Dr. John D. Stobo is the University of California’s senior vice president for health sciences and services. This op-ed ran originally on Aug. 26 in California Healthline’s Think Tank.

Health reform is a historic opportunity. It will increase the number of insured people and provide a platform to transform the delivery of health care. Nowhere will this be noticed more than in California, where the focus should be on ensuring access to quality medical care.

The University of California is addressing the need for more family physicians — particularly doctors who treat Medi-Cal patients — on three fronts: expanding medical education, making innovations in health care delivery and advancing its medical safety net role.

Expanding medical education

UC Health trains three of every five medical students in California. UC has increased medical student enrollment for the first time in three decades, thanks to its Program in Medical Education — known as PRIME —  aimed at training physician-leaders committed to helping California’s underserved communities. PRIME enrollment is expected to grow from nearly 200 students last year to 300 students next year.

UC is slated to open a sixth medical school in 2012 at UC Riverside. UC Merced, which starts a PRIME program next year, is developing plans that could lead to a medical school. Also, UC Davis’ nursing school welcomes its inaugural class this fall. These are chances to train more health professionals where they are needed most.

Health care innovations

Increasing medical school enrollment is only part of the solution. To close the gap, medical school graduates would need to increase by more than two-thirds by 2015.

UC is using technology and improving care coordination to deliver health services more effectively and efficiently. The just-launched California Telehealth Network is a UC-led partnership that uses technology to expand access to care to all corners of the state. UCLA’s Pediatric Medical Home Program serves more than 90 children with special health care needs, a team approach to high-quality, cost-effective care. UC San Diego’s IMPACT-ED program, which will expand under a $15 million federal grant, uses an Internet-based referral system that allows emergency departments to schedule follow-up clinic appointments, thus improving care and reducing return ED visits. Health reform will encourage more such innovations that improve health care delivery.

Medical safety net role

Finally, the safety net must be stabilized. This is a priority for UC, where nearly one-fourth of patients are covered by Medi-Cal — a figure expected to increase with health reform.

Renewing the Medi-Cal waiver, set to expire at the end of August, is crucial to stabilizing Medi-Cal funding for safety net hospitals such as UC medical centers.

Read more

By Santiago Munoz

University of California Health leaders held a health care reform briefing Wednesday (June 30), the second discussion in an ongoing assessment of the new federal law.

The latest briefing focused on the transition period between now and 2014, when key provisions will take effect such as the opening of commercial health insurance exchanges – marketplaces that will offer affordable health insurance options to individuals and small businesses. The briefing covered important issues that will affect UC medical center funding, including decisions on the federal share of Medicaid costs, a pending hospital provider fee and renewal of California’s Medicaid hospital financing waiver.

To listen to a recording of the June 30 briefing, visit https://cc.readytalk.com/play?id=9dxorb (registration required). To download a PowerPoint presentation that accompanied the briefing, visit www.universityofcalifornia.edu/news/documents/uc_health_care_reform_briefing2_6.30.10.pptx.

This briefing follows up on one in April that gave an overview of the health reform law’s major components and the potential impacts in California and nationally. To listen to a recording of that briefing, visit https://cc.readytalk.com/play?id=fjdwkg. To download an accompanying PowerPoint presentation, visit www.universityofcalifornia.edu/news/documents/uc_health_care_reform_briefing1_4.6.10.pptx.

Please share any comments with us if you have observations or follow-up questions.

Santiago Munoz
Associate Vice President
UC Health Sciences and Services

By John D. Stobo

When President Obama signed health reform into law last month, it was the most significant moment in health care since Medicare and Medicaid were established in 1965. The law will add health insurance coverage for 32 million more Americans by 2019. We’re proud to say that University of California Health played an important role in shaping the final health reform bill. Here are three examples.

Geographic variations
UC’s five academic medical centers are a major part of California’s safety net. We provide complex care to a diverse population that includes many low-income patients. But a proposal from some members of Congress to equalize “geographic variations” would have potentially reduced Medicare reimbursements to California hospitals by approximately $3 billion over 10 years and redistributed those funds to purportedly “high-value” providers located in more rural areas of the country such as Minnesota. Had the proponents of the provision succeeded, UC’s medical centers would have lost $175 million over 10 years.

Throughout the health care debate, UC helped educate legislators on the importance of socioeconomic population differences. Health care costs are significantly higher in areas of poverty, where patients have less access to care and tend to be sicker when they arrive at hospitals, requiring more extensive, and thus more expensive, care. Thanks to the work of people such as UCLA Chief Medical Officer Tom Rosenthal, the health reform bill did not revise Medicare payments based on geographic variations. However, the issue has not gone away. The bill calls for two studies and a national summit on geographic variations, which we will follow closely.

Medical education training
UC Health runs the nation’s largest health sciences training program, with more than 14,000 students and 16 health professional schools. We train 60 percent of medical students in California, a role that will become more important as health insurance coverage expands, increasing the need for medical professionals. We fought strongly to maintain Medicare’s graduate medical education payments to teaching hospitals for physician training. There will be no reduction in GME payments. This is quite remarkable considering all the cuts to providers in the health reform bill.

We were not able to expand the number of residency slots subsidized by Medicare – the residency cap – but we did help insert critical provisions related to physician training. One is adding reimbursement for resident time spent in non-hospital settings, which will help train doctors to treat patients with chronic diseases such as diabetes. Another adds rules for counting resident time for didactic/scholarly activities such as seminars.

DSH payments
UC medical centers provide care to a large number of low-income individuals. Disproportionate share hospital (DSH) payments serve to compensate hospitals for this type of care, which is more costly, and to help provide low-income individuals access to treatment. In order to expand health insurance coverage to another 32 million people, the health reform law reduces DSH payments to California hospitals by $4.8 billion over 10 years. Nationally, DSH payments will be cut by $36.1 billion over 10 years. There were proposals to reduce DSH payments even further; however, UC Health was instrumental in preventing these reductions from occurring. Due to the efforts of UC Health, our medical centers saved $110 million over 10 years, therefore allowing UC Health to continue providing quality care to low-income individuals.

The health reform law is historic. While not perfect, it contains key provisions that expand access to care, preserve the safety net and support training of health professionals. UC Health took an active role in fine-tuning the bill to meet those needs. As the law is being implemented, we will continue to be very involved in efforts to strengthen our health care delivery system and our nation’s health.

John D. Stobo, M.D.
Senior Vice President
UC Health Sciences and Services

By Santiago Munoz

The new health reform law is a historic opportunity to improve the nation’s health and its health care delivery system. University of California Health leaders held a briefing earlier this month as part of an ongoing and thorough assessment of the health reform law.

The new law will expand health insurance coverage to another 32 million Americans by 2019. We are excited at the prospect of covering more people. We view the new law as a chance to advance UC Health’s mission of patient care, education and research, and want to collaborate to make that happen.

After teaming to help shape the health reform bill, UC Health Sciences and Services continues to work closely with other components of UC Health and UC Federal Government Relations to assess the law’s impacts. The new law will expand Medicaid coverage, make major changes to Medicare and create commercial health insurance exchanges – marketplaces that will offer affordable health insurance options to individuals and small businesses.

This briefing was an initial effort to share information about the new law with our stakeholders. A financial assessment is under way, with more updates to come. Please share any comments with us if you have observations or follow-up questions.

In the meantime, to listen to a recording of the UC briefing on the health reform law, visit https://cc.readytalk.com/play?id=fjdwkg (registration required). To download a PowerPoint presentation that accompanied the briefing, visit www.universityofcalifornia.edu/news/documents/uc_health_care_reform_briefing1_4.6.10.pptx.

Santiago Munoz
Associate Vice President
UC Health Sciences and Services

Dr. John Stobo, University of California senior vice president for health sciences and services, sent letters today (March 19) to President Barack Obama and House Speaker Nancy Pelosi writing in support of HR 3590, the Patient Protection and Affordable Care Act:

On behalf of the University of California (UC) Health System and its academic medical centers located at the Davis, Irvine, Los Angeles, San Diego and San Francisco campuses, our 4,800 faculty physicians, and our schools of allied and public health, I commend you for your strong leadership and tireless efforts to reform our nation’s healthcare system and achieve our common goal of expanding healthcare coverage to millions of uninsured Americans.

While we have not agreed on every provision included in the healthcare reform bills that have been approved by Congress, the University believes the time has come for Congress to pass meaningful healthcare reform legislation that moves our nation closer to expanding healthcare coverage to all Americans.

The University of California supports your efforts to pass HR 3590, the Patient Protection and Affordable Care Act, into law along with companion legislation that would make necessary changes to the Senate bill. In addition we stand ready to work closely with your administration and Congress to develop further solutions to critical issues regarding healthcare financing, medical education and delivery system change that will enable the University to continue to fulfill its mission of serving the citizens of California, including those who will receive new coverage under this historic legislation.

Sincerely,

John D. Stobo, M.D.
Senior Vice President, Health Sciences and Services
UC Office of the President

Download letters (PDF) to President Barack Obama, House Speaker Nancy Pelosi

More than 50 University of California Health executives, key faculty and staff met Feb. 22 in Oakland to discuss their role as academic medical centers in assessing, developing and promoting enhanced coordination of care.

UC Health leadership is following up on those discussions to explore ways to better coordinate care as a system for patients, professional students and the overall organization, said Dr. John Stobo, UC senior vice president for health sciences and services.

UC has agreed to work with Health Net to develop a special health plan for UC employees, an accountable care organization that would emphasize delivering coordinated care, Stobo said. Also, UC will consider developing a systemwide entity to advance UC’s agenda with regard to care coordination and health care quality.

“UC has enormous power to bring to this issue,” said Stobo, who convened the retreat with facilitator Terry Leach, UC Office of the President manager of health policy.

Improving care coordination is an integral component of recent health care reform proposals and current UC innovations. At the retreat, UC’s academic and clinical enterprise leadership discussed trends in health care and reviewed innovations already under way at the five UC campuses with medical centers that may prove to be a model for the entire UC system and other health care providers. These innovations include:

• The Improving Medical home and Primary care Access through the Emergency Department (IMPACT-ED) program at UC San Diego Medical Center, which works with community clinics to improve follow-up care for emergency room patients;

• The care management program at UC Irvine Medical Center, which uses service teams to improve care coordination;

• The medical home for kids model at UCLA Medical Center, whose focus is to provide accessible, family-centered coordinated care to children with special health care needs;

• The International Medical Graduate Program from UCLA, which trains Spanish-speaking foreign-trained doctors to prepare for U.S. residency spots;

• Healthy San Francisco, a comprehensive medical care program for uninsured adults in San Francisco; and

• The Transforming Education and Community Health (TEACH) program at UC Davis Medical Center for residents interested in caring for the medically underserved and becoming leaders in general internal medicine.
  

The patient-centered medical home and accountable care organizations, two types of health care delivery models, were defined and described for the group. Work force challenges also were discussed, as was the role of technology and process/change management in the health care delivery system.

A key component of the planning session was a spirited discussion regarding the culture of academic medical centers and ensuring a proactive role in health policy and payment changes.

Several participants also attended a tour of Kaiser Permanente’s Garfield Health Care Innovation Center in San Leandro and a talk by the chief medical officer of Kaiser’s Care Management Institute to learn how another health system translates evidence based medicine into clinical practice.

The planning session is one component of an ongoing effort to ensure UC Health is regularly pursuing opportunities to improve quality and safety for patients and ensuring best practices are integrated into its health system. Look for updates as these efforts develop.

Related resources:
Reinventing Health Care Delivery: Innovation and Improvement Behind the Scenes, California HealthCare Foundation
Commentary: Academic Health Centers as Accountable Care Organizations, Academic Medicine
Right Care Initiative (PDF), California Department of Managed Health Care
Patient Safety At Ten: Unmistakable Progress, Troubling Gaps, Health Affairs
Medical Homes: Collaborative Care, Proto Magazine
Is California Ripe for Global Payment, ACOs?, California Healthline
Community Care of North Carolina: Improving Care Through Community Health Networks, Annals of Family Medicine
Billing, Quality Risks Escalate as HHS’s OIG, CMS Make Hospital Readmissions a Top Enforcement Priority for 2010, Report on Medicare Compliance
Redesign of the Health Care Delivery System, Journal of the American Medical Association
Replicating High-Quality Medical Care Organizations, Journal of the American Medical Association

By Jasmine L. Kiai and John D. Stobo

Conflict of interest policies at U.S. medical schools are receiving more public scrutiny due to the introduction of the Physician Payments Sunshine Act by Sen. Charles Grassley, information made public by health industry companies and the emergence of recent conflicts of interest at medical schools. The Physician Payments Sunshine Act would require drug and device manufacturers to disclose certain information regarding payments made to physicians and physician ownership or investment interests in the manufacturers. Some health industry companies have made available online lists naming physicians who received money from them. For example, some orthopedic device manufacturers (e.g., Stryker, Smith & Nephew, Zimmer) posted online the names of physicians who served as their consultants and the large amounts of money they received for their consulting services.

Also, more medical schools are coming under fire for potential violations of conflict of interest policies. One example is the Baylor College of Medicine, which faces sanctions from the National Institutes of Health after the NIH found out that one of its physicians had recommended the use of an anti-cholesterol drug while being paid by the drug manufacturer. The Physician Payments Sunshine Act, the online lists made available by health industry companies and the Baylor example highlight the need to re-evaluate current conflict of interest policies at medical schools.

Two main types of conflicts are particularly troublesome and raise immediate concerns for medical schools and the public. First, when a physician recommends or prescribes a drug to a patient and the physician has an interest in the pharmaceutical company that develops the drug – and does not disclose the interest. Second, when a physician recommends a medical device or uses the device in treating a patient and the physician has an interest in the device manufacturer – and does not disclose the interest, specifically to the patient. Medical schools should also be aware of the fact that pharmaceutical companies and device manufacturers are using different means of influencing physicians besides paying them money; for example, sending gifts to physicians such as pharmaceutical samples, office supplies and textbooks.

In light of recent conflicts of interest, and in an effort to avoid future conflicts, medical schools should voluntarily review their conflict of interest policies regarding faculty members. It is imperative to take a proactive approach to protect medical schools from any potential liability or elimination of funding and to sustain the public trust in the medical profession. Without proper and adequate disclosure to patients, medical schools and/or appropriate agencies, it will be hard to determine whether a physician’s interest in a company affects a patient’s treatment. Also, patients should be made aware of any potential conflicts their physicians may have.

In reviewing their conflict of interest policies, medical schools should consider three main issues: 1) whether faculty members understand their school’s conflict of interest policies; 2) whether the current policies take into account real or perceived conflicts of interest, and allow faculty members to easily disclose such conflicts; and 3) whether there is follow-up to review disclosures. In other words, if a faculty member does not disclose any conflicts, how will the medical school independently confirm that is the case; and if the faculty member discloses a conflict, is it acceptable and how can it be managed? Even if medical schools make their policies more stringent, there needs to be adequate and continued oversight of the disclosure of conflicts. This is necessary to protect the public interest.

The University of California takes conflict of interest issues seriously. It is currently working on reviewing its conflict of interest policies and developing an online annual conflict of interest disclosure form for medical school faculty.

Jasmine L. Kiai, J.D.
Health Policy and Project Analyst
UC Health Sciences and Services

John D. Stobo, M.D.
Senior Vice President
UC Health Sciences and Services

Dr. John Stobo, UC senior vice president for health sciences and services, sent a conference letter Jan. 13 concerning the House-passed Affordable Health Care for America Act (HR 3962) and the Senate-passed Patient Protection and Affordable Care Act (HR 3590). The letter, addressed to House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid, outlines UC Health’s recommendations for a final bill.

Read the letter (PDF)

For more information: The health-care debate in Congress: What’s at stake for higher education, The Chronicle of Higher Education

By Jasmine L. Kiai and John D. Stobo

Gov. Arnold Schwarzenegger recently proposed in his State of the State address to limit the amount of state general funds given to the prison system (from 10 percent to 7 percent) and to direct these savings to higher education. He also proposed an amendment to the state constitution stipulating that state spending on higher education (University of California and California State University) would not go below 10 percent (it is currently 6-7 percent). This proposal is a good first step toward reinvesting in higher education. We agree with the governor’s statement that California should not be spending more money on prisons than it does on higher education.

Some have said that decreasing the budget for the California Department of Corrections and Rehabilitation must wait until the number of prisoners has been decreased. This is not entirely true. California is spending approximately $2 billion a year for prison health care and this is much higher than what is spent in other states. Savings in this portion of the prison budget could be addressed relatively quickly and applied to higher education without decreasing the prison population.

The cost of health care for each inmate per year in California is approximately $11,600, while the cost of prison healthcare in New York is $5,757; Florida, $4,720; Pennsylvania, $4,418; and Texas, $2,920. Why is it more expensive to provide health care to inmates in California than it is in other states? Are the inmates in California older or do they have more health problems than inmates in other states? The answer is no. There is no evidence that the inmates in California are older, sicker or have more costly conditions than inmates in other states. Furthermore, the Texas prison system has roughly the same number of inmates as California – approximately 170,000. Therefore, the difference in the cost of prison health care in California versus other states is explained by how health care is delivered.

It is possible for the California prison system to decrease cost and increase quality. Texas was able to spend less on health care and improve the quality of care by transforming the way health care was delivered within the prison system. For example, the prison system started implementing clinical protocols, an electronic medical records system, pharmacy management practices and telemedicine. The number of yearly telemedicine consultations in Texas is 80,000 while the number in California is approximately 16,000. Furthermore, the Texas prison system used other health care professionals (e.g., physician assistants, nurse practitioners) to treat inmates. This was a key factor in decreasing health care costs.

If California implemented a system similar to the one in Texas, the anticipated yearly savings could be approximately $1.5 billion. If the cost for prison health care in California approached that in New York, the savings could be approximately $993 million. These savings could then be invested in higher education (UC and CSU) where funds are desperately needed to continue providing high quality education to our students.

While UC’s role in prison health care remains to be determined, we feel we have a responsibility as a public trust to be an important part of the discussions of how prison health care in California can be improved. The governor’s commitment to use savings in the prison system to support higher education is another imperative supporting UC’s role in determining how health care is delivered in California state prisons.

Jasmine L. Kiai, J.D.
Health Policy and Project Analyst
UC Health Sciences and Services

John D. Stobo, M.D.
Senior Vice President
UC Health Sciences and Services

By Jasmine L. Kiai and John D. Stobo

Several organizations (e.g., the Association of American Medical Colleges) have pointed to a serious physician shortage in the United States. It has recently been estimated that there will be a shortage of 100,000-150,000 physicians by 2020-2025. According to the AAMC, 30 million people live in federally designated shortage areas and 1 out of 3 active physicians are 55 and over, and therefore likely to retire soon. The impact of this shortage could be magnified by present efforts to provide health insurance to the presently uninsured.

Many commentators believe that the solution to the physician shortage is to increase the number of medical schools and existing class sizes. Indeed, the AAMC has called for increasing the number of medical school graduates by 30 percent by the year 2015. However, even if the number of medical school graduates increases by 30 percent by the year 2015 (5,000 physicians a year), this still falls short of closing the gap. From 1960 to 2009, the number of U.S. medical schools increased from 86 to 129, resulting in an increase in the number of medical school graduates by 792 students – but this has not solved the physician shortage.

The impact of the physician shortage is a decrease in health care access manifested by longer wait times to see physicians and an increase in emergency room visits. Access to health care will not improve using the approach of solely increasing the number of physicians – in other words, we can’t get there from here. A different approach needs to be used.

An alternative approach is to create a different model for the delivery of health care – one that leverages the capabilities of existing numbers of physicians as well as other health care professionals, and uses advances in technology.

For example, the way health care is delivered can be changed by increasing the involvement of other health professionals (nurses, allied health professionals, community-based workers, health navigators, promatoras), and allowing them to play a more significant role in addressing health needs. The traditional belief is that only physicians are qualified to treat patients. This is not the case. Furthermore, physicians and other health care professionals need to be taught to work in interprofessional teams in order to provide more patient-centered care.

Another way to change how health care is being delivered is by relying more on technology (telemedicine, electronic/personal health records) to provide faster and comprehensive treatment to patients. This has the added benefit of increasing access to health care among medically underserved populations as well as potentially decreasing health care costs.

There are many examples of how UC Health is working on reducing the physician shortage and reforming the way it delivers health care to Californians. Below are a few examples:

• UC Nursing: UC Davis established a school of nursing in 2009. There are plans being developed to increase the number of graduates by 342 in UC schools of nursing by the year 2013-2014.
  
• UCLA’s Medical Home Project: This project serves over 90 children with special health care needs. Physicians, patients and care coordinators work as a team to meet the health care needs of these children.
• UCSF’s Housecalls Program: This program serves almost 100 San Francisco elderly residents who have difficulty getting to a doctor. UCSF physicians travel to the homes of the elderly patients so that they may obtain treatment earlier.
• California Telehealth Network: Managed by UC, the California Telehealth Network is a statewide initiative using telemedicine to improve health care access in rural and underserved communities.
• UC San Diego’s IMPACT-ED program (Improving Medical home and Primary care Access to the Community clinics Through the Emergency Department): This program uses an Internet-based referral system that allows emergency room departments to schedule follow-up clinic appointments for patients.

There are many more examples of how UC Health is reforming the way it delivers health care. UC Health is well positioned to transform the way health needs are met and how health care is delivered. We will keep you abreast of these as national health care reform unfolds.

Jasmine L. Kiai, J.D.
Health Policy and Project Analyst
UC Health Sciences and Services

John D. Stobo, M.D.
Senior Vice President
UC Health Sciences and Services

In a letter to House Speaker Nancy Pelosi and other members of California’s delegation to the House of Representatives, the University of California extended its support for congressional efforts to pass meaningful health care reform legislation to improve the nation’s health and health system. While a number of the financing provisions in H.R. 3962, “America’s Affordable Health Choices Act of 2009” raise a series of concerns for UC’s academic medical centers, UC is very supportive of the legislation’s underlying intent to expand coverage for the uninsured and implement insurance market and delivery system reforms that will result in a health system that works better for all Americans. UC also outlined its areas of concern with the legislation.

Read the letter (PDF)

UC is supporting AB 188, which would provide the necessary appropriation for the state Department of Health Care Services to begin its work to seek the federal approvals to implement AB 1383 (Jones/Alquist). AB 1383, signed into law by Gov. Arnold Schwarzenegger on Oct. 11, is a proposal developed by California hospitals that would assess a fee on hospitals to raise more than $2 billion annually to be used to obtain federal matching funds through December 2010. The funds would generate supplemental payments to hospitals to ensure access to care for the state’s Medi-Cal and uninsured population. In addition, the hospital fee would provide the state with $320 million annually for children’s coverage, which could be used to draw down additional federal matching funds. This generous commitment would ensure that hundreds of thousands of children have health care coverage.

AB 188 would provide the immediate funding to cover the state’s administrative and staffing expenses to seek federal approval; provide the state with authority to make the supplemental payments to hospitals; and allow the state to disburse the funds for children’s health care coverage. AB 188 is completely funded and there is no cost to the state, to taxpayers or to patients.

Read more (PDF)