most adolescents live in denial of the harm they are inflicting on their bodies. JUUL “e-liquid” is comprised primarily of propylene glycol and glycerin. Along with nicotine, users inhale aerosol, ultrafine particles, flavoring, volatile organic compounds, cancer-causing chemicals, and heavy metals such as nickel, tin, and lead. Consequently, teenagers’ misconception that they are simply inhaling water vapor brings myriad health risks, both documented and unknown.

Vaping is now seen as the cool thing to do. Increasingly, concerned adults and teens alike are striving to share their knowledge and end the use of JUULs in middle and high schools.

Vocabulary is a powerful tool in this discussion. Especially with younger adolescents and kids, using “JUULing” as a verb eliminates the negative connotations brought along with the term “smoking.”

Thus, I encourage parents to talk to their kids, kids to talk to their friends, and society to spread awareness of the harm these devices can, and will, cause. Teenagers are impressionable.

If research exposing the true nature of e-cigarettes is directed towards teenagers specifically, we can begin to eradicate their use of electronic cigarettes.

Courtney Islam is a high school student in Marin. Her video on this topic may be found at https://www.youtube.com/ watch?v=oSL-47Pxh1c

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Southwest CARE Center (SCC) is seeking a full time HIV/HCV Physician experienced in treating populations with HIV and HCV to support our growing patient population. Founded in 1996 for the treatment and care of people living with HIV, SCC has also become a thriving primary care practice offering care and support to patients across the life span. Providing judgment-free healthcare that every person deserves, our growing practice currently includes 3 clinic locations Albuque in Santa Fe and 1 in Albuquerque.

Southwest CARE Center (SCC ) is seeking a Physician to serve as a core member of a collaborative care team that includes a consulting psychiatrist, case managers, nurses, and Clinical Pharmacists at our growing Specialty Services clinic in Santa Fe focusing on HIV treatment, care, and prevention. Our clinic is also the largest provider of hepatitis C treatment in northern New Mexico. Providers are supported by two dedicated HCV case managers assisting with medication authorizations and coordination of care. Board certification in Infectious Disease (ID) is beneficial with opportunities to see general ID patients if desired. We have an active clinical research program and a high resolution anoscopy clinic for diagnosis and treatment of anal dysplasia.

Experience in anoscopy, or willingness to be trained, is a plus but not required.

Please take a moment to review the short film on our web site, www.southwestcare.org, which chronicles the great work going on at SCC. We offer an outstanding benefit package including health and welfare benefits, generous time off and CME support. We will also provide relocation assistance and student loan forgiveness to qualified candidates

Human Resources contact Teenamarie Hernandez | HR Generalist 810 W San Mateo Rd., Suite 202 | Santa Fe, NM 87505 thernandez@southwestcare.org | Phone: 505.216.0322 | Fax: 505.983.8135

Policymaking Report

CMA APPLAUDS THE ENACTMENT OF FEDERAL OPIOID LEGISLATION The California Medical Association (CMA) applauded the

enactment of H.R. 6 – a sweeping bipartisan bill that addresses nearly every component of the national opioid epidemic.

The legislation would improve access to preventive services, opioid use disorder treatment programs, medication-assisted treatment (MAT) and non-opioid therapies, including mental health services. It would lift restrictions on using telemedicine for treatment of substance use disorders. To address the escalation in overdose deaths, it would also strengthen law enforcement efforts to crack down on international shipments of illicit drugs such as fentanyl. H.R. 6 also includes an innovative Medicare alternative health care delivery model to allow a multidisciplinary approach to managing and coordinating care for patients with substance use disorders.

“H.R. 6 provides crucial resources to expand access to treatment and prevention programs to combat opioid use disorder,” said CMA President David H. Aizuss, MD “On behalf of California physicians, we commend Congress for working with CMA and others to create a balanced approach that ensures patients have access to appropriate treatment, while reducing the risk of prescription misuse, addiction and overuse.”

Even prior to the passage of H.R. 6, California has been making significant strides in addressing the opioid epidemic. A recent AMA report found that California saw two consecutive years of decreases in prescription-related opioid deaths, as well as a 24% decrease in opioid prescriptions between 2014 and 2017, which surpassed the national average. CMA offers physicians who prescribe opioids and other controlled substances access to upto-date information on a wide range of issues, including how to provide treatment that meets the community standard of care, and how to manage the risks that come with prescribing opioids.

“These additional federal resources, combined with our current state efforts, further enable California physicians to lead the nation in implementing effective policies that focus on treatment for those suffering from substance use disorders, while ensuring access to high-quality, evidence-based treatment for pain,” said Dr. Aizuss.

CMA’s emphasis on these principles has remained constant, including advocacy on opioid-related activities in 2018, which include:

Controlled Substance Utilization Review and Evaluation System (CURES): CMA has been working with the state for years to ensure adequate educational and technical support for physicians who will have to check CURES as part of their prescribing workflow, starting on October 2, 2018. CMA has advocated for sustained user outreach and educational efforts by the state that provide clarity of this new law, as well as prioritize the clinician perspective on an ongoing basis following implementation.

Ensuring Fair Enforcement: The Medical Board of California is examining deaths associated with the use of prescription opioids and is reviewing whether the care and treatment provided by physicians to those individuals met the standard of care.

As part of a “routine” review, the board sent letters to physicians who were identified as prescribing opioids in a manner that, after physician review, merited further investigation, and requested that those physicians submit additional information including a summary of the care provided, the patient’s medical records, and any additional materials that would be pertinent to the board’s investigation.

CMA has raised concerns about the board’s process and will continue to work with the board to address physician concerns, monitor the board’s process to determine whether disciplinary actions are based on the appropriate standard of care, and if the process used to identify physicians subject to these inquiries needs additional transparency or modification. Physicians who are under review may contact CMA (800-786-4262, CMAdocs. org) for information about the disciplinary process and their legal rights.

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SFMMS Election Results Access to Medication-Assisted Treatment and Overdose Reversal Medications: The federal opioid bill continues to push treatment in the right direction by providing grants to improve access to MAT and codifying the ability for physicians to prescribe MAT for up to 275 patients, which is critical since the current caps are far too limiting and leave many patients on waiting lists for years.

Individual Patient Care: At the federal level, CMA successfully fought back against legislation that would have required onesize-fits-all medicine by mandating prescription drug dosage and duration limits. California legislators also sought to statutorily limit dosages and durations of opioid pain relievers through AB 2741 (Burke) and AB 1998 (Rodriguez), using arbitrary and minimal amounts. Both bills were defeated.

Physician Education on Safe Prescribing and Treatment: Governor Brown recently signed AB 2487 which originally mandated all California physicians to take an eight-hour course required to qualify for a federal waiver to the Drug and Addiction Treatment Act of 2000 in order to allow physicians to prescribe MAT drugs, like buprenorphine, outside of an opioid treatment center. After CMA-led negotiations, the bill was amended to allow physicians who seek to prescribe MAT to fulfill their annual continuing education requirement by completing the DATA-Waivered Physician course along with four additional credit hours on treating substance use disorders. Successful advocacy prevented additional and mandatory continuing education.

From the California Medical Association; for more, see https://www.cmadocs.org/

President-Elect: Brian Grady, MD Secretary: Monique Schaulis, MD, MPH Treasurer: Michael Schrader, MD, PhD, FACP Editor: Gordon L. Fung, MD, PhD, FACC, FACP

2018 President-Elect: Kimberley Newell Green, MD automatically succeeds to the office of President

2018 President: John Maa, MD

automatically succeeds to the office of Immediate Past President.

Board of Directors

(seven elected for three-year term 2019-2021):

Nida F. Degesys, MD Michael K. Kwok, MD Heyman Oo, MD Sarita Satpathy, MD, MPH, CPE Jeffrey L. Stevenson, MD Kristen Swann, MD Winnie Tong, MD Nominations Committee

(four elected for two-year term 2019-2020):

Tracey Hessel, MD Kenneth Katz, MD, MSC, MSCE Susan Nguyen, MD Kenneth Tai, MD

Delegation to the CMA House of Delegates (two-year term 2019-2020):

WELCOME NEW SFMMS MEMBERS! Students Marcella Gigena Lina Khoeur

CLASSIFIED: North East Medical Services is one of the largest community health centers in the United States targeting the medically underserved Asian population in San Francisco. They are searching for a Medical Director with at least 2 years clinical and leadership experience.

Candidate must be Board Certified/Board Eligible Family Medicine or Internal Medicine. Cantonese and/ or Mandarin language skills preferred. This position is approximately 30% clinic, 70% administrative. For more information please contact Galen Roberts groberts@ jordansc.com (636) 542-8310 WWW.SFMMS.ORG

Delegates Brian Grady, MD

(automatically serves in capacity as SFMMS President-Elect)

Lawrence Cheung, MD, FAAD, FASDS Gordon Fung, MD, PhD, FACC, FACP Pratima Gupta, MD John Maa, MD Richard Podolin, MD, FACC Andrea Wagner, MD Alternates Beth Griffiths, MD Keith Loring, MD Robert Margolin, MD Heyman Oo, MD, MS David Pating, MD Sarita Satpathy, MD Jeffrey Stevenson, MD Matt Willis, MD (term ending 2019) Resident Section Delegate Ryan Guinness, MD DECEMBER 2018

SAN FRANCISCO MARIN MEDICINE

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DECEMBER 2018

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SAN FRANCISCO

MARIN MEDICAL SOCIETY

UPCOMING EVENTS Holiday Mixer December 11, 2018, 5:30 pm to 8:30 pm | South Beach Yacht Club, San Francisco, CA SFMMS is pleased to be co-hosting a Holiday Mixer on December 11 at the South Beach Yacht Club with the Northern California Medical Group Management Association. This is a free event for SFMMS members and their guests, but registration is required. For more information or to RSVP, visit

COMMUNITY NEWS KAISER PERMANENTE

https://sfmms.pingg.com/sfmmsholidaymixer.

2019 SFMMS Annual Gala Friday, January 25, 2019 | Cavallo Point, Sausalito, CA

Purchase your tickets for the 2019 SFMMS Annual Gala! President-Elect, Kimberly Newell Green, MD, will be installed as the 2019 SFMMS President. Watch for your invitation to arrive in the mail. Tickets may be purchased online at www.sfmms.org/events.aspx. Sponsorship opportunities are available—contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

LETTER TO THE EDITOR Editor, The November issue, with the focus on Pediatrics, was excellent and informative. I specially want to acknowledge Dr. Ben Meisel for his leadership and call to action for special needs children and their need for anesthesia dentistry. The idea of a 2-3 year wait for painless dental procedures is a travesty. This is a subject that is out of the mainstream news and knowing that physicians are advocating for these children is so important. As parents and clinicians, this is what we are here to do. We need to put our combined voices where it really matters.

Sincerely, Toni Brayer, MD Past-President

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