Below please find a discussion of issues for our CPC Medical Staff Meeting. The meeting is this coming Wednesday, April 30, from 8:00 a.m. to 12:00 noon at CHN Headquarters, 2789 - 25th Street (corner of Potrero Ave.), 2nd floor, room 2001.

We will discuss selected topics from this Issues Document at the meeting. The budget situation is the major topic.

Potential agenda items include the following:

1) Budget Update - The Dept. of Public Health (DPH) fiscal year 2003-'04 baseline Budget was presented to the Health Commission at its Feb. 4 meeting. The Budget reflects a deteriorating City and State economy, both of which are stagnant or worse. City revenues are down with the economy, and state budget cuts are likely to negatively affect DPH revenues. DPH was asked to absorb all COLAs (cost of living adjustments to union contracts, approximately $20 million) and cut approximately $18 million from the City’s General Fund portion of the budget.

In order to accomplish these reductions in the baseline budget, DPH reduced staffing at the Mental Health Rehab Facility (MHRF, which will become an Adult Residential Facility), eliminated a variety of outreach and referral services, discontinued multiple substance abuse outpatient programs, discontinued several mental health day treatment programs, reduced SFGH interpreter services and eliminated the SFGH Patient Referral program, and reduced or eliminated a number of other services. The Office of Managed Care was eliminated and most of its functions transferred to the San Francisco Health Plan. Cuts to Primary Care included elimination of Adult Dental Services, elimination of several contracts, and elimination of several vacant positions. A proposal to expand the SFGH Urgent Care Center was the only Primary Care budget initiative proposed, and it was accepted. Of note is the fact that the medical care portion of the MHRF budget probably will remain, and there is no current plan to delete the MHRF from the duties of the CPC on-call service.

According to Director of Health Mitch Katz, “These reductions were hard for the Department to propose, painful for the members of the public, our organized labor partners, and our community partners to hear, and agonizing for the Health Commission to deliberate on.” The Health Commission approved submission of the Budget, but noted they were “opposed to these service cuts and urged the Mayor and the Board of Supervisors to consider alternatives to cutting these vital safety net services.”

In addition to the cuts in the baseline budget, the Mayor asked the City departments to present contingency budget cuts that would be implemented if they were necessary to balance the City budget (which is required by law to be balanced). The contingency plan was to total 15% of General Fund support, or $40 million for DPH.

On March 14, Director of Health Mitch Katz presented the Health Commission with a list of Contingency Cuts to the FY 2003-'04 budget. The listed cuts for DPH totaled $16 million, and Dr. Katz indicated he would have to come up with an additional $24 million in cuts in the near future. The listed cuts came mostly from Primary Care, Mental Health, and Substance Abuse. Dr. Katz described these cuts as "unprecedented decreases in services," with an "unclear ... impact ... of a dismantling of the public health system of this magnitude. Certainly our clients will suffer. Certainly our facilities will be more crowded and we will have less to offer. Similar budget reductions in our sister departments ... will magnify the misery caused by these cuts." Dr. Katz indicated that the Contingency Plan was not in keeping with DPH’s Strategic Plan, since the Plan cut community care and prevention, 2 key areas of emphasis in the Strategic Plan.

The Primary Care cut in the Contingency Plan involved consolidation of 8 CPC clinics (Castro Mission, Maxine Hall, Silver Avenue, Chinatown Public, Ocean Park, Potrero Hill, Southeast, Tom Waddell). The large amounts required by the Contingency cuts would normally have required closure of several clinics, but Dr. Katz instead proposed keeping all these clinics open but cutting half of their General Fund-supported staff. This would at least allow the clinics to be more fully staffed in the future if the economy improved. The specific proposal involved pairing the Health Centers into 4 pairs (CMHC-TWHC, MHHC-PHHC, SAFHC-SEHC, CPHC-OPHC). The reduced staff of each pair of Health Center would be combined into one team which would staff each Health Center approximately 2 1/2 days per week (i.e., each Health Center would be open only half the time). The Health Center management teams would be consolidated as well, and 1 management team would oversee 2 Health Centers in a pair.

This consolidation would result in a projected 95,000 + visits "lost" by staff reductions, translating into approximately 18,000 + patients going without care (27.5% of the total in Primary Care, given that the SFGH Primary Care Clinics, North of Market, SPY, and Balboa/Cole St./Larkin St. clinics were not cut). According to Dr. Katz, "those patients who stay in our system will wait longer for appointments. ... other available community health centers certainly will not be able to absorb all our indigent clients. ... Sadly, some clients will go without care."

This plan results in a decrease of about 129 FTE (full time equivalent) positions, and saves $8.6 million net in General Fund ($11.9 million in salary & fringe benefits & operating expenses, minus $3.3 million in lost revenues). The document submitted by Dr. Katz included a detailed breakdown of the positions cut by civil service classification, obtained by cutting approximately half of all FTEs funded by the General Fund and not cutting those FTEs funded by grants (such as the CARE-HIV grant, Health Care for the Homeless grant, and others). Since Primary Care is largely funded by the General Fund, this process resulted in a cut of just under 50% of the staff at these 8 Health Centers.

The cuts to provider positions detailed in this Contingency plan included:

2230 Physician Specialists (staff physicians) - a cut of 11.09 FTEs

2232 Sr. Physician Specialists (clinic medical directors) - a cut of 4.37 FTEs

2328 Nurse Practitioners - a cut of 3.82 FTEs

This plan was heard by the Health Commission at its March 18 meeting, accompanied by powerful testimony from clients and organizations and staff concerning the human impact of these cuts. The individual Health Commissioners mostly talked about the unacceptable nature of these cuts, with final action on the proposal deferred to the April 8 Commission meeting.

Since the Contingency Budget Plan was submitted, Dr. Katz agreed to consider an alternative plan with a similar cut in staff but with 1 team per health center, each with half the General Fund-funded staff that exists now. Primary Care leadership was asked to come up with a specific staffing plan, with the net cut of $8.6 million being a fixed target.

A modified staffing plan for the Contingency Budget cuts was submitted under very short timelines, and reflected several mandates from DPH leadership. Some of the highlights include: 1) an attempt to preserve direct service positions over administrative positions, 2) maintenance of the MD to NP ratio of about 2:1, 3) preservation of sufficient higher skilled staff to perform evaluation and triage functions, as more episodic and urgent care is anticipated if the staffing reductions occur, 4) Primary Care Administrator (Patricia Perez-Arce), Medical Director (David Ofman), and Nursing Director (Phyllis Harding) would be reduced to 0.5 FTE positions, 5) current Health Center management team members would be reduced and either assigned to more than 1 health center or assigned to a specific function for all 8 health centers; the exception would be the medical directors, who would remain at 1 per health center but would be working as clinicians 60 - 70% of the time, 6) a mandate was issued to have NPs perform all clinical duties that are billable when performed by an NP but not when performed by an RN, such as triage visits or diabetes education visits; the staffing pattern would reflect this mandate, 7) support staff to provider ratios would be similar to current ones, 8) exam room to provider ratios will improve, with decreased provider numbers, 9) public health nurses would be reduced more than 50%.

Subsequent to the March 18 Health Commission meeting, DPH proceeded as if the Contingency Budget Plan would be implemented on 7/1/03. In order to do so, layoff notices needed to go out at the end of April in order to give the required 60-day layoff notice. For non-exempt positions (non-physicians), pre-layoff notices were scheduled to go out in early April to those employees whose positions would be eliminated, along with a survey of their special qualifications. Then, after the bumping scenarios are determined, layoff notices would go out by the end of April. Because of bumping by seniority, some employees laid off might be in health centers other than the 8 health centers affected by the Contingency Budget Plan. Staff who received pre-layoff notices might not be the ones ultimately laid off, due to bumping procedures by seniority.

Any cuts to NPs would be according to seniority and special qualifications of the job, and would involve bumping, per the union MOU. Physicians are exempt employees and have no civil service bumping rights. The UAPD MOU states that: “In the event layoffs are necessary, the City will encourage voluntary reductions in hours. … In determining layoffs and reductions in hours, the Department shall consider the following factors: professional performance, medical specialty, seniority, affirmative action, and hours of work.” For physicians, a specific plan has not yet been determined to structure layoffs consistent with the requirements of the UAPD MOU.

In order to plan for these contingency cuts, the Center Directors requested seniority lists by civil service classifications from Human Resources. The seniority lists were widely misinterpreted as layoff lists, which they are not. There is no layoff list at this point for Primary Care. There is certainly no layoff list for physicians, and layoffs for all other positions are determined by Human Resources by seniority and special job requirements; such lists do not yet exist. Furthermore, the seniority lists circulated were incomplete and partial. This confusion added to understandable demoralization experienced by Primary Care staff.

On April 3, Dr. Katz informed the Health Commission that the Contingency Plan involving 50% General Fund cuts to 8 Health Centers was no longer on the table, at least at that moment. Instead, the City proposed cutting the budget deficit with $80 million from employees paying their own portion of their retirement contribution (if the relevant unions agree to this or other concessions), an increase of $45 million from the State compared to earlier more pessimistic projections, and $75 million of citywide departmental cuts. For its portion of the latter cuts, DPH proposed $6.7 million in revenue increases and $5.3 million in General Fund cuts. These included elimination of a number of vacant positions and administrative positions and cuts to Mental Health day treatment, HIV contracts, Employee Assistance Program, Health at Home, and the Primary Care Substance Abuse Services (PCSUS) counselors. These cuts are now part of the base DPH budget and are not part of a Contingency Plan.

The cuts to the PCSUS program will make it very difficult to implement DPH’s planned OBOAT (Office-Based Opiate Addiction Treatment) and Buprenorphine programs, which are prioritized programs. They will hopefully be modified.

In his April 3 message to the Health Commission, Dr. Katz noted that “one of the most critical services at risk if we are required to take further contingency cuts are our primary care centers.” Dr. Katz noted the modified staffing model for the Contingency Plan described above, but “even with this model, there will still be a significant decrease in our ability to provide primary care.”

On April 23, DPH announced an additional $5 million in cuts to its base budget, as requested by the Mayor. These cuts were in Substance Abuse and Mental Health outpatient services, case management services, day treatment services, HIV prevention, and others. Many of these cuts had previously been included in the March 14 Contingency Budget plan.

According to Dr. Katz, “the City’s FY 03-04 budget is clearly a work in progress. It is likely to change many times before the Mayor submits his budget to the Board of Supervisors on June 1, and many times thereafter while in the hand of the Board of Supervisors.” We all need to be prepared for a fluid situation, which could range all the way from no Contingency cuts to Primary Care to implementation of the full Contingency cut to Primary Care plus additional cuts, or anything in between.

In addition to the fluid budget situation, a number of other reductions to the Primary Care budget are being implemented. The Ryan White-CARE contract has been cut by the feds over the last 2-3 years, but the reductions have been absorbed without eliminating positions; DPH can no longer do that, and the defunded positions are now being eliminated. This will affect primarily Tom Waddell Health Center, Castro Mission Health Center, and Maxine Hall Health Center. Those Health Centers are still developing plans for which specific positions will be eliminated. The Primary Care budget is “overspent” in other ways, and there is pressure to cut positions to reconcile the “overspending.” In addition, there are ongoing efforts to limit expenditures on P103 (per diem nurses), as-needed MDs and NPs, and overtime. There is also a virtual hiring freeze in place.

Primary Care was instructed to implement the change in NP utilization first proposed as part of the March 14 Contingency Budget plan, whether or not the Contingency Budget is implemented. Implementation of the change in NP utilization is to include both CPC and SFGH Primary Care clinics. The goal is to have potentially billable visits (such as triage exams or diabetes education visits) performed by NPs rather than RNs; according to Patient Financial Services, such visits are currently not billable if performed by an RN but are billable if performed by an NP. A taskforce that includes NPs and RNs is being put together to develop specific recommendations.

The budget situation is both fluid and complicated.

2) Pharmacy Changes - As noted in the Issues document for our 1/28/03 meeting, the current PBM system (Pharmacy Benefits Management) system, by which uninsured patients could go to most pharmacies in the City to fill prescriptions from Primary Care clinics or SFGH, is being changed. Under the new system, the PBM system would be discontinued and patients previously covered by the PBM system (uninsured, sliding scale, MediCal share of cost) will now have to go to the 1 pharmacy contracted with their Primary Care Clinic or to the SFGH pharmacy. These pharmacies are either one of the Rite Aid Pharmacies, AG Pharmacy (near St. Lukes Hospital), and a mail-order pharmacy

A small group has been working on operational issues. Implementation has been put back from the original April 1 date to July 1. Patients will be linked to a clinic (and subsequently to the Pharmacy linked to that clinic) by the PCC (Primary Care Clinic) field in the LCR/Invision. When a patient has a PCP (Primary Care Provider) in the LCR, the PCC field is automatically populated. When not, the Primary Care clinics have been encouraged to populate the PCC field on patients whom they see regularly or exclusively. When the PCC field is unpopulated, clinic staff will be instructed to populate it with the clinic where the patient is seen, so that the patient can get prescriptions filled at the pharmacy affiliated with that clinic. When a patient is linked to 1 Primary Care Clinic in the LCR/Invision but is seen at another, the patient must go to the Pharmacy linked to his PCC, unless the clinic which is currently seeing him changes the PCC in the LCR/Invision. Note that populating the PCC field does not automatically populate the PCP field, and does not imply any individual PCP's clinical responsibility for the management of that patient's care. Also, the Rite Aid at Market and Van Ness will be open until midnight, and patients assigned to another pharmacy may go to this Rite Aid if their own assigned pharmacy is closed.

The patient flyer outlining the prescription benefit change and identifying the pharmacy contracted with each clinic will be available shortly. When available, PCPs will be asked to start giving their regular patients prescriptions for their ongoing medications. This is because the process of transferring existing prescriptions from a patient's prior PCN pharmacy to the new contracted pharmacy requires pharmacists at both pharmacies to speak to each other, by law, and could delay refill of prescriptions after July 1. If a prescription has no more refills, additional delays may occur in contacting the PCP to refill the prescription. Delays and interruption in patients' drug therapy will be less likely if the patient has a written or computer-generated prescription to take to their new pharmacy. If a patient receives prescriptions for their chronic medicines before July 1, they can either take them to the Pharmacy that will be contracted with their Primary Care clinic under the new system (all these pharmacies are part of the old PCN system), or they can hang on to the prescription and take it to their new Pharmacy after July 1.

Concerns should be directed to David Ofman, Rita Lam (Clinical Pharmacist), or Sharon Kotabe (Director of Pharmacy Services). Sharon and/or Rita will be available at our meeting to answer questions.

3) ED Transfers - The Ambulatory Care Committee recently approved ED Transfer Guidelines which state, “All patient transfers from clinics off the SFGH campus to the SFGH ED require prior authorization from the ED ‘Attending in Charge’. … If SFGH is ‘on diversion,’ such transfer requests will not be granted due to patient overcrowding. A few specific clinics, however, will always be able to transfer patients regardless of the diversion status. These exceptions include the … clinics located on the SFGH campus.”

The ED is on diversion about 30% of the time. ED staff emphasize that diversion means that the ED is not a safe place to send patients to. When the fast track closed several months ago so that more higher-acuity patients could be seen, the left-without-being-seen rate went up to 20%, while the diversion rate decreased from 32% to 28%.

Diversion applies only to ambulance transfers, but the ED is still not a safe place for non-ambulance transfers when it is on diversion. Diversion status does not apply to trauma, peds, acute Ob, psych, burns, and prisoners. The underlying problem is more patient flow than volume; ED volume has actually gone down, but admitted patients wait an inordinate amount of time in the ED before a bed becomes available.

ED clerks are instructed to transfer all calls requesting to transfer a patient to the Attending in Charge, and to look at a screen and tell the caller if the ED is on divert, and if asked, which other EDs are not. Alan Gelb, Chief of the ED, has instructed the Attendings in Charge to not accept non-ambulance transfers when the ED is on diversion, due to safety issues. However, patients who walk into the ED when the ED is on diversion are seen. We need to clarify with the SF Health Plan whether they pay non-SFGH EDs if the SFGH ED is on diversion.

Several problems with the above policy were discussed at the Primary Care Medical Directors meeting with Alan Gelb and were noted at the 1/28/03 CPC Medical Staff meeting. 1) Patients may refuse to go to non-SFGH EDs or leave such EDs without being seen due to fears of being billed and hassled. 2) Other EDs “hassle” referring providers concerning attempted referrals of uninsured patients and attempt to not accept such referrals. Some non-SFGH EDs tell referring providers that it is an EMTALA violation to send a patient from a DPH clinic to a non-SFGH ED, which is not true. 3) If SFGH ED is on divert, other EDs may also be on divert. 4) It can be very time-consuming to contact multiple EDs.

The Ambulatory Care Committee has been requested to change the ED Transfer Guidelines to reflect the reality that referral to the ED and transfer to the ED are 2 separate things. Some patients will go to the SFGH ED despite referrals elsewhere, and there are some patients for whom no alternate referral can be found; these patients need to be discussed with an ED attending, and Alan Gelb will instruct the ED attendings to accept information on such patients. The Ambulatory Care Committee has asked PCPs to document with Unusual Occurrence reports their difficulties getting uninsured patients to non-SFGH EDs or adverse clinical outcomes. The ED has agreed to come up with a list of San Francisco EDs and which ones are full service or limited, etc. A web site can tell clinicians in real time which EDs are on diversion.

a) SARS - DPH and national recommendations will be e-mailed to Primary Care Providers. DPH Disease Control staff have emphasized that routine infection control procedures which should be done anyway (putting masks on clinic patients with a cough and fever, isolating real suspects, scrupulous hand washing practices, etc.) should be the primary response. There are at present only 1 or 2 suspected cases in San Francisco despite all the travel back and forth to Asia. Confirmation is by exclusion of other infectious etiologies, given the lack of a definitive diagnostic test. Anxiety and concern over the disease is at a high level, and should be addressed with facts and an emphasis on infection control to avoid panic. There have been 200 cases of SARS in the US and no deaths. It is not a particularly easy disease to catch and requires close, prolonged contact with an infected person.

b) Proposed Change in CPC Clinics Admitting to Family Practice Inpatient Service - Family and Community Medicine has proposed reducing the number of CPC clinics whose patients are automatically admitted to the Family Practice Inpatient Service from the ED due to higher volume than they can accommodate. Chinatown, North of Market, Castro Mission, and Consortium clinic patients would primarily be admitted to the Medicine Service. Implementation has been deferred until June so that discussions with the Medicine Service over implementation issues can be addressed.

c) Diabetes Conference - A conference on "Caring for Patients with Chronic Illness in the Safety Net - Focus Diabetes" is being held on May 21. Each clinic is sending a multidisciplinary team to the conference. Many providers have already signed up; those interested should contact their clinic medical director or Pam Speich at 206-3539, e-mail - pam.speich@sfdph.org.

d) Change in Answering Service - The answering service for the CPC on-call service changed a few months ago, with a noticeable decrease in complaints. There are still unresolved issues, such as the mechanism for obtaining translation for monolingual patients, and these will hopefully be resolved soon.

e) Revenue Enhancement - Efforts previously described to enhance revenues (obtaining UPIN/PIN Medicare ID numbers for all providers, ensuring all lab and diagnostic requests have appropriate ICD9 diagnostic codes, ensuring all encounter forms are turned in and have the provider identified and ICD9 diagnostic codes, etc.) are all ongoing, and budget targets for FY 2003-'04 assume that revenues will increase with these efforts. If they do not, budget cuts will be even larger.

5) Other Issues - Meeting participants may suggest other items for discussion.