May 2017 by San Francisco Marin Medical Society

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

MEDICAL ADVOCACY & ACTIVISM THE PHYSICAN'S ROLE IN HEALTH POLICY PUBLIC HEALTH IN MARIN

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IN THIS ISSUE

SAN FRANCISCO MARIN MEDICINE May 2017 Volume 90, Number 4

Medical Advocacy and Activism FEATURE ARTICLES

MONTHLY COLUMNS

11 Uncertain Times: Why Physicians Must Drive Health Policy Sandra R. Hernández, MD

Membership Matters

President’s Message Man-Kit Leung, MD

12 The American Health Care Act: An Ethical Analysis Charles E. Binkley, MD, FACS, and David S. Kemp

14 The Physician's Role: A Talk with Christine Cassel, MD Steve Heilig, MPH

16 Public Health in Marin: An Interview with Matt Willis, MD Mimi Towle 18 Health Reform in San Francisco: The Future Barbara Garcia, MPA

Editorial Gordon Fung, MD, PhD, and Steve Heilig, MPH

26 Medical Community News 23 Upcoming Events 23 Classified Ads

19 Suicide Barrier Update: Prevention on the Golden Gate Bridge Mel Blaustein, MD 20 Health Policy Perspective: Reproductive Health: Time for New Commitment Steve Heilig, MPH

SAN FRANCISCO

ADDICTION SUMMIT 5th Annual David E. Smith, MD Symposium

OF INTEREST

Friday, June 9, 2017 8:30am - 5:30pm UCSF Mission Bay Conference Center 1675 Owens Street, San Francisco

10 SFMMS Advocacy Activities 23 In Memoriam 23 Making Our Voices Heard at CMA Legislative Advocacy Day

Join us for an action-oriented forum with leading multidisciplinary faculty covering: • • • •

Opiates • Advances in addiction medicine Pain management and primary care Alcohol abuse • San Francisco problems and Tobacco responses, and more!

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

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

SAN FRANCISCO

MARIN MEDICAL SOCIETY

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMMS Members

SFMMS Merger Approved We are excited to announce that the merger agreement and proposed bylaws for the San Francisco Marin Medical Society (SFMMS) have been approved by the Marin Medical Society (MMS) and San Francisco Medical Society (SFMS) Boards and both memberships. MMS and SFMS will be merged as of May 1, 2017 and will begin using the new name, San Francisco Marin Medical Society (SFMMS). MMS and SFMS publications will be combined including San Francisco Marin Medicine, and our monthly eNewsletter. A combined SFMMS physician directory will be published this summer. SFMMS will consist of over 2,200 physicians, residents and medical students, including nearly 1,600 active members. The combined organization will significantly strengthen its ability to serve its membership and provide a strong voice for physicians and their patients in the Bay Area. We are continuing to work with the California Medical Association (CMA) on a new charter for SFMMS and to consolidate the memberships. Please bear with us as we work through the formal process with the CMA, and feel free to contact us with any questions or concerns. SAN FRANCISCO

MARIN MEDICAL SOCIETY

SFMMS Participated in the March for Science

On Saturday, March 22nd, SFMMS members participated in the March for Science in support of public discovery, understanding, and distribution of scientific knowledge as crucial to freedom, success, health, and safety.

Congratulations to SFMMS Members, Edward Chow, MD & David Pating, MD The San Francisco Marin Medical Society would like to congratulate longtime SFMS members, Drs. Edward Chow and David Pating, for their new respective positions as SF Department of Public Health Commission President and Vice President. 4

SFMMS/CMA Strongly Support SB 63 (Jackson) the New Parent Leave Act SFMMS/CMA is working together with Senator HannahBeth Jackson and SFDPH to pass SB 63 (Jackson)—the New Parent Leave Act, which will extend twelve weeks of job-protected bonding leave to California workers at companies with at least twenty employees within seventy-five miles of the employee’s worksite. SFMMS has long supported practices to improve the health status of parents and their children. SFMMS/CMA supports SB 63 because access to parental leave leads to improved maternal health, birth outcomes, and child health.

Video Help on the Way for Family Caregivers Who Must Draw Blood or Give Injections

Fifteen organizations recently formed a national consortium, the Home Alone Alliance, devoted to providing better training and instructional materials for family caregivers. This summer, nine videos on wound care and topics will be added and include dealing with newly sutured wounds, bed sores, cellulitis and diabetic foot care, among other topics. By the end of the year, another twenty videos should be available. Read more at http://bit.ly/2ouY5E4.

CMA Foundation Launches Program to Increase Diversity in Clinical Trials

The CMA Foundation and its Network of Ethnic Physician Organizations (NEPO) have launched a campaign to increase minority participation in clinical studies. The “Encouraging Diversity in Clinical Trials” campaign hopes to increase clinical trial participation among California’s multi-ethnic patient populations. The campaign is part of the CMA Foundation’s ongoing commitment to raising awareness about critical health disparities and their impact on California’s underserved communities. Read more at http://bit.ly/2pjmvF6.

CHPI Publishes Physicians’ Quality Ratings for Cycle 2

On March 22, 2017, the California Healthcare Performance Initiative System (CHPI) released its second cycle of physician quality ratings to the public. The ratings can be accessed at CHPI’s newly launched website, CAqualityratings.org, which allows consumers to search ratings on approximately 10,000 California physicians. The individual quality measurement scores were based on claims data for patient care provided January 1, 2012, through December 31, 2014. Physicians were assigned a star rating of one to four stars, based on where they fall as a percentile within a “peer group,” for each measure as well as a composite score. For more information on the CHPI Cycle 2 rating methodology, visit the CHPI website at www.chpis.org. CHPI has also

SAN FRANCISCO MARIN MEDICINE MAY 2017 WWW.SFMMS.ORG

May 2017 Volume 90, Number 4

published an FAQ on its rating program. If you have questions or concerns about the CHPI rating results, email chpicorrections@pbgh.org and expect a response within forty-eight hours.

$14 Million Reasons to Be a CMA Member

The CMA Center for Economic Services (CES) has recouped $14 million from payors on behalf of CMA member physicians over the past eight years. These monies represent actual physician reimbursements that would have likely gone unpaid without the intervention of the CES team. CES provides CMA members with one-on-one assistance for billing, contracting and payment problems. With more than 125 years of combined medical practice operations experience, CES staff helps members with issues ranging from underpayment or denials by payors to assisting with contract analysis during negotiations. Assistance from CES also includes education on how to increase practice efficiency and direct intervention with payors or regulators. This support is reserved exclusively for CMA members. For practice management tools and other online assistance, visit www.cmanet.org/ces.

CMA Updates MACRA Preparation Checklist

The CMA’s Center for Economic Services has published an update to its Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) preparation checklist (http://bit.ly/2o8wAVx). CMA published this important checklist to help physicians understand MACRA payment reforms and what they can do now to start preparing for the transition. Also available in the MACRA resource center (www.cmanet.org/macra) is an overview of MACRA, and a comprehensive list of tools, resources and information from CMA, the American Medical Association and the Centers for Medicare and Medicaid Services.

CMA Conducting Annual Member Phone Survey

The CMA will be calling physician members to understand the priorities and opinions of our membership. “We do this every year to improve CMA member value and understand what our advocacy priorities should be,” said Mike Steenburgh, CMA vice president of membership, marketing and component relations. “We have found the feedback helpful for staying aligned with our physician members’ needs.” Conducted by a third-party researcher, the phone survey is a random, representative sample of members and allows for anonymous responses. Contact: CMA member service center, (800) 786-4262 or memberservice@cmanet.org.

CMA’s Practice Manager Tip of the Month

Take charge of your online reputation. In today’s digital world, monitoring and managing a physician’s online presence is essential to avoiding potential harm to their reputation that could negatively affecting their practice. While it might not be feasible for physicians to prevent every negative comment, establishing a process to monitor their digital presence and taking control of information about the practice online will significantly reduce the potential impact of a bad review. For more information, see http://cal. md/apr-2017-tip.

Editor Gordon Fung, MD, PhD Managing Editor Steve Heilig, MPH Production Editor Amanda Denz, MA Copy Editor Amy LeBlanc, MA EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Erica Goode, MD, MPH Michel Accad, MD Erica Goode, MD, MPH Stephen Askin, MD Shieva Khayam-Bashi, MD Toni Brayer, MD Arthur Lyons, MD Chunbo Cai, MD John Maa, MD Linda Hawes Clever, MD David Pating, MD SFMS OFFICERS President Man-Kit Leung, MD President-Elect John Maa, MD Secretary Brian Grady, MD Treasurer Kimberly L. Newell, MD Immediate Past President Richard A. Podolin, MD MMS Officers President Peter Bretan, MD President-Elect Michael Kwok, MD Secretary/Treasurer Naveen Kumar, MD Immediate Past President Jeffrey Stevenson, 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 Director of Administration Posi Lyon Membership Coordinator Ariel Young SFMMS BOARD OF DIRECTORS Term: Jan 2017-Dec 2019 David T. Duong, MD Robert A. Harvey, MD Dawn D. Ogawa, MD Ray Oshtory, MD Justin P. Quock, MD Dennis Song, MD Joseph W. Woo, MD

Term Ending: June 30, 2017 Larry Bedard, MD Lori Selleck, MD Matt Willis, MD

Term: Jan 2016-Dec 2018 Charles E. Binkley, MD Benjamin L. Franc, MD Nida Degesys, MD Raymond Liu, MD David R. Pating, MD Monique D. Schaulis, MD Winnie Tong, MD

Term Ending: June 30, 2018 Imran Junaid, MD Michael Kwok, MD Jeff Stevenson, MD

Term: Jan 2015-Dec 2017 Steven H. Fugaro, MD Todd A. May, MD Stephanie Oltmann, MD William T. Prey, MD Michael C. Schrader, MD Albert Y. Yu, MD

Term Ending: June 30, 2019 Peter Bretan, MD Irina deFischer, MD Naveen Kumar, MD Jason Nau, MD

CMA Trustee Shannon Udovic-Constant, MD AMA Delegate Robert J. Margolin, MD AMA Alternate Gordon L. Fung, MD, PhD

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MAY 2017 SAN FRANCISCO MARIN MEDICINE

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PRESIDENT’S MESSAGE Man-Kit Leung, MD

SFMMS: One Hundred Fifty Years of Health Advocacy It was early on a summer day in 2001. I had just finished my third year of medical school at the University of California at San Francisco but instead of pre-rounding in an urban hospital, I found myself in a remote rural area, surrounded by thousands of white jasmine buds that shivered, as I did, from the morning breeze. Instead of San Francisco, I was in Heng County, located in Guangxi province in southwest China. It was here where I would spend my year off from medical school to conduct clinical research abroad. The study design was simple: Enroll a cohort of human immunodeficiency virus (HIV) negative injection drug users (IDUs) and follow each of them over a specified time to see how many of the subjects would become HIV positive. Each subject was to undergo regular interviews, blood work, and counseling every few months. Located along the drug trafficking route between the Golden Triangle (the border areas of Thailand, Myanmar, and Laos) and the rich shores of Hong Kong and China’s eastern seaboard, Guangxi was the chosen study site due to the surging rates of both IDU and HIV. My charge was to implement the study protocol—to work alongside the local public health department to iron out the logistics and execute the clinical trial according to design. How hard could that be, I remember naively thinking to myself. Frankly put, there were numerous logistical challenges. At the time, eighty percent of the health care workers in Heng completed a total of nine to twelve years of education, the equivalent years of education as a high school student in the U.S. In addition to fundamental counseling skills, including concepts such as privacy and confidentiality, many of the workers needed training in basic administrative skills such as record keeping, word processing, and filing. There was also the challenge of earning the trust of the local Public Security Bureau (i.e., police) who were not keen on acknowledging that illicit drug use even existed in their precincts. Our biggest challenge, however, was engaging the local community. “How do we convince respectable farmers that they must be concerned about the plight of the IDU? How do we explain to poor, hard-working farmhands that IDUs ought to be protected and even given monetary incentives to participate in research studies?” I remember local public health workers asking me. “How can health advocacy be successful in China?” My year abroad taught me what it meant to be a public health advocate— to raise awareness of an unmet societal health need, to engage communities, to build coalitions, and to promote reform. Now, more than fifteen years later, I am so proud to be part of SFMMS, an organization with a history of successful health advocacy. On issues such as HIV, tobacco, sugar-sweetened beverages, and the environment, SFMMS has consistently championed policies both locally and beyond that improve the health of WWW.SFMMS.ORG

our city and state. For members who are interested in advocacy, opportunities within SFMMS include joining our delegation’s activities in the CMA House of Delegates (HOD), participating in the annual Legislative Day, and/or writing an article in our journal San Francisco Marin Medicine. Any SFMMS member can author a policy idea for consideration by CMA and are encouraged to work with our HOD delegation to introduce the resolution. Recently, the CMA instituted a new process where resolutions are considered year-round instead of annually. Furthermore, any SFMMS member may submit written testimony online on any resolution in the Year-Round Resolutions area of the House of Delegates section of the CMA website. Participation in the annual Legislative Day is open to all SFMMS members. Held in April each year, “Leg Day” provides members the opportunity to meet with State Senators and Assemblypersons. Participants are briefed on bills of significance to physicians that are being considered by the legislature and then discuss issues of concern to their elected officials. This year, SFMMS members met with Senator Scott Wiener, Assemblymember David Chiu, and Assemblymember Phil Ting’s staff to discourage diversion of funds allocated for Medi-Cal generated from the passage of the California Healthcare, Research, and Prevention Tobacco Tax Act of 2016 (Proposition 56) as well as to restore funding dedicated to Graduate Medical Education. Finally, I would encourage any SFMMS member to submit articles for publication in San Francisco Marin Medicine and/or correspond with us through social media. It is only through open communication can SFMMS hear the concerns of individual physicians and amplify those concerns through our collective voices to effect policy change. I recall little of my time in medical school (except maybe parts of the Krebs cycle) but I will never forget the lessons learned during my year abroad. Although time passes and issues change, the basics of advocacy including raising awareness, building coalition, and promoting reform still stay the same. These are lessons mastered by SFMMS during its nearly 150 year history of health activism. Man-Kit Leung, MD, is an otolaryngologist in private practice and the current President of the San Francisco Marin Medical Society. He welcomes correspondence at mleung@SFMMS. org. MAY 2017 SAN FRANCISCO MARIN MEDICINE

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EDITORIAL Gordon Fung, MD, PhD, and Steve Heilig, MPH

The Evolution of Activism The medical profession has long been famously, or some might say infamously, apolitical. There are good reasons for this tradition, including the ethical imperative to remain impartial regarding nonclinical considerations when treating patients, and, when venturing into public issues, to be seen as objective and strictly "evidence-based." These are time-tested constraints on individual and organized medical politics, intended to keep medicine "above the fray." But of course there have always been exceptions. And perhaps now more than ever. Physicians in organizations have long fought for proposals that impact medicine and public health; and yes, sometimes medical lobbying has been seen as overly selfserving, especially in a financial sense. But there is also a longer and nobler history of doctors standing up for what is not necessarily in their own interest, and even more commonly, for that which benefits both private and public health. Advocacy is most generically defined as "the act or process of supporting a cause or proposal." That's a fairly innocuous role. Going further, Activism is "a doctrine or practice that emphasizes direct vigorous action especially in support of or opposition to one side of a controversial issue." Note that, compared to advocacy, this includes "vigorous" work regarding something "controversial." The SFMS does both. It's a fair bet that we've brought more forward-looking policies to our state and national medical associations than any other county group; quite a few of these have become translated into, or at least influenced, laws and legislation. And yes, sometimes the issues involved have been controversial enough to attract much media and public attention, not all of it positive. That comes with the activism turf, but we have always been confident that our positions rest upon both science and the values of compassion and minimizing harms. The ongoing political battle over access to care—which is what the battle over the ACA is not solely but mostly about—and a broader perception that the scientific research and progress we all rely upon is also threatened, has brought about unprecedented concern, and moved many beyond advocacy to activism. A "science march" might have seemed very unlikely not long ago— and the prior "women's march" had much to do with health and science as well. The science march itself was called "political but not partisan"—a clever way of trying to thread the needle of objectivity. But it must be said that the current threats to research, care, healthy policy and regulation, and the concept of scientific truth itself are undeniably under attack since the new federal administration took office. Our state senator and pediatrician Richard Pan, MD, put it well at the science march by warning "We are in a dangerous place. When we make laws or policies that are disconnected from the facts, that is the route to disaster." He cited not only proposed cuts to the NIH and EPA but a resurgence of anti-vaccine sentiWWW.SFMMS.ORG

ment, enabled by the White House. The president of the National Physicians Alliance put it a bit more pithily: "Unfortunately, Washington D.C. is often an evidence-free zone." The SFMS has long had the image of an active physician's organization; our succinct mission is to be "an advocate for physicians and their patients." SFMS leaders proudly marched with that banner in the San Francisco march last month. But more important are the long list of issues on which SFMS has had an impact, listed on another page in this issue. Following are a number of perspectives both historical and contemporary, including national and local issues, including "case studies" regarding local medical advocacy for a suicide barrier on the Golden Gate Bridge, and nationally for reproductive health access. On all of these, physicians have taken leading roles, as despite whatever other changes have occurred in medical roles and prestige, the public, and many if not most of our elected representatives, view medical opinion with respect. That is especially true when physicians are seen as advocates—and yes even activists—for the greater good. Another battle has been the issue of the funding for health care. Physicians are in a unique position to provide guidance to the administrators, legislators, and government regarding ways to streamline paperwork and focus on the providing the best quality care. One innovative idea (long ago) was the possibility of single payer. The history and debates of this method of funding has been long drawn out along political, economic, administrative and budget lines. At every discussion of health care reform, the option of creating a single payor model is brought up and most times rapidly swept off the table. Interestingly, the new ironic shift to a majority of public and medical opinion favoring a single-payer system, with even state legislation to institute that now introduced. Well over a century back, pioneering virologist Rudolph Virchow held that "physicians are the natural attorneys of the poor." Many physicians might well chafe under at least part of that analogy of the role of the medical profession as attorneys - and even the limitation of beneficiaries of medical activism to the impoverished. For, properly conceived and carried out, effective medical advocacy benefits everyone. We should just remember to always consider who might need our advocacy— and activism—the most. One announcement to our audience, this is the first issue of the newly-retitled San Francisco Marin Medicine. We welcome our new Marin members, readers - and potential authors! MAY 2017 SAN FRANCISCO MARIN MEDICINE

SFMMS ADVOCACY ACTIVITIES AN ADVOCATE FOR PATIENTS, PHYSICIANS, AND THE COMMUNITY As the only medical association in San Francisco and Marin to represent the entire spectrum of medical specialties and interests, the San Francisco Marin Medical Society (SFMMS) has been a champion for community health issues since its inception in 1868. Our policymaking efforts through collaborations with state/national medical and political leaders, as well as articles in our awardwinning journal, have given us a reputation for being influential far beyond the Bay Area. The SFMMS agenda and activities continue to focus on the community and the following areas of involvement.

UNIVERSAL ACCESS TO CARE: With ongoing, vigilant efforts

to preserve programs and prevent cuts in Medi-Cal reimbursement, SFMS leaders have long advocated that everyone should have access to quality medical care. SFMS additionally joined in the lawsuits to preserve the Healthy San Francisco program, a curriculum designed by those (including our own representatives) serving on the Mayor’s Task Force. SFMS advocated for, and even helped create, community clinics dating back to the original Haight-Ashbury Free Clinics in the 1960s, and, more recently, argued for preservation of the Affordable Care Act’s best features.

ANTI-TOBACCO ADVOCACY: SFMS advocates were instrumental in the banning of tobacco smoking in San Francisco restaurants, an accomplishment that was ahead of the rest of the state and nation. SFMS advocated for many policies, including ever-stronger protections from secondhand smoke, higher taxes on tobacco products, and the removal of tobacco products from pharmacy settings. SFMS later signed onto an amicus brief in support of upholding San Francisco’s law banning the sale of tobacco in pharmacies. SFMS actively worked to pass legislation to tax tobacco products in order to provide additional funding for Medi-Cal. HIV PREVENTION AND TREATMENT/HEPATITIS B:

Having been among the first to push for legalized syringe exchange programs, appropriate tracking and reporting processes, optimal funding, and more, the SFMS was, naturally, at the center of medical advocacy for solid responses to the AIDS epidemic in the 1980s. SFMS is a partner in the Hep B Free program in San Francisco and helps educate physicians and patients on the prevention and treatment of hepatitis B.

SUGAR TAXATION AND HEALTH: SFMS has long been on record combating overconsumption—and marketing—of sugar and soda, especially where young people are concerned. To help prevent and battle obesity and other associated ills, SFMS has not only endorsed the broad coalition, but is also at the forefront of instituting a landmark local tax on soda with revenue marked for health needs. We have authored policy on this issue for the California Medical Association (CMA) as well. SCHOOL AND TEEN HEALTH: SFMS helped establish and

staff a citywide school health education and condom program, removed questionable drug education efforts from high schools, worked on improving school nutritional standards, and provides medical consultation to the San Francisco Unified School District 10

school health service. SFMS has authored a resolution allowing minors to receive vaccines to prevent Sextually Transmitted Infections (STIs) without parental consent.

END-OF-LIFE CARE: SFMS leaders have developed numerous policy and educational efforts to improve care toward the end of life, including promulgation of the Physician Orders for Life-Sustaining Treatment (POLST) medical order. The SFMS was instrumental, after decades of advocacy, in getting the CMA to remove its blanket opposition to physician-assisted dying and to thus allow for legalization of that in 2016.

ANTIBIOTIC RESISTANCE: SFMS leaders have presented national meetings and policy on this topic, including the American Medical Association’s first statement on antibiotic overuse in agriculture and numerous subsequent efforts. ENVIRONMENTAL HEALTH: SFMS’ many efforts include

establishing the Collaborative on Health and the Environment, a nationwide educational network on scientific approaches to environmental factors in human health, and advocating for reduced exposure to mercury, lead, and air pollution.

REPRODUCTIVE HEALTH AND RIGHTS: SFMS has been a

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

ORGAN DONATION: SFMS has been the vanguard in seeking improved donation of organs to decrease waiting lists and deaths due to the shortage of organs through educating the public and proposing new policies regarding consent and incentives for organ donation.

OPERATION ACCESS: SFMS is a founding sponsor of this local

organization which provides free surgical services to the uninsured, and has provided office space, volunteers, and funds.

DRUG POLICY: SFMS has been a leader in exploring and advocating new and sound approaches to drug abuse, including some of the first policies regarding syringe exchange, medical cannabis, and treatment instead of incarceration. We were integral in the development of CMA’s landmark report on decriminalization and regulation of cannabis, and even in creation of the official subspecialty of Addiction Medicine.

MEDICAL ETHICS: SFMS has developed and promulgated forward-looking policies and approaches regarding end-of-life care, patient directives, physician-assisted dying, and other topics of interest to patients, physicians, policymakers, and the general public.

PARTNERSHIPS: SFMS works closely with many local specialty and health organizations such as the San Francisco Department of Public Health, Health Commission of San Francisco, San Francisco Emergency Physicians Association, San Francisco Pediatric Council, San Francisco Community Clinic Consortium, West Bay Hospital Conference, Chinese Community Health Care Association, and others.

SAN FRANCISCO MARIN MEDICINE MAY 2017 WWW.SFMMS.ORG

Medical Advocacy and Activism

UNCERTAIN TIMES Why Physicians Must Drive Health Policy Sandra R. Hernández, MD No matter what changes may emerge from this year’s unprecedented political and policy turmoil in Washington, this much seems inevitable: resources for health care are going to tighten. Clinicians and pay-

ers are going to have to do different with less. Physicians will need to cooperate with other health professionals while accepting increased transparency and accountability for their efforts. Whether caring for consumers who have private insurance or people enrolled in Medi-Cal, physicians can’t avoid the resource constraints that I expect will drive governments, health systems, and medical groups to reorganize the way clinicians work. Here are some key trends you can expect to take hold in this era of health policy ferment.

If You Aren’t Already Engaged in Value-Based Care, It’s a Safe Bet That You Will Be

I have no doubt that the pathway to medicine’s future runs through value-based care. That’s why the California Health Care Foundation (CHCF) has been investing in the cultivation of alternative payment models for sixteen years. Physicians have already evolved away from compensation that was untethered to the quality and cost of patient care. Much of our investment in this area has focused on the Integrated Healthcare Association (IHA), which has worked with California health plans and physician organizations to effectively develop value-based pay for performance (P4P) into one of the largest alternative payment models in the country. The P4P project involves ten health plans and more than two hundred California physician organizations serving more than nine million enrollees in California commercial health plans. In P4P, common performance measures and benchmarks enable market forces to propel care improvements across all health plans and physician organizations. In combination with data aggregation that provides increasingly accurate depictions of performance with reduced physician reporting burdens, we now have potent tools that lead to desirable patient care outcomes while rewarding physician leadership. Since 2001, more than five hundred million dollars have been awarded as incentive payments.

weaknesses of health maintenance organizations and preferred provider organizations. The IHA atlas analysis indicates that California health care purchasers need to rethink whether it makes sense to opt for lower-premium, lower-quality preferred provider organizations (PPOs) instead of lower-cost, higher-quality health maintenance organizations (HMOs). If California purchasers and consumers of insurance products focus only on premiums and not on the total cost of care and quality performance, it’s likely that they’re miscalculating the quality-cost value equation. Employer purchasers especially should take a fresh look at HMOs and the integrated care delivery systems that support them. The table below illustrates why benchmarking and tracking performance on key health care quality and cost measures are critical steps toward reducing unwarranted geographic variations in services and driving the health care world toward team-based care.

Medical Professionals Will Adopt More Expansive Approaches to Assembling Care Teams

Workforce initiatives being formulated now will change the landscape for all the allied health professions as delivery sys-

Continued on page 13 . . .

Physicians Will See the World Through a New Lens

Building on its P4P expertise, IHA has produced significant new data insights into regional variations in cost and quality of care. This data enables health care organizations to apply concrete benchmarks to their improvement efforts. With CHCF support, IHA last year produced the California Regional Health Care Cost & Quality Atlas (an updated atlas will be released again this year), and it produced dramatic insights into the strengths and WWW.SFMMS.ORG

MAY 2017 SAN FRANCISCO MARIN MEDICINE

Medical Advocacy and Activism

THE AMERICAN HEALTH CARE ACT An Ethical Analysis Charles E. Binkley, MD, FACS, and David S. Kemp On Thursday, March 23, the U.S. House of Representatives was scheduled to vote on the American Health Care Act of 2017 (AHCA)—the proposed replace-

ment for the Patient Protection and Affordable Care Act (PPACA). Response to the AHCA came from many sectors, often with partisan bias. One perspective that was notably lacking from the debate—and the one we present here—is a nonpartisan ethical analysis of the proposed law. We are limiting our analysis to the micro level—the level of the individual. Analysis at the macro level is valuable and deserving of its own discussion, but we believe our micro-analysis alone presents compelling reasons that core characteristics of AHCA are unethical. There is a global consensus that modern societies have an obligation to provide essential health services to all of their members, thus our purpose is not to provide ethical justification for provision of these services. Americans value the highest-quality care, the greatest freedom of choice, the greatest affordability, and the most widely accessible healthcare; however, governmental resources will always fall short of what is required. This creates a need to identify and define priorities in health coverage (“priority setting”). As a result of priority setting, there must inevitably be tradeoffs—the deliberate decisions to allocate resources to certain areas of healthcare provision over others. There must be some ethical structure by which to assess the priorities. We analyze the proposal using the ethical principles of impartiality and justice, and we identify what we believe to be ethically unacceptable tradeoffs within this construct. Extrapolating from the core principles of impartiality and justice, one can discern values around which to prioritize healthcare coverage. The first of these is cost effectiveness of healthcare—that is, the financial burden of the provision of healthcare relative to the benefits they confer. Second is priority to the worst off, accounting for socio-economic status, health status, and access to care. Access is particularly important given the growing scarcity of medical resources in the rural areas of the United States. The last is financial risk protection. On the micro level, a citizen ought not have to suffer financial ruin in order to access adequate healthcare.

Cost Effectiveness

The cost effectiveness of prevention and public health is well established. Among the ten essential health benefits covered under the AHCA, only preventive services exempted cost sharing (co-pay or deductible). This might suggest prioritization on the basis of cost effectiveness, but none of the other nine essential benefits were prioritized on that basis. Moreover, if the AHCA had truly prioritized cost effectiveness, it would not 12

have attempted to eliminate the Prevention and Public Health Fund, which provides evidence-based and innovative grants to improve the health of Americans. There was no mechanism in the AHCA for analyzing individual healthcare provisions on the basis of cost effectiveness. One could argue that until the cost effectiveness of healthcare is considered and prioritized, the gap between what the government can provide and what its people need will continue to increase.

Priority to the Worst Off

The second ethical criteria on which to assess the AHCA is priority to the worst off. The worst off can be defined by economics (poorer more so than wealthier), health status (sicker more so than the well), and geography (rural more so than urban). Pre-existing conditions are one surrogate marker for health status, and the AHCA provided coverage of pre-existing conditions. Thus, it succeeded at prioritizing the worst off, at least as defined by this particular marker of health status. The AHCA failed, however, to prioritize care for the worst off in several other important ways. As mentioned previously, the AHCA ensured ten essential health benefits to everyone covered. Tax credits, calculated linearly based on age, indirectly subsidize healthcare coverage. There was also provision for a 5:1 ratio age rating, meaning that insurance providers would have been allowed to charge older citizens up to five times more for coverage than younger people, for the same level of coverage. According to a Milliman study, the impact of a 5:1 ratio would be a significant premium increase for older people, who often have a limited, fixed income. The AHCA also significantly cut funding for Medicaid, a program that provides care to the poorest, the sickest, and those with the most limitations to access. In these respects, the AHCA clearly did not prioritize the worst off.

Financial Protection

Financial protection should be prioritized to assure that healthcare costs do not impoverish citizens, particularly in acute or catastrophic settings. The AHCA excelled in that citizens covered could have reasonably relied on protection from financial ruin. For instance, it prohibited lifetime and annual dollar maximums. However, those not covered would have been remarkably vulnerable to significant financial hardship, even for relatively routine care. The nonpartisan Congressional Budget Office estimated that under the AHCA, in 2018, an additional fourteen million would be uninsured, increasing to twenty-four million in 2026. By increasing the number of uninsured so drastically, the AHCA failed to provide financial protection to the people of the United

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States on the whole. Consider instead a policy that ranked the same ten essential health benefits by cost effectiveness and eliminated the lowest ranked one. That reduction in individual coverage could in turn be used to cover more people, providing them with fewer but higher priority services.

Unacceptable Tradeoffs

The previous example calls for a distinction between ethically acceptable tradeoffs in the prioritization of healthcare benefits and unacceptable ones. Coverage of low or medium priority services before there is consistent coverage of high priority services is an unacceptable tradeoff. This brings us once again to consider prioritization, potentially on the basis of cost effectiveness, of the ten essential health benefits. The AHCA sacrificed coverage of more people for higher individual levels of care. Those covered would have enjoyed high quality and ready access without a maximum limit, coverage of pre-existing conditions, and choice in provider and delivery. However, this robust level of individual services necessarily limits the number of people with coverage. This tradeoff is ethically unacceptable under the principles of impartiality and justice. Another unacceptable tradeoff in prioritization is expansion of benefits for well off groups before doing so for worse off groups. As detailed previously, the increased number of uninsured, the cuts to Medicaid, and the increased premium expenses to older citizens allow for expansion of benefits to well off groups and in many cases excludes worse off groups—the elderly, the poor, the sick, and those with limited access. Again, this is an ethically unacceptable tradeoff.

Conclusion

Recognizing the necessity of priority setting in healthcare provision, an ethical framework based on impartiality and justice is necessary. It thus follows that coverage should be primarily based on need and not on ability to pay or political power. Laudably, the AHCA did not directly exclude or place exceptions to coverage on certain groups of citizens based on considerations of race, ethnicity, religion, gender, political beliefs, or sexual orientation. It also nominally acknowledged the value of cost effectiveness, ensured the coverage of those with pre-existing conditions, and provided financial protection in the form of prohibiting lifetime and annual maximums. However, it failed to consistently apply standards for cost effectiveness, it neglected the worst off as measured by access and economic status, and it provided no financial protection for the great number of people who would have become (or remained) uninsured. Based on these shortcomings, the AHCA failed to meet the ethical standards for government-supported healthcare.

Charles E. Binkley, MD, FACS, is an Hepatobiliary and Pancreatic Surgeon at Kaiser Permanente Medical Center in San Francisco, where he is co-chair of the Ethics Committee. He is on the Board of Directors of the San Francisco Medical Society and a member of the CMA Council on Ethical, Legal and Judicial Affairs. David S. Kemp is an attorney and managing editor at Justia, an online platform that provides the community with open access to the law, legal information, and lawyers. A version of this article first appeared on Justia’s Verdict on March 21, 2017. WWW.SFMMS.ORG

Uncertain Times Continued from page 11 . . . tem leaders move to toward expanding primary care capacity and integrating physical and behavioral health care. A sufficient population of qualified and diverse health professionals is essential for these tasks. In California, the current deployment of the health care workforce does not yet fully align with this goal of spurring the adoption of whole-person care. Severe and growing shortages already exist in many key health professions. California’s growth and changing demographics will exacerbate these shortages and significantly increase demand. The problem is particularly acute in rural and underserved urban areas and for safety-net providers. California’s non-white population groups are significantly under-represented in almost all health professions. Our health workforce is rapidly aging, with many nurses, doctors, health administrators, and others nearing retirement at a time when demand is increasing. We have to address barriers to developing and retaining the health workforce of the future. California does not have sufficient educational capacity to produce the workforce we need, and whole-person care requires cross-training and competencies that are not part of the current training for physical health or behavioral health providers. The mismatch between the health workforce of today and the workforce required to fully deploy the health care delivery system of tomorrow is an ongoing and serious impediment to care transformation. During the critically important deliberations on how the health system should adapt, it would be a grave mistake for physicians to focus their energies solely on caring for their patients. They must look up from their clinical tasks and engage in the public dialogue surrounding the health policy upheavals. It is in the best interests of neither doctors nor patients for physicians to sit back and await instructions from policymakers and budgeteers. In the brutal world of political policymaking, physicians have the power to exert great influence over decisions. The people of California are counting on us to make our voices heard.

Dr. Sandra R. Hernández has been president and CEO of the California Health Care Foundation since January 2014. CHCF is an independent foundation with assets of more than $700 million, headquartered in Oakland, California, and dedicated to making health care work for all Californians. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also co-chaired San Francisco's Universal Healthcare Council, which designed Healthy San Francisco. Sandra is an assistant clinical professor at the University of California, San Francisco, School of Medicine. She practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016. She is a graduate of Yale University, the Tufts School of Medicine, and Harvard University's John F. Kennedy School of Government. MAY 2017 SAN FRANCISCO MARIN MEDICINE

Medical Advocacy and Activism

THE PHYSICIAN'S ROLE A Talk with Christine Cassel, MD Steve Heilig, MPH “The physicians are the natural attorneys of the poor.” —Rudolf Ludwig Carl Virchow (1821–1902), physician, anthropologist, pathologist, prehistorian, biologist, writer, editor, and politician, known as “the father of modern pathology.”

Christine K. Cassel is a leading figure in geriatric medicine, medical ethics, and quality of care. She is Planning

Dean of the new Kaiser Permanente School of Medicine, and has been President and Chief Executive Officer (CEO) of the National Quality Forum, President and CEO of the American Board of Internal Medicine (ABIM), Chair of the ABIM Board of Directors, and President of the American College of Physicians. She chaired Institute of Medicine (IOM) reports on end-of-life care and public health and is author or co-author of fourteen books and more than two hundred journal articles. She edited four editions of Geriatric Medicine, a leading textbook in the field. Dr. Casell recently gave University of California, San Francisco Grand Rounds on the topic of “Frontiers of Professionalism: The Physician’s Role in Challenging Times,” using four “case studies” of renowned medical activists.

What sparked your talk on this particular topic?

What made me think and talk about this time is that we are now in a particularly challenging time for healthcare, especially now that we know so much more about what some of the social determinants of health are. There are extraordinary threats to the infrastructure that we’ve come to rely on, our ability to innovate, and to basic things like coverage and access. So it seemed to me the right time to go back to what drives medical activism, which has a long and storied history in other challenging times. But it also makes some people uncomfortable. Much of my work in medical ethics has been in trying to understand and articulate the values of the profession that forge physician advocacy. My reaction to the election was to dive back into that work.

The bulk of medical ethics literature and teaching, including formal codes, has been about responsibility to patients and related to patient care. Why does going beyond that make some uncomfortable?

I think most physicians don’t think of themselves as political people, and if they do get involved in advocacy it tends to be about more money for research—which is completely understandable— 14

more money for the specific patients they care for, or becoming a spokesperson for a particular point on an issue like immigration, to choose a current example. Speaking out in public and in print is a time-honored way of getting involved. More and more people are frustrated with the limits of our healthcare system. One relatively recent example of group advocacy is the Physician Charter, published in early 2000, in recognition and response to the fact that traditional documents in medical ethics from Percival to Hippocrates and Maimonides all talk about putting patients’ interests before your own, but don’t talk about societal good and healthcare as a social phenomenon. The groups that put together the Charter, which happened to be all internal medicine groups in the U.S. and Europe, produced what has been called the “new Hippocratic Oath”—it doesn’t replace the older codes, but it says other relatively new things, seen as necessary. One fundamental value there is patient autonomy, respecting the wishes of the patients. In our modern world, with so many more treatments with many risks and benefits, and many different cultural backgrounds and values, the need for informed consent and shared decision-making have remade the medical encounter. Social justice appears nowhere in the ancient documents, and this group felt that with the increasing effectiveness and cost of healthcare, and the recognition that having a healthy population even leads to a healthy economy, physicians naturally have an important role in society in the broader sense.

I’m sure you often get the pushback that clinicians are just too busy already to get involved in advocacy, and that we are in an era of ever-increasing physician burnout.

Yes, and it’s a personal decision that everyone has to make. Burnout is a special challenge and a huge one, of course, and will be one of the things we will try to address in our new medical school. There is a new statement from the ABIM Foundation, recently published in the Journal of the American Medical Association (JAMA), which notes that institutions—from hospitals to health systems to insurers to regulators—often create barriers that contribute to burnout and driving doctors crazy. All of that is true. But even with all that, we all make decisions on what we want to do. I’m not saying that every doctor should be out marching in the streets, although some will. Some are just more motivated than others in this way. Some physicians have found that working for change in a frustrating world can actually energize them. One of the elements of burnout is a feeling of being victimized in some way, even helpless. So advocacy can actually be empowering, and make one feel one is part of the solution and not just a cog in the wheel. There’s a wonderful newer organization called the National Physicians Alliance, started by a group of younger doctors who were involved in the American Medical Student Association (AMSA) and

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wanted to continue advocacy after they graduated. So they took on things like conflicts of interest with drug companies, gun violence, the Affordable Care Act, and issues where they saw too much attention being paid to the bottom line rather than patients. These were young physicians starting their careers, having families, and somehow they find the time and energy to create a vibrant new organization. That’s worth looking at.

How about the four examples of physician advocacy you chose—what did they have in common?

I guess I’d say that each did different things and in different times but all did something very concrete to make things better, beyond just writing articles and speaking out. All were leading physicians and surgeons who could have just done their good medical work, but went far beyond that. And they all paid the price in some way, and had to have thick skins. Ernest Codman was fired by Mass General and went on to found his own hospital. Try and imagine in 1920 what it took to do that! Sydney Garfield had the good luck to be hooked up with Henry J. Kaiser in founding his Kaiser health system, but his doctors were all blacklisted by the CMA, called communists, and denied hospital privileges. Jack Geiger desegregated hospitals in the South during a very tough time there, and it took progressive white physicians joining with African-American activists to create community health centers, while taking part in the marches and demonstrations. Charles Drew was a scientist and surgeon who brought his prestige and science to stop the ban on mixing black and white blood in blood banking, and even he paid the price and had to resign. It would be interesting to each one of them to ask what those struggles were like, were they angry, afraid, and so on, and especially, what gave them moral courage.

Addressing “social determinants” of health unavoidably means confronting inequality and other huge issues that seem insurmountable. Many if not most simply throw up their hands and give up from the start. How does one inspire people to take those first steps? Part of that is showing examples, such as the four I chose. And to show that thinking “there’s nothing I can do” is wrong. There is something each of us can do. We do need to be thoughtful about choosing our issues, identifying the sources moral courage in ourselves, and using our brains—doctors are problem-solvers and analytical people, and we can use these skills along with courage in strategic ways. And it’s important to know that we don’t have to do it by ourselves, we can find groups of doctors and others working for good goals.

A landmark political event occurred recently with the defeat of the Trump/Ryan attempt to repeal the ACA. That seems part of an anti-science, anti-health backlash that many are trying to resist.

It’s very strong and we do need to stand up in any ways we can. The Republicans are still working on ways to repeal the ACA, and Tom Price doesn’t seem to believe in subsidizing more efficient, accountable, and charitable care. He does seem to wish to go back to an old era of “doctor knows best” and patients must pay whatever they charge. That’s not going to happen—the payers aren’t going to put up with that, for one thing—but they can do a lot of damage, and we have to be vigilant. And in this unexpected moment some interesting things are developing, such as single-payer advocates getting more visible and with more defenders. I obviously don’t know how all that will play out, but I am interested in finding ways to leverage the instability we are all living with now to benefit people.

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MAY 2017 SAN FRANCISCO MARIN MEDICINE 5/2/17 12:2315 PM

Medical Advocacy and Activism

PUBLIC HEALTH IN MARIN An Interview with Matt Willis, MD Mimi Towle In November of 2010, a forty-four-year-old Matt Willis was sent from his job at the Centers for Disease Control in Atlanta to Marin County to study the outbreak of pertussis (whooping cough). A graduate

of Harvard’s School of Public Health, with a medical degree from Temple University, Willis grew up in Marin. He’d previously returned to the county as a pro cyclist on the racing circuit, but it was during this visit that he started to think about moving back with his wife and three kids. His next assignment for the CDC that year was a trip to Haiti, after the earthquake that displaced millions, where he reported on outbreaks of vaccine-preventable disease—a situation clearly brought on by lack of access. He thought back to Marin County, where, ironically, residents were facing the same outbreaks by choice. Fast-forward three years to his relocation in Marin, where one of the first items on his agenda as the county’s Public Health Officer was to find out why so many Marin parents were choosing to not vaccinate their children—at a rate four times greater than in any other county in the state. He decided to do something about it. Willis and the rest of the team in the Public Health Department, trying to devise forward-thinking approaches to Marin residents’ health issues, have already created a handful of protocols that have been shared with agencies across the country. The latest project, a partnership with other County of Marin departments called Hack4Health, wrapped up this month.

How is the health of our county residents?

Marin has been ranked the healthiest county in California seven years in a row by the Robert Wood Johnson Foundation, has the longest life expectancy of any county in the nation, and was named the country’s healthiest county for children by U.S. News & World Report. When I took this job, I wasn’t interested in being the Maytag repairman of public health, and when we dig deeper we see that we have plenty of work to do to. We’re at risk of outbreaks because of low vaccination rates. We have huge disparities in health status between communities across the county, with much higher rates of preventable illnesses like heart disease in some low-income neighborhoods. And we stand out year after year as having high rates of substance use and have been deeply impacted by the national epidemic of opioid painkiller abuse. These problems are the focus of Hack4Health.

What are you hoping for with Hack4Health?

The County of Marin is committed to using technology in innovative ways and this program was created by the Information Services and Technology Department here. They have important data, such as on the 15,000 calls that came through 911 last 16

year, as well as community information on vaccinations, childhood obesity and opioids. To make sense of this information they have asked us here at Health and Human Services to analyze it. Think of it like CSI Marin. We brought in high school and college students to come up with innovative solutions to some of our biggest [health] challenges here in the county. Ideally, we will end up with important information such as where bike crashes might occur most often, or is there a city where seniors are having more issues. Our goal is to come out with a few ideas such as an app for a patient with pain. For instance, because of the opioid epidemic, doctors are prescribing fewer narcotics for pain; we’d make even more progress if we had an easy way to access healthy alternatives like physical therapy, acupuncture or chiropractic. An app could help with that.

Can you describe your work with the vaccination issue and tell us what the current status is here in the county?

When I came on board we had the lowest vaccination rate in the Bay Area and were about four times lower than the state average. The message that vaccines were safe and effective just wasn’t penetrating, and our first step was to understand why. We did a survey of parents to ask what their beliefs were when they decided to not vaccinate. This was something that hadn’t really been done at a community level before, and it added nuance to the conversation. One of the big factors, we learned, is that parents really didn’t understand that vaccination is not just a personal decision. When we vaccinate our kids it protects their friends, neighbors and classmates. When they see it as part of community well-being, I think more people opt in. A local measles outbreak, understanding of the risks of non-vaccination and changes in vaccine policy have all played a role in improving our rates. Since 2012 our rates have improved every year.

Can you talk about the crisis surrounding opioid abuse?

The leading cause of accidental death in Marin is prescription drug overdose. Opioid painkillers are driving most of this. They’re highly addictive and even one too many pills can end a life. In the years 2012 and 2013 one person overdosed accidentally every two weeks in Marin, one in five high school juniors reported they’d taken painkillers recreationally, and the problem was getting worse. To me, this data was a real call to action, and we convened a town hall–style meeting in early 2014. One hundred or so people including doctors, police officers, elected officials, educators, and parents came, and we spent five hours designing a game plan. Out of that grew RxSafe Marin, our countywide prescription drug abuse coalition. This has been

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one of the most rewarding projects, since I’ve gotten to work with great people who share responsibility for protecting our community inside and outside of government. Now we’re sharing our coalition model with other communities as people are looking for solutions to the opioid epidemic nationally. Our positive health scores are off the charts, but we seem to be on the opposite side of the scale when it comes to substance abuse. High rates of substance use are really inconsistent with the other health norms in Marin and it’s a concern. In California, the Healthy Kids Survey says eighty percent of high school juniors report that alcohol and marijuana are easy to access, and half that number report using these in the past month. With changing laws and the likely increased availability of marijuana, we approach this a lot like alcohol. Whatever our beliefs about adult marijuana use, we should all agree that it’s not safe for young people. In considering dispensary locations and practices, we’re working with the county to help ensure that kids are protected. We’re also learning more and more about adolescent brains, and it’s clear that use at that age impairs development and increases risk of lifelong addiction. I also see how hard Marin parents and kids work to set themselves up for success. While substance use threatens that goal of high performance, we’re also hearing from kids that stress is one reason they’re looking to alcohol and other drugs. The county health rankings are a stark reminder of our substance abuse problem. While we rank far above most counties in almost all established indicators of community health, we rate near the bottom in three: adult binge drinking, DUI rates and accidental drug overdoses.

How can parents who like to have that drink or two at the end of the day model good behavior?

It’s important to me to show our kids that we can be together and celebrate with friends without alcohol. There’s a big difference between a beer or wine with dinner, versus sneaking a flask into a high school soccer game. I don’t think it helps our kids to pretend they don’t have choices—but we can help them navigate the real choices they have by modeling good judgment.

Are you concerned about losing Affordable Care Act benefits?

Totally. We have made such positive gains with this program. Under the ACA, 14,000 uninsured Marin residents gained health insurance. We saw a reduction in emergency room visits for that population since people had access to a regular doctor. When people don’t have access to preventative primary care, too often they end up going to the emergency room, either for small things that are best dealt with in a clinic or they’ve waited so long and are so sick they need to be hospitalized. Not only is this WWW.SFMMS.ORG

expensive for the county, but it’s dangerous as well. In the case of communicable diseases, people will wait longer to get help, thereby infecting many more people.

What is the current state of health equity within the county?

While our health scorecard is very high for the most part, there are communities within Marin that do not share these healthy statistics. For instance, the life expectancy of someone in Marin City is fifteen years shorter than for someone in Ross. We don’t think that your ZIP code should determine how long you can expect to live. Again, looking at the data we gain some clues in how to address this injustice. Turns out that the leading driver of preventable death in our low-income communities is heart disease. We can do something about that by making sure everyone has the same chance to have good nutrition, recreation for an active life, and access to health care. For the kids, we’re focusing on schools with higher obesity rates. For the adults, we partner with clinicians, who identify individuals who would benefit from our Parks Rx program, which offers boot camp–like workouts at parks around the county.

What was it about Marin that lured you back?

Last weekend I was at the top of Tam with a group of high school students. My daughter is on the Drake mountain bike team and I help lead team rides. When I see those kids digging deep and making it under their own power all the way up Tam, I’m so grateful to be part of that picture. It’s a really unique place. The promise of that kind of day was part of what brought us here. Most of my best memories of growing up here revolved around being outside with friends. I wanted a place where my kids could roam safely and have little adventures and feel capable and have healthy relationships. Professionally, I thought this would be a wonderful place to do a deep dive into what sustains health in a community, to define those factors that correlate to health and longevity and spread them to every community.

How do you like your job?

I love my job. This is a well-resourced county with a real dedication to well-being—quality of life is important to people in Marin County. So I think I have the best job in the county, for sure. I get to step back and say what can optimize this community, what are we doing well and what could we improve. I’m really interested in how we organize to support the basics of health for everyone across the age spectrum, while protecting ourselves from harmful things like substance abuse. We have solid ways of measuring the vital signs of our community through data. It’s no coincidence that the county with the longest life expectancy also has measurably high rates of regular exercise, healthy eating and access to health care. Our number-one status is exciting, but we have an even more important goal: when those health benefits extend to every community, we’ll really have something to celebrate. Reprinted with permission from Marin Magazine. Photo by Lenny Gonzalez.

MAY 2017 SAN FRANCISCO MARIN MEDICINE

Medical Advocacy and Activism

HEALTH REFORM IN SAN FRANCISCO The Future Barbara Garcia, MPA San Francisco has long been a pioneer in advancing health through policy and health care reform. Before

the Affordable Care Act (ACA), our programs were championed by innovative health coalitions as models of success. In these uncertain times, our country’s administration and congressional leaders continue to seek ways to profoundly change our health care landscape. Now, more than ever, San Francisco’s health care community needs to come together as a broad coalition to continue to meet our resident’s health needs, especially the most vulnerable. San Francisco has a long history of coalition building and partnerships in health policy and reform. In 2006, San Francisco passed the Health Care Security Ordinance, which requires employers to offer health insurance, provide a health reimbursement account, or contribute to the City Option Program. In 2007, Healthy San Francisco was created as part of the City Option Program. It covers San Francisco residents regardless of employment, pre-existing conditions, or immigration status, as well as people who don’t qualify for Medi-Cal, the state’s version of Medicaid. These innovative health care policies put San Francisco at the forefront when the ACA passed in 2010 and was implemented in 2014. The Health Care Security Ordinance and Healthy San Francisco still exist today and have been modernized to complement the ACA. Like the journey of the ACA, the Health Care Security Ordinance and Healthy San Francisco faced opposition, but our local hospitals, community organizations, and advocates came together to move the dial on health care. We must continue these partnerships to meet today’s challenges. In San Francisco, we have invested in developing strong connections and deep roots in our health care system. The combination of San Francisco’s health care programs and the ACA has been widely successful. The rate of uninsured individuals in San Francisco has been cut in half since the ACA was initiated. Furthermore, Medi-Cal enrollment has almost doubled due to the Medicaid expansion policy in the ACA. Currently, ninety-seven percent of San Franciscans are insured, or covered by Healthy San Francisco. Coverage also has been made affordable in our state as eighty-one percent of policies are subsidized by Covered California, California’s official health care marketplace. When people have health insurance, they are more likely to schedule regular checkups and preventative care. That provides better quality of life and reduces the City’s overall health care cost, largely due to the health care system’s ability to divert patients away from expensive emergency department visits by diagnosing health issues before they escalate to severe conditions. With fewer San Franciscans delaying medical care, more residents are assessing their own health as good or better. We are becoming a healthier city and are ensuring our most vulnerable residents have access to health insurance and quality health care. 18

Success of the ACA and Health Reform in San Francisco However, the path forward for health care on a national level is less clear. The proposed American Health Care Act (AHCA)—the legislation to repeal and replace the ACA—was projected to increase the number of uninsured individuals by fourteen million in 2018 and twenty-four million by 2026.7 The AHCA would have increased average premiums prior to 2020 and would also have made major changes to the Medicaid program by phasing out enhanced federal funding and capping federal funding to states. This would have resulted in at least three million Californians, including 133,000 San Franciscans, losing their health care coverage. Furthermore, California would have lost as much as $17.3 billion in federal funding for the state’s expanded Medi‐Cal program. The AHCA would have adversely impacted patients, families, communities and providers throughout the state—including here in San Francisco—putting our most vulnerable residents at risk. In late March, the ACHA legislation was pulled from a scheduled vote on the floor of the House of Representatives. The failure to vote on this bill means that the ACA— enacted seven years ago—continues to remain in place, but efforts to repeal it continue. We do not know exactly how, when, or if congressional leaders will resurrect the failed health care bill. However, we remain concerned about proposals to restructure Medicaid and eliminate subsidies for low-income individuals purchasing insurance through the exchanges. At the San Francisco Department of Public Health, we will continue to monitor activity at the state and federal level to understand policy developments and work with local leaders and partners to protect our City’s advancement in health as a result of health care reform. The uncertain Affordable Care Act landscape does not change the Health Department’s mission. We will continue to serve all those in need of care, without regard to immigration or insurance status. The City is fortunate that it has deep roots in health care embedded in its policy system, such as the Healthy San Francisco program and Health Care Security Ordinance. Our strong connections have fostered collaborations that will carry us through these uncertain times. Now is the time to renew our collective commitment to health care in our City and ensure access and continuity for all San Franciscans. Our next phase will contend with important health challenges and ensure comprehensive and affordable health care for our residents. As in the past, our path forward for health care reform will require broad and robust political support from all of our partnerships. The people of San Francisco are increasingly aware of the values of health care and access to quality services. We need to ensure continuity in their coverage and work together to serve our most vulnerable residents and keep San Francisco healthy. Barbara Garcia is the San Francisco Health Director. A list of references is available online at www.sfms.org.

SAN FRANCISCO MARIN MEDICINE MAY 2017 WWW.SFMMS.ORG

Medical Advocacy and Activism

SUICIDE BARRIER UPDATE Prevention on the Golden Gate Bridge Mel Blaustein, MD

Finally, after eight campaigns to build a barrier on the Golden Gate Bridge since its construction in 1937, the Bridge Board is moving forward to build a suicide deterrent. Probably the most beautiful bridge in the

world—certainly the most photographed—this iconic symbol of San Francisco is also the number one suicide site in the world. As we approach the eightieth anniversary in May, the number of deaths looms at about two thousand. In this decade, we are counting thirty-three found bodies annually, or two to three deaths per month. Jumpers are attracted by the facility of the final leap—a four-foot barrier, a parking lot, and even bus access. Jumpers run the gamut, from age fourteen to the late eighties; from mentally ill, to depressed, to substance abusers, to the impulsive. Some jumpers obviously choose the Golden Gate Bridge for its romantic and dramatic value. For others, it’s a quick fix for transiently stressful situations. Fifteen percent are under age twenty-four. Nearly ninety percent are from the adjacent six counties—one survey from 1995 to 2005 indicated that only five percent of the jumpers came from out of state. These are our neighbors and our friends. I’ve spoken with three of the only thirty survivors of the past eighty years. Something that they all had in common: were there a barrier, they wouldn’t have jumped. Nor would they have gone elsewhere. The recurrent argument to oppose a barrier that we confronted was specifically that issue. Richard Seiden, in a 1978 study of 515 people taken forcibly off the bridge by the California Highway Patrol and followed over twenty-five years, found that ninety-four percent were still alive or had died of natural causes. They didn’t go elsewhere. Suicidal individuals have preferred methods—based on familiarity and access. Thus, in New York City, the majority of suicides in the borough of Queens are by carbon monoxide because the bulk of residences are private homes with garages. Whereas in Manhattan, with its apartment buildings, jumping is the preferred method. On March 9 of this year, I was invited, with eight other members of the public who had been involved with the barrier campaign, to receive a briefing on where things currently stand. WWW.SFMMS.ORG

Presenters were Public Information Manager, Priya Clemens, Chief Engineer Ewa Bauer, Deputy Chief Engineer John Eberle, and Bridge Patrol Captain, Lisa Locati. Our group included parents of two adolescents who suicided from the bridge, members of the Bridge Rail Foundation (a survivor’s group), members of San Francisco Suicide Prevention, and myself, representing the Northern California Psychiatric Society. The barrier is scheduled to be completed on January 12th, 2021—just under four years from now. The barrier will be a stainless steel net extending twenty feet below and twenty feet out from the bridge. It will not affect visibility—so important to citizens and visitors. A similar net in Meunster, Switzerland has had no jumpers in the past ten years. The public will not be able to see the work going on until eighteen months from now. The initial phase is focused on purchasing American steel (á la Trump) and establishing command headquarters and staging areas. The West side, which has limited pedestrian access, will be completed first, allowing the builders to complete all measurements, drawings, and adaptations to a structure originally built in the 1930s. Ninety percent of the suicides do occur on the East side facing the city, but working on the West side initially will iron out all the kinks. There will be increased security during the construction phase, and fences will be installed to avoid debris and safeguard the workers. Bridge lanes may be closed early morning to unload materials. A landmark international JAMA study showed that the two most effective suicide deterrents are restriction of access to lethal means and education by physicians and mental health workers to their patients. As doctors, you are apart of the suicide prevention story—asking your patients if they are suicidal and intervening when appropriate. As a final note, we at last have an online 24/7 resource—the Crisis Text Line—for those in need. By texting ‘BAY’ to 741741, anyone can be matched with a trained crisis counselor. Mel Blaustein has been the Medical Director of Psychiatry at St. Francis Memorial Hospital since 1997. As president of the Psychiatric Foundation of Northern California, in 2004 he convened a task force composed of one jumper who survived (Kevin Hines), two University of California, San Francisco suicidologists (Jerome Motto, Anne Fleming), the Executive Director of Suicide Prevention (Eve Meyer), and two consultants (Paul Muller and Janis Tagart). This group initiated the eighth and final barrier campaign.

MAY 2017 SAN FRANCISCO MARIN MEDICINE

Medical Advocacy and Activism

HEALTH POLICY PERSPECTIVE Reproductive Health: Time for New Commitment Steve Heilig, MPH Decades back, medical and public health students at the University of California, Los Angeles were sometimes taken on a tour of an old hospital ward, previously dedicated to women suffering the aftereffects of illegal abortions. There had been

something like seventy beds then, and the veteran professor who guided us on the visit said that until 1970, when abortion was legalized in California, the ward was always full of suffering and dying women. “We used to have to mop their blood from the floors here—it reminded me of serving in World War II,” he said. After the laws changed, the ward quickly emptied out and was no longer needed. That historical lesson stuck with me as no lecture could— as the professor likely intended. Then, in the late 1980s, articles began appearing in the medical literature and public media about a potential “abortion pill,” developed in Europe to allow termination of early pregnancies without need for surgical intervention. This seemed potentially hugely significant, as a way to reduce the need for surgical intervention, expand access, and, not incidentally, defuse the then-rampant anti-choice activity that even included murdering doctors. I drafted a policy statement for the SFMS, urging that the new medication, RU486, or Mifepristone (brand name Mifeprex), be made as available to American women as in Europe. The SFMS adopted it readily and then convinced the CMA to do likewise. Submitted to the AMA by the CMA, it was also adopted—which made national news. I also conducted and published a survey of almost five hundred obstetricians and gynecologists, showing that over ninety percent favored having this option available to their patients. But no policy change seemed forthcoming where it mattered most— Washington, DC. Thus, a small group of physicians and advocates began meeting at the SFMS offices. We developed a plan, which some came to call a “stunt”: Find a woman with an unwanted early pregnancy who would be willing to fly to Europe, get the medication, and return to the U.S. for a public “bust.” After screening a number of women sent to me by the SFMS members, we chose one, and staged a “smuggling” of RU486 into JFK airport in New York. Federal officials had been tipped off—but so had all the major media. It worked like a charm; the woman was detained, her pills confiscated, and soon she was on the front page of the New York Times and all the big television networks. Mobbed by the media, she went into hiding and I had to serve as her public filter, always saying that we were just trying to further something the AMA advocated. Responding to the news, newly-elected President Bill Clinton vowed to legalize the medication. Numerous studies,

especially in the New England Journal of Medicine (NEJM), confirmed the medication’s effectiveness and safety. Approval for American women took years but was accomplished in 2000. End of story, with a medically-sound ending? Not entirely. Anti-choice politics have intruded every step of the way, and while “medical abortion” is now widely practiced, burdensome restrictions remain. Mifepristone is subject to some of the strictest regulations, under the Food and Drug Administration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS). Less-restrictive labeling came from the FDA last year, but the American Association of Obstetricians and Gynecologists stated that even those requirements are unwarranted, due to the safety of Mifepristone and need for the medication. This year, a large group of experts agreed and published in the NEJM an editorial titled “Sixteen Years of Overregulation: Time to Unburden Mifeprex.” Why recount all this here, other than as a kind of case study? First, it was an example of a mix of organized medical and grass-roots advocacy that worked in making a medical advance accessible. But also, as I survey the current reproductive health arena, I find myself becoming depressed. Does the hard work of reproductive health advocates have lasting impact, when elections and other non-scientific events threaten to derail everything? I am no longer sure—which is very disheartening. Prospects now can seem grim. Many leading politicians, from the White House outward, are vowing to restrict access to abortion any way they can, and even to “punish” patients and physicians. An unprecedented number of anti-choice laws are being proposed and enacted nationwide. What must be stressed is that any “success” of these laws is purely political in both cause and effect—there is little to no evidence that they actually decrease abortions, but will only make them harder and more expensive to attain, and also more dangerous to the pregnant women who desire and need them. Banning funds for Planned Parenthood and other reproductive health groups overseas and domestically is political theater with lethal results for women. Requiring “waiting periods” and all the other nuisances only results in later, more dangerous, and more expensive abortions. Even the horrible murder of doctors has not “saved” anyone or anything. Making a safe abortion more difficult and costly to find is simply cruel and counterproductive. Forcing women to give birth to children is not good for anyone, and adoption has never come close to providing enough loving homes and families for every unwanted child. The numbers of abortions have been declining for some time in many places. There are multiple reasons for that, but researchers do know how to minimize the need. The equation

SAN FRANCISCO MARIN MEDICINE MAY 2017 WWW.SFMMS.ORG

includes fact-based sex education, accessible contraception, and resources for adoption if that’s what an informed pregnant woman chooses—based on facts, not on biased misinformation from deceptive “clinics” such as have sprung up nationwide. And not only is real family planning effective in health terms, but it’s also cost-effective, saving at least triple the amount of funding spent on it, public dollars or otherwise, by preventing the need for more expensive services later. These are all factual lessons, unlearned. I would wager that Planned Parenthood has prevented more abortions than any amount of “pro-life” advocacy, but they are still the focus of so many attacks. Still, the majority of Americans believe that a pregnant women and her physicians should be the ones to decide what is best for them. Most of our relevant laws still reflect that. Many of us have fallen into some degree of complacency that the fundamental battles had been won for good. But now, when I read of all the ill-advised restrictions noted above, about politicians seeking to “reform” healthcare by gutting services for poorer women, denying medical consensus, saying physicians should be punished for practicing in accord with their expertise and conscience, I can’t help but recall the bloody image of that closed women’s ward, and vow not to let such a tragic place again become necessary.

Resources

Physicians for Reproductive Choice and Health: www.prch.org Medical Students for Choice: www.ms4c.org Planned Parenthood: www.plannedparenthood.org

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SAN FRANCISCO

ADDICTION SUMMIT 5th Annual David E. Smith, MD Symposium

Friday, June 9, 2017 | 8:30am - 5:30pm

UCSF Mission Bay Conference Center, 1675 Owens Street, San Francisco Join us for an action-oriented forum with leading multidisciplinary faculty covering: S.F. Medicine • Opiates • Advances in addiction 02-20-14 • Pain management medicine and primary care • Alcohol abuse • Tobacco

• San Francisco problems and responses, and more!

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

WWW.SFMMS.ORG

MAY 2017 SAN FRANCISCO MARIN MEDICINE

MEDICAL COMMUNITY NEWS CPMC

Edward Eisler, MD

Kaiser Permanente

ZSFG

Alice Chen, MD

Maria Ansari, MD

Congratulations to Dr. Lory Wiviott who has been reappointed for a third and final term as Chair of the Department of Medicine. Our two new hospital projects are well on their way to being completed, and opening in June 2018 and January 2019. We will be closing one location, opening two new hospitals, and converting another from inpatient to outpatient care. That creates ample opportunity for confusion. California Pacific Medical Center (CPMC) decided to conduct research to help determine if there was a better way to identify our campuses. The results from hundreds of surveys and multiple focus groups indicate that a more useful way to understand our physical locations would be to designate all campus names by neighborhood. The first move in our comprehensive transition will be the opening of the new Mission Bernal campus in 2018. The change in campus names for our Davies campus to Castro, and Pacific campus to Pacific Heights Outpatient campus will happen in concert with the opening of the Van Ness campus in early 2019. CPMC’s Dr. Anne Peled is among the first surgeons in California to combine innovative techniques and new technology to improve the treatment of breast cancer. Dr. Peled is using an approach called oncoplastic surgery and a tiny new implant, called BioZorb, to provide better cosmetic outcomes after surgery and allow more precise targeting of radiation treatment. The three-dimensional device is placed during lumpectomy surgery. This approach facilitates oncoplastic techniques, which involve rearrangement of the patient’s own breast tissue to provide both cancer control and more aesthetically pleasing results. Using this device provides a framework to help reshape the breast after surgery. It also allows the radiation oncologist to more precisely target radiation therapy and makes it easier to track the site of tumor removal on follow-up mammograms.

Health care by its very nature is political and, at times, demands that clinicians become advocates for specific initiatives. At Kaiser Permanente (KP), our clinicians often champion public health efforts and legislation, especially when vulnerable populations have needs best addressed through public policy changes. A good example of this is the recent November 2016 ballot initiative in San Francisco, Prop V, which proposed levying a tax on soda and other sugar-sweetened beverages. KP San Francisco Pediatrician Shannon Udovic-Constant, MD, advocated for its passage because there was compelling evidence and solid science that showed these types of taxes lead to a reduction in soda consumption and also raise public awareness of the health hazards related to sugar-sweetened beverages. Prop V passed in San Francisco with similar measures also passing in Oakland and Albany, California. Currently, there is discussion of a statewide sugar-sweetened beverage tax. Another effort involved pediatric endocrinologist Louise Greenspan, MD, who has done research on early puberty and the environmental triggers that contribute to it. Her work facilitated the passage of legislation in California to remove flame retardant chemicals from furniture, which will decrease exposure to these potentially endocrine disrupting chemicals. Pediatrician Aparna Kota, MD, MPH, advocates for child abuse prevention as Co-Chair of the KPSF Child Abuse Services and Prevention team and in the community by serving on the Board of the San Francisco Child Abuse Prevention Center. This center highlights the importance of screening for adverse childhood experiences and also provides education about the protective factors that promote resilience in children and families. One way to participate in these critical efforts is to attend the San Francisco Child Abuse Prevention Center’s annual fundraiser, held on May 12. Tickets can be purchased here: http://sfcapc. org/events/luncheon2017/

Advocacy is alive and well in San Francisco’s next generation of physicians. Nowhere is this more evident than at Zuckerberg San Francisco General (ZSFG). ZSFG serves as “home base” for three University of California, San Francisco (UCSF) residency programs whose focus is on care for the urban underserved: Pediatrics Leadership for the Underserved (PLUS), San Francisco General Primary Care Internal Medicine (SFPC), and Family and Community Medicine (FCM). PLUS’ mission is to train pediatricians as collaborative leaders to advance health equity for children, with a particular focus on social determinants of health. SFPC’s goal is to train primary care internists as leaders for the underserved, with a focus on some of the most medically and socially complex patients in the safety net. FCM aims to prepare a diverse cohort of family physicians to practice and eliminate healthcare disparities in urban underserved communities. Each of these programs has a robust policy and advocacy curriculum that includes legislative advocacy, policy-oriented research, media advocacy, and community based interventions. Key partners include the California Pan-Ethnic Health Network, Berkeley Media Studies Group, and Policy Link, as well as the American Academy of Pediatrics and the California Academy of Family Physicians. No surprise, then, in the context of the recent effort to repeal the ACA, that residents from the SFPC program founded #KeepAmericaCovered (#KAC). They quickly expanded, joining with leaders from the UCSF medical student-led #ProtectOurPatients as well as other healthcare professionals. Over 200 strong, #KAC has organized a demonstration at ZSFG, held educational sessions about the ACA for its members, organized phone calls and participation in town halls, and co-organized a storytelling event about justice in healthcare. While many of us breathed a sigh of relief when the ACA repeal vote was pulled, the fight is far from over, and physician advocacy will continue to play a critical role. The silver lining is that, when it comes to our physician leadership in this area, our future looks bright.

SAN FRANCISCO MARIN MEDICINE MAY 2017 WWW.SFMMS.ORG

MEMORIAM UPCOMING EVENTS IN Roland Barakett, MD CME Program: Resilience – A New Take on Physician Wellness May 11, 2017 – 6:00pm to 7:30pm | Location TBD | Presented by the Cooperative of American Physicians | Attend a physician mixer and educational program highlighting resilience, with its emphasis on developing the capacity to live life to the fullest and face adversity, change and challenge with purpose and determination, as a more realistic, achievable and enduring response to the demands of a physician’s life. Open to SFMMS members and non-members—bring a colleague! Drinks and hors d’oeuvres will be provided. To register, contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

San Francisco Addiction Summit: 5th Annual David E. Smith, MD Symposium

June 9, 2017 8:30am - 5:30pm | UCSF Mission Bay | Join us for an action-oriented forum with leading multidisciplinary faculty covering opiates, pain management, alcohol abuse, tobacco, advances in addiction medicine and primary care, and more. Event co-sponsored by SFMMS, SFDPH, CAFP, UCSF. CME provided by CAFP. For more information, visit www.drsmithsymposium.com.

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Dr. Roland Barakett, a past-President of the SFMS, passed away April 11, 2017, at the age of eighty-four, peacefully surrounded by his family at CPMC in San Francisco. Loved and respected, he touched and impacted many people's lives and was a father figure and uncle to many. Known to be dapper and intellectual, he was a true gentleman who exemplified courage, grace and dignity. Born outside of Montreal, Roland graduated from Laval Medical School in Quebec and came with his devoted wife to the Bay Area for his medical residency in 1958. He cherished medicine and had a private practice as a General Surgeon for 38 years. He served as Chief of Staff at CPMC, President of the SF Medical Society, and Vice Chief of Staff at Children's Hospital. He was a UCSF Clinical Professor for thirty-one years and taught at SFGH, St. Mary's, Mt. Zion, Marshal Hale, and the American Red Cross. Highly respected in the French community, he was President of the French Foundation for Medical Research and Education for nine years and involved for sixteen. Roland is survived by his wife Jacqueline of sixty years, his children Joan (Rob) and John (Laura), grandsons Tyler and Justin; cherished sister, brother and numerous nieces and nephews. The sparkle in his eyes will shine in our memory. Donations in his memory can be sent to French Foundation for Medical Research and Education, 210 Post, #401, San Francisco, CA 94108.

Making our Voices Heard at CMA Legislative Advocacy Day More than 300 physician, residents and medical students, including 20 SFMMS members, participated in CMA’s 43rd Annual Legislative Advocacy Day on April 18th at the State Capitol. The SFMMS group met with Senator Scott Wiener, Assemblymember David Chiu, Assemblymember Mark Levine, and staff from Senator Mike McGuire’s office and Assemblymember Phil Ting’s office. The SFMMS delegation shared powerful stories to help illustrate the importance of utilizing Proposition 56 (tobacco tax) funds as voters intended—to increase Medi-Cal reimbursement rates and access to care—and restoring GME funds to increase residency slots. The Governor’s budget proposes to take $1.2 billion of tobacco tax revenues for existing budget obligations, and to eliminate funding that was intended to increase the number of primary care and emergency physicians trained in California. The group also shared information about AB 1048 (Arambula) related to reducing pressure to prescribe opioids, and SB 641 (Lara) related to CURES database privacy. The day included presentations from CMA leadership, as well as Attorney General Xavier Becerra and HHS Secretary Diana S. Dooley. WWW.SFMMS.ORG

The SFMMS Delegation meets with Assembly-member Marc Levine.

MAY 2017 SAN FRANCISCO MARIN MEDICINE

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