Making a Difference

Mitchell H. Katz, MDDirector

Los Angeles County Department of Health Servicesmkatz@dhs.lacounty.gov

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Needle Exchange 1992

Cities with needle exchange programs have lower rates of HIV infection among IDUs and their babies.

California law - syringes can only be dispensed with a doctor’s prescription

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San Francisco Needle Exchange 1992

Not enough private funding to sustain underground needle exchange programs.

Can you publicly fund an illegal activity?

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San Francisco Needle Exchange 1992

State law allows counties to suspend laws in cases of Public Health Emergency.

San Francisco Board of Supervisors declares public health emergency. Mayor signs bill. Needle exchange is funded.

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San Francisco Needle Exchange Program

Board renews public health emergency every 2 weeks for 9 years.

2 million dirty needles exchanged for 2 million clean ones.

Infections prevented: HIV, Hepatitis B and C

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Needle Exchange Funding

1999 California passes law (AB 136) allowing counties to establish needle exchange programs if they declare an emergency

2011 California passes law (AB 604) allowing needle exchange programs without emergency order

Federal government allows federal funds to finance needle exchange in 2009 but ban reinstated in 2011 by Congress

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Problem: High re-infection rate among clients at STD Clinic

Difficulty getting clients to bring in their partners for treatment.

California Medical Practices Act forbids prescription of antibiotics by a physician without examining the patient.

California Heath and Safety Code authorizes county local health officer to take all necessary measures to prevent the transmission of infectious diseases.

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Solution: Change policy to allow clinicians to bring home treatment to their partner (1998).

Study Impact. Telephone survey of STD clients who received partner packets (N=54).

73% of partners took treatment.

57% of couples discussed STDs.

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Develop support for a broader change

San Francisco Medical Society votes to support partner treatment.

California Medical Association votes to support partner treatment.

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Improve the world

SB -648 (2001) Authorizes physicians and mid-level practitioners

to prescribe partner antibiotic therapy for Chlamydia.

AB-2280 (2006) Authorizes patient delivered therapy to partners

of individuals diagnosed with gonorrhea or other sexually transmitted diseases.

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Randomized-controlled trial of expedited therapy versus standard practice(Golden MR; NEJM 2005; 352: 676)

Expedited therapy: patient delivered or clinician delivered without a physical examination outcome: persistent or recurrent gonorrhea or chylamydial infection standard.

Standard therapy: patients told to bring their partners in.

Outcome: persistent or recurrent gonorrhea or chylamydial infection.

Standard treatment Expedited treatment

13% (121/931) 10% (92/929)

(Relative risk, 0.76; 95% CI 0.59 –0.98)

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Problem: Twenty years after licensing of HIV test estimated 252,000 to 312,000 in US are unaware that they are infected.

Numerous barriers to testing.

Change those you can.

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Solution:

Eliminate written consent for HIV testing in San Francisco

delivery system

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Develop Support for a Broader Change

Work with HIV activists.

AB 682 - - changed the standard for testing by medical providers to right to decline. Passed by legislature and signed by governor.

Similar bills in other places

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Problem: Tobacco Use

Problem: Tobacco is the number 1 cause of preventable death in San Francisco, State of California and the US as a whole.

One Solution: San Francisco becomes the first locality to ban pharmacies from selling tobacco to avoid sending a mixed message to nonsmokers and those trying to quit.

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Universal Health Care Coverage, 2008

‘93 Clinton’s health reform bill fails.

‘08 CA Gov. Schwarzenegger’s bill fails.

‘08 San Francisco set’s out to achieve Universal health care coverage.

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Healthy San Francisco

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Coverage initiative for providing comprehensive coverage for health services to the uninsured regardless of:

- Income- Immigration Status- Pre-existing conditions

What does Healthy San Francisco provide?

Outpatient, inpatient, laboratory, behavioral health, and pharmacy services

Choice of medical homes Broad-based network of providers Affordable fee structure Common eligibility and

enrollment system Identification card Participant handbook Centralized customer service

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Satisfaction with Healthy San Francisco

94% of enrollees are satisfied. 92% would recommend to a friend to join

HSF. 41% report that their health needs are being

better met now than before HSF.

Katz MH, Brigham T. Transforming a traditional safety net into a coordinated care system: Lessons from Healthy San Francisco. Health Affairs Feb. 2011;1-9.

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Access to Care

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US UninsuredSF UninsuredHSF

47%76%78%Any outpatient use during 12-month period

48%60%86%Usual source of care

HSF Improves access to care

Emergency Department Use

For HSF enrollees, 9% of ED visits were judged to be unnecessary compared to 17% of visits by California Medicaid managed care recipients.

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HSF results in decreased inappropriate emergency department use

Healthy San Francisco

Healthy Howard

President Obama shouts out to Mayor Newsom about HSF during health reform debate.

Restaurant Association challenges employer spending requirement on ARISA grounds. SF prevails in 9th Circuit U.S. Court of Appeals; Supreme Court upholds.

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Prepare Los Angeles for Health Reform

Second largest safety net system in the country.

Four hospitals, 2 former hospitals functioning as multispecialty centers, 15 large community centers, many small clinics.

700,000 unduplicated clients a year.

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Preparation for Health Reform

History of public insurance expansions not a cause for optimism in LA

Medicare – seniors leave In 1966-67, discharges of elderly persons decreased from 22% to 8% at one hospital (Harbor) and 15% to 11% at another (LAC+USC)

Medicaid for pregnant women – moms and babies leave 1990-91: 41,406 babies born at DHS hospitals (~20% of live births in LAC) 2010-11: 2,766 babies born at DHS hospitals (~3% of live births in LAC)

Among low-income Californians, 67% of those with “no choice” on where they receive care want to change their current provider

(Blue Shield of CA Found, 2011)

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Transformation of LA Health Service System

Enrollment of over 300,000 patients to “Bridge to Medicaid”

Empanelment of over 400,000 patients into primary care homes

Successful implementation of an electronic health record and electronic specialty referral system

Improving patient experience

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Transformation of LA Health Service System

Problem: Unacceptably long waits for specialty care

Solution: eConsult and teleretinal screening

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e-Consult Summary (as of 2/25/15)

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Evaluation of Hematuria

Median days from urinalysis to completed work-up

Prior to e-Consult 239 daysAfter e-Consult 170 days

p=.0013

Bergman J, et al. Building a medical neighborhood in the safety net: an innovative technology improves hematuria workups. Urology 2013; 82(6):1277-82.

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Tele-Retinal Screening Program for Diabetic Retinopathy (as of 1/30/15)

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Cases

Reviewed 8,778

• No Referral Needed

5,828

• Referred (with diabetic retinopathy)

1,784

• Referred (with other eye condition)

1,166

Awaiting Review 165

Total Cases 8,943

5,828 of 8,778 = 66% no

referral needed.

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