San Francisco adapts for health reform

by Bob Roehr
Published 08/26/2010

San Francisco's director of health Dr. Mitch Katz is concerned about how national health reform legislation passed earlier this year is going to affect safety net health care programs for low income people.

He wrote broadly about those challenges and opportunities in JAMA – Journal of the American Medical Association (August 11) and he talked with the Bay Area Reporter about how they specifically apply to San Francisco.

"Safety net systems generally were designed for people who had no choice" about where to go for health care because they lacked health insurance, Katz said. "Now comes health reform and suddenly about half of the people being taken care of by the safety net have a choice."

Research has shown that across the nation, a third of people eligible for Medicaid, called Medi-Cal in California, have never applied for it. "Which means that safety nets are currently losing money because they are not eligiblizing patients for benefits that they are entitled to," Katz said. "This is going to get all the more intense under health reform, because now a larger number of people are going to be eligible for Medicaid, but that doesn't mean they are going to be on it."

Katz's concern is that if all of those people, or even a substantial fraction, opt for private sector health providers, the safety net programs will become hollowed out, unable to support the fixed costs of infrastructure such as facilities and expensive equipment like CT scanners. They could slip into an economic death spiral, unable to cut those costs fast enough.

He fears an exodus will mean that safety net programs "will be left only with those people who are not eligible for health reform, by and large the undocumented." It is a group with little political clout in the struggle for adequate health care resources.

"The question to me is, how to make sure that safety net systems thrive under health reform," said Katz.

Healthy San Francisco

About a third of San Franciscans now receive health care through Kaiser Permanente, a third through other private insurance programs, and a third through safety net programs.

The city's program, Healthy San Francisco, covers 53,000 of the 60,000-70,000 uninsured people. About 55 percent have their medical homes at facilities operated by the Department of Public Health and 45 percent chose a community clinic.

The city is well prepared to not simply survive but to prosper under reform, said Katz.

"It is a system that prides itself on social justice," he said, one that draws upon the medical talent and innovation of UCSF, and that has the benefit of a compact geography. The programs have a good reputation and "in the past when people have gotten insurances under other programs, they have tended to stay with us."

One reason is that safety net providers offer services like language capabilities and links to other programs for low income persons – general assistance, childcare, transportation – that private and small group practitioners cannot.

The Healthy San Francisco program requires that every person using the safety net programs choose a medical home.

"Now, for the first time, we have an unduplicated count of how many uninsured people are in care" at city clinics and other health centers, Katz said. That allows for better planning and allocation of resources.

The Department of Public Health also has created a web-based application process that Katz said has helped it "to identify many clients and their family members who are eligible for other public benefits." That improves the recipient's quality of life and "also ensures the economic viability of our system."

Attitudes also are changing. Katz acknowledged at one point the view was that the poor "are lucky to get care." But that has begun to change and it will accelerate under health reform. The new watchword is "customer service;" responsive to both the needs and desires of patients.

DPH has consolidated its problem-solving to a single telephone number staffed by multilingual personnel. It is implementing an electronic medical records system that will become fully functional next year.

"When people gain Medicaid their utilization will grow. Right now, we don't have as much capacity as we will need. Increasing capacity in cost effective ways is going to require different models of care, not necessarily all of the care delivered between a doctor and a patient," Katz said.

HIV-positive

"Overall, I think health reform is good for people who are HIV-positive because, if they are low income, it is going to make them eligible for Medicaid, regardless of their health status," said Katz, who is openly gay.

Current Medicaid regulations require persons to be both low income and certified as "disabled" in order to receive benefits. In other words, people with HIV infection must progress to an AIDS diagnosis before the program will pay for the drugs that will keep them from becoming sick. This is contrary to treatment guidelines that recommend starting treatment much earlier.

Katz believes that HIV programs offer "some of the best models" for delivering quality care in a cost effective manner. One is better linking patients with pharmacists. "Often pharmacists are better than doctors on drug-drug side effects, when to take medications," he said.

He is particularly keen on support groups at San Francisco General Hospital for people dually infected with HIV and hepatitis B or C.

"I have a number of my patients attend those groups and frankly, they learn more in those groups than they would ever learn from talking one on one with their doctor about treatment options," said Katz. "It is really a question of informed patients making the right decisions for themselves. I think that is a great model."

While Katz worries that some safety net health systems, particularly those in more rural areas, may not be able to respond well to the challenges and opportunities of health reform, he believes that San Francisco can prosper.

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