Making a Difference
Mitchell H. Katz, MD
Director
Los Angeles County Department of Health Services
mkatz@dhs.lacounty.gov
1
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
2
San Francisco Needle Exchange
1992


Not enough private funding to sustain
underground needle exchange
programs.
Can you publicly fund an illegal
activity?
3
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.
4
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
5
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
6
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.
7
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.
8
Develop support for a broader
change
 San Francisco Medical Society votes to
support partner treatment.
 California Medical Association votes to
support partner treatment.
9
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.
10
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)
11
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.
12
Solution:
Eliminate written consent for
HIV testing in San Francisco
delivery system
13
14
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
15
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.
16
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.
17
Healthy San Francisco
Coverage initiative for providing
comprehensive coverage for health
services to the uninsured regardless of:
- Income
- Immigration Status
- Pre-existing conditions
18
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
19
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.
20
Access to Care
HSF Improves access to care
HSF
SF Uninsured
US Uninsured
Usual source of care
86%
60%
48%
Any outpatient use during
12-month period
78%
76%
47%
21
Emergency Department Use
HSF results in decreased inappropriate
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.
22
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.
23
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.
24
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)
25
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
26
Transformation of LA Health
Service System


Problem: Unacceptably long waits for
specialty care
Solution: eConsult and teleretinal
screening
27
e-Consult Summary (as of 2/25/15)
28
Evaluation of Hematuria
Median days from urinalysis to completed
work-up


Prior to e-Consult
After e-Consult
239 days
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.
29
Tele-Retinal Screening Program for
Diabetic Retinopathy (as of 1/30/15)
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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