ACA Med­i­caid ex­pan­sion forced public sys­tem to im­prove

Modern Healthcare - - Q & A -

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.

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