November/December 2022

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SENATOR RICHARD PAN END OF AN ERA FOR A HEALTHCARE HERO

Official Publication of SDCMS NOVEMBER / DECEMBER 2022

Celebrating Independent Physicians

At the Cooperative of American Physicians (CAP), we celebrate you—the independent and solo practitioner who keeps healthcare personal. We are here to support you with exceptional medical malpractice coverage supplemented by a host of outstanding risk management and practice management services, so you can stay focused on what’s important—patient care. For over 40 years, CAP has delivered financially secure medical malpractice

Medical professional liability coverage is provided to CAP members through the Mutual Protection
(MPT), an unincorporated interindemnity arrangement organized under Section
of the California Insurance Code. Scan the QR code to see how much you can save on your medical malpractice coverage More than 12,500 California physicians rely on CAP to protect their practices every day.
coverage options and practice solutions to help California physicians realize professional and personal success. Find out what makes CAP different. CAPphysicians.com 800-356-5672 MD@CAPphysicians.com
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Editor: James Santiago Grisolia, MD

Editorial Board: James Santiago Grisolia, MD; David E.J. Bazzo, MD; Robert E. Peters, MD, PhD; William T-C Tseng, MD

Marketing & Production Manager: Jennifer Rohr

Art Director: Lisa Williams

Copy Editor: Adam Elder

OFFICERS

President: Toluwalase (Lase) A. Ajayi, MD

President–Elect: Nicholas (dr. Nick) J. Yphantides, MD, MPH

Secretary: Steve H. Koh, MD

Treasurer: Preeti S. Mehta, MD

Immediate Past President: Sergio R. Flores, MD

GEOGRAPHIC DIRECTORS

East County #1: Catherine A. Uchino, MD

East County #2: Rakesh R. Patel, MD

Hillcrest #1: Kyle P. Edmonds, MD

Hillcrest #2: Stephen R. Hayden, MD (Delegation Chair)

Kearny Mesa #1: Anthony E. Magit, MD, MPH

Kearny Mesa #2: Alexander K. Quick, MD

La Jolla #1: Karrar H. Ali, DO, MPH

(Board Representative to the Executive Committee)

La Jolla #2: David E.J. Bazzo, MD, FAAFP

La Jolla #3: Sonia L. Ramamoorthy, MD, FACS, FASCRS

North County #1: Arlene J. Morales, MD

North County #2: Christopher M. Bergeron, MD, FACS

North County #3: Nina Chaya, MD

South Bay #1: Paul J. Manos, DO

South Bay #2: Maria T. Carriedo-Ceniceros, MD

(Board Representative to the Executive Committee)

AT–LARGE DIRECTORS

#1: Thomas J. Savides, MD

#2: Kelly C. Motadel, MD, MPH

#3: Irineo (Reno) D. Tiangco, MD

#4: Miranda R. Sonneborn, MD

#5: Daniel Klaristenfeld, MD

#6: Marcella (Marci) M. Wilson, MD

#7: Karl E. Steinberg, MD, FAAFP

#8: Alejandra Postlethwaite, MD

ADDITIONAL VOTING DIRECTORS

Young Physician: Emily Nagler, MD

Resident Director: Alexandra Kursinskis, MD

Retired Physician: Mitsuo Tomita, MD

Medical Student: Jessica Kim

CMA OFFICERS AND TRUSTEES

President: Robert E. Wailes, MD

Trustee: William T–C Tseng, MD, MPH

Trustee: Sergio R. Flores, MD

Trustee: Timothy A. Murphy, MD

AMA DELEGATES AND ALTERNATE DELEGATES

District I: Mihir Y. Parikh, MD

District I Alternate: William T–C Tseng, MD, MPH

At–Large: Albert Ray, MD

At–Large: Robert E. Hertzka, MD

At–Large: Theodore M. Mazer, MD

At–Large: Kyle P. Edmonds, MD

At–Large: Holly B. Yang, MD, MSHPEd, HMDC, FACP, FAAHPM

At–Large: David E.J. Bazzo, MD, FAAFP

At–Large: Sergio R. Flores, MD

At–Large Alternate: Bing Pao, MD

CMA DELEGATES

District I: Steven L.W. Chen, MD, FACS, MBA

District I: Franklin M. Martin, MD, FACS

District I: Vimal I. Nanavati, MD, FACC, FSCAI

District I: Peter O. Raudaskoski, MD

District I: Kosala Samarasinghe, MD

District I: James H. Schultz, MD, MBA, FAAFP, FAWM, DiMM

District I: Mark W. Sornson, MD

District I: Wynnshang (Wayne) C. Sun, MD

District I: Patrick A. Tellez, MD, MHSA, MPH

RFS Delegate: Rachel B. Van Hollebeke, MD

any advertising. Address all editorial communications to Editor@SDCMS. org. All advertising inquiries can be sent to DPebdani@SDCMS.org. SanDiegoPhysician is published monthly on the first of the month. Subscription rates are $35.00 per year. For subscriptions, email Editor@SDCMS.org. [San Diego County Medical Society (SDCMS) Printed in the U.S.A.]

Contents NOV/DEC VOLUME 109, NUMBER 10 Features 4 He Stood His Ground: California State Senator Will Leave Office As Champion of Tough Vaccine Laws By Angela Hart 6 Separate and Unequal Critics Say Newsom’s Pricey Medicaid Reforms Leave Most Patients Behind By Angela Hart 16 Champions for Health Casino Night Pictorial 18 ‘Fourth Trimester’ Focus Is Pushed to Prevent Maternal Deaths By April Dembosky 20 CDC Just Changed Its Opioid Prescribing Guidelines. Here’s What to Know By Judy George 21 Classifieds SANDIEGOPHYSICIAN.ORG 1 Departments 2 Briefly Noted: GERM • Political Advocacy • Student Grants • AMA Resources for Physicians • Climate Change 11 Hospitalized or Not, COVID Symptoms Persist in Many After 2 Years By Ingrid Hein 12 Putting the ‘We’ in Wellness By Julie Çelebi, MD 14 Let’s Make a Difference Together By Adama Dyoniziak Opinions expressed by authors are their own and not necessarily those of San Diego Physician or SDCMS. SanDiegoPhysician reserves the right to edit all contributions for clarity and length as well as to reject any material submitted. Not responsible for unsolicited manuscripts. Advertising rates and information sent upon request. Acceptance of advertising in SanDiegoPhysician in no way constitutes approval or endorsement by SDCMS of products or services advertised. SanDiegoPhysicianand SDCMS reserve the right to reject
PHOTO BY LORIE LEILANI SHELLEY, SENATE RULES PHOTOGRAPHY

BRIEFLY NOTED

GERM Jessica Merchant Is Lead Author on GERM Article Regarding HIV Prevention

JESSICA MERCHANT, DNP, ANP WAS the lead co-author of an article with Dr. Michael Butera titled “Biomedical HIV Prevention Strategies and Getting to Zero, 2022 Updates,” which appeared in the October GERM issue of San Diego Physician. Unfortunately, due to a miscommunication, Ms. Merchant’s name was accidentally left off of the article. We deeply regret the error and want to make sure she receives proper credit. Jessica Merchant is a graduate of East Carolina University. She is currently working as a nurse practitioner in a very busy infectious disease practice, covering both inpatient and outpatient consultative services. She has extensive prior training in internal medicine and geriatrics during NP training. Prior to that, she had five years of ICU experience in caring for critically ill patients as a critical care RN. Ms. Merchant is a current active participating member of IDAC, and the San Diego County Medical Society GERM group. She has contributed to two ID-related articles published in San Diego Physician with special area of interest including promoting uptake of PREP use in our community with goals of getting to zero. We are grateful for Ms. Merchant’s contributions to our magazine and San Diego’s medical community.

POLITICAL ADVOCACY

CALPAC Sets New All-Time Fundraising Record at 2022 House of Delegates

ON OCT. 23, THE CALIFORNIA MEDICAL Association (CMA) Political Action Committee (CALPAC) shattered all previous fundraising records in its history for the third year in a row, raising $232,855 as it launched its 2022–23 membership year at CMA’s 151st House of Delegates. This record figure represents a nearly 10% increase over CALPAC’s 2021 HOD fundraising total.

CALPAC also reports a record increase in donor participation at the 151st House of Delegates with 425 donors contributing. This broad commitment to success is exemplified by nine delegations to the House — the Academic Practice Forum, Administrative Medicine Practice Forum, Community Health Clinics, Medium Group Practice Forum, Organized Medical Staff Section, and geographic Districts 1, 2, 5, and 8 — achieving the milestone of all delegates and alternates contributing to CALPAC.

Among these delegations, District 1 (San Diego and Imperial counties) and District 8 (San Francisco and Marin counties) were recognized as the winners of CALPAC’s Victory Bell for having the highest average contribution and highest net total contributed, respectively.

Funds donated to CALPAC go directly to support its political advocacy efforts, which help turn policy decisions into advocacy success. CALPAC also prioritizes working to elect more physicians to office, like Dr. Jasmeet Bains, a family practitioner running for the State Assembly this year.

Before House of Delegates began, CALPAC board members had been engaged in a successful program fundraising from their peers. CALPAC also hit an historic total of seven Diamond Level ($6,500) donors to begin its membership year, from Dr. Peter N. Bretan, Dr. Jack Chou, Dr. Donaldo Hernandez, Dr. Ramin Manshadi, Dr. Tanya Spirtos, Dr. Robert E. Wailes, and Dr. Roger Wu.

If you have not yet renewed your annual membership to CALPAC, please visit calpac. org/donate today.

2 NOVEMBER / DECEMBER 2022

PHC Medical Student Grant Program Now Accepting Applications

THE PHYSICIANS FOR A HEALTHY

California (PHC) MedStudentsServe program is now accepting applications for its 2023 grant cycle. The MedStudentsServe grant funds medical student organizations to support educational, advocacy, community service and outreach programs that enhance the health and wellbeing of California’s communities. Funded through endowment and restricted funds and administered by PHC, the program aims to develop the next generation of California’s physician leaders.

Eligible applicants include Californiabased medical student clubs, student organizations, and group projects based at an allopathic or osteopathic medical school.

Awardees will receive up to $2,500 to support their project. Priority will be given to projects for which funding is not traditionally provided by medical schools or local community sponsors. Sample projects include family health fairs, student-run community health screenings, educational programs for youth, public health outreach initiatives, mentoring programs, safety fairs, and more.

Interested applicants are encouraged to apply early; the application window for the grant cycle closes on Jan. 6, 2023.

For more information, please visit the MedStudentsServe webpage.

New AMA Resource Helps Physicians Fight Inappropriate E/M Downcoding

IN 2021, MAJOR CHANGES WERE made to the evaluation and management (E/M) services Current Procedural Terminology CPT code set and reporting guidelines to reduce documentation

burdens, simplify coding, and allow physicians to spend more time with patients. Unfortunately, some health plans are disputing E/M levels for submitted claims and implementing E/M downcoding programs that inappropriately — and often automatically, through claim editing algorithms—reduce payments for provided services.

The American Medical Association (AMA) has created a new resource to support physician practices in navigating such payor E/M downcoding programs. The document offers examples of downcoding scenarios, sample plan communications, guidance on reviewing remittance advice to identify downcoding, and documentation tips to support successful appeals. Also included are sample downcoding appeal letters, which are available in an editable format on the AMA website.

If your practice has been subject to payer downcoding, please consider completing this informational survey so AMA can to track health plans’ downcoding practices. Results will be used to help support physician practices in responding to payor downcoding initiatives.

CLIMATE CHANGE

CMA Climate Health Panel Discussion Now Available On Demand

THE CALIFORNIA MEDICAL Association hosted a panel discussion on the climate health crisis last month during the association’s annual House of Delegates meeting in Los Angeles. The event — “Understanding the Climate Health Crisis and How California Physicians Can Make an Impact” — which was also streamed live via Zoom, is now available for on-demand viewing.

Co-sponsored by Climate Health Now and the California Foundation on the Environment and the Economy, this discussion explores the health impacts of climate change in California and the opportunities for California’s physicians to advance policy-level climate solutions with enormous public health co-benefits.

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FOR PHYSICIANS

He Stood His Ground

California State Senator Will Leave Office As Champion of Tough Vaccine Laws

ACALIFORNIA LAWMAKER

who rose to national prominence by muscling through some of the country’s strongest vaccination laws is leaving the state legislature later this year after a momentous tenure that made him a top target of the boisterous and burgeoning movement against vaccination mandates.

State Sen. Richard Pan, a bespectacled and unassuming pediatrician who continued treating low-income children during his 12 years in the state Senate and Assembly, has been physically assaulted and verbally attacked for working to tighten childhood vaccine requirements — even as Time magazine hailed him as a hero. Threats against him intensified in 2019, becoming so violent that he needed a restraining order and personal security detail.

“It got really vicious, and the tenor of

these protests inside the Capitol building didn’t make you feel safe, yet he stood his ground,” says Karen Smith, director of the California Department of Public Health from 2015 to 2019. “Dr. Pan is unusual because he has the knowledge and belief in science, but also the conviction to act on it.”

“That takes courage,” she adds. “He’s had a tremendous impact in California, and there’s going to be a hole in the legislature when he’s gone.”

The Democrat from Sacramento is leaving the Capitol because of legislative term limits that restrict state lawmakers to 12 years of service. He has overseen state budget decisions on healthcare and since 2018 has chaired the Senate Health Committee, a powerful position that has allowed him to shape healthcare coverage for millions of Californians.

Pan, 56, helped lead the charge to

restore vision, dental, and other benefits to California’s Medicaid program, called Medi-Cal, after they were slashed during the Great Recession. Since then, he has pushed to expand social services to some of the most vulnerable enrollees.

He was instrumental in implementing the Affordable Care Act in California, and when Republicans attacked the law after Donald Trump was elected president, Pan spearheaded measures to cement its provisions in state law. After the Republican-controlled Congress axed the federal coverage mandate in 2017, he led the effort to create the state penalty for not having health insurance. And he negotiated with the governor to expand health insurance subsidies for low- and middle-income Californians.

In 2020, Pan authored legislation that will put California in the generic drugmaking business, starting with insulin.

4 NOVEMBER / DECEMBER 2022 POLITICAL ADVOCACY

“What drives me is my commitment to health and healthy communities,” Pan told KHN.

But he hasn’t always succeeded. Some of his bills — including those to expand benefits and improve the quality of care for Medi-Cal enrollees — were stalled by the influential health insurance industry or opposition from his own party. And this year, Pan retreated on his contentious proposal to require schoolchildren to get vaccinated against COVID-19.

Pan has also faced criticism that he’s too closely aligned with the healthcare industry, including the California Medical Association, or CMA, a deep-pocketed group that lobbies in Sacramento on behalf of doctors. On contentious policy fights, such as those dealing with provider pay or physician authority, Pan has often sided with his fellow doctors.

For instance, he rallied with the doctor association against a long-sought attempt to give nurse practitioners the ability to practice without physician supervision — a bill that was one of the association’s top legislative targets but one that ultimately passed despite its vehement opposition. And two key bills that sought to rein in healthcare costs died in his committee after clearing the state Assembly — one in 2019 to limit surprise medical bills for emergency room visits and another this year to give the state attorney general authority over some hospital and health system mergers.

“He’s inseparable from the doctors’ lobby, and obviously he carries water for the CMA,” says Jamie Court, president of the advocacy group Consumer Watchdog, arguing that Pan has stood in the way of progressive healthcare bills such as a proposal to create a government-run, single-payer healthcare system.

Pan rejects claims that he’s too close to the industry. “I’m proud to be a member of the CMA, but I don’t just blindly follow CMA,” he says. When it came to the nurse practitioner legislation, he says, his concerns “came from my knowledge about professional medical education and how that influences patient outcomes.”

Pan isn’t running for anything this year but isn’t ruling out the possibility of doing so in the future. For now, he says, he’s focusing on his work in Sacramento until his term ends Nov. 30. After that, he

plans to practice medicine full-time.

Pan said the public hasn’t heard the last of him when it comes to improving MediCal. The state must do more to ensure high-quality care and equitable access for the 14.5 million Californians enrolled in the low-income health program, he says.

Pan explains that he entered politics to improve community health. He left his job as a faculty member and head of the pediatric residency program at the University of California-Davis to run for state Assembly in 2010. He served two terms before being elected to the state Senate in 2014.

Early on, he found himself at the forefront of California’s wars over vaccination mandates.

In 2012, he authored a law making it more difficult for parents to obtain personal belief exemptions for vaccines that are required for children entering public and private schools and that prevent communicable diseases such as measles and polio. In 2015, he succeeded in banning personal belief exemptions for schoolchildren altogether.

In 2019, when lawmakers were voting on Pan’s bill that cracked down on bogus medical exemptions for required school immunizations, a protester hurled menstrual blood at them on the Senate floor. Pan also clashed with Gov. Gavin Newsom, who watered down the bill by demanding amendments that allowed doctors to retain significant authority over the exemptions. Newsom ultimately signed the measure.

“I didn’t run for the legislature because I was planning to do vaccine legislation, but I care about children and that’s what I’ve devoted my life to,” said Pan, who got his medical degree from the University of Pittsburgh and a master’s degree in public health from Harvard University. “We had a whooping cough outbreak, and 10 infants died. And I was very concerned about the fact that we could prevent these diseases, yet we were failing.”

This year, Pan introduced legislation to require COVID vaccinations for school-age kids but pulled it in April, saying it would be difficult for California officials to enforce. At the time, the COVID vaccination rate for schoolchildren “was too low — around 30%,” Pan says. He concluded the state should redouble

its efforts to increase vaccination rates before instituting a mandate.

Pan also notes that Covid-19 was mutating fast and that emerging research indicated that the vaccines weren’t very good at combating new variants. “The vaccine is very effective protecting against death, but its ability to slow down transmission seemed to decrease,” Pan says. “Unfortunately, it has also been so politicized, so we have more work to do.”

As chair of California’s Asian & Pacific Islander Legislative Caucus, Pan in 2021 helped secure a $157 million investment to combat violence and hate crimes against Asian Americans and was a powerful force advocating for more money for the state’s beleaguered public health system — a fight Democrats finally won last year when Newsom approved $300 million in ongoing funding.

State Sen. Scott Wiener (D-San Francisco) says that Pan inspired his interest in introducing tough vaccination and public health bills and that he regularly asks Pan’s advice before unveiling legislative proposals. “I’d randomly call him all the time,” Wiener says. “There’s really no one in the Senate with the experience and knowledge he has.”

Brainy and studious, Pan regularly delves deep into scientific evidence during legislative floor debates. Interviews with reporters often result in lengthy discourses about the history of the U.S. healthcare system — like the time a question about hospital financing led to a lesson in how hospitals are both profitearning enterprises and institutions that provide charity care.

“How serious you are about every undertaking — it really can be a joy and an irritation,” said Senate leader Toni Atkins, who affectionately thanked Pan for his work on the floor of the Senate in midAugust. “You took a lot of flak from folks in a lot of ways, and through it all, your integrity, your sense of humor, and your very good nature has withstood it all.”

Angela Hart is a senior correspondent for Kaiser Health News, where this article first appeared. She covers healthcare politics and policy in California and the West, with a focus on California Gov. Gavin Newsom, government accountability, and political influence.

SANDIEGOPHYSICIAN.ORG 5
HEALTHCARE POLICY 6 NOVEMBER / DECEMBER 2022
Say Newsom’s Pricey Medicaid Reforms Leave Most Patients Behind
Separate and Unequal
Critics

Around the same time, James Woodard, a homeless man, appeared for his third visit that week. He wasn’t in medical distress. Nurses said he was likely high on meth and just looking for a place to rest.

In an overflow tent outside, Edward Green, a restaurant cook, described hearing voices and needing medication for his bipolar disorder.

The three patients were among dozens who packed the emergency room at MLK Community Hospital, a bustling healthcare complex in South Los Angeles reincarnated from the old hospital known as “Killer King” for its horrific patient care. The new campus serves the 1.3 million residents of Willowbrook, Compton, Watts, and other neighborhoods — a heavily Black and Latino population that suffers from disproportionately high rates of chronic conditions like diabetes, liver disease, and high blood pressure.

Arguably, none of the three men should have gone, on this warm April afternoon, to the emergency room, a place intended to address severe and life-threatening cases — and where care is extremely expensive.

But patients and doctors say it is nearly impossible to find a timely medical appointment or receive adequate care in the impoverished community, where fast food is easy to come by and fresh fruits and vegetables are not. Liquor stores outnumber grocery stores, and homeless encampments are overflowing. A staggering 72% of patients who receive care at the hospital rely on Medi-Cal, the state’s Medicaid program for low-income people.

“For some people, the emergency room is a last resort,” says Dr. Oscar Casillas, who runs the department. “But for so many people who live here, it’s literally all there is. Most of what I see is preventable — preventable with normal access to healthcare. But we don’t have that here.”

The community is short 1,400 doctors, according to Dr. Elaine Batchlor, the hospital’s CEO, who says her facility is drowning under a surge of patients who are sicker than those in surrounding communities. For instance, the death rate from diabetes is 76% higher in the community than in Los Angeles County as a whole, 77% higher for high blood pressure — an early indicator of heart disease — and 50% higher for liver disease.

But dramatic changes are afoot that could herald improvements in care — or cement the stark health disparities that persist between rich and poor communities.

Gov. Gavin Newsom is spearheading a massive experiment in Medi-Cal, pouring nearly $9 billion into a five-year initiative that targets the sickest and costliest patients and provides them with nonmedical benefits such as home-delivered meals, money for housing move-in costs, and home repairs to make living environments safer for people with asthma.

The concept — which is being tested in California on a larger scale than anywhere else in the country — is to improve patient health by funneling money into social programs and keeping patients out of costly institutions such as emergency departments, jails, nursing homes, and mental health crisis centers.

The initiative, known as CalAIM, sounds like an antidote to some of the ills that plague MLK. Yet only a sliver of its patients will receive the new and expensive benefits.

Just 108 patients — the hospital treats about 113,000

people annually — have enrolled since January. Statewide, health insurers have signed up more than 97,200 patients out of roughly 14.7 million Californians with Medi-Cal, according to state officials. And while a growing number of Medi-Cal enrollees are expected to receive the new benefits in the coming years, most will not.

Top state health officials argue that the broader Medi-Cal population will benefit from other components of CalAIM, which is a multipronged, multiyear effort to boost patients’ overall physical and mental health. But doctors, hospital leaders, and health insurance executives are skeptical that the program will fundamentally improve the quality of care for those not enrolled — including access to doctors, one of the biggest challenges for Medi-Cal patients in South Los Angeles.

“The state is now saying it will allow Medicaid dollars to be spent on things like housing and nutritious food — and those things are really important — but they’re still not willing to pay for medical care,” Dr. Batchlor says.

Dr. Batchlor has been lobbying the Newsom administration and state lawmakers to fix basic healthcare for the state’s poorest residents. She believes that increasing payments for doctors and hospitals that treat Medi-Cal patients could lead to improvements in both quality and access. The state and the 25 managed-care insurance plans it pays to provide health benefits to most Medi-Cal enrollees reimburse providers so little for care that it perpetuates “racism and discrimination,” she says.

SANDIEGOPHYSICIAN.ORG 7
It wasn’t exactly an emergency, but Michael Reed, a security guard who lives in Watts, had back pain and ran out of his blood-pressure medication. Unsure where else to turn, he went to his local emergency room for a refill.

Dr. Batchlor says the hospital gets about $150, on average, to treat a Medi-Cal patient in its emergency room. But it would receive about $650 if that patient had Medicare, she explains, while a patient with commercial health insurance would trigger a payment of about $2,000.

The hospital brought in $344 million in revenue in 2020 and spent roughly $330 million on operations and patient care. It loses more than $30 million a year on the emergency room alone, according to Dr. Batchlor.

Medicaid is generally the lowest payer in healthcare, and California is among the lowest-paying states in the country, experts say.

“The rates are not high enough for providers to practice, Dr. Bachlor says. “Go to Beverly Hills and those people are overdosing on healthcare, but here in Compton, patients are dying 10 years earlier because they can’t get healthcare. That’s why I call it separate and unequal.”

In September, Newsom vetoed a bill that would have boosted Medi-Cal payment rates for the hospital, saying the state can’t afford it. But Dr. Batchlor isn’t giving up. Nor are other hospitals, patient advocates, Medi-Cal health insurers, and the state’s influential doctors’ lobby, which are working to persuade Newsom and state lawmakers to pony up more money for Medi-Cal.

It’ll be a tough sell. Newsom’s top health officials defend California’s rates, saying the state has boosted pay for participating providers by offering bonus and incentive payments for improvements in healthcare quality and

equity — even as the state adds Medi-Cal recipients to the system.

“We’ve been the most aggressive state in expanding Medi-Cal, especially with the addition of undocumented immigrants,” says Dustin Corcoran, CEO of the California Medical Association, which represents doctors and is spearheading a campaign to lobby officials. “But we have done nothing to address the patient-access side to healthcare.”

The hospital previously known as Martin Luther King Jr./Drew Medical Center was forced to shut down in 2007 after a Los Angeles Times investigation revealed the county-run hospital’s “long history of harming, or even killing, those it was meant to serve.” In one well-publicized case, a homeless woman was writhing in pain and vomiting blood while janitors mopped around her. She later died.

MLK Community Hospital rose from its ashes in 2015 as a private, nonprofit safety-net hospital that runs largely on public insurance and philanthropy. Its state-of-the-art facilities include a center to treat people with diabetes and prevent their limbs from being amputated — and the hospital is trying to reach homeless patients with a new street medicine team.

Still, decades after the deadly 1965 Watts riots spurred construction of the original hospital — which was supposed to bring highquality healthcare to poor neighborhoods in South Los Angeles — many disparities persist.

Less than a mile from the hospital, 60-year-old Sonny

Hawthorne rattled through some trash cans on the sidewalk. He was raised in Watts and has been homeless for most of his adult life, other than stints in jail for burglary.

He hustles on his bike doing odd jobs for cash, such as cleaning yards and recycling, but says he has trouble filling out job applications because he can’t read. Most of his day is spent just surviving, searching for food and shelter.

Hawthorne is one of California’s estimated 173,800 homeless residents, most of whom are enrolled in Medi-Cal or qualify for the program. He has diabetes and high blood pressure. He had been on psychotropic medicine for depression and paranoia but hasn’t taken it in months or years. He can’t remember.

“They wanted me to come back in two weeks, but I didn’t go,” he says of an emergency room visit this year for chronic foot pain associated with diabetes. “It’s too much responsibility sometimes.”

Hawthorne’s chronic health conditions and homelessness should qualify him for the CalAIM initiative, which would give him access to a case manager to help him find a primary care doctor, address untreated medical conditions, and navigate the new social services that may be available to him under the program.

But it’s not up to him whether he receives the new benefits.

The state has yielded tremendous power to Medi-Cal’s managed-care insurance companies to decide which social services they will offer. They also decide which of their sickest and most vulnerable enrollees get them.

One benefit all plans must offer is intensive care management, in which certain patients are assigned to case managers who help them navigate their health and social service needs, get to appointments, take their medications regularly, and eat healthy foods.

Plans can also provide benefits from among 14 broad categories of social services, such as six months of free housing for

8 NOVEMBER / DECEMBER 2022
HEALTHCARE POLICY

some homeless patients discharged from the hospital, beds in sobering centers that allow patients to recover and get clean outside the emergency room, and assistance with daily tasks such as grocery shopping.

L.A. Care Health Plan, the largest Medi-Cal managed-care insurer in Los Angeles County, with more than 2.5 million enrollees, is contracting with the hospital, which will provide housing and case management services under the initiative. For now, the hospital is targeting patients who are homeless and repeat emergency room visitors, says Fernando Lopez Rico, who helps homeless patients get services.

So far, the hospital has referred 78 patients to case managers and enrolled 30 other patients in housing programs. Only one has been placed in permanent housing, and about 17 have received help getting temporary shelter.

“It is very difficult to place people,” Lopez Rico says. “There’s almost nothing available, and we get a lot of hesitancy and pushback from private property owners not wanting to let these individuals or families live there.”

Patrick Alvarez, 57, has diabetes and was living in a shed with out running water until July, when an infection in his feet grew so bad that he had several toes amputated.

The hospital sent him to a rehabilitation and recovery center,

where he is learning to walk again, receiving counseling, and looking for permanent housing.

If he finds a place he can afford, CalAIM will pay his first month’s and last month’s rent, the security deposit, and perhaps even utility hookup fees.

But the hunt for housing, even with the help of new benefits, is arduous. A onebedroom apartment he saw in September was going for $1,600 a month and required a deposit of $1,600. “It’s horrible,

Hawthorne needs help just as badly. But he’s unlikely to

phone or permanent address — and wouldn’t be easy for the

hospital to find. The homeless encampments where he lives are routinely cleared by law enforcement officials.

“We have so many more people who need help than are able to get it,” Lopez Rico explains. “There aren’t enough resources to help everyone, so only some people get in.”

L.A. Care has referred about 28,400 members to CalAIM case managers, roughly 1% of its total

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are lucky enough to receive new benefits, according to Baackes. But he isn’t convinced it will save the healthcare system money and believes it will leave behind millions of other patients — without greater investment in the broader Medi-Cal program.

“Access is not as good for Medi-Cal patients as it is for people with means, and that is a fundamental problem that has not changed with CalAIM,” Baackes says.

Evidence shows that basic Medi-Cal patient care is often subpar.

Year-over-year analyses published by the state Department of Healthcare Services, which administers Medi-Cal, have found that, by some measures, Medi-

Cal health plans are getting worse at caring for patients, not better. Among the most recent findings: The rates of breast and cervical cancer screenings for women were worse in 2020 than 2019, even when the demands that COVID-19 placed on the healthcare system were factored into the analysis. Hospital readmissions increased, and diabetes care declined.

“The impact of COVID is real — providers shut down — but we also know we need a lot of improvement in access and quality,” said State Medicaid Director Jacey Cooper. “We don’t feel we are where we should be in California.”

Cooper says her agency is cracking down on Medi-Cal insurance plans that are

failing to provide adequate care and is strengthening oversight and enforcement of insurers, which are required by state law to provide timely access to care and enough network doctors to serve all their members.

The state is also requiring participating health plans to sign new contracts with stricter quality-of-care measures.

Cooper argues CalAIM will improve the quality of care for all Medi-Cal patients, describing aspects of the initiative that require health plans to hook patients up with primary care doctors, connect them with specialty care, and develop detailed plans to keep them out of expensive treatment zones like the emergency room.

She denied that CalAIM will leave millions of Medi-Cal patients behind and said the state has increased incentive and bonus payments so healthcare providers will focus on improving care while implementing the initiative.

“CalAIM targets people who are homeless and extremely highneed, but we’re also focusing on wellness and prevention,” she tells KHN. “It really is a wholesale reform of the entire Medicaid system in California.”

A chorus of doctors, hospital leaders, health insurance executives, and healthcare advocates point to Medi-Cal reimbursement rates as the core of the problem. “The chronic condition in Medi-Cal is underfunding,” says Linnea Koopmans, CEO of the Local Health Plans of California.

Although the state has restored some previous Medi-Cal rate cuts, there’s no move to increase base payments for doctors and hospitals. Cooper says the state is using tobacco tax dollars and other state money to attract more providers to the system and to entice doctors who already participate to accept more Medi-Cal patients.

When Newsom vetoed the bill to provide higher reimbursements primarily for emergency room care at MLK, he said the state cannot afford the “tens of millions” of dollars it would cost.

MLK leaders vow to continue pushing, while other hospitals and the powerful California Medical Association plot a larger campaign to draw attention to the low payment rates.

“Californians who rely on Medi-Cal — two-thirds of whom are people of color — have a harder time finding providers who are willing to care for them,” says Jan Emerson-Shea, a spokesperson for the California Hospital Association.

For Dr. Casillas at MLK, the issue is critical. Although he’s a highly trained emergency physician, most days he practices routine primary care, addressing fevers, chronic foot and back pain, and missed medications.

“If you put yourself in the shoes of our patients, what would you do?” asks Casillas, who previously worked as an ER doctor in the affluent coastal city of Santa Monica. “There’s no reasonable access if you’re on Medi-Cal. Most of the providers are by the beach, so emergency departments like ours are left holding the bag.”

Angela Hart, senior correspondent for Kaiser Health News, where this article first appeared, is an award-winning journalist who covers healthcare politics and policy in California and the West, with a focus on California Gov. Gavin Newsom, government accountability, and political influence.

10 NOVEMBER / DECEMBER 2022
HEALTHCARE POLICY

Hospitalized or Not, COVID Symptoms Persist in Many After 2 Years

Fatigue, Pain, and Memory Loss Cited Most Frequently BY INGRID HEIN

OVER HALF OF PATIENTS were still experiencing at least one post-COVID-19 symptom two years after acute infection, whether they had been hospitalized or not, a cross-sectional cohort study showed.

Among nearly 700 patients infected during the first wave of the pandemic, 59.7% of those who were hospitalized and 67.5% of those who were not hospitalized still had at least one symptom two years later (P=0.01), reported César Fernández de las Peñas, PT, PhD, of Universidad Rey Juan Carlos, in Madrid, Spain, and colleagues in JAMA Network Open

The most prevalent symptoms for hospitalized and nonhospitalized groups at two-year follow-up were:

• Fatigue: 44.7% vs 47.7%

• Pain (including headache): 35.8% vs 29.9%

• Memory loss: 20% vs 15.9%

“Our results revealed similar proportions of hospitalized and nonhospitalized patients with post-COVID-19 symptoms two years after the acute infection, suggesting that, despite having not been hospitalized during the acute phase, the symptoms of long COVID are also found in the nonhospitalized cohort,” the

authors wrote. “This finding could be explained by the fact that COVID-19 severity is not a risk factor for the development of long COVID symptoms.”

“Long COVID will require specific management attention independently of whether the patient has been hospitalized or not,” they concluded.

Of note, uninfected controls were not included in this study. “Lack of inclusion of uninfected controls limits the ability to evaluate a direct association of SARSCoV-2 infection with overall and specific post-COVID-19 symptoms two years later,” they wrote. “Accordingly, future studies could include uninfected control populations.”

When patients first presented with COVID-19, the most frequent symptoms were fever, dyspnea, myalgia, and cough, but dyspnea was more prevalent among hospitalized patients (31.1% vs 11.7% of nonhospitalized patients, P<0.001). Anosmia was more prevalent among nonhospitalized patients (21.4% vs 10.0%, P=0.003).

“These differences could be explained by the fact that individuals experiencing less bothersome and less severe symptoms (e.g., anosmia, ageusia, and throat pain) did not seek hospitalization during the first wave of the pandemic,” Fernán-

dez de las Peñas and team wrote.

Among hospitalized patients, the number of pre-existing comorbidities was associated with post-COVID fatigue (OR 1.93, 95% CI 1.09-3.42, P=0.02) and dyspnea (OR 1.91, 95% CI 1.04-3.48, P=0.03), while the number of pre-existing comorbidities (OR 3.75, 95% CI 1.67-8.42, P=0.001) and the number of symptoms at illness onset (OR 3.84, 95% CI 1.33-11.05, P=0.01) were linked with post-COVID fatigue among nonhospitalized patients.

Most previous studies looking at postCOVID symptoms had shorter follow-up periods. One meta-analysis that included 40 studies and followed patients for up to 120 days suggested a greater prevalence of post-COVID symptoms among hospitalized patients versus nonhospitalized patients. “Data on nonhospitalized patients are based on follow-up periods no longer than six months; accordingly, we cannot directly compare our results with previous data,” the authors noted.

To evaluate COVID-19 symptoms two years after infection, Fernández de las Peñas and team included 360 hospitalized patients (mean age 60.7, 45% women) and 308 nonhospitalized patients (mean age 56.7, 59.4% women) from two urban hospitals and several general practitioner centers who were infected with SARSCoV-2 from March 20 to April 30, 2020. These patients did not experience reinfection over the two years of follow-up.

Common comorbidities among hospitalized and nonhospitalized patients included hypertension (33.3% vs 24.7%), diabetes (13.6% vs 4.9%), cardiac disease (11.9% vs 11.0%), and obesity (7.8% vs 10.1%).

Participants were scheduled for a telephone interview two years after acute infection. Hospitalization and clinical data were collected from medical records.

Other study limitations besides not including uninfected controls included the fact that the researchers did not control for vaccination status. Furthermore, data were self-reported through telephone interviews, which can lead to recall bias.

Ingrid Hein is a staff writer on infectious diseases for MedPage Today, where this article first appeared.

INFECTIOUS DISEASE
SANDIEGOPHYSICIAN.ORG 11

Putting the ‘We’ in Wellness

HAS YOUR WELLNESS improved, worsened, or stayed the same since before the pandemic?” I was amazed to hear that the vast majority of faculty colleagues I interviewed from my department reported that their wellness had been maintained or actually improved. After much study and reflection on this topic, I have come to a simple conclusion — we can do hard things, if we do it together.

As wellness director for my department, I completely empathize with the fact that even the word “wellness” can be a trigger for some. When we are sub -

jected to chronic distress, i.e., overwork in understaffed environments, societal mistrust and disinformation, a seemingly never-ending pandemic existence … many understandably feel it is shortsighted and misplaced to focus on physician wellbeing as its own entity. “It’s not a me problem, it’s a system problem.”

But I would argue that it’s both. If you are feeling so unwell that you can’t advocate for yourself and what you need, you are at risk of stagnation and for some, their very lives are at risk. I often tell my patients struggling with emotional distress, we can’t always change what is happening around us, but we can change

how we respond to it. This is just as true for those of us struggling to find work-life integration in the practice of medicine. This isn’t a charge to be more resilient in the face of moral injury. It is a challenge to explore a paradigm shift that might promise a new way forward.

Really what I’m talking about here is building a culture of wellness from the ground up. It does not minimize the need for systemic change where it is needed, but it can empower individuals to forge a path from surviving to — dare I say it? — thriving. This is beyond the basic inventory of physiological and safety needs from Maslow’s hierarchy (it goes

12 NOVEMBER / DECEMBER 2022
PHYSICIAN WELLNESS

without saying that we need to eat well, sleep enough, and stay safe) to more complex issues of belonging, esteem, and self-actualization.

So maybe you’re feeling so burned out that the ideal of absolute professional fulfillment is a bit of a reach. Let’s slow down here. Where can one start when everything seems so overwhelming? One potential area is taking small steps to help build strong working relationships with other members of the care team. Sometimes we forget the powerful role we have as physicians in terms of setting the tone in the workplace, where folks feel valued, connected, and engaged in

this important work. This doesn’t mean everyone’s happiness rests on our shoulders, but we do have the potential to make a strong impact. When we take a beat to help promote the wellbeing of our teams through even subtle ways — acknowledging a dyad partner’s strong work during clinic huddle, leaving a note of encouragement on a colleague’s desk, playing some music in a shared office to lighten the mood — we are taking important steps to build a culture of wellness.

While we have the capacity to help promote wellness, it is just as important that we take a step back to let others play a part. If there’s one thing I’ve learned in the wellness space during this pandemic, it’s this: When times are tough, you can’t go it alone. We all know that patient care is a team sport, yet physicians have historically carried too much of the load for too long, and now more than ever, we are feeling just how unsustainable that has been. Having support from folks who are empowered to work at the top of their license allows you to focus on what matters most in your work.

Faculty members in our department have felt some substantial unburdening of work, thanks to institutional investment in enhanced team-based care initiatives, from prescription refill teams, to inbox coverage and population health support. When I can rest assured that the triage team can address my patient calling in with chest pain, I can focus my full attention on the patient in front of me in clinic. When the medical assistant on my team is empowered to schedule our patient messaging with a non-urgent concern into a telehealth appointment with me, rather than shuttle it to my inbox, that’s less after-hours work and more time with my family.

By having mutual support with a comprehensive care team, we have been able to improve quality of care as well as the patient and physician experience.

As you reflect on your own workplace, do you feel that you have adequate staff support? I’d encourage you to open some dialogue with colleagues to identify deficits and escalate more systemic concerns to clinical leadership to address the unmet needs. I cannot overstate how vital it is to advocate for what you need

— you teach people how to treat you. If you aren’t feeling supported to speak up for yourself at work, consider if you can identify one “battle buddy” — a trusted colleague with whom you can be open and authentically yourself, especially during the hard times. While the inertia to struggle in silence is strong, taking steps to unite your voice with colleagues can help ignite a movement for change in the workplace.

Some might worry that their concerns will fall on deaf ears. I would ask, do you have engaged leadership who partner with you and help advocate on your behalf? Are physicians well represented at the table where decisions are made? If not, why, and how can that be changed? A physician-led movement for a shift to a shared primary care governance structure was a pinnacle moment at our institution, whose impact has continued to reverberate in positive ways. Ensuring your voice is heard and that you have some autonomy in your work life is so vital to feeling that you are part of a thriving and well workplace.

When individual actions and organizational change help promote the wellbeing of healthcare workers, morale is lifted and previously insurmountable challenges can become a little less daunting. Nowadays, when I identify thorns in my side at work, I see it as a “we” problem — what part do I play in this, and how can I partner with the organization to envision a better way? Most of us have more agency than we realize, and I wish for you to remember that, even in the hardest of times.

Dr. Çelebi is a proud full-spectrum family medicine physician and associate clinical professor in the Department of Family Medicine at UC San Diego. She is the wellness director for UCSD’s Department of Family Medicine, spearheading and studying a myriad of initiatives to optimize clinician wellness. She is also presidentelect of the San Diego Academy of Family Physicians, and some of her interests include reproductive health and obstetrics, office procedures, LGBTQ+ healthcare, health equity, and advocacy for medically vulnerable populations. Her blog is www. compassionatehealing.blogspot.com.

SANDIEGOPHYSICIAN.ORG 13

Let’s Make a Difference Together

of a child walking along a beach after a terrible storm that washed up thousands of starfish. The child is throwing starfish back into the water when someone admonishes the child that they cannot save them all, cannot really make a difference. The child picks up another and replies, “I made a difference to that one.”

Every day, we rush around, dealing with personal and professional lives, juggling competing priorities. We want to keep a balance between making sure that our family members know they are loved and cared for, and making sure our interactions at work with colleagues and patients are engaging and meaningful. Some days it is harder than other days,

“People will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

especially as we move forward from the past two years. We each have a purpose … we want to make a difference.

Champions for Health works with our dedicated network of physician volunteers, hospitals, surgery centers, nurses, schools, community, and private and public partners to improve the health of our community where San Diegans live, work, play, and pray. But what does that mean? 450 patients receive 1,100 specialty care appointments and 80 surgeries. Twenty-five thousand COVID doses and boosters and 8,000 flu doses are administered to children, youth, and adults in every corner of the county. These services are provided for free to the participants. But the impact is priceless! No need to worry about ER visits; loss of work due to excruciating pain; deciding between paying for food or for a desperately needed medical appointment; or being hospitalized due to severe COVID, flu symptoms, or complications.

Access to care for all is our mission. Our staff and volunteers offer the highest standards of medical and healthcare services with responsiveness, compassion,

and attention to detail. When you support Champions for Health, you contribute to the health and wellbeing of thousands of individuals in San Diego. Each of these people show their gratitude in a smile, with a hug, with a sigh of relief that there are unsung heroes such as you who are ready to step up in their time of need.

There are so many ways to help your neighbors. Choose the way that works best for you! You can donate once or join our monthly giving program for consistent, ongoing support. It’s the end of the year: Stocks and securities can be transferred to Champions for Health. Direct charitable distributions of IRA funds can be contributed up to $100,000. While shopping online for the holidays and celebrating life events, use Amazon Smile and select San Diego County Medical Society Foundation (dba Champions for Health) as your charity. Amazon Smile will donate 0.5% of the price of your eligible purchases to Champions for Health. We invite you to join us in making a difference. Your contribution will create real change, one person at a time. Thank you for supporting us, your foundation, and your physician and nurse colleagues in making San Diego the healthiest place to live! www.championsforhealth.org/ donate.

CHAMPIONS FOR HEALTH 14 NOVEMBER / DECEMBER 2022
Adama Dyoniziak is executive director of Champions for Health.
“The two most important days in your life are the day you are born and the day you find out why.”
— MARK TWAIN
“Real change, enduring change, happens one step at a time.”
— RUTH BADER GINSBURG

Vista Community Clinic has outstanding opportunities for Full-Time and Part-Time Physicians. We are looking for dedicated, motivated and enthusiastic team players who want to make a difference in the community.

Vista Community Clinic is a federally qualified, not-for-profit healthcare clinic with more than 800 employees and nine state-ofthe-art clinics treating more than 69,000 patients every year. We provide healthcare throughout the Southern California regions of North San Diego, Orange and Riverside Counties.

Our compensation and benefits program includes: Competitive compensation, sign-on bonus, relocation bonus, health, dental, vision, company-paid life, longterm disability, flexible spending accounts , 403(b) retirement plan, malpractice coverage, NHSC loan repayment eligible organization, CME allowance, and no oncall hours

For more information visit www.vcc.org or email hr@vcc.org EEO

Join a team that’s been helping to redefine what it means to be a community clinic for 50 years.
PHONE : 800-919-9141 OR 805-641-9141 FAX: 805-641-9143 EMAIL: JNGUYEN@TRACYZWEIG.COM TRACYZWEIG.COM PHYSICIANS NURSE PRACTITIONERS PHYSICIAN ASSISTANTS LOCUM TENENS PERMANENT PLACEMENT FEBRUARY2020 Official Publication of SDCMS Celebrating 150 Years Artificial Intelligence and Medicine THE DEBATE Official Publication of SDCMS Celebrating 150 Years How to BUILD DIABETES Reversing the Risks DEMENTIA Reducing the Burden GUN SAFETY Engaging Patients BREAST CANCER Preventing Deaths NOVEMBER/DECEMBER2019 PREVENTION Contact Jennifer Rohr 858.437.3476 • Jennifer.Rohr@SDCMS.org PLACE YOUR AD HERE SANDIEGOPHYSICIAN.ORG 15

IN EARLY OCTOBER, Champions for Health held a glamorous “Casino Night” fundraiser at The Vault at Veloce Motors in San Diego. Champions’ efforts to provide healthcare assistance and vaccinations to San Diego County’s underserved populations were the beneficiary. Thank you to Veloce Motors and the generous sponsors of this successful event as well as all who attended.

16 NOVEMBER / DECEMBER 2022
SANDIEGOPHYSICIAN.ORG 17

‘Fourth Trimester’ Focus Is Pushed to Prevent Maternal Deaths

FOR SEVERAL WEEKS A YEAR, the work of nurse-midwife Karen Sheffield-Abdullah is really detective work. She and a team of other medical investigators with the North Carolina public health department scour the hospital records and coroner reports of new moms who died after giving birth.

These maternal mortality review committees look for clues about what contributed to the deaths — unfilled prescriptions, missed postnatal appointments, signs of trouble that doctors overlooked — to figure out how many of them could have been prevented.

The committees are at work in 36

states, and in the latest and largest compilation of such data, released in September by the Centers for Disease Control and Prevention, a staggering 84% of pregnancy-related deaths were deemed preventable.

Even more striking to nurse-detectives like Sheffield-Abdullah is that 53% of the deaths occurred well after women left the hospital, between seven days and a year after delivery.

“We are so baby-focused,” she says. “Once the baby is here, it’s almost like the mother is discarded. Like a Reese’s Peanut Butter Cup. The mom is the wrapper, and the baby is the candy. Once you remove the wrapper, you just discard the

wrapper. And what we really need to be thinking about is that fourth trimester, that time after the baby is born.”

Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic women most likely to die from suicide or drug overdose, while cardiac problems were the leading cause of death for non-Hispanic Black women, according to the CDC report.

The data highlights multiple weaknesses in the system of care for new mothers, from obstetricians who are not trained (or paid) to look for signs of mental trouble or addiction, to policies that strip women of health insurance

18 NOVEMBER / DECEMBER 2022 MATERNAL HEALTH

coverage shortly after they give birth.

The number-one problem, as Sheffield-Abdullah sees it, is that the typical six-week postnatal checkup is way too late. In the North Carolina data, new moms who later died often missed this appointment, she says, usually because they had to go back to work or they had other young children.

“We really need to stay connected while they’re in the hospital,” SheffieldAbdullah says, then make sure patients are referred for the appropriate followup care “within one to two weeks after delivery.”

Increased screening for postpartum depression and anxiety, starting at

the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation — as is better coordination of care between medical and social services, says David Goodman, who leads the maternal health team at the CDC’s Division of Reproductive Health, which issued the report.

A common crisis point in the months after childbirth is when a parent’s substance use problem gets so bad that child protective services takes the baby away, precipitating a mother’s accidental or intentional overdose. Having access to treatment and making sure child visitations happen regularly could be key to preventing such deaths, Goodman explains.

The most important policy change underscored by the data, he says, has been the expansion of free health coverage through Medicaid. Until recently, pregnancy-related Medicaid coverage typically expired two months after delivery, forcing mothers to stop taking medications or seeing a therapist or doctor because they couldn’t afford the cost without health insurance.

Now, 36 states have either extended or plan to extend Medicaid coverage to a full year postpartum, partly in response to the early work of maternal mortality review committees. For years, the data showed about a third of pregnancyrelated deaths occurred one year after delivery, but in this report, they jumped to more than half, Goodman says, putting more urgency on the importance of longer-term Medicaid coverage.

“If this is not a call to action, I don’t know what is,” says Adrienne Griffen, executive director of the Maternal Mental Health Leadership Alliance, a nonprofit focused on national policy. “We’ve long known that mental health issues are the most common complication of pregnancy and childbirth. We just haven’t had the will to do anything about it.”

The latest CDC study from September analyzed 1,018 deaths in 36 states, significantly more than in the previous report. The CDC is providing additional funding for maternal mortality reviews, Goodman says, with the hope of capturing more complete data from more states in the future.

Advocates and doctors have been

heartened by the increased awareness and attention on maternal mortality, especially efforts to correct racial disparities: Black women are three times as likely to die from pregnancy-related complications as white women.

But many of these same advocates for better maternal care say they are dismayed by the recent U.S. Supreme Court decision eradicating the federal right to abortion; restrictions around reproductive healthcare, they say, will erode the gains.

Since states like Texas began banning abortions earlier in pregnancy and making fewer exceptions for cases in which the pregnant person’s health is endangered, some women are finding it harder to get emergency care for a miscarriage.

States are also prohibiting abortions — even in cases of rape or incest — for young girls, who face much higher risks of complications or death from carrying a pregnancy to term.

“More and more women and other birthing individuals are receiving messages that ‘You don’t have ownership of your body,’” says Jameta Nicole Barlow, an assistant professor of writing, health policy, and management at George Washington University. “Whether it’s through policy, whether it’s through your doctor who has to adhere to policy, whether it’s through your daily work experience, there’s this acknowledgment that ‘I don’t own my body.’”

This will only exacerbate the mental health struggles women experience around pregnancy, Barlow says, especially Black women who are also coping with a long, intergenerational history of slavery and forced pregnancy. She suspects the maternal mortality numbers will get worse before they get better, because of the way politics, policy, and psychology are intertwined.

“Until we address what’s happening politically,” she says, “we’re not going to help what’s happening psychologically.”

This story is part of a partnership that includes KQED, NPR, and KHN.

April Dembosky is a health reporter for KQED and a contributor to NPR. This article is part of a collaboration between KQED, NPR, and Kaiser Health News, where this article first appeared.

SANDIEGOPHYSICIAN.ORG 19

CDC Just Changed Its Opioid Prescribing Guidelines. Here’s What to Know.

Guidance Covers Acute, Subacute, and Chronic Pain, and Replaces 2016 Guidelines

HARD THRESHOLDS FOR

pain medication doses and duration are no longer promoted through the CDC’s new Clinical Practice Guideline for Prescribing Opioids for Pain.

The new guidance — which covers acute, subacute, and chronic pain for primary care and other clinicians — updates and replaces the controversial 2016 CDC opioid guideline for chronic pain. The 2016 guideline was interpreted as imposing strict opioid dose and duration limits and was misapplied by some organizations, leading the guideline authors to clarify their recommendations in 2019.

The 2022 recommendations are voluntary and give clinicians and patients flexibility to support individual care, explained Christopher Jones, PharmD, DrPH, MPH, acting director of CDC’s National Center for Injury Prevention and Control in a CDC press briefing. They should not be used as an inflexible, onesize-fits-all policy or law, or applied as a rigid standard of care, or replace clinical judgement about personalized treatment, he emphasized.

“Patients with pain should receive compassionate, safe, and effective pain care,” Jones stated. “We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life.”

The guidance, published in Morbidity and Mortality Weekly Report , addresses four key areas: initiating opioids for pain, selecting opioids and dosages, deciding

prescription duration and conducting follow-up, and assessing risk and potential harms of opioids. It suggests that clinicians work with patients to incorporate plans to mitigate risks, including offering naloxone.

The 100-page document indicates opioids should not be considered as first-line or routine therapy for subacute or chronic pain, and points out that non-opioid therapies often are better for many types of acute pain.

“For patients receiving opioids for 1 to 3 months (the timeframe for subacute pain), the 2022 guideline recommends that clinicians avoid continuing opioid treatment without carefully reassessing treatment goals, benefits, and risks in order to prevent unintentional initiation of long-term opioid therapy,” wrote Debbie Dowell, MD, MPH, chief clinical research officer for CDC’s Division of Overdose Prevention, and guideline co-authors in a commentary published in The New England Journal of Medicine

For chronic pain, clinicians should maximize use of non-opioid therapies and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks, Dr. Dowell and colleagues noted. When opioids are needed for chronic pain, clinicians should start at the lowest effective dose, evaluate benefits and risks before increasing dosage, and avoid raising dosage above levels likely to yield diminishing returns, they added.

“These principles do not imply that nonpharmacologic and non-opioid pharmacologic therapies must all be tried unsuccess-

fully in every patient before opioid therapy is offered,” Dr. Dowell and colleagues wrote. “Rather, expected benefits specific to the clinical context should be weighed against risks before therapy is initiated.”

The new guideline offers tips for tapering opioids when warranted, but is not intended to lead to rapid opioid tapering or discontinuation, Jones noted. The recommendations do not apply to sicklecell-disease-related pain, cancer pain, and palliative or end-of-life care.

The 2022 document incorporated feedback from approximately 5,500 public comments since the new version was first proposed in February, including reactions from people who discussed their experiences with pain or opioid addiction and barriers to pain care. An independent federal advisory committee, four peer reviewers, and members of the public reviewed the draft version.

“The science on pain care has advanced over the past six years,” Dr. Dowell said in a statement. “During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians. We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care.”

The clinical practice guideline supports the HHS Overdose Prevention Strategy, the CDC said. The agency also is providing additional information associated with the guideline to clinicians and patients.

Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more.

NEUROLOGY OPIOIDS
20 NOVEMBER / DECEMBER 2022

CLASSIFIEDS

VOLUNTEER OPPORTUNITIES

CHAMPIONS FOR HEALTH - PROJECT ACCESS SAN DIEGO:

Volunteer physicians are needed in the following specialties: endocrinology, rheumatology, vascular surgery, ENT or head and neck, general surgery, GI, and gynecology. These specialists are needed in all regions of San Diego County to provide short term pro bono specialty care to adults ages 26-49 who are uninsured and not eligible for Medi-Cal. Volunteering is customized to fit your regular schedule in your office. Champions for Health is the foundation of the San Diego County Medical Society. Join hundreds of colleagues in this endeavor: Contact Evelyn.penaloza@championsfh.org or at 858-300-2779.

CHAMPIONS FOR HEALTH PROJECT ACCESS: Volunteer physicians are needed for the following specialties: endocrinology, ENT or head and neck, general surgery, GI, gynecology, neurology, ophthalmology, orthopedics, pulmonology, rheumatology, and urology. We are seeking these specialists throughout all regions of San Diego to support those that are uninsured and not eligible for Medi-Cal receive short term specialty care. Commitment can vary by practice. The mission of the Champions for Health’s Project Access is to improve community health, access to care for all, and wellness for patients and physicians through engaged volunteerism. Will you be a health CHAMPION today? For more information, contact Andrew Gonzalez at (858) 300-2787 or at Andrew.Gonzalez@ChampionsFH. org, or visit www.ChampionsforHealth.org.

PHYSICIAN OPPORTUNITIES

PSYCHIATRIST SPECIALIST: The County of San Diego is currently accepting applications from qualified candidates. Annual Salary: $258,294.40. Note: An additional 10% is paid for Board Certification, or 15% for Board Certification that includes a subspecialty. Why choose the County?Fully paid malpractice insurance; 13 paid holidays; 13 sick days per year; Vacation: 10 days (1-4 years of service); 15 days (5-14 years of service; 20 days (15+ years); Defined benefit retirement program; Cafeteria-style health plan with flexible spending; Wellness incentives. Psychiatrist-Specialists perform professional psychiatric work involving the examination, diagnosis, and treatment of specialty forensics, children/adolescents and or geriatric patients. This is the specialty journey level class in the series that requires a fellowship or experience in child and adolescent psychiatry or forensic psychiatry. For more information, visit our website at sandiegocounty.gov/hr or select this link to link to go directly to the Psychiatrist Specialist application.

PRIMARY CARE PHYSICIAN: Imperial Valley Family Care Medical Group is looking for Board Certified/Board Eligible Primary Care Physician for their clinics in Brawley & El Centro CA. Salaried/full time position. Please fax CV/salary requirements to Human Resources (760) 355-7731. For details about this and other jobs please go to www.ivfcmg.com

ASSISTANT, ASSOCIATE OR FULL PROFESSOR (HS CLIN, CLIN X, ADJUNCT, IN_RESIDENCE) MED-GASTROENTEROLOGY: Faculty Position in Gastroenterology. The Department of Medicine at University of California, San Diego, Department of Medicine (http:// med.ucsd.edu/) is committed to academic excellence and diversity within the faculty, staff, and student body and is actively recruiting faculty with an interest in academia in the Division of Gastroenterology. Clinical and teaching responsibilities will include general gastroenterology. The appropriate series and appointment at the Assistant, Associate or Full Professor level will be based on the candidate’s qualifications and experience. Salary is commensurate with qualifications and based on the University of California pay scales. InResidence appointments may require candidates to be self-funded. For more information: https://apol-recruit.ucsd.edu/JPF03179 For help contact: klsantos@health.ucsd.edu

CARDIOLOGIST POSITION AVAILABLE: Cardiology office in San Marcos seeking part-time cardiologist. Please send resume to albertochaviramd@yahoo.com

DERMATOLOGIST NEEDED: Premier dermatology practice in La Jolla seeking a part-time BC or BE dermatologist to join our team. Busy practice with significant opportunity for a motivated, entrepreneurial physician. Work with three energetic dermatologists and a highly trained staff in a positive work environment. We care about our patients and treat our staff like family. Opportunity to do medical/surgical and cosmetic dermatology in an updated medical office with state-of-the art tools and instruments. Incentive plan will be a percentage based on production. If you are interested in finding out more information, please forward your C.V. to jmaas12@hotmail.com

INTERNAL MEDICINE PHYSICIAN: Healthcare Medical Group of La Mesa located at 7339 El Cajon Blvd is looking for a caring, compassionate, and competent physician for providing primary care services. We require well-organized and detail-oriented with excellent written and oral communication skills, and excellent interpersonal skills to provide high-quality care to our patients. We provide a competitive salary, paid time off, Health insurance, 401K benefits, etc. We provide plenty of opportunities to refine your clinical competency. Our CEO Dr. Venu Prabaker who has 30 years of teaching experience as a faculty at multiple universities including Stanford, UCSD, USC, Midwestern, Western, Samuel Merritt, Mayo, etc. will be providing teaching rounds once a week. You will also get plenty of opportunities to attend other clinical lectures at many of the 4- to 5-star restaurants in San Diego. We also have once a week one-hour meeting for all the staff for team building and to create a “family atmosphere” to improve productivity and thereby create a win-win situation for all. Visit us at caremd.us.

RADY CHILDREN’S HOSPITAL PEDIATRICIAN POSITIONS: Rady Children’s Hospital of San Diego seeking board-certified/ eligible pediatricians or family practice physicians to join the

Division of Emergency Medicine in the Department of Urgent Care (UC). Candidate will work at any of our six UC sites in San Diego and Riverside Counties. The position can be any amount of FTE (full-time equivalent) equal to or above 0.51 FTE. Must have an MD/DO or equivalent and must be board certified/eligible, have a California medical license or equivalent, PALS certification, and have a current DEA license. Contact Dr. Langley glangley@rchsd.org and Dr. Mishra smishra@rchsd.org.

TUBERCULOSIS CONTROL & REFUGEE HEALTH CHIEF AND MEDICAL DIRECTOR: recruitment is attached and linked herehttps://www.governmentjobs.com/careers/sdcounty/jobs/3223044/ chief-tb-control-refugee-health-public-health-medical-officer21412809uth

PUBLIC HEALTH SERVICES MEDICAL CONSULTANT M.D., D.O: Medical Consultant-21416207 | Job Details tab | Career Pages (governmentjobs.com)<https://www.governmentjobs.com/ careers/sdcounty/jobs/3148610/m-d-d-o-medical-consultant21416207?keywords=medical%20consultant&pagetype=jobOppor tunitiesJobs

PER DIEM OBGYN LABORIST POSITION AVAILABLE: IGO Medical Group is seeking a per diem laborist to cover Labor and Delivery and emergency calls at Scripps Memorial Hospital in La Jolla. 70 deliveries/month. 24-hour shifts preferred but negotiable. Please send inquiries by email to IGO@IGOMED.com.

MEDICAL CONSULTANT, SAN DIEGO COUNTY: The County of San Diego, Health and Human Services Agency’s Public Health Services is looking for a Board Certified Family Practice or Internal Medicine physician for the Epidemiology and Communicable Disease Division. Under general direction, incumbents perform a variety of duties necessary for the identification, diagnosis, and control of communicable diseases within the population. This position works closely with the medical and laboratory community, institutional settings, or hospital control practitioners. Learn more here: https://www.governmentjobs.com/careers/sdcounty?keywords=21416207

KAISER PERMANENTE SAN DIEGO PER DIEM PHYSIATRIST: Southern California Permanente Medical Group is an organization with strong values, which provides our physicians with the resources and support systems to ensure they can focus on practicing medicine, connecting with one another, and providing the best possible care to their patients. For consideration or to apply, visit https:// scpmgphysiciancareers.com/specialty/physical-medicine-rehabilitation. For questions or additional information, please contact Michelle Johnson at 866-503-1860 or Michelle.S1.Johnson@kp.org. We are an AAP/EEO employer.

PRIMARY CARE PHYSICIAN POSITION: San Diego Family Care is seeking a Primary Care Physician (MD/DO) at its Linda Vista location to provide direct outpatient care for acute and chronic conditions to a diverse adult population. San Diego Family Care is a federally qualified, culturally competent and affordable health center in San Diego, CA. Job duties include providing complete, high quality primary care, and participation in supporting quality assurance programs. Benefits include flexible schedules, no call requirements, a robust benefits package, and competitive salary. If interested, please email CV to sdfcinfo@sdfamilycare.org or call us at (858) 810- 8700.

FAMILY MEDICINE OR INTERNAL MEDICINE PHYSICIAN: TrueCare is more than just a place to work; it feels like home. Sound like a fit? We’d love to hear from you! Visit our website at www.truecare. org. Under the direction of the Chief Medical Officer and the Lead Physician, ensure the provision of effective quality medical service to the patients of the Health center. The physician is responsible for assuring clinical procedures are continually and systematically followed, patient flow is enhanced, and customer service is extended to all patients at all times.

PUBLIC HEALTH LABORATORY DIRECTOR: The County of San Diego is seeking a dynamic leader with a passion for building healthy communities. This is a unique opportunity for a qualified individual to work for a Level 3 Public Health Laboratory. The Public Health Services department, part of the County’s Health and Human Services Agency, is a local health department nationally accredited by the Public Health Accreditation Board and first of the urban health departments to be accredited. Public Health Laboratory Director21226701UPH

NEIGHBORHOOD HEALTHCARE MD, FAMILY PRACTICE AND INTERNISTS/HOSPITALISTS: Physicians wanted, beautiful Riverside County and San Diego County- High Quality Family Practice for a private-nonprofit outpatient clinic serving the communities of Riverside County and San Diego County. Work full-time schedule and receive paid family medical benefits. Malpractice coverage provided. Be part of a dynamic team voted ‘San Diego Top Docs’ by their peers. Please click the link to be directed to our website to learn more about our organization and view our careers page at www.Nhcare.org.

PHYSICIAN WANTED: Samahan Health Centers is seeking a physician for their federally qualified community health centers that emerged over forty years ago. The agency serves low-income families and individuals in the County of San Diego in two (2) strategic areas with a high density population of Filipinos/Asian and other lowincome, uninsured individuals — National City (Southern San Diego County) and Mira Mesa (North Central San Diego). The physician will report to the Medical Director and provide the full scope of primary care services, including but not limited to diagnosis, treatment, coordination of care, preventive care and health maintenance to patients. For more information and to apply, please contact Clara Rubio at (844) 200-2426 EXT 1046 or at crubio@samahanhealth.org.

PRACTICE FOR SALE

FOR SALE! LOOKING TO EXPAND? OR MOVE? Established 25+ years Gastroenterology GI office practice for sale in beautiful San Diego County, California. 500 active strong patient relationships and referral streams. Consistent total gross income of $600,000 for the past couple years; even through pandemic. Located in a professionalmedical building with professional contract staff. All records and billing managed by a professional service who can assist with insurance integration. Office, staff & equipment are move-in ready. Seller will assist buyer to ensure a smooth transition. Being on-call optional. Contact Ferdinand at (858) 752-1492 or ferdinand@zybex.com

OTOLARYNGOLOGY HEAD & NECK SURGERY SOLO PRACTICE FOR SALE: Otolaryngology Head & Neck Surgery solo practice located in the Ximed building on the Scripps Memorial Hospital La Jolla campus is for sale. The office is approximately 3000 SF with 1 or 2 Physician Offices. It has 4 fully equipped exam rooms, an audio room, one procedure room, one conference room, one office manager room as well as in-house billing section, staff room and a bathroom. There is ample parking for staff and patients with close access to radiology and laboratory facilities. For further information please contact Christine Van Such at 858-354-1895 or email: mahdavim3@gmail.com

OFFICE SPACE / REAL ESTATE AVAILABLE

HILLCREST OFFICE TO SUBLEASE OR SHARE: Gorgeous office located across from Scripps Mercy hospital. Office is approximately 2,000 sq. ft. with procedure/effusion room. Office is fully staffed and looking to add a new provider. We currently have Rheumatology/ Pulmonary/Allergy specialists but can accommodate any specialty or Internal Medicine. Multiple days per week and full use of office is available. If interested please reach out to Melissa Coronado at Melissa@sdpulmonary.com or call (619) 819-7224.

HILLCREST OFFICE TO SUBLEASE OR SHARE: Beautifully appointed office in Hillcrest next to Mercy Hospital to sublease or share. Office is approximately 1500 sq feet and has AAAASF certified operating room to share or use as needed. Currently occupied by plastic surgery, the office is ideal for Dermatology, Gynecology, Podiatry, or other specialty. Multiple days per week full use of office available as needed. Please contact amez.cookie@gmail.com or at 619-961-7200.

SUBLEASE AVAILABLE: Sublease available in Del Mar off 5 freeway. Share rent. 2,100 sq ft office in professional building. Utilities included. Great opportunity in a very desirable area. 858-342-3104.

CHULA VISTA MEDICAL OFFICE: Ready with 8 patient rooms, 2000sf, excellent parking ratios, Lease $4,000/mo. No need to spend a penny. Call Dr. Vin, 619-405-6307 vsnnk@yahoo.com

OFFICE SPACE AVAILABLE IN BANKERS HILL: Approximately 500sq feet suite available to lease, includes private bathroom. Located at beautiful Bankers Hill. For more details, please call Claudia at 619-501-4758.

OFFICE AVAILABLE IN MISSION HILLS, UPTOWN SAN DIEGO: Close to Scripps Mercy and UCSD Hillcrest. Comfortable Arts and Crafts style home in upscale Mission Hills neighborhood. Converted and in use as medical/surgical office. Good for 1-2 practitioners with large waiting and reception area. 3 examination rooms, 2 physician offices and a small kitchen area. 1700 sq. ft. Available for full occupancy in March 2022. Contact by Dr. Balourdas at greg@ thehanddoctor.com.

OFFICE SPACE IN EL CENTRO, CA TO SHARE: Office in El Centro in excellent location, close to El Centro Regional Medical Centre Hospital is seeking Doctors of any specialty to share the office space. The office is fully furnished. It consists of 8 exam rooms, nurse station, Dr. office, conference room, kitchenette and beautiful reception. If you are interested or need more information please contact Katia at 760-427-3328 or email at Feminacareo@gmail.com

OFFICE SPACE / REAL ESTATE WANTED

MEDICAL OFFICE SPACE WANTED IN HILLCREST/BANKERS

HILL AREA: Mercy Physicians Medical Group (MPMG) specialist is looking for office space near Scripps Mercy Hospital. Open to lease or share office space, full time needed. Please respond to rjvallonedpm@sbcglobal.net or 858-945-0903.

NON-PHYSICIAN POSITIONS AVAILABLE

OFFICE MANAGER: 1. Hiring, Training, Managing staff on procedures/policies. Monitors continuing compliance and office statistics. Oversee stocking/maintenance of supplies, retail. Equipment/ facilities management. Daily bookkeeping, collections. 2. Ensure smooth/efficient patient flow with increasing production/collections. 3. Create a friendly environment where patients expectations are exceeded, where staff can work together as a team. 4. Ensure staff working at maximum productivity/efficiency. Salary: 60-70K depending on experience/qualifications. Benefits: healthcare reimbursement, PTO, retirement, employee discount, bonuses, commission. Contact: info@manageyourage.com

ASSISTANT PUBLIC HEALTH LAB DIRECTOR: The County of San Diego is currently accepting applications for Assistant Public Health Lab Director. The future incumbent for Assistant Public Health Lab Director will assist in managing public health laboratory personnel who perform laboratory activities for the purpose of identifying, controlling, and preventing disease in the community, as well as assist with the development and implementation of policy and procedures relating to the control and prevention of disease and other health threats. Please visit the County of San Diego website for more information and to apply online.

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San Diego County Medical Society 8690 Aero Drive, Suite 115-220 San Diego, CA 92123 [ Return Service Requested ] $5.95 | www.SanDiegoPhysician.org PRSRT STD U.S. POSTAGE PAID DENVER, CO PERMIT NO. 5377 Friday May 12, 2023 6-10pm San Diego Natural History Museum 1788 El Prado San Diego CA 92101 CHAMPIONS FOR HEALTH & SAN DIEGO COUNTY MEDICAL SOCIETY GALA CHAMPIONSSOIREE.ORG • GABRIELA.STICHLER@CHAMPIONSFH.ORG • 858-300-2789 RISE Together We SAVE THE DATE FRIDAY MAY 12, 2023