Winter 2021

VOL . 72 NO. 1 Wi nter 2 0 2 1

1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org

Officers and Board

Staff

President David Bazzo, MD, FAAFP

Lisa Folberg, MPP Chief Executive Officer lfolberg@familydocs.org

Immediate Past President Walter Mills, MD, MMM, FAAFP President-elect Shannon Connolly, MD, FAAFP Speaker Lauren Simon, MD, MPH, FAAFP Vice-Speaker Raul Ayala, MD, MHCM Secretary/Treasurer Alex McDonald, MD, FAAFP Chief Executive Officer Lisa Folberg, MPP Foundation President Marianne McKennett, MD AAFP Delegates Jeffrey S. Luther, MD, FAAFP Lee Ralph, MD AAFP Alternates Jay W. Lee, MD, MPH, FAAFP Michelle Quiogue, MD, FAAFP

Morgan Cleveland Manager, Operations|Governance and FP-PAC mcleveland@familydocs.org Jerri Davis, CHCP Vice President, Professional Development, CME/CPD jdavis@familydocs.org Adam Francis Director, Government Affairs afrancis@familydocs.org Arlanna Henry Manager, Educational Programs ahenry@familydocs.org Josh Lunsford Director, Membership and Marketing jlunsford@familydocs.org Jonathan Rudolph Manager, Finance jrudolph@familydocs.org

CMA Delegation Raul Ayala, MD Kimberly Buss, MD, MPH Jay W. Lee, MD, MPH Felix Nunez, MD, MPH Kevin Rossi, MD

Looking for a job?

Go to www.fpjobsonline.com Questions? Call 888-884-8242 and a HEALTHeCAREERS representative will help you.

Brent Sugimoto, MD, Editor Josh Lunsford, Managing Editor

The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.

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California Family Physician Winter 2021

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EDITION 37

Wi nter 2 0 2 1

features 24 The Face of Family Medicine

Brent K. Sugimoto,, MD, MPH, AAHIVS, FAAFP

departments 6 Editorial

A Prescription for the Surge?

8 President’s Message

We Need Family Physicians Now More than Ever

12 Political Pulse

Despite Tumultuous Year, CAFP Secures Important Victories

Brent Sugimoto, MD, MPH David Bazzo, MD, FAAFP Carla Kakutani, MD

16 CAFP Staff News 18 Legislative Update

New Laws for 2021 May Affect Your Practice and Patients

Adam Francis

20 CAFP Foundation

CAFP Looks Back at 2020 Virtual Family Medicine Clinical Forum

30 CEO Message

CAFP Twirls into 2021

Lisa Folberg, MPP

For upcoming CME activities visit familydocs.org/cme California Family Physician Winter 2021

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Brent K. Sugimoto,, MD, MPH, AAHIVS, FAAFP

editorial

A Prescription for the Surge?

Welcome to the New Year. Welcome, finally, to 2021.

Saying that we made it through the past year is no small feat. As the specialty that provides more primary care than any other, family medicine has been on the frontlines of the pandemic from the very first reports of a new and deadly virus. As our health system became overwhelmed, it was you, the family physician, who was asked to fill the shortages.

Outpatient docs became hospitalists. Family physicians ensured L&D wards kept delivering. Our colleagues helped save the sickest in the ICUs. The COVID-19 pandemic was a seismic event that shook the house of medicine down to its foundation, and family physicians were the braces that helped our system resist collapse.

In an unprecedented year, the American Academy of Family Physicians made an unprecedented award of the 2020 Family Physician of the Year to all of you. You were the clutch player in our health system, an all-around specialist who could fill any need in the public health emergency. You were the factotum in medicine, the Latin roots of which (facere “to make, do” + totum “all”) mean to do it all.

I reflected on our role in the healthcare ecosystem when I was deployed to Porterville, a city in the Central Valley, by the Emergency Medical Services Authority (EMSA) through the California Medical Assistance Teams (Cal-MAT). Slated for closure by the state, the Porterville Development Center—a residential campus for individuals with developmental and intellectual disabilities—was repurposed into a low-acuity hospital for stable COVID-19 patients to help offload local facilities so that they could maintain their capacity to care for those with severe COVID-19.

I met mission-driven people focused on the same purpose: fighting COVID-19 through the care and treatment of patients under our roof. The diverse skillsets of a volunteer workforce—from physicians, physician assistants, nurses, pharmacists, emergency medical technicians, respiratory therapists, physical therapists, administrators and more— convened to form and operate a hospital in a vacant building

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constructed for another purpose. Seeing what the staff built in the foothills of the Sierras—with creativity, collaboration, and resourcefulness—was an inspiration.

What struck me was how family physicians were able to fill many roles outside of our principal job of hospitalist care.

Academy member Dr. Jasmeet Bains—member and chair of the California Healthcare Workforce Policy Commission at the Office of Statewide Health Planning and Development— helped to establish the hospital in an empty building. Member Dr. Yolanda Backus and I created a short notice clinic for volunteer staff, many of whom were far away from home and their primary care physicians. With physician staff coming from all specialties, family physicians often had more comfort in managing patients’ home medications on the inpatient

wards, and thus had a key role in preventing complications, medication interactions, and worsening of chronic conditions.

If have any questions about volunteering with Cal-MAT, DM me on Twitter (@BrenticusMD), Instagram (@elmcsugi) or Facebook.

Notable was an unmeasurable and intangible aspect of care with which family physicians were apt to infuse their care. Many patients were understandably frightened and some traumatized by their experience with COVID-19. Many patients felt uninformed about their care at the local, referring hospitals, and so they filled that knowledge vacuum with assumptions of the worst. With the overwhelming volume of patients overrunning hospitals in California, this is not surprising—communication in a hospital is always challenging.

But I was proud to see my colleagues reintroduce humanity into our patients’ care—family physicians naturally put patients at the center.

This winter has brought the darkest days of the pandemic. Possessed with a singularly diverse skillset, family physicians are filling a multitude of roles in the fight against COVID-19.

Many of you may have patients or responsibilities that cannot afford your absence.

However, as Cal-MAT mobilizes to meet the COVID-19 surge, it needs family physicians like you. The need of many hospitals is desperate and Cal-MAT’s work is key to alleviating that. Seeing how our state is organizing a response to the pandemic makes me proud to be a Californian, and I am proud of my work with Cal-MAT. If you have time you can spare, or know someone who may, your service or referral would be a great contribution to the state’s efforts to beat back this pandemic.

Visit https://www.healthcarevolunteers. ca.gov/ to volunteer.

Patient by patient, each of you is working to bring us closer to what we can accept as normal. Thank you for your service. Here is to a brighter New Year!

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p r e s i d e n t ’s m e s s a g e

David E.J. Bazzo, MD, FAAFP

We Need Family Physicians Now More than Ever This issue of California Family Physician highlights the diversity of family medicine practice. From direct primary care to comprehensive managed care organizations, and from outpatient all ages care to hospital medicine to urgent care to procedural medicine to pediatrics and women’s health, family physicians are unique in the training and experience that allows them to provide a broad range of primary and specialty care.

care and coverage. Like all states, California is struggling with controlling health care costs while improving access, equity, and quality. There is consistent and growing evidence that investing in primary care promotes health equity, improves patient outcomes and experience, increases the supply of primary care providers, and reduces health care spending. The breadth and depth of our training allows us to adapt our practices to meet the specific medical needs of our communities.

As the stories featured in this issue highlight, California family physicians have diverse practice types. CAFP recently engaged a The breadth of knowledge and ability to provide high-value polling firm to get to know our members better. We learned that primary care to patients across all settings is particularly 87% of our members are MDs valuable in rural and other parts and 13% are DOs. Over 20% of of California where certain members primarily practice in a specialists and subspecialists Federally Qualified Health Center may not be available. Although There is consistent and growing or other clinic environment, 12% family physicians make up only identify that they practice in 39 percent of the U.S. primary evidence that investing in the Kaiser Permanente system, care work force, they comprise primary care promotes health 11% of members describe their almost half of the visits to primary practice as a family physicians’ offices in rural areas. equity, improves patient medicine group practice, and A study from the Robert Graham outcomes and experience, another 11% work in hospitalCenter indicated that, if family increases the supply of primary based practices. Almost 10% of physicians were removed from the members identify small and solo 1,548 rural U.S. counties that are care providers, and reduces practice as their primary practice not Primary Care Health Personnel health care spending. type, and 9% are in primarily Shortage Areas (PCHPSAs), 67.8 academic practices (although percent of those counties would many more include academic become PCHPSAs. practice as a secondary practice). Still other members work in urgent care, veterans’ affairs, locum tenens, or in some other Family physicians understand the diverse nature of patients setting. About a third of our members divide their time between better than other specialties. We screen for, address and multiple practice settings. advocate for factors outside of “the pathophysiologic” malady that affect health. Family physicians are among the most racially This information provides a data canvas on which this issue diverse specialty in medicine and are poised to understand social paints the stories of our members. This practice diversity determinants of health. When recent events show medicine has also highlights the breadth and depth of training family a long way to go to eliminate health disparities, we should proud physicians receive. A skill set that is uniquely positioned to of our diversity and perspective that make family physicians best meet this moment. suited to lead the change for greater equality.

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COVID-19 did not create new issues in health access and equity as much as highlighted and made worse existing gaps in 8

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Despite the strong evidence of primary care's critical role, it has been chronically underfunded. California spends just 6% continued on page 10 >

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p r e s i d e n t ’s m e s s a g e < continued from page 8

to 11% percent of total health care dollars on primary care. A Commonwealth Fund analysis identified underinvestment in primary care as one of four fundamental reasons the U.S. health system ranks last among high-income countries. Other states that have invested in primary care have seen significant reductions in expenditures.

Oregon found that for every $1 increase in primary care expenditures resulted in $13 in savings in other services, such as specialty care and emergency department and inpatient care. In addition, Oregon saved an estimated $240 million over the first three years of the initiative.

An increased supply of primary care physicians is associated with improved health outcomes and life expectancy. Research published in 2019 found that having ten additional primary care physicians in an area was associated with a 51.5-day increase in life expectancy. In addition, increasing the supply of primary care providers and thereby increasing access to preventive and primary care also narrows health disparities and promotes health equity.

Family physicians will take many different paths in meeting the needs of their communities. CAFP policy and advocacy support and fight for family physicians’ ability to practice full spectrum family medicine.

This is part of what makes family medicine so special and such a valuable part of helping to solve California’s health care woes.

COVID-19 has been nothing if not disruptive.

While we have had unprecedented advances in the development of a vaccine, we now focus on effective delivery. COVID-19 has required new thinking and has shined a light on fundamental problems with our health care system that have hampered efforts to address this pandemic. If we get anything positive from COVID-19, it will be as a catalyst for change.

I hope that in a decade, we can mark 2021 as the moment an ideal health care system took shape with family medicine at its center.

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political pulse

Carla Kakutani, MD Chair, CAFP Legislative Affairs Committee

Despite Tumultuous Year, CAFP Secures Important Victories The 2019-20 Legislative Session was like no other session in history. The COVID-19 pandemic caused havoc in the Legislature, with multiple legislators and staff contracting the virus, legislators reducing their bill portfolios significantly, and a severely truncated legislative calendar. CAFP joined its members and patients in combating the effects of COVID-19 on individual health and on the economic viability of physician practices and of our communities. Despite significant challenges, CAFP advanced its strategic priorities of payment reform, increased primary care workforce, practice transformation, and public health. These victories were in no small part due to the incredible advocacy of family physicians throughout the state, including Melissa Campos, MD, who shared her perspective as a family physician on the frontlines of the COVID-19 pandemic directly with Governor Gavin Newsom.

Governor Signs Five CAFP-Supported Bills • AB 732 (Bonta) – Requires jails and prisons to offer inmates who may become pregnant, possibly pregnant, or pregnant, a pregnancy test, medical treatment, and services related to prenatal care.

• AB 1196 (Gipson) – Prohibits law enforcement

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•

•

•

agencies from authorizing carotid restraint holds and choke holds.

SB 406 (Pan) – Delinks two Affordable Care Act (ACA) requirements on health plans from federal law to ensure they continue in California even if the ACA is eliminated. The first requires preventive services to be offered without any cost-sharing. The second prohibits health plans from putting annual or lifetime dollar limits on most benefits.

SB 793 (Hill) - Bans flavored tobacco in vaping products, traditional cigarettes, mass-produced cigars, chewing tobacco and non-tobacco nicotine pouches.

While the flavor ban would apply to most tobacco products, including menthol cigarettes, carveouts were included for hookah, premium cigars, and looseleaf tobacco. Tobacco companies filed an injunction in court to prevent enforcement of SB 793. CAFP signed onto an amicus brief opposing their efforts.

Now a coalition representing the tobacco industry submitted one million signatures to the California Secretary of State seeking to qualify a referendum for the November 2022 ballot to overturn SB 793.

SB 852 (Pan) – Requires the California Health and

Human Services Agency to enter into partnerships to increase competition, lower prices, and address shortages in the market for generic prescription drugs; reduce the cost of prescription drugs for public and private purchasers, taxpayers, and consumers; and to increase patient access to affordable drugs.

funds. Since 2017, FMRPs have been awarded more than $100 million in total. These grants support existing programs, provide startup funds for new programs, help programs increase their class sizes through new slots, and support Teaching Health Center (THC) residency programs. continued on next page >

To learn about other bills that will become law next year, please see the New Laws article later in this magazine.

The 2020-21 State Budget Maintains Health Care Funding The California Legislature passed, and the Governor signed, a compromise State Budget that included $33 million for the Song-Brown Primary Care Physician Training Program. In addition, the 202021 budget deal saved all Prop 56 funding from cuts, including CalHealthCares (loan repayment), CalMedForce (residency funding), and Medi-Cal provider payments. The budged also contained various policy changes, including a ban on a new type of gun , more federally funded unemployment aid for people who lost jobs because of COVID-19 , and a new tax credit for undocumented immigrants with young children.

CAFP Advocacy Nets More than $100 Million for Family Medicine Residencies The Song-Brown Program awards grants to primary care (family medicine, pediatrics, internal medicine, obstetrics and gynecology) residency programs located in underserved areas, that serve underserved populations, and that graduate ethnically diverse physicians who remain in primary care. Through tremendous advocacy efforts, CAFP and its members have secured and protected an annual $33 million investment in the Song-Brown Program for the past four years. Family medicine residency programs (FMRPs) were awarded $27 million, more than 80 percent of the

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political pulse < continued from previous page

Year

Existing Programs

New Programs

New Slots

THCs

2017

$11,750,000

$4,700,000

$1,500,000

$5,100,000

2018

$16,575,000

$2,400,000

$1,200,000

$5,100,000

2019

$15,625,000

$2,400,000

$3,000,000

$7,480,000

2020

$15,000,000

$2,400,000

$3,000,000

$6,800,000

Care for California Initiative Advances in New Form In April 2020, it became clear that the COVID-19 pandemic was going to have a tremendous negative effect on Californian’s health and the state’s economy. This included a devastating loss of revenue for small primary care practices operating on a fee-for-service basis. Patients across California missed essential care for chronic disease management, preventive services, and mental health care. This laid bare the fragility of our primary care health system. Primary care is particularly vulnerable given its longstanding low compensation, and most independent primary care physicians do not have the financial reserves to weather crises. After collaboration with CAFP and the California Medical Association, the Pacific Business Group on Health released a proposal called the Care for Californians Initiative , which would require health plans to immediately distribute emergency payments to primary care physicians with feefor-service contracts, and would require the State to convene payers, patients and providers to develop a new value-based payment and care delivery model that ensures primary care has the resources to deliver patient-centered care to all populations.

CAFP rallied consumers, health care providers, and other advocacy groups to urge legislators to adopt the Initiative.

While the Newsom Administration ultimately resisted the mechanism in which the Initiative would be implemented, our coalition worked with the Department of Managed Health Care (DMHC) and the Administration to require audits of health plan provider networks. On September 23rd, the Governor signed an Executive Order that gives DMHC the authority to assess the impact of the COVID-19 pandemic on health care providers by requiring health care service plans to report on their networks.

CAFP Past President Chosen for COVID-19 Vaccine Advisory Committee In recognition of the important role family physicians will play in the COVID-19 inoculation strategy and implementation,

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Governor Newsom appointed CAFP past president Jeff Luther, MD to the California COVID-19 Vaccine Advisory Committee. The Committee will help guide state efforts to ensure equitable COVID vaccine allocation, distribution, and administration.

CAFP Continues to Set the Bar for State Advocacy For the sixth time in seven years, CAFP won the AAFP's Leadership in State Government Award. The Advocacy Award recognizes outstanding chapter contributions to further family medicine through legislative accomplishments and initiatives, or the support of public policy efforts. Thank you to the CAFP Government Relations team and all the CAFP members who worked to support the Care for Californians Initiative, and continue to push for support for small primary care practices.

If you would like to be involved in CAFP’s advocacy efforts in 2021 and beyond, please visit the Advocacy section of CAFP’s website: www.familydocs.org/advocacy/get-involved/ References 1. https://www.sacbee.com/news/politics-government/ capitol-alert/article243803037.html 2. https://www.sacbee.com/news/california/ article243768812.html 3. https://bhw.hrsa.gov/funding/apply-grant/teachinghealth-center-graduate-medical-education 4. https://www.pbgh.org/storage/documents/Care_ for_Californians_Initiative_Concept-May_20-2020_ Final.pdf 5. https://www.familydocs.org/wp-content/ uploads/2020/05/Care-for-Californians-InitiativeCoalition-Letter.Final_.pdf 6. https://www.gov.ca.gov/wp-content/ uploads/2020/09/9.23.20-EO-N-80-20-COVID-19text.pdf

IN THE NEWS Winter 2021 CAFP Physicians Selected for AAFP Commissions The AAFP Board of Directors appointed two California family physician leaders to important AAFP Commissions.

During the December 2020 AAFP Board of Directors meeting, Brent Sugimoto, MD, FAAFP was appointed to the Commission on Quality and Practice. His term of service begins on December 15, 2020 and ends December 14, 2024.

Jay W. Lee, MD, MPH, FAAFP was appointed to AAFP’s Commission on Health of the Public and Science.

Adrian “Eric” Ramos, M.D., FAAFP has been appointed as the new Chief Medical Officer (CMO) for Doctors Medical Center in Modesto and the Northern California Group for Tenet Healthcare.

CAFP Represented in Statewide COVID-19 Vaccine Response Jeffrey Luther, MD, FAAFP is serving on California’s Community Vaccine Advisory Committee.

Katherine Flores, MD, USCF Fresno Latino Center for Medical Education and Research, was named as part of the California Department of Public Health Drafting Guidelines Workgroup to Advise State on COVID-19 Vaccines.

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cafp staff news

Catrina Reyes, J.D., M.P.A. Joins CAFP as Vice President of Advocacy and Policy

Jerri Davis, CHCP, Promoted to Vice President of Education

CAFP welcomes Catrina Reyes, J.D., M.P.A. as Vice President, Advocacy and Policy. Prior to joining CAFP, Catrina was an Associate Director with the Center for Health Policy at the California Medical Association wherein her issue areas included managed care, health care reform, quality, pharmaceuticals, Covered California, and Medicare. Catrina also worked at Claremont Insurance Services as a Policy Analyst and Compliance Manager. In this position, she analyzed healthcare legislation and regulations that impact licensed agents, employers, and carriers. Catrina also advised employers on their compliance requirements.

Catrina is licensed to practice law in California and has an M.P.A. in which her thesis was on implementation theories and the effective implementation of the ACA.

CAFP is pleased to announce that Jerri Davis has been promoted to Vice President, Education and Professional Development.

Jerri will be a familiar face to many at CAFP. Jerri has served for 23 years with CAFP as Director, Continuing Professional Development (2001-2020) and with the CAFP Foundation as Executive Director (1998-2000) and Director of Corporate Development (1997-1998).

Prior to law school, Catrina went to culinary school, experience she now uses to whip up sweet treats with her 7-year-old daughter, Hannah. Catrina also likes to trail run with her husband and watch movies (and the Mandalorian, of course) on Friday family movie nights.

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In her new role as Vice President, Jerri will oversee all aspects of CAFP’s educational work. Jerri’s years of experience managing programs, her relationships with collaborative partners, and knowledge of Continuing Medical Education will help CAFP continue to deliver premium educational and professional development programs.

Jerri has 30 years of experience in medical society management, prior to CAFP as Executive Director of the Arizona Academy of Family Physicians. At CAFP, she is involved in everything from grant writing, needs assessments and curriculum development to collaboration coordination, compliance, and accreditation. She led CAFP’s last re-accreditation effort in November 2019 that resulted in ACCME accreditation with commendation. She has presented at several Alliance for Continuing Education in the Health Professions (ACEhp) annual meetings and served on the ACEhp Medical Specialty Society Committee.

legislative update

Adam Francis CAFP Director of Government Relations

New Laws for 2021 May Affect Your Practice and Patients Whether CAFP supports or opposes legislation, every January a new slough of requirements and changes in law will affect you, your practice, and your patients. January 1, 2021 will be no exception. Please review the following bills, which are just a few of many that may change the way you practice family medicine in the new year.

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AB 1710 (Wood) – Authorizes a pharmacist to independently initiate and administer any COVID-19 vaccines approved or authorized by the federal Food and Drug Administration (FDA).

AB 2537 (Rodriguez) – Requires any person or organization that employs workers in the public or private sector that provides direct patient care in a general acute care hospital to maintain a stockpile of unexpired personal protective equipment (PPE) in an amount equal to six months of normal consumption.

SB 275 (Pan) – Requires the Department of Public Health (CDPH) to establish a PPE stockpile for health care workers and essential workers in the state and requires health care employers to establish a PPE inventory that is sufficient for at least 45 days of surge consumption. “Health care employer" is defined as a person or organization that employs direct patient care professionals in a general acute care hospital setting, a skilled nursing facility, a medical practice that is operated or maintained as part of an integrated health system or health facility, or a licensed dialysis clinic. CAFP originally opposed this bill but worked with the author to remove provisions that would have required significant burden and costs on small and medium-sized practice.

SB 932 (Wiener) – Requires health care providers who are in attendance on a case of a reportable disease to report the patient’s sexual orientation and gender identity, if known. The new law also requires any electronic tool used by local health officers for the purpose of reporting cases of communicable disease to the Department of

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Public Health to include the capacity to collect and report data relating to the sexual orientation and gender identity.

SB 1237 (Dodd) – This new law is a compromise bill between physicians and certified nurse midwifes (CNMs) to allow CNMs to attend to low-risk pregnancies and establish alternate collaboration and relationship requirements with physicians. It revises the provisions defining the practice of midwifery; authorizes a CNM to attend cases out of a hospital setting; authorizes a CNM to furnish or order drugs or devices in accordance with standardized protocols with a physician; and establishes new reporting and data collection requirements. CAFP originally opposed this bill but worked to ensure a CNM would not handle complicated pregnancies, would have a referral system in place should complications arise, and to clarify that a CMN’s scope does not include ongoing primary care.

Nurse Practitioner Scope Expansion Bill Becomes Law Despite an outstanding effort by CAFP’s Government Relations team and family physicians throughout the state, the Legislature passed AB 890 (Wood) bill in the final minutes of session, and Governor Gavin Newsom signed it into law. It is important to note that AB 890 does NOT prohibit the supervision of current NPs. It does, however, authorize two newly created types of NPs to perform certain function without standardized procedures.

Unlike the bills above, this new law will not take effect for a few years as significant aspects of its implementation must be determined through the regulatory process, including care standards, and educational and training requirements. CAFP will fight to ensure those standards and requirements are stringent enough to protect patients and, to the extent possible, limit the creation of two tiers of care. Please read CAFP's AB 890 fact sheet (https:// www.familydocs.org/wp-content/uploads/2020/10/AB890-Fact-Sheet.pdf ) to learn more about what this may mean for family physicians.

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cafp foundation

CAFP Looks Back at 2020 Virtual Family Medicine Clinical Forum CAFP is thrilled with the wonderful feedback received from the first and second sessions of the 2020 Virtual Family Medicine Clinical Forum held on Nov. 14-16 and Dec 12, 2020. More than 95.5 percent of attendees indicated they were satisfied or very satisfied with their sessions.

NOVEMBER On Day One of the November meeting, we celebrated our new AAFP Fellows and had fun shaking and mixing with CAFP President Dave Bazzo, MD during our virtual Happy Hour.

On Day Two, we were humbled and inspired by the firsthand accounts of service workers and community service organizers who have positively affected their communities during the COVID pandemic. These unsung heroes opened our eyes to all the good going on around us with

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stories of: Project Room Key, a program offering hope for more sustainable housing solutions; Careers Sparks, an organization providing mentorship opportunities for disadvantaged students; and a mini-documentary Keepers of the House, highlighting the importance of hospital environmental service workers and the meaningful relationships they develop with patients, making them a lifeline to the outside world during the COVID pandemic.

Attendees then enjoyed the wide variety of sessions (13 of them!) as well as the fun activities during the breaks.

— Kim Yu, MD, FAAFP, Orange County

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Thank you CAFP for having a #HealthEquity track at #FMforum20! Good resources for all regarding race conscious medicine and research.

course and the #DocsWhoRock virtual jam session.

The day concluded with an address by Mark Ghaly, MD, MPH, Secretary of California Health and Human Services, who provided us with important recognition of our role on the front lines of this pandemic and notice that we are in for more hard times.

DECEMBER In December, CAFPers gathered for the second installment of the Clinical Forum. The day started with a bang as Jeff Luther, MD presented the keynote “The Latest on COVID-19 Vaccines: Answering Family Physicians' Questions.”

Dr. Luther is CAFP’s representative on the California Community Vaccine Advisory Committee. He encouraged everyone to engage in ongoing conversation on SPARK where he will provide ongoing updates and take your comments and questions to his statewide meetings.

On Day Three, we were inspired by the powerful message on equity and inclusion. Attendees were encouraged to take steps to address racism in medicine and recognize ways we continue to promote it without even knowing.

Another 13 CME sessions were offered along with engagement sessions like a mindful stress reduction

Drs. Monica Hahn and Stephen Richmond returned to the topic of racism in medicine and provided learners with excellent suggestions to engage in these discussions and take next steps. Following the plenary session, several breakout rooms were available for attendees’ informal conversations on November topics including vaping, women's health, dementia, increasing efficiencies, COVID clearance for return-to-play, FM update, and antiracism strategies. continued on next page >

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cafp foundation

LOOKING AHEAD We will now take all the commitment to change statements and feedback received from attendees to ensure that the final event (Jan. 16, 2021) of the 2020 Virtual Family Medicine Clinical Forum exceed everyone’s expectations!

By the time you receive this, we will have returned on January 16, 2021 for a final gathering to hear from Rishi Manchanda, MD, MPH, author of The Upstream Doctors.

To access the recorded content from November, you will need to go to CAFP’s Homeroom and register for the 2020 Family Medicine Clinical Forum – RECORDED event. It will be free for those who have already registered for the live event with an access code you will receive before launch.

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— Alex M. McDonald, MD, CAQSM FAAFP, Riverside-San Bernardino

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Race-based medicine provides a false sense of health equity and undermines the health disparities engendered by racism. Our learning does not stop here.

Next step: critical self-reflection. Such amazing speakers at #FMForum20!!

— Laura Murphy, DO, San Diego

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We're going to be called upon not to be heroes once or twice, but again and again in the coming weeks. And I want to figure out how to support you; it is going to be tough, and you are the ones carrying a huge load.

— Secretary Mark Ghaly, MD, California Health and Human Services

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We would be remiss not to mention the Celebration of the Retirement of Shelly Rodrigues, CAE, FACEHP, FAAMSE. It was a celebration of Shelly as she was toasted and thanked her 28 years as CAFP's Deputy EVP.

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So many great tips and a practical and patient centered approach! #fmforum20.

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The day ended with a plenary session, "The Power of Social Media: Using Your Voice to Combat Misinformation” with Drs. Laura Murphy and Robin Linscheid Janzen, and social media consultant Corey Perlman.

Following the plenary session, Lisa Folberg, MPP, CAFP's CEO, gave an update on "Virtual Advocacy, Leadership, and You." Our final speaker of the day was AAFP President Ada Stewart, MD, FAAFP, who offered a view of what is happening nationally.

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Brent K. Sugimoto,, MD, MPH, AAHIVS, FAAFP

The Face of Family Medicine When family physicians mention full spectrum family medicine, they usually mean the traditional definition that refers to the breadth of skills family docs need to care for all their patients from “cradle to grave.” I am proud that this issue features a dynamic group of family physicians who highlight a different type of full spectrum family medicine: one where innovative practices adapt to the diverse needs of patients and setting to deliver the best care possible according to context. As individual practices, these members fill a particular niche.

After reading, I think you will conclude from this sample that, as a whole, we family physicians likely occupy the full spectrum of patient need throughout the state.

This is profound. Collectively, we insist that any patient’s personal context not be a barrier to getting care from a family doctor. Whether that context might be the ability to pay, gender identity, immigration status, homelessness, specific lifestyle needs, locale (whether it be urban underserved versus rural setting), or countless others, we family physicians are there.

Steven W. Harrison, MD The clinic where I work is a rural health clinic in Gonzales, a farming community just south of Salinas. The Salinas Valley is an agricultural area with many farm workers and those who work in agricultural-related businesses. Taylor Farms is a large agricultural company that donated land and money to Salinas Valley Memorial Hospital System to create the Taylor Farms Family Health and Wellness Center in Gonzales.

The basis for this practice was the rural health clinic of Christine Ponzio, MD in Gonzales.

We see primarily patients in the safety net but accept all forms of insurance. None of us currently conduct hospital services, we perform primary care services. although the two physicians who have been in the area for decades, Dr. Ponzio and me, previously performed hospital services, assisted in surgery and other related family medicine duties. It is my privilege to be allowed to work in this community and care for my patients who are the salt of the earth.

Family Medicine was the only medical discipline I considered, and I chose it before I went to medical school. My rationale was that I wanted to work in a rural area and I thought that family 24

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medicine was best suited to rural medicine primarily because of the broad spectrum of patients and diseases that were covered under its umbrella. It is certainly possible to see patients in rural areas under any of the medical disciplines, and many are wellsuited to the task but none are as focused on the task as family medicine, which covers patients from cradle to grave. I have not seen or experienced anything that would change my mind.

Jeannine Rodems, MD, FAAFP What if you had the opportunity to see your patients for thirty to sixty minutes at a time, perform procedures you were trained to do, be able to communicate and advocate for patients in a timely manner, and have a better work/ life balance while practicing medicine the way you were trained as a family physician?

Sound unbelievable? When I first heard about Direct Primary Care (DPC) in May of 2013, I didn’t believe any of this was possible either. I had multiple doubts about the model -- it could only work in rural areas of the country, it could never work in California, there would be some regulatory issue that would stop the movement. But as I learned more about the DPC model, the appeal of practicing a broader scope of family medicine and to be a true advocate for my patients won out over those doubts.

After much education, hard work, and learning about the business structure of DPC, I opened Santa Cruz Direct Primary Care in February of 2016. I have never looked back. Hospital medicine, skilled and assisted living facility visits, home visits, casting, stitches, spirometry, joint injections, routine care – the breadth of family medicine – is what we are able to perform in DPC. We are completing our fifth year in our office and continue to grow in spite of the current pandemic. The DPC model has brought back my joy of practicing family medicine, and DPC needs to be an integral part of the specialty’s future as a better model of care for family physicians and their patients -- a better structure for affordable, quality, sustainable, patient-centered family medicine.

Jay W. Lee, MD, MPH, FAAFP Share Our Selves is a federally-qualified health center (FQHC) in Orange County, CA, the sixth largest county in the United States.

We are celebrating our 50th anniversary this year. Our roots were built on a social mission; our founders were members of a local church who were troubled by rising social inequality in the late 1960's. We serve all patients irrespective of ability to pay and deliver medical, pharmacy, dental, behavioral, and social services including a food pantry and housing assistance. These services are delivered at five brick-and-mortar sites as well as via a mobile unit which services local shelters for people experiencing homelessness. Many of our physicians are family docs and many of our NPs/PAs are family medicine trained. It is gritty work caring for our county's most vulnerable populations but it's meaningful and fulfilling work.

mission is to provide free medical care for the uninsured, and to help train future generations of primary care providers. In an average year, the clinic provides over 6,000 patient visits treating the full range of acute and chronic illnesses, with a special emphasis on primary care (over 35 senior medical students and residents from UCSF, Stanford, Yale, USC, and CPMC each spend 4 weeks at the clinic training in primary care). Because the clinic evolved from within the medical community, the clinic receives a large amount of donated help from colleagues in Bay Area hospitals and private practice specialties. Completely supported by private foundations and individuals, the clinic is a unique collaboration between the medical community and private philanthropic funding. With no billing system and no administrative staff (the physicians, nurses, and medical assistants share admin duties), donated funds go directly to patient care.

I chose to work at Share Our Selves because of its social mission and values as "servants who provide care and assistance to those in need and act as advocates for systemic change." This perfectly captures why I became a family physician. As much as my work involves direct clinical care, my work also takes me outside the four walls of the clinic engaging with the communityat-large and policy makers to impact the upstream factors that determine the health of our patients. I love the fact that I work closely with other professionals to fully embrace our patients with the care that they deserve.

Why we chose this work In our last year of medical school, we made one of the best decisions of our lives – to train together in family medicine. The residency years instilled the desire to recognize and treat the whole patient and to emphasize primary and preventive care as the most beneficial contribution that physicians can make.

We opened our own private practice in the Bay Area, and after three years it was thriving. But something didn’t feel right. We were treating more and more patients who had no insurance and could not afford to pay. In time we realized that nearly 25% of Bay Area residents had no health insurance, including 40,000 children. With a fully paid-for clinic, two eager doctors, and one dedicated medical assistant, we made the decision to convert the clinic to a non-profit and only treat people with no insurance.

Our goal was to see the whole patient and provide primary care to the uninsured while continuing the teaching environment that we had known through med school and residency. In retrospect, it was the breadth of family medicine training that made the clinic possible. The ability to see children and the extra training in gynecology, orthopedics, and in-office procedures allowed the two of us to establish a free clinic offering comprehensive primary care. It was the second best decision in our lives – what can be better than providing primary care, and especially preventive care, to people who cannot find it elsewhere?

Drs. Richard and Tricia Gibbs

Shani Muhammad, MD, FAAFP

The San Francisco Free Clinic The San Francisco Free Clinic is a state licensed community clinic founded in 1993 by family physicians Drs. Richard and Tricia Gibbs to treat people with no health insurance. The

I work as a Family Medicine Physician in primary care practice for the telemedicine company SteadyMD. I have been working with them since April 2019. This company provides primary care services solely via telemedicine in all 50 states. I am licensed in continued on next page > California Family Physician Winter 2021

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approximately 15 states and have patients in all states in which I hold a license.

Patients can select any physician they choose who is accepting new patients and is licensed in the state in which they reside. Every physician has a detailed profile on the company site that we've written ourselves with the marketing team, along with various photos that capture the essence of that physician's values, lifestyle and other important things to them (family, pets, activities).

If patients wish to have assistance selecting a primary care physician, there is a tool that matches patients with the physician best equipped to handle that patient’s unique needs and approach to their own health care. For example, many patients who select me are people interested in weight loss or who are very active in functional fitness and weightlifting, and wish to have a physician who supports that. Patients can select by fitness activities, dietary needs, lifestyle choices such as being a parent, and more.

I have a medical assistant who helps to schedule patient appointments, send referrals, and complete orders just as any other in office medical assistant would do. The service is selfpay through a monthly subscription, but many of my patients have insurance which they use to cover the cost of labs/tests, medications, and specialty referrals.

Physicians make their own schedule and can choose how often to see patients as well as how many patients to accept on their panel. Initial patient visits are scheduled for 60 minutes and include a comprehensive history. Follow up visits are scheduled at the physician and patient’s discretion and are 30 minutes.

The service allows for as many visits as needed, and outside of visits, patients have access to the chat platform online or via app where they can message their doctor 24/7 as well as the medical assistant and other support staff. The chat is HIPAA compliant and secure and serves as part of the medical record. Many of my patients use the chat function in lieu of scheduling follow up visits because I respond typically within minutes to hours.

I chose SteadyMD at a time when I was looking for a change. I had cut my clinical practice down to urgent care only (once or twice a week) after becoming disillusioned and frustrated in my primary care large group practice. What stood out to me initially was the idea of having patients who select me as their physician based on what my unique traits are. With this method, I have had very few patients find me to be a less than ideal fit. I also enjoy 26

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that I never feel rushed with any patient and have essentially eliminated the "doorknob" moment that used to happen so often in clinical practice with 20/40 minutes visits. Patients regularly express relief to me at finally feeling heard and understood and I think the real difference is simply that I am not ever distracted or in a hurry to move on to the next patient, because there is no next patient. I never schedule patients back-to-back.

I also love having autonomy over my schedule, how often I see patients and the time I can give to someone who I decide needs more time. I know that for me personally, a large contributing factor to my own burnout in clinical practice was the complete lack of autonomy I felt.

I have been working in telemedicine for over six years so the concept of video visits is not new for me, and when I saw this option, I knew it would be a great fit, especially as it allowed me to move my clinical practice to home. I know many people find working from home challenging, but with older children and my personality, it has been an amazing fit.

Robin Linscheid Janzen, MD I work at Fresno Women's Medical Group (FWMG), a small private practice owned by an OB/Gyn Dr. Sharon Kopacz. Our mission is to provide exceptional healthcare for women and their families based on whole-person wellness with physical, emotional, intellectual and spiritual sensitivity.

At FWMG we believe in patient choice and responsibility through education. I provide full spectrum family medicine care alongside my colleague who is an OB/Gyn. Together we have a unique partnership that provides holistic care to patients within one practice. I take call for a larger OB group for deliveries, Dr. Kopacz backs me up for cesarean sections and gynecological surgeries, and I am available to assist her with cesarean sections and other gynecological surgeries.

My interests are in women's health, obstetrics and pediatrics so FWMG was a natural fit for me. The group expanded their practice to include primary care for their patients in 2011 because they recognized the need for comprehensive care in one office.

I provided guidance in the expansion of FWMG and helped to update the delivery of both OB/Gyn and family medicine services. This allowed me to continue offering obstetrical care including deliveries, and primary care services for my patients. I find the partnership to be mutually beneficial. I consult my OB/ Gyn colleagues as much as they consult me on primary care

issues. For example: my partnership with Dr. Kopacz and our OB call group has allowed me to advocate for broader obstetric privileges for my family medicine colleagues practicing in the Community hospital system (which includes 3 hospitals).

Patients often choose us because they can come to one place for both primary care and OB/Gyn visits. They can bring their children, parents, and partners to us as well. Our practice is owned by a female surgeon of color and serves a very diverse group of patients. We recognize the health disparities faced by our minority patients and work hard to improve these for our latinx, black and LGBTQ patients.

Ann-Gelle Carter, MD, MS Family physicians emphasize whole person care, including chronic disease management for all organ systems as well as mental health care.

As a Family Medicine physician, I believe that primary prevention through health education is truly the key to improving health outcomes, with the goal to prevent the onset of disease before the development of a cadre of complex co-morbid conditions in the future. As a family physician in this community, I take a special pride in the ability to interact with my patients in a multitude of settings including the inpatient hospital setting, outpatient clinic, long term care facilities such as skilled nursing and acute rehabilitation facilities.

Locally in our medically underserved community of Tulare County, with an index of medically underserved population score ~56 of 100, physician providers often learn to navigate the existing barriers to care such as limited specialty provider access locally, food insecurity for families faced with limited available resources to obtain fresh and healthy food options exacerbating the existing obesity epidemic, environmental challenges such as poor air quality leading to a disproportionate amount of patients with exacerbations of respiratory diseases such as asthma and COPD to name a few.

Life in the Central Valley is unique. During my training at Kaweah Delta, I have had the opportunity to care for so many incredibly resilient people from all walks of life. It is my passion for people, desire for connectivity with my community, and commitment to serving underserved populations that inspired me to ultimately select this residency program to complete my

training. Understanding the nuanced complexities contributing to the existing social determinants of health and desire to achieve health equity for all, provides me with daily motivation to provide effective and quality health care, while empowering my patients to achieve their individual and family health goals to move the needle toward a healthier thriving Tulare County.

Travis Bias, DO, MPH, FAAFP I currently work as a consultant for 3M on a team of physicians, nurses, industrial engineers, and project managers to leverage our Performance Matrix Platform (PMP) to improve clinical operations for hospital clients. The PMP points to groups of admissions that have interdependencies which may have led to an inefficiency - essentially using data to get us closer to the root cause of inefficiencies and to do so quicker. Our team then does a sample chart review and talks with and observes our client clinicians and leaders to understand more about their operations. We then organize and prioritize our findings to help facilitate the client's performance improvement team's implementation of small, high-yield tests of change. The goal is efficiency and lower costs of care, and as clinicians we ensure our interventions are evidence-based and will improve outcomes.

My experience as a Family Medicine physician is ideal for this kind of work. Family physicians are trained to listen to patients and to approach their care holistically. So, whether we are diagnosing a patient or assessing a service line or organization, we can better take in the whole picture and drive client-led interventions that will have an overall positive impact without unintentionally negatively affecting performance in another area of the organization. Additionally, we know "a little about a lot," making us quite versatile and able to translate between diverse topics or groups. Whether we are speaking to a hospital CEO, a nurse manager, a cardiologist, or a multidisciplinary performance improvement team, we can communicate effectively and facilitate discussions towards improved outcomes and lowered costs.

Additionally, I see patients via telemedicine for Circle Medical in San Francisco. When I was told of how versatile family medicine was, I had no idea I would eventually be impacting hospital efficiency and seeing patients from my home office during a pandemic.

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ceo message

Lisa Folberg, MPP

CAFP Twirls into 2021 We have all been anxiously awaiting the arrival of 2021. The change in the calendar will not eradicate the struggles of 2020, but the New Year brings new hope. With a vitriolic Presidential election behind us, I hope leaders and lawmakers will come together to focus on helping America heal... heal from COVID-19, heal from being out of work and losing health coverage, and doing the work to start to heal the wounds of racism that have become scars on our systems and institutions.

In 2020, family physicians showed their strength and adaptability. Many of you have told me that you would have thought it impossible to convert your practices to see patients virtually. Even if possible, you might have said making those practice changes in weeks not months would be the stuff of fiction. Yet, that is exactly what happened for many family medicine practices in California.

Every year Merriam-Webster, Inc. chooses top words of the year. Not surprisingly, “pandemic” was the top word in 2020.

More surprisingly, “pivot” did not make the list. Pivot seemed to define this year for many of us. So much so, that some of us at CAFP started to use “twirl” instead to take a break from “pivot” which seemed to be a constant part of our lexicon.

Your CAFP did a lot of twirling this year to help our members weather the storms of 2020: from securing PPE to providing a place to connect and share stories through community conversations. We partnered with Covered California to provide members with masks and put a family physician on the Governor’s Vaccine Advisory group as a way to keep you well informed and to make sure the voice of family medicine is heard. The restrictions that came with the pandemic also challenged us to think about how we provide family physicians with education and professional development tools. In 2020, we launched a new on-line educational effort called CAFP Homeroom, your one-stop shop for CME and other education. Our education related to ACEs, substance use disorder, and pain management felt more relevant than ever. Although we missed seeing you in person at the Clinical

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Forum, our members were able to enjoy the same highquality sessions virtually… and we got to tour an alpaca farm!

When the severity of the pandemic started to take shape in March, I thought we would need to twirl away from our pursuit of CAFP’s strategic objectives to promote value based payment models, primary care workforce and raise the profile of family medicine. It turned out those elements of our strategic plan were not superfluous to helping our members survive the pandemic; they are essential to it.

COVID-19 shined a light on fundamental problems with our health care system that have hampered efforts to address this pandemic, notably, reliance on a payment system that rewards volume instead of value and under-resources primary care. Through advocacy efforts, coalition building, member surveys, and media outreach, CAFP pushed for emergency funding for primary care practices and a move toward a value-based model of care. We demanded that the health plans share responsibility for helping their contracted practices survive.

CAFP fought for sustained funding for primary care physician training and loan repayment. Largely due to the incredible response from our members to contact their local representatives, we were able to prevent large cuts to statefunded programs important to primary care, including the Song-Brown program.

As I am writing this, Californians have started to receive COVID-19 vaccinations. Estimates are that in California alone, there are 1.7 million health care workers with direct patient contact or who are residents of nursing facilities. Life before COVID-19 is hard to remember and what life will look like after the pandemic is impossible to know. I hope we can return to the simple pleasures we once took for granted — giving hugs, going to a crowded restaurant, or smiling at a passer-by.

As we say goodbye to 2020, I hope that we will collectively twirl, whirl, or pivot into a brighter 2021.

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