ACA Medicaid expansion forced public system to improve
Since 2011, Dr. Mitchell Katz has served as director of the Los Angeles County Department of Health Services, an integrated safety net system with 19 health centers and four hospitals.
He oversees a 19,000-person staff and a $4 billion budget. Katz previously led the San Francisco Public Health Department, where he implemented the nationally recognized Healthy San Francisco coverage program serving more than 53,000 uninsured San Franciscans through a public-private partnership. The National Center for Healthcare Leadership recognized Katz with its Gail L. Warden Leadership Excellence Award in 2012. Modern Healthcare reporter Andis Robeznieks recently spoke with Katz about making the L.A. system more patient-centered, the importance of assigning patients a regular provider, and the need to incorporate social services into healthcare. This is an edited transcript.
Modern Healthcare: How did you lead the transformation of your department from a system of last resort to one that people choose for quality care?
Dr. Mitchell Katz: The passage of the Affordable Care Act provided a fantastic opportunity to help the system transform itself. Historically, this was a system, for good and bad, where people went because they had no choice. On one hand, it’s a wonderful thing to take care of people who are refused at other offices and hospitals. On the other hand, psychologically, if you’re a healthcare provider and the only people you see are people who have no choice but to see you, it doesn’t give you strong incentive to do your very best. An often-heard complaint was that people would be told by reception staff, “Sit down. If you have to wait too long, well you don’t have any other choices anyway.”
Healthcare reform gave me an opportunity to talk to my staff about the importance of our being a system of choice, that patients would be able to choose what system to go to and they could go to other places and our department would shrink and there would be fewer jobs. And most importantly, there would be no system to take care of the remaining uninsured. So there was a very strong motivation to make sure the system survived. People have had choice now for 16 months, and our Medicaid numbers have not dropped a bit, because of the transformational changes that we made.
MH: What were the biggest challenges in keeping your patients?
Katz: Patient service, modernization and a crumbling infrastructure. When I arrived, for example, I was told that the electronic system that held all of our data was sunsetted by the vendor, meaning no further updates were to be made. And customer service was such that when people would call the clinics, they would almost definitely get a busy signal. Los Angeles Health System always had a tradition of providing really good medical care—if you could get in. It was just that the waits to get in and the infrastructure made it very hard to provide that highquality care.
MH: Describe the transformation of your outpatient clinics into patientcentered medical homes, and how that has made a difference in convenience and quality for patients.
Katz: There’s nothing more important than the relationship that a patient has with an individual doctor, nurse practitioner or physician assistant. Before I came, the system was such that a patient with an ongoing problem would see a different provider every time they came. This was an incredibly inefficient, nonpatient-centered way to deliver care, because when you’re a primary-care doctor and you’re evaluating someone, how I evaluate a patient with a headache depends quite a lot on what I know about them. When you see a new provider, they don’t have any of the advantage.
So we changed that. We said from now on, we’re impaneling people. We used our computer technology to figure out what doctor our existing patients had seen the most in the past. We assigned them to that provider, and we created a way going forward of giving people a doctor whenever they entered our system. We have now
“There’s nothing more important than the relationship that a patient has with an individual doctor, nurse practitioner or physician assistant.”
impaneled 500,000 people to a specific provider. And I think that’s what has enabled us to maintain our patients.
MH: How has health IT facilitated this process?
Katz: When you admit your patients, you can see who their primary-care doctor is. You can read their historical information so that you don’t repeat tests. And you can communicate with their primary-care provider. So while electronic systems will never replace the importance of the human relationship, they can really enhance continuity by allowing providers to see information from prior visits.
MH: Have you tried to replicate your Healthy San Francisco Program in Los Angeles?
Katz: We have replicated it. Healthy Way LA currently has over 100,000 people in it. They are the remaining uninsured, people who do not qualify for Medicaid or for the Covered California insurance exchange. We think we’re going to hit an enrollment of 146,000 in the coming months.
MH: How do you find the time to still see patients?
Katz: I love taking care of people and making them feel better. It’s very much an expression of who I am and what I like to do. I insisted that all our other administrative physicians start seeing patients.
One of the responses I got from some physicians was, “Well, I’m too busy to see patients.” And my response, which I think reverberated throughout the organization, is, “I don’t know how you could be too busy to take care of patients because I don’t see anything we do that’s more important than that.”
Beyond that, practicing medicine in the system alerts me to what is working and what is not working in our system. And it gives me a level of legitimacy, so when I ask people to do things, I’m not asking them to do anything that I myself am unwilling to do.
MH: You ride your bicycle to work. What is healthcare’s role in encouraging green, healthy communities?
Katz: My bicycling to work is a way of saying we all need to exercise more and that we should care about the quality of our air and that we should save scarce resources.
L.A. is an ideal place to bicycle. It’s quite flat, unlike San Francisco, and it’s almost always sunny. So I’m hoping that more people will bicycle.
MH: Do you have any predictions for the way healthcare reform might be affecting your system and state?
Katz: Healthcare has a long way to go. Healthcare systems are too bureaucratic and are not sufficiently focused on what people actually need. It’s too much about diagnostic testing and prescription writing, when often what people need is something different. There needs to be more attention to socialservice issues people have, whether that’s homelessness, food insecurity, lack of transportation, or having experienced terrible trauma.
Sometimes those other issues are much more prominent for patients than disease. I hope the coming era brings us closer to what people are looking for in terms of being healthier.