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1520 Pacific Avenue • San Francisco, California 94109 • www.familydocs.org Phone (415) 345-8667 • Fax (415) 345-8668 • E-mail: cafp@familydocs.org
Officers and Board
Staff
President David Bazzo, MD, FAAFP
Lisa Folberg, MPP Chief Executive Officer lfolberg@familydocs.org
Immediate Past President Walter Mills, MD, MMM, FAAFP President-elect Shannon Connolly, MD, FAAFP Speaker Lauren Simon, MD, MPH, FAAFP Vice-Speaker Raul Ayala, MD, MHCM Secretary/Treasurer Alex McDonald, MD, FAAFP Chief Executive Officer Lisa Folberg, MPP Foundation President Marianne McKennett, MD AAFP Delegates Jeff Luther, MD Carol Havens, MD AAFP Alternates Jay W. Lee, MD, MPH Lee Ralph, MD CMA Delegation Raul Ayala, MD Kimberly Buss, MD, MPH Jay W. Lee, MD, MPH Felix Nunez, MD, MPH Kevin Rossi, MD
Morgan Cleveland Manager, Operations|Governance and FP-PAC mcleveland@familydocs.org Jerri Davis, CHCP Director, CME/CPD jdavis@familydocs.org Adam Francis Director, Government Affairs afrancis@familydocs.org Melissa Grindstaff Manager, Member Engagement mgrindstaff@familydocs.org Arlanna Henry Manager, Educational Programs ahenry@familydocs.org Josh Lunsford Director, Membership and Marketing jlunsford@familydocs.org Shelly Rodrigues, CAE, FACEHP Deputy Executive Vice President srodrigues@familydocs.org Jonathan Rudolph Manager, Finance jrudolph@familydocs.org
Looking for a job? Go to www.fpjobsonline.com Questions? Call 888-884-8242 and a HEALTHeCAREERS representative will help you.
Brent Sugimoto, MD, Editor Josh Lunsford, Managing Editor Shelly Rodrigues, CAE, Consulting Editor
The California Family Physician is published quarterly by the California Academy of Family Physicians. Opinions are those of the authors and not necessarily those of the members and staff of the CAFP. Non-member subscriptions are $35 per year. Call 415-345-8667 to subscribe.
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EDITION 36
features 12 Shelly Rodrigues, CAE, FACEHP, FAAMSE, Prepares to Retire 14 To CAFP Members: The Second Shoe
Carol S. Havens, MD, FAAFP Shelly Rodrigues, CAE, FACEHP, FAAMSE
Focus on Health Equity 22
COVID-19 is Affecting California’s Latinx Community at an Alarming Rate
24
Family Medicine Revolution: The Origin Story and How to Become the Heroes Our People Need
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Influencing Health Via the Community Environment
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We Need Better Representation in Leadership to Advance Gender Equity
José Alberto Arévalo, MD, FAAFP; Sergio Aguilar-Gaxiola, MD, PhD, MS; and Bobby Pena Jay W. Lee, MD, MPH, FAAFP Wendel Brunner, PhD, MD, MPH Shannon Connolly, MD, FAAFP
departments 6 Editorial
Family Medicine is Like Yeast
Brent Sugimoto, MD, MPH
8 President’s Message
Health Equity Begins with Us
David Bazzo, MD, FAAFP
10 Political Pulse
Election Could Mean Major Changes in Health Care
16 Advocacy Update
Is it Monumental Change, Much Ado About Nothing, or Somewhere In Between? Adam Francis
18 CAFP Foundation
Building Family Physician Leaders and a Strong Primary Care Workforce
30 CEO Message
Finding Hope in the Time of COVID
Carla Kakutani, MD
Pamela Mann, MPH Lisa Folberg, MPP
For upcoming CME activities visit familydocs.org/cme California Family Physician Fall 2020
editorial
Brent K. Sugimoto, MD, MPH, FAAFP
Family Medicine is Like Yeast On March 3, 1991, four White officers of the Los Angeles Police Department beat an unarmed Rodney King, a Black man, 56 times until he had among his injuries, a fractured cheekbone, 11 broken bones at the base of his skull, and a broken leg. This would not even have become public knowledge but for George Holliday, who captured the police beating on his camcorder and gave it to local television station KTLA. The LAPD belatedly confiscated the original video, but KTLA had already made a copy and the brutality soon became known to the world. Mr. King’s voice was heard only because of another who felt it was his moral duty to report what he saw as wrong. Mr. Holliday understood his role in that moment and rose to it. Technology has been a powerful force in democratizing the national conversation through citizen journalism. Cell phone cameras enable millions of people to become George Holliday. Social media platforms force pundits, experts, and government to make room for all stakeholders in the discussion. Even so, not all voices are given the same level of legitimacy. And those less affluent and with less access to the levers of power are still less likely to be heard. I am very grateful to this issue’s contributors to California Family Physician. Each, with their expertise and leadership, makes a strong case for family medicine’s role in advancing health equity. As former CAFP president Dr. Jay Lee argues, family physicians must know the difference between our job and our work. Our job may be the quotidian tasks of patient care, but our work extends far beyond the exam room. The inequities of our society are very much on display in the national conversation in an unprecedented way. And when there are still voices that are not heard, family doctors, in our privileged position as physicians, must ask ourselves what our role is in this moment, and how do we rise to it. On April 29, 1992, the four officers tried for Mr. King’s beating were acquitted. Within hours of the verdict, the disbelief and anger transformed into protest and violence. Until the now regular arrival of our interminable wildfire seasons, I had never witnessed such destruction. I remember the dozens of smoke
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columns from burning buildings rise up as if they were strange weather formations. I recall seeing street beatings blur by from raised freeways while in my car. I still have flashbacks of willing my Asian self-invisible, moments after being carjacked, when the Asian-owned convenience store I was next to was destroyed. In the days that followed, I tried to make sense of all of this, but it was far beyond my capabilities as a high school adolescent. Yet, it seemed, my teachers could not explain it, nor could my parents, nor could my Buddhist sensei. And on television, journalists only reported the violence. There was a lesson that I should have learned then, but did not, and that is primarily because the Black, Latinx, and Korean-American communities that suffered the most from the violence were underrepresented and unheard. So how do we ensure that our patients are heard? You do a lot for your patients—every day. But in this period of national reflection on race and inequity, as physicians, our words and actions are privileged with influence and power. What is your role in this moment? Advocate within your health system? Encourage your patients to vote? Write an editorial? Sit down with your legislator? Treat protesters on the street? There are so many ways to rise to the moment and family physicians should rise to it. Family Medicine is like yeast. When family medicine rises to the moment, our patients rise, too. My apologies to the good people at EMILY’s list. References “The Rodney King Affair: …” Los Angeles Times. March 21, 1991. https://www.latimes.com/archives/la-xpm-1991-03-24-me-1422story.html Ximénez de Sandoval, Pablo. “Meet the man who recorded the world’s first viral video.” El País. May 25, 2017. https://english. elpais.com/elpais/2017/05/25/inenglish/1495709209_218886. html.
p r e s i d e n t ’s m e s s a g e
David E.J. Bazzo, MD, FAAFP
Health Equity Begins with Us My dear colleagues, in this edition of the California Family Physician we explore many of the aspects surrounding health equity and health inequity. The writing of this comes on the heels of yet another incident of police violence against a black man that has sparked further unrest. Social inequity is health inequity encapsulated. In considering health inequity, we must make sure we understand the definition of health inequity.
Family Physicians are particularly geared toward understanding, empathizing and advocating to correct these inequities. We, more than any other specialty, are trained to assess how a person’s social situation impacts their health. These “social determinants of health are the conditions in the places where people live, learn, work and play that affect a wide range of health and quality-of-life-risks and outcomes (CDC).�
“Health inequities are the differences in health status While we understand and screen for these social or in the distribution of health resources influences, and their impact on our patient’s between different population groups, lives, we’ve also found it difficult to arising from the social conditions remedy the situations that so gravely in which people are born, impact the well-being of our grow, live, work and age. patients. The time has passed to Health inequities are state, “There is a problem!� I
avoidable inequalities add my voice in the call-to in health between action and describe a few groups of people ways to help improve within countries the world for everyone, and between particularly those who countries. These have suffered most. inequities
arise from First, understand inequalities yourself and where Fear Zone Learning Zone Growth Zone within and biases lie. A true, Becoming between mindful look at the Anti-Racist societies. way you think and Social and the actions you take
economic are the first steps to conditions and becoming antiracist. their effects on Dr. Ibrahim’s website, people’s lives surgerydesign.com, determine their provides a pictorial risk of illness and look at self-evaluation.
the actions taken to prevent them becoming Find yourself on this ill or treat illness when diagram and dedicate to it occurs (World Health residing in the “Growth Zone�.
Organization).�
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Second, declare your commitment to antiracism. However, be wary of the paradoxical effect this may have on your actions. As described by Dr. Kevin Gutierrez in his piece “The Performance of “Antiracism” Curricula” published in NEJM (n engl j med 383;11 September 10, 2020) quoting Dr. Sara Ahmed, declaring oneself or an institution as standing against racism could be a block against recognizing structural racism that is existent, “how can we be racist if we are committed to equality and diversity?” (Ahmed S. On being included: racism and diversity in institutional life. Durham, NC: Duke University Press, 2012.) We must ensure equality, equal standing and representation in our practices and institutions. What do we as a group look like and does this represent our community? It is important to commit to antiracist training but… do we have leaders, staff and colleagues who are Black or Latinx? Third, as highlighted in another NEJM article “Stolen Breaths” (n engl j med 383;3 nejm.org July 16, 2020) there are steps that health care systems can take to “dismantle structural racism and improve the health and well-being of the black community and the country.” We must “address the social, economic, political, legal, educational, and health care systems that maintain
structural racism.” We know rapid change in healthcare is possible. The response to the COVID-19 pandemic has shown that systemic change can happen quickly. As the article states we must: 1. “Divest from racial health inequities.” The tiered system for the delivery of health care must be dismantled. 2. “Desegregate the health care workforce.” Health care entities are frequently one of the largest employers in regions. Extending employment opportunities to underrepresented communities will serve as economic drivers to improve quality of life. 3. “Make ‘mastering the health effects of structural racism’ a professional medical competency.” Understand how structural racism impacts health. 4. “Mandate and measure equitable outcomes.” Adopting rigorous standards for addressing structural racism and measuring progress toward success is required. 5. “Protect and serve.” We must advocate vigorously for our patients and lead to end police brutality as a preventable cause of death. Finally, I encourage you to attend the CAFP Virtual Clinical Forum, November 13-15, 2020 with follow-up sessions on December 12, 2020 and January 16, 2021 to learn, connect and celebrate with your fellow Family Physicians to further pursue information and discussion on health equity.
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Carla Kakutani, MD
political pulse
Chair, CAFP Legislative Affairs Committee
Election Could Mean Major Changes in Health Care From State Assembly, State Senate, US House of Representatives to US President, Californians will go to the polls this November and set our state on a new policy path. While we could fill this entire magazine with analysis of each race, the competition that will most affect Californians and all Americans is that of U.S. President. No matter who wins that election, AAFP and CAFP will continue our push for sciencebased solutions to the COVID-19 epidemic and fight to ensure primary care is the foundation of our health care system. The November 2020 election will also include 12 ballot initiatives on which Californians can vote. The CAFP Board adopted a Support position on two of the initiatives, but chose not to adopt any position on the remaining ten. CAFP strongly encourages all members to learn more about each initiative. A description of the ballot measures follows, as well as links where you can learn more about each one. CAFP Recommends Support for: Proposition 16: Allowing Affirmative Action Voting YES on this initiative would reverse Proposition 209 (1996), California’s voter-approved ban on affirmative action. Passage of Prop 16 would mean that public universities, schools and government agencies are no longer prohibited from using race or sex in their admissions criteria, hiring and contract decisions. AAFP and CAFP endorse the goal of equitable representation and leadership opportunities throughout U.S. medical institutions. We support programs which aim to increase medical school applicants and matriculants who are underrepresented in medicine, and to continue their professional development in residency and practice. We support leadership by family physicians who are underrepresented in medicine in both academic and other health systems. We recommend that medical schools and academic health centers commit to and facilitate the development of medical careers among those underrepresented or underpowered in medicine. https://ballotpedia.org/California_Proposition_16,_Repeal_ Proposition_209_Affirmative_Action_Amendment_(2020) Proposition 25: Referendum on a 2018 Law that Replaced Money Bail System with a System Based on Public Safety Risk Voting YES on this initiative would maintain a 2018 law that eliminated cash bail as a requirement to release people from jail before trial, and instead required judges to decide whether a defendant should be released based on an assessment of their risk to the public and the likelihood they would return to court for trial. 10
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AAFP policy calls for a review and changes to the cash bail system, as it increases the risk of both short- and long-term negative health outcomes, exacerbates socioeconomic disparities, and is racially biased. https://ballotpedia.org/California_Proposition_25,_Replace_Cash_ Bail_with_Risk_Assessments_Referendum_(2020) CAFP recognizes that most issues that reach the ballot may have some effect on family physicians or their patients. However, CAFP only takes positions on initiatives where there is clear AAFP or CAFP policy. CAFP chose to not adopt a position on the following initiatives: Proposition 14: Authorizes Bonds to Continue Funding Stem Cell and Other Medical Research The initiative would renew funding for the California Institute for Regenerative Medicine, the state’s stem cell agency, by allowing it to issue $5.5 billion in bonds for research, training and facilities construction. It dedicates $1.5 billion to fund research and therapy for Alzheimer’s, Parkinson’s, stroke, epilepsy, and other brain and central nervous system diseases and conditions. https://ballotpedia.org/California_Proposition_14,_Stem_Cell_ Research_Institute_Bond_Initiative_(2020) Proposition 15: Increases Funding for Public Schools, Community Colleges, and Local Government Services by Changing Tax Assessment of Commercial and Industrial Property The initiative would rewrite Proposition 13, the landmark 1978 measure that limits property tax increases and allows residential and commercial property to be reassessed only when it is sold. The $7.5 billion to $12 billion boost in property taxes on large commercial and industrial property would go to school districts and local governments. Prop. 13 rules for residential property would be unchanged and the initiative exempts agricultural properties, as well as and owners of commercial and industrial properties with combined value of $3 million or less. https://ballotpedia.org/California_Proposition_15,_Tax_on_ Commercial_and_Industrial_Properties_for_Education_and_Local_ Government_Funding_Initiative_(2020) Proposition 17: Allowing Parolees to Vote The initiative would restore the voting rights of all people on parole if they have completed their state or federal prison terms. https://ballotpedia.org/California_Proposition_17,_Voting_Rights_ Restoration_for_Persons_on_Parole_Amendment_(2020)
Proposition 18: Elections: voting age The initiative would allow 17-year-olds to vote in primary elections if they would turn 18 before the general election. https://ballotpedia.org/California_Proposition_18,_Primary_Voting_ for_17-Year-Olds_Amendment_(2020) Proposition 19: The Home Protection for Seniors, Severely Disabled, Families, and Victims of Wildfire or Natural Disasters Act The initiative would allow people age 55 and older, and victims of wildfires and other disasters, to keep lower property tax rates when they move to new homes. This initiative is very similar to the voter-rejected Proposition 5 from 2018. https://ballotpedia.org/California_Proposition_19,_Property_Tax_ Transfers,_Exemptions,_and_Revenue_for_Wildfire_Agencies_and_ Counties_Amendment_(2020) Proposition 20: Restricts Parole for Non-Violent Offenders and Authorizes Felony Sentences for Certain Offenses The initiative would revise two previous initiatives, Proposition 47 and Proposition 57, by: • Expanding the list of violent crimes for which there is no early release, adding sex trafficking of a child and felony domestic violence. • Imposing restrictions on parole program for non-violent offenders who have completed the full term for their primary offense. • Expanding the list of offenses that disqualify an inmate from this parole program. • Changing standards and requirements governing parole decision. • Authorizing felony charges for specified theft crimes currently chargeable only as misdemeanors, including some theft crimes where the value is between $250 and $950. • Requiring persons convicted of specified misdemeanors to submit to collection of DNA samples for state database. • https://ballotpedia.org/California_Proposition_20,_Criminal_ Sentencing,_Parole,_and_DNA_Collection_Initiative_(2020) Proposition 21: Expands Local Governments' Authority to Enact Rent Control on Residential Property The initiative would repeal the Costa-Hawkins Rental Housing Act, which prohibits cities from passing rent control ordinances for housing built since 1995. Voters overwhelmingly rejected a similar measure, Proposition 10, in 2018. By allowing local governments to establish rent control on residential properties over 15 years old, Prop 21 would allow rent increases on rent-controlled properties of up to 15 percent over three years from previous tenant’s rent above any increase allowed by local ordinance. Exempts individuals who own no more than two homes from new rent-control policies.
https://ballotpedia.org/California_Proposition_21,_Local_Rent_ Control_Initiative_(2020) Proposition 22: Changes Employment Classification for AppBased Transportation and Delivery Drivers The initiative would exempt app-based drivers, including those working for Uber, Lyft and DoorDash, from a state law (AB 5) that classifies those workers as employees. The companies want to undo part of AB 5, which classifies their independent contractor drivers as employees and makes them eligible for benefits. Under the ballot measure, the companies could keep drivers as independent contractors, but be required to provide specified alternative benefits, including: minimum compensation and healthcare subsidies based on engaged driving time, vehicle insurance, safety training, and sexual harassment policies. It also restricts local regulation of app-based drivers, criminalizes impersonation of such drivers, and requires background checks. https://ballotpedia.org/California_Proposition_22,_App-Based_ Drivers_as_Contractors_and_Labor_Policies_Initiative_(2020) Proposition 23: Authorizes State Regulation of Kidney Dialysis Clinics This initiative is essentially a repeat of Proposition 8, which voters rejected in 2018. Prop 8 was sponsored by the Service Employees International Union-United Healthcare Workers (SEIU) and sought to cap revenue for dialysis companies at 115 percent of the cost of direct patient care and treatment quality efforts. If a company’s revenue exceeded that threshold, it would have to issue rebates, primarily to commercial health insurers. Prop 23 shares many of these requirements, but also prohibits clinics from discriminating against patients based on their source of payment, requires at least one licensed physician on site during treatment at outpatient kidney dialysis clinics. https://ballotpedia.org/California_Proposition_23,_Dialysis_Clinic_ Requirements_Initiative_(2020) Proposition 24: Amends Consumer Privacy Laws This initiative would expand current consumer privacy law by tripling the penalties for companies that break laws regarding the collection and sale of children’s private information, create a state agency to enforce consumer privacy protections, and permit consumers to: • Prevent businesses from sharing personal information. • Correct inaccurate personal information. • Limit businesses’ use of “sensitive personal information”—such as precise geolocation; race; ethnicity; religion; genetic data; union membership; private communications; and certain sexual orientation, health, and biometric information. https://ballotpedia.org/California_Proposition_24,_Consumer_ Personal_Information_Law_and_Agency_Initiative_(2020)
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In December, CAFP will say goodbye to long-time staff member Shelly Rodrigues. Over the years, Shelly has served the CAFP in several roles, including as current Deputy Executive Vice President. Shelly has had an important place in the lives and hearts of many of our physician members and every staff person. We are grateful for Shelly's service and friendship over the years. Below you will find a tribute by Carol Havens, MD that echoes the gratitude of all of us as we welcome a new relationship with Shelly.
Shelly Rodrigues, CAE, FACEHP, FAAMSE, Prepares to Retire by Carol S. Havens, MD, FA AAFP
One of the best pieces of advice I ever got from a mentor (and which I pass on to others) was to get involved in my professional society. So, in 1996, I volunteered to be on CAFP’s Committee on Continuing Medical Education (COCME); my career and life were definitely enriched. That was when I met Shelly Rodrigues. She was welcoming, engaging, thoughtful and wicked smart, and she made me feel like I had something to offer and could contribute, and challenged me to carefully consider how to improve education. That is who Shelly is … she always looks for – and finds – some kernel of talent, or interest in people, then works to nurture, support, develop and promote that whenever she can. She is a coach, a cheerleader, a trusted advisor who provides redirection when needed, as well as kudos and support. She is a force of nature. Though we in CAFP have been at the center of the tsunami that is Shelly, the effects have been felt nationally, and now internationally. She is always striving to push the envelope, to try new things, to figure out what works and what doesn’t. She has never been satisfied with the status quo because we can always be better. Everything she does is to improve things, to help us be better, to do better. She has designed and delivered leadership development for CAFP, AAFP, ACEHP, AAMSE and a whole lot of other initials. She spearheaded both the CAFP’s Family Medicine Women Leaders program and the CME Leaders, which has affected so many lives. When COVID-19 cancelled the AAFP’s Chief Residents course she was approached about doing one virtually for California, of course she said yes.
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In fact, her constant striving for excellence shows as she is always trying to make education better, more effective and that includes making faculty more effective. And on top of it all, she always makes it enjoyable! If you have been to other CME activities, you know the ones at CAFP are different and that’s because of Shelly. She would be the first to demur and pass any compliments on to others, but we know the truth. Shelly is the driving force behind our difference. I write this tearfully. I will miss her terribly, as we all will. However, I think the greatest tribute we could give her is to continue her work, to continue to strive to improve. She found the kernel in many of us; we owe it to her to find it in others, to support our amazing colleagues on the staff and in our membership and to prove her faith in us was not misplaced. Join me in wishing Shelly and Eddie only the best in the next phase of their lives. I love you, dear friend and thank you for nurturing that kernel in me.
Shelly Rodrigues, CAE, FACEHP, FAAMSE
To CAFP Members: The Second Shoe Now is the time … The first shoe dropped in September 2018, when Susan Hogeland retired after 28 years as CAFP Executive Vice President. With the support and confidence of the CAFP Officers and Board, Academy members and staff, Lisa Folberg has elegantly and successfully picked it up and taken it to new places. Now, it’s time for the second shoe to drop, or hopefully to be placed carefully on the shelf. After 28 years at the CAFP/ CAFP-F, and with both trepidation and excitement, I am dropping my shoe … and announcing my retirement from the Academy I love. It is time. It has taken me a great deal of consideration and soul searching, conversations with family and friends, and a review
of the promises I made to the leadership when Susan retired, to come to the conclusion that it is time for me to retire. My last day will be December 31, 2020, with 28 years at the CAFP behind me and hopefully a different time with you ahead. I joined the CAFP in 1992, as a young medical executive and leave now as a seasoned executive with immense experience gained. I have learned so much from California family physicians, residents and students, our leaders and incredible staff, our partners, physicians and colleagues around the country and globally, and I am so very thankful for the education and opportunities. I take with me what I have learned, but most importantly I take with me the friendships I have gained into my next adventure. And, please rest assured, you have not heard the last of me. I promise all the loose ends will be neatly tied up when I leave. I will do everything I can to ensure a smooth transition for whomever comes to fill my shoes. The next four months will be busy ones for us all, and I am confident that Lisa and the CAFP staff will chart a path forward that continues the work we have done together these past twoplus decades. I am excited to see what the future holds for CAFP. I hope I can, where appropriate, be part of it. Thank you from the bottom of my heart! I am a better person for my time here, and like Susan, I know my shoes will be elegantly and successfully filled. The CAFP and CAFP Foundation will continue to prosper as they represent the very best of family medicine. It really has been an honor and a privilege to work for you and with you.
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Adam Francis CAFP Director of Government Relations
advocacy update
Is It Monumental Change, Much Ado About Nothing, or Somewhere In Between? As of this writing, several pieces of legislation sit on Governor Gavin Newsom’s desk, awaiting his decision to sign them into law or send them to the dustbin with a veto. Aside from the serious health and fiscal consequences created by COVID-19, the pandemic also wreaked havoc on the legislative session: multiple legislators tested positive for the virus, the halls of the Capitol were closed to the public, virtual committee hearings were held, and remote voting was allowed in the State Senate. The pandemic also led legislators to change previous policy positions, leading to unexpected legislative outcomes. One of the biggest examples of this is AB 890 (Wood), which will allow nurse practitioners (NPs) to practice medicine without physician supervision. Despite an outstanding effort by CAFP’s Government Relations team and family physicians throughout the state, the legislature passed the bill in the final minutes of session. CAFP remains concerned that the bill lacks sufficient patient safety guardrails and ignores access to care concerns, and is strongly urging the Governor to veto the bill. By the time you read this, we will know whether or not he has taken that action. Some think the bill could change health care market dynamics across the state and create a two-tiered system of care. Others think very little will change. One change may be increased health care costs. As the experience of major health systems has shown, NPs prescribe and refer more than primary care physicians, driving up costs. Some fear that NP independent practice could lead to a further shortage of primary care physicians or change the nature of what services family physicians provide. Many worry that the insufficient training and oversight requirements for NPs to practice medicine will compromise the care patients receive. Throughout committee hearings and floor sessions, CAFP focused its arguments against the bill on the lack of ongoing competency training in the bill, as well as its lack of provisions to require or even create incentives to increase care in rural and underserved areas. While the legislation was amended to delay implementation until January 2023, and added guidance on oversight, minimum qualifications, and physician collaboration AB 890 still falls woefully short of meeting CAFP’s Principles on the Independent Practice of Medicine by Nurse Practitioners. Oversight While oversight of NPs will continue to be the responsibility of 16
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the Nursing Board, the bill creates a Nurse Practitioner Advisory Committee consisting of four NPs, two physicians, and one member of the public. The committee will advise and make recommendations on all matters relating to NPs, including, but not limited to, education, standards of care, and disciplinary action against an NP. Individual Requirements An NP could practice independently if they meet all of the following criteria: • Pass a national certification examination. • Complete a Transition to Practice program – A minimum of three full-time equivalent years of practice/4,600 hours of clinical experience and mentorship provided to prepare a nurse practitioner to practice independently, including, but not limited to, managing a panel of patients, working in a complex health care setting, interpersonal communication, interpersonal collaboration and team-based care, professionalism, and business management of a practice. • Have practiced as a nurse practitioner in good standing for at least three years, not inclusive of the transition to practice. • Maintain professional liability insurance. • Verbally inform all new patients that the NP is not a physician. • Post a notice in a conspicuous location accessible to public that the NP is regulated by the Board of Registered Nursing, including the board’s telephone number and website. Online educational programs that do not include mandatory clinical hours will not meet these requirements. Collaboration Requirements An NP must establish a plan for referral of complex medical cases and emergencies to a physician or other appropriate health professional. Physician consultation specifically must be obtained when: • Emergent conditions require prompt medical intervention after initial stabilizing care has been started. • Acute decompensation of patient situation exists. • A problem has not resolved as anticipated. • A history, physical, or lab findings are inconsistent with the clinical perspective. • If the patient requests it.
Up Next: Regulations Should Governor Newsom sign the bill, the next step in the process will be for the Nursing Board to create regulations for independent NPs. There will need to be considerable work done around defining what is included in the required “Transition to Practice” program. CAFP has already begun the process of gathering with interested stakeholders to direct our regulatory advocacy to address the issues not solved in AB 890, particularly requiring ongoing competency training similar to that which physicians must undergo to practice medicine independently. CAFP will not let AB 890 be the sole takeaway of the Legislative Session. In particular, CAFPsupported SB 732 was just signed into law and will create an historic ban on flavored tobacco. Seven other CAFP-supported bills sit on the Governor’s desk that we hope will soon become law: • AB 732 (Bonta) – requires jails and prisons to offer inmates who are possibly pregnant or capable of becoming pregnant a pregnancy test, or medical treatment and services for inmates who are pregnant. • AB 1196 (Gipson) – prohibits law enforcement agencies from authorizing carotid restraint holds and choke holds. • AB 2054 (Kamlager) – establishes the Community Response Initiative to Strengthen Emergency Systems (C.R.I.S.E.S.) Act pilot grant program to test methods to ensure those who are likely to face disproportionate police contact (young people of color, people with disabilities, gender nonconforming, formerly incarcerated, immigrants, or the unhoused) have ready access to quality emergency services from professionals trained to deescalate crises, reduce reactive violence, and send vital services to people who have a difficulty accessing critically needed emergency services. • AB 2164 (Rivas, Robert) – allows a “visit” for the purposes of Medi-Cal payment to a Federally Qualified Health Center (FQHC) or Rural Health Center (RHC) to include a visit using telehealth
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through synchronous interaction (faceto-face over video) or asynchronous store-and-forward (the sending of images such as x-rays to a health care provider). It also allows FQHCs and RHCs to establish a patient through synchronous interaction or asynchronous store-and-forward. The bill will sunset 180 days after the state of emergency for the COVID-19 pandemic has been terminated. AB 2360 (Maienschein) – requires health plans, by July 1, 2021, to provide access to a telehealth consultation program for children, pregnant individuals, and individuals up to one year postpartum. It also requires health plans to inform beneficiaries about the telehealth program at least twice a year in writing. SB 406 (Pan) – among other broad provisions, delinks two Affordable Care Act (ACA) requirements on health plans from federal law to ensure they continue in California even if the ACA is eliminated. The first requires preventive services to be offered without any cost sharing. The second prohibits health plans from putting annual or lifetime dollar limits on most benefits. SB 852 (Pan) – requires the California Health and Human Services Agency to enter into partnerships to increase competition, lower prices, and address shortages in the market for generic prescription drugs; reduce the cost of prescription drugs for public and private purchasers, taxpayers, and consumers; and to increase patient access to affordable drugs.
As always, CAFP is only as strong as our members’ involvement. Whether the decisions by the Legislature and Governor anger or inspire you, we cannot make change without your participation and strong grassroots action. Please consider contributing to our political action committee, FP-PAC (www.familydocs.org/ advocacy/fppac), and signing up to be a Legislative Key Contact (www.familydocs. org/advocacy/get-involved). California Family Physician Fall 2020
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cafp foundation
Pamela Mann, MPH
Building Family Physician Leaders and a Strong Primary Care Workforce The California Academy of Family Physicians Foundation (CAFP-F) is an educational 501(c)(3) dedicated to advancing the specialty of family medicine in California. Serving as the philanthropic arm of the California Academy of Family Physicians (CAFP), the Foundation supports academic projects, scholarly activities, and leadership development for medical students and family medicine residents throughout the state. In addition to programs and services, CAFP-F strives to meet the special interests of students and residents, particularly through the work of the CAFP Student and Resident Council (the council). CAFP represents more than 3,000 student and resident members combined and serves as a resource hub for 14 medical schools and more than 65 family medicine residency programs. To overcome California's geographical size, the council exists to facilitate communication across the state, increase teamwork among all programs, and establish
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lasting relationships between family medicine leaders. A key component of the council is to strategize and implement activities important to medical students and family medicine residents. In 2020, the council maximized their potential by establishing working groups focused on membership engagement, procedure workshops, advocacy, networking and wellness. Through these efforts, they shared feedback on proposed resolutions with the CAFP Board of Directors, designed and executed a successful procedures workshop, and engaged members in new, creative ways. California’s medical students and family medicine residents play a prominent role in building a strong primary care workforce in our state. Beyond the classroom and clinic walls, they promote health and well-being within their communities, champion justice for their patients, and fight for equitable health care services/systems. This group of dedicated learners and leaders has a very important seat at the table.
The council is the official studentresident voice of the Academy. By bringing students and residents together, the council promotes the exchange of ideas, builds leadership skills, pursues transformational advocacy and enriches California’s primary care workforce with a strong family medicine pipeline. Through meetings, workshops and social events, the councils not only advance family medicine interests, but also have fun celebrating the joy of our specialty. This premier forum is led by student and resident co-chairs, who serve as members of the CAFP Board of Directors and CAFP Foundation Board of Trustees. Currently, 30 students and residents from every region of the state make up the council. They meet monthly to help shape and drive CAFP’s initiatives.
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José Alberto Arévalo, MD, FAAFP; Sergio Aguilar-Gaxiola, MD, PhD, MS; and Bobby Pena
Focus on Health Equity
COVID-19 is Affecting California’s Latinx Community at an Alarming Rate As COVID-19 continues transforming our society as an everyday reality, it is also exposing glaring and pervasive social and structural inequities in our broken health care system and disproportionately affecting underserved Latinx communities in California. The Latinx population, which accounts for 39 percent of California’s total population, is the most affected by COVID-19. With a significant number of Latinx people employed in jobs that are essential and often not amenable to wearing appropriate personal protective equipment and maintaining adequate physical distancing, their numbers of cases and deaths continue to rise. Being essential workers and having to work regardless of high risk of infection, lack of health insurance, exposure to discrimination and exclusion, and fear and mistrust of government, they are risking their own health and lives in order to meet our state’s and nation’s needs. According to the California Department of Public Health , as of August 28, 2020, more than 275,000 Latinx cases of COVID-19 have been identified, more than three-and-a-half times as many cases as Whites. To-date, Latinx represent 59.9 percent of COVID-19 cases and 48.4 percent of all deaths. Among children ages 0-17, only 8.8 percent of COVID-19 cases are White, whereas 72.3 percent of children and youth cases are Latinx. Almost four out of five deaths in the 35-49 age group are Latinx. Latinx older adults between ages 65-79 have been reported to suffer twice the death rate (67.3 percent) compared to their California representation (32.2 percent). With regards to hospitalizations due to the coronavirus, Latinx people are hospitalized at four times the rate of White Americans and Latinx children at eight times the rates of Whites. This disturbing impact and the related fear have led to an alarming reality, a recent Centers for Disease Control and Prevention survey showed that higher percentages of Latino and Black respondents had seriously considered suicide in the past 30 days. Three main factors help explain the steep surge in disproportionate cases of COVID-19 and death rates among the Latinx population in California: 1. The Latinx community including immigrants are overrepresented as essential workers in agricultural, health, infrastructure, manufacturing, service, food, and safety sectors increasing their vulnerability to infection 22
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due to close working quarters and inadequate personal protection equipment; The Latinx community are among the most socially and economically disadvantaged people living in overcrowded, mutigenerational households and are unable to safely isolate to reduce transmission of the virus; and The Latinx community lacks adequate health insurance coverage as well as access to public assistance (e.g., Medi-Cal and Medicare) benefits, which increases their vulnerability to COVID-19 and severe co-morbid disabling conditions such as diabetes, heart disease, hypertension, and obesity increasing their vulnerability to COVID-19.
According to data from the Centers for Disease Control and Prevention, there is a significant disparity in the number of COVID-19 cases in general, and deaths that underscores structural inequities closely associated with the pandemic. Fear, stigma, or simply not getting accurate information about COVID-19 and testing can be major barriers for Latinx communities to receive access to appropriate safety and avoidance precautions, testing and necessary treatment. Communicating COVID-19 information in Spanish, and in some rural regions indigenous languages (e.g., mixteco, zapoteco, triqui), and using appropriate trusted platforms to disseminate essential information like Radio Bilingue, Mexican Consulates and other key community partners throughout California is critical to dispel fears and provide accurate and easy to understand information. Sadly, an enduring history of mistrust of government and healthcare institutions built on decades of neglect and abuse, most recently the federal anti-immigrant, anti-Latino language, and separating families at the U.S. border, has exacerbated a climate of fear and silence around the Coronavirus. Recommendations: • Outreach and engagement. Work with promotoras, Latinx physicians and healthcare professionals and other trusted, engaged community partners who are frontline public health workers and are trusted members of the community or have an unusually close understanding of the community they serve, with shared lived experiences. Enlist people who speak the same language and understand cultural issues to disseminate reliable information about
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COVID-19 and engage the Latinx community in educational forums in safe community spaces that allow for physical distancing. Mobilize existing mobile teams. To reach the most vulnerable Latinx communities (e.g., immigrants/ undocumented, indigenous, and farm workers) use mobile teams at the point of care where these underserved communities live, access transportation and work. Recognize that Latinx communities are resilient. Build on their resilience as a protective factor to deal with COVID-19. Appreciate Latinx communities’ capacity to persevere in the face of adversity as they remain committed to their roles in the labor force, and continue to provide significant contributions to the overall well-being of California. Harness this resilience and provide them with the information to empower them to share with and inform their close-knit community. Ensure an appropriate workforce. Staff testing locations, health centers and contract tracing programs with culturally and linguistically appropriate personnel including promotoras.
The mission of the Latinx Physicians of California is to support Latinx physicians and mentees through education, advocacy, and health policy for health equity, optimal health and quality of life for all of Californians. José Alberto Arévalo, MD, FAAFP is the Chair of the Latinx Physicians of California; Sergio Aguilar-Gaxiola, MD, PhD, MS is Vice Chair; and Bobby Pena is Chief Executive Officer. More information is available at www. latinxphysiciansofca.org. https://www.cdph.ca.gov/Programs/CID/ DCDC/Pages/COVID-19/Race-Ethnicity. aspx https://www.cdc.gov/mmwr/volumes/69/ wr/mm6932a1.htm?s_cid=mm6932a1_w California Family Physician Fall 2020
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Focus on Health Equity
Jay W. Lee, MD, MPH, FAAFP
Family Medicine Revolution: The Origin Story and How to Become the Heroes Our People Need When faced with the seemingly insurmountable work of being a family physician, I often hear the voice of Master Yoda quip: “Do or do not; there is no try.” I mean, it’s only the future of the health care system in our hands, right? No big deal. Not for heroes like us. As Atul Gawande wrote on the heroism of Incremental Care (the kind of care you and I deliver every day), “we devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.” Let me be clear: family physicians are heroes and every hero has an origin story. What is the anatomy of a hero’s origin story? Give us a reason to care. Don’t make your hero a chosen one; give her a chance to prove herself. It may be useful to tie your character’s origin story to the villain’s plot. Give us a chance for a happy ending. I believe these are all applicable to family physicians, don’t you? The happy
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ending for the communities we serve is a family physician for every human being. The villain in our case is the broken health care system. None of us are chosen ones but each of us should have a chip on our shoulder after being told repeatedly: “You’re too smart for family medicine.” (to which, I quip, “Use your whole brain; become a family physician”). And the reason for caring? Each of us could share a story about a patient whose life we’ve impacted; I’ve got dozens of patient stories I could share but I have only been granted 500 words or so in this space. In short, our origin story is embedded in our personal statements, and we should all strive to become the physicians we wrote about in them. Our specialty of family medicine has its origin story as well. Family medicine was born as a countercultural response to the corporatization and over-specialization of health care taking hold
in the late 1960’s. As Dr. G. Gayle Stephens, a founding father of family medicine, noted during his plenary address during the 2012 AAFP National Conference of Special Constituencies (now National Conference of Constituency Leaders), a family physician’s fundamental role is: (a) to be there; (b) to “give a damn” about your patients; and (c) to know the difference between your job and your work. He continues that our job may involve writing notes and completing paperwork but our work is getting what our patients need from an increasingly complex health care delivery system. What this kind of care requires of us is to be fully present in the fight to advocate for our patients and to work outside the confines of a 15-minute visit. It requires courage and a willingness to break the mold. It seems so simple yet seems so elusive, doesn’t it? In 2011, the social media hashtag #FMRevolution for Family Medicine Revolution was born. It was featured in an article in Forbes and described as a “primary care spring” representing the voice of a “large group of primary care physicians.” In short, it represents family physicians doing what they do best: building relationships. We put the ‘social’ in social media. CAFP was featured in an article for AAFP news: “It makes the world a smaller place. It makes you feel like you have buddies who are cheering for you and are proud of what we do and what we bring to the health care system. And it raises awareness among the general public.” Since April 2011, there have been well over 100,000 tweets creating more than 10 million impressions for the Family Medicine Revolution hashtag and indications are that we are growing. So where do we go from here? We continue building our (increasingly global) community with in-real-life connections. We own and amplify our messaging; don’t allow others to appropriate our voice. We better understand legislative issues to perform the legislative judo to inspire and execute policy change. We transform broken health systems to better serve our patients. We become the physician leaders our patients and communities need us to be. And by so doing, we change the world by inventing the future. I think this would be nothing short of heroic. Let’s get to work. California Family Physician Fall 2020
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Focus on Health Equity
Wendel Brunner, PhD, MD, MPH
Influencing Health Via the Community Environment As family physicians, we know our patients’ health depends upon so much more than health care, medicine, or even the behaviors they adopt. The COVID pandemic has illuminated the extensive health inequities associated with ethnicity, education and income that exists across our communities. In California, the mortality rate from COVID in Hispanics is 1.5 times the rate in Whites; among African Americans, the rate is two times as great. The United States spends 18 percent of its gross domestic product on health care, much more than any other country, yet basic health outcomes and chronic disease rates are worse than for most other advanced nations. US life expectancy is less than in Cuba or Costa Rica; our infant mortality is greater than in Bosnia or Belarus. For African Americans, the situation is even worse. Systemic racism, lack of employment or educational opportunity and the long legacy of housing discrimination even in California have left African Americans concentrated in neighborhoods of poverty, poor schools, aggressive policing, inadequate housing, junk food outlets and liquor stores, and with poor access to fresh food and quality parks. The life expectancy for African Americans is California is nearly five years less than for Whites. No wonder millions of Americans felt compelled this Spring to brave the streets in a pandemic to proclaim something that really shouldn’t need saying, but apparently does: Black Lives Matter. And for the first time in history, driven by drugs and alcohol, the life expectancy of working-class Whites actually declined since 2014, and by enough to drive a decline in life expectancy for white males overall. Family physicians, even whole health care systems, can’t by themselves change the environmental factors that hinder community and individual health. We need to work as a community to create the social, political and physical environments that can enable and encourage healthy behaviors and promote vibrant, equitable neighborhoods. A Health in All Policies approach emphasizes that everything community and governmental agencies do influences health, and the impact on community health should be one of the factors all agencies consider when developing plans or implementing policies. City Planning Departments can 26
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advance health by developing bicycle lanes and safe sidewalks to promote physical activity, encouraging compact, transitoriented development to reduce automobile miles, and zoning for grocery stores in low-income communities. Transit Agencies can facilitate access to health care and healthy food for lowincome communities. Parks and Recreation promote physical activity and can also eliminate sugar sweetened beverages from the vending machines in recreation centers. Schools can model healthy eating through healthy school cafeteria menus and promote vital school retention through discipline policies that minimize suspension. Family physicians see the ravages of poor policies and unhealthy environments, not just through statistics, but in the individual patients sitting in their offices. Doctors can be powerful advocates for health. City councils considering banning flavored vaping products targeted at children, planning commissions looking to where to expand green spaces, parks and healthy food outlets, or day care providers grappling with sugary beverage policies can all be profoundly influenced by local doctors testifying to the impact of these policies on the health of their patients. Physicians understand their responsibility to advocate for their patients’ health. That responsibility goes beyond ensuring they get the proper medical treatment and encouraging healthy behaviors. The community environment has an enormous impact on individual health. Our responsibility to the individual’s health includes a responsibility to promote a healthy community environment. Dr. Brunner received his MD from UCSF. He did an internship in family medicine and a residency in preventive medicine. He received a PhD in biophysics and an MPH in epidemiology from UC Berkeley. From 1983 to 2015 he was Director of Public Health for Contra Costa Health Services (CCHS) and now works with the California Chronic Disease Prevention Leadership Project and with CCHS on COVID response. Dr. Brunner helped the California Senate craft the bill to implement Health in All Policies for the state. He is also a part of the California Physicians Alliance, whose mission is to achieve guaranteed, high-quality, comprehensive and equally accessible care for all.
Focus on Health Equity
Shannon Connolly, MD, FAAFP
We Need Better Representation in Leadership to Advance Gender Equity My summer college internship mentor was African American, a single mom, a physician, and Vice President of Clinical Services for a large hospital system with an internationally recognized name. The chairs of more than 20 clinical departments reported to her. At the end of my internship, I asked her if she had any final career advice for me. Her response, while crushing to hear, was memorable. She said, “As a woman and a minority, don’t be surprised when you have to work twice as hard to get half as far. Expect it.” Staring at the nameplate on her desk, trying to process those words, I almost missed the barely noticeable teeny tiny letters under her name and title that warned, “Does not tolerate bullsh*t.” My mentor knew all too well about overcoming the dual challenges of structural racism and sexism. Two decades later, while our country is amid a national reckoning on race and gender, the house of medicine remains frustratingly stuck. A 2018 Harvard Business Review article noted that even with more womxn than men in medical school, womxn account for only 18 percent of hospital CEOs, 16 percent of dean and department chair positions, and 10 percent of senior authorships. People of color, people with disabilities, and LGBT physicians are even less represented. A friend who is Chief of the Division of Surgery for a large health system recounted the story of a female neurosurgery resident—from a different hospital on campus—who walked into her office and introduced herself. After a few minutes of chatting, the resident thanked my friend and turned to leave. My friend stopped her to ask if the resident needed something in particular. The resident hesitated before saying that after months of facing harassment, discrimination, and feeling bullied into stopping breastfeeding by her male co-residents, she just wanted to know that there was another black female surgeon in her hospital system who had made it through training. Even in family medicine, where half of residents are womxn, gender inequality persists. A 2017 survey conducted by Medical Economics found that womxn family physicians make only 83 cents on the dollar compared to men. I was recently asked to do some education consulting in collaboration with a male colleague. Until I demanded parity, they initially offered to pay my male colleague 20 percent more despite our similar backgrounds and credentials. 28
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It’s abundantly evident that we have a problem, but how do we shift the needle? We need a multi-pronged approach that looks critically at pipeline, advancement, and retention of womxn and other underrepresented groups in medicine, using data that are transparent and readily available, such as the diversity reports or dashboards many organizations now publish. Pipeline: This past year, the CAFP invested substantially in pipeline through the 18-month Ready to Lead Program: Physician Leadership for Women Family Physicians. Programs such as these highlight the importance of early identification of promising talent and the effect of formal mentorship. The Ready to Lead graduates have already demonstrated their ability to transform health care and health policy through their remarkable projects. Advancement: Look at your C-suite, your board of directors, your departmental leadership. Are they representative of the workforce and the community? Is it time to advance someone who offers a different perspective? Is it time for you to step aside to allow for someone else’s voice to be represented? Retention: Advancing women into leadership positions is not enough. We must retain them. This is achieved through creating working environments where individuals can thrive and offer their best. Studies on burnout in medicine cite that just being female is a risk factor. Let me tell you about my friend Amy (name changed), the only female physician in her private practice. Four years into her tenure, she had a baby. She worked normal hours right up until labor and drove herself to the hospital. She had a difficult labor ending in a crash c-section, and her baby required time in the NICU. I went to see her the next day. I was floored to find this new mother had her laptop out, furiously click-clacking away to complete only week-old charts after receiving a nastygram from an administrator who threatened to hold her paycheck until all the notes were signed. We can do better than this. As family physicians, we know the importance of fostering families, and we must provide our colleagues the same consideration that we dutifully provide to our patients. Furthermore, we know that health equity for our communities is about ensuring the conditions where all people can have optimal health. We will never be able to fully realize health equity until we address the lack of leadership diversity in medicine. Let’s critically evaluate what we can each do to advance diversity within our organizations and beyond.
ceo message
Lisa Folberg, MPP
Finding Hope in the Time of COVID COVID-19 has wreaked havoc on every facet of our society. Unemployment has skyrocketed, businesses have shuttered, children are going to school in front of computers and the health care system has been tested. More than six months into the pandemic and still health care workers don’t have the personal protective equipment they need, telehealth has been widely adopted and safety protocols have changed. COVID-19 has shone a light on inequities in access and outcomes in health care, and has turned basic public health measures, like mask wearing, into political statements. Many lawmakers, health care providers, and policy experts have been focused on the immediate needs of reducing the spread of COVID-19 and providing care to those who are affected. Even after COVID-19 has been better contained, the pandemic will leave a scar on the psyche of America and will likely change the health care system long-term. COVID-19 has highlighted the fragility of our primary care system and the problems with fee-for-service payment. Shelter-in-place orders and patient fear have resulted in many Californians forgoing essential care for chronic disease management, preventive services and mental health care. In a July 2020 CAFP web-based survey of family physicians, 87 percent of respondents reported that COVID-19 has negatively affected their practices’ financial stability, with 77 percent reporting a moderate to extreme negative effect. While patients have started returning to physician practices for primary and preventive care, it is not clear what job losses, and resulting loss of insurance could mean for practices. What is clear is that primary care practices, which were often teetering on fiscal solvency even before the pandemic, are vulnerable. A June 2020 study in the journal Health Affairs estimates that primary care practices across the country will lose $15 billion in revenue due to COVID-19. In the absence of assistance, many primary care physicians are considering retiring earlier than planned, closing their practices, reorienting their practices away from primary care, or selling their practices. Your CAFP has been advocating for immediate help for
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these financially vulnerable primary care practices. The short (and crowded) legislative session stymied our efforts to pass legislation to provide immediate temporary health plan prospective payment for primary care practices. The legislation would have also kick-started longer-term payment reform. We are now working with business groups and the California Medical Association to urge Governor Newsom to issue an Executive Order to require the Department of Managed Health Care (DMHC) to identify distressed primary care physician practices and collect information on the financial support that health plans have been voluntarily providing to aid distressed practices. This information will help shed light on how Health Plans have (or have not) used their record-breaking pandemicera profits to help fortify the primary care infrastructure on which their enrollees depend. Even if assistance and practice changes allow primary care practices to remain financially viable, without significant policy and payment system changes, independent practice may seem less appealing. While market consolidation is not new, COVID-19 has the potential to greatly accelerate the trend. As experience has shown, bigger is not always better, and market consolidation in all its forms can lead to higher prices without any improvements in quality. It is easy to be overwhelmed with the hardship and tragedy of this pandemic, but I am confident we will see some positive longer-term changes. Recently learning that the Centers for Disease Control and Prevention issued a moratorium on housing evictions as a disease control and prevention measure makes me hopeful that the importance of social determinants like housing stability will become part of our common health care lexicon. Seeing attention to the health care infrastructure gives me hope that the primary care foundation of this wobbling house of health care will be fortified. Knowing that the slow crawl of health system reform has in some areas, like telehealth, been forced to accelerate, helps me see a path to larger reform. Your CAFP and AAFP will not rest on hope alone, we are inspired by the strength and resilience of our members. We will use the grief and frustration our members have felt to strengthen our fight for significant and lasting reform.
CALIFORNIA ACADEMY OF FAMILY PHYSICIANS 1520 PACIFIC AVE SAN FRANCISCO, CA 94109 -2627
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