CHCF Health Care Forum: Charting a Course in Uncertain Times

May 16, 2017

On May 8, CHCF's Health Care Forum and 20th Anniversary Celebration brought together leaders from health care delivery and health policy to share ideas for making meaningful, measurable improvements in the way the health care delivery system provides care to the people of California.

The day began with a discussion with health policy journalist Sarah Kliff from Vox, who described where California sits in the national health care debate. Participants then chose from six breakout sessions, each offering real-world examples of health care that is working. The program culminated with a keynote address by acclaimed novelist and professor of medicine Abraham Verghese, MD. The event ended with a celebration of our mission, and a reflection on the achievements of the past, as we look forward to working with our partners to achieve a health care system that works for all Californians.

Read on for a summary of the day's events.

The View of California from the Nation's Capital

With the drama of the House's nail-biter vote to repeal and replace the Affordable Care Act (ACA) still lingering in the air, the forum kicked off with a lively plenary session that featured Vox health reporter Sarah Kliff showcasing her encyclopedic knowledge of health policy. Kliff confessed she was surprised that the Republicans' second attempt to repeal and replace Obamacare in the House succeeded (albeit by only a handful of votes). She noted that it's hard to know what will happen next, since the Senate will be writing its own version of the bill.

Watch Sarah Kliff's plenary presentation:


San Francisco-based journalist Scott Shafer, who leads KQED's politics and government desk, moderated a conversation with Kliff and handled questions from the audience. Shafer asked Kliff why California's Republican House members ended up voting for the bill if the ACA is working well here. She called it a game of "health care hot potato," with no one wanting to be responsible for standing in the way of the GOP's long-promised vow to repeal Obamacare. Yet, Kliff noted, Republicans have been surprised to find that Medicaid has vocal advocates who want to protect beneficiaries, making it harder to execute their plans to shrink the program.

Watch our Facebook Live interview with Kliff and CHCF Senior Communications Officer Anne Sunderland:



Innovations in Access: The Future of Primary Care in California's Safety Net

Veenu Aulakh, executive director of the Center for Care Innovations and former CHCF program officer, moderated a discussion about the future of primary care with three safety-net leaders who have undertaken successful care delivery innovations: San Francisco Health Network's Chief Medical Officer Alice Chen, West County Health Centers' Medical Director Jason Cunningham, and Inland Empire Health Plan's (IEHP) Chief Medical Officer Jennifer Sayles. Cunningham talked about how by adding more staffing, his organizations enabled its nurses to do complex case management (instead of triage), fueling a transition to team-based care that's translated into higher scores on quality measures.



Chen talked about an innovation that began in Zuckerberg San Francisco General Hospital's gastroenterology department to address a mismatch in supply and demand. In 2005, the department decided to test an electronic referral system, where an expert reviewed all requests to determine what was needed: tests, dialogue with the primary care physician (PCP), or expedited care (previously, referrals came via phone, fax, email, and pages). Chen said that wait times were cut in half, and specialists, PCPs, and patients agreed that the system worked better. It's now been adopted by more than 140 systems.

Sayles talked about how IEHP teamed behavioral health specialists with medical care providers to create health homes for patients with complex care needs. She stressed IEHP's role as a health plan and how they support practice partners by providing start-up funds, user-friendly data to show impact, and technical assistance through practice coaches.

How Integrating Care Can Help End the Opioid Epidemic

With 2,000 Californians dying from opioid overdose every year, CHCF is focused on helping reverse the epidemic in California. During this session, CHCF Director of High-Value Care Dr. Kelly Pfeifer interviewed clinicians working in diverse settings — ED, community health center, hospital system — to gauge their progress in turning the tide.

Dr. Andrew Herring, an emergency physician directing pain and addiction treatment at Oakland's Highland Hospital, championed the idea of starting buprenorphine treatment in the ED for patients who have overdosed and are in withdrawal — rather than simply referring them out for treatment. The result, he said, is that patients' retention in treatment doubles, mortality drops, and it can have an anti-burnout effect on ED staff.

Dr. Yolanda Briscoe, a psychologist leading the Addiction Recovery Program at Petaluma Health Center, described how her clinic overhauled its approach to addiction treatment. In the past, patients would have to wait 10 days just for an assessment. Today, the clinic makes a "warm handoff" to a mental health provider from the primary care provider, ensuring same-day access and much greater engagement in treatment. She discussed the value of shared medical visits, where patients learn from each other and share coping strategies.

Dr. Clayton Chau, a psychiatrist and the regional executive medical director with St. Joseph/Hoag Health System's new Institute for Mental Health and Wellness, discussed the importance of an integrated system of care, where people can access different levels of treatment without getting lost in the system. He advocated for thinking of addiction as a chronic disease, so that "lapses" — mistakes and inevitable imperfections that are tolerated in a medical condition — are not equated with "relapses" where the patient is lost to treatment.

Putting Capital to Work: Health Care Investing to Spur Innovation

When it began in 2010, CHCF's Health Innovation Fund, which invests in emerging companies to bring innovations and technologies in health care to underserved Californians, was one of the first of its kind. During this breakout session, Lynn Chou from Kleiner Perkins Caufield and Byers, Chris Grant of KP Ventures, and Sanjay Shah of Dignity Health joined the foundation's Innovation Fund team to talk about the challenge of scaling innovation in health care.

In the Medicaid market, where reimbursements for providers are 60% of those for commercial insurance, Shah said, there is the "need for innovation to come in and change models to improve care delivery and efficiencies." The panel stressed the need for employing technologies regardless of politics.

The bar for innovations will be high. Said Shah: "Just creating more data doesn't help; you need to then help the consumer or provider. You need to change behavior." Chou emphasized that not all innovations are cutting-edge medical technologies, pointing out the need to address whole-person care and "find innovations in social determinants of health." Grant summed up the session: "The silver lining is that the ACA spurred innovation in health care — and that's here to stay."

Turning the Ship: How California's Health Care Leaders Are Transforming Care Delivery in Large Public Health Systems

Former CHCF board member Ian Morrison, a Scottish-born futurist who is always ready with a quip, led this panel discussion with Dr. Susan Ehrlich, CEO of the Zuckerberg San Francisco General Hospital and Trauma Center, and USCF Fresno/Valley Medical Foundation Chief of Medicine Michael Peterson. Morrison asked Ehrlich and Peterson about what they're working on in this environment of great change.



Ehrlich reminded the audience of Zuckerberg San Francisco General Hospital's mission: "Our focus on the most vulnerable in our community leads us to a payer mix that is very vulnerable to the politics of today. This uncertainty makes it even more critical that we are focused on value — high-quality care with an exceptional patient experience at the lowest cost possible." Ehrlich shared an example of how ZSFG is putting this into practice. "This week, we have a values stream mapping project going on in the perioperative area. The workshop leader is one of our hospitalists. We're getting our physicians and other providers involved in fixing problems."

Peterson's organization faces a different challenge: Their five-county service area is large, almost 50% of the population is on Medi-Cal, and there is a shortage of specialists. He noted: "We retain 50% of the doctors we train, but that's been unchanged in decades. We can't work harder, so we have to work smarter." To him, this means employing innovative approaches such as team-based chronic care, focused disease management programs, redesigning ER workflow and staffing, electronic consults that increase access for PCPs to specialists, and even home visits to clinic no-shows.

"The hospital needs to think outside the walls of the hospital," Peterson said. "It's now being recognized the critical role that primary care plays in the hospital system — both before the patient enters the system and keeping them out of the hospital once they leave.

Moving Beyond Patient-Centered to a Customer-Driven System of Care

Former head of CMS Don Berwick called Southcentral Foundation's NUKA system of care in Alaska the "leading example of health care redesign in the nation, maybe the world." Southcentral is a nonprofit health provider owned and operated by — and serving — Alaska native people. Southcentral sees health as being interconnected between physical, emotional, spiritual, and social well-being — a truly whole-person approach to care.

In a riveting presentation, April Kyle, Southcentral's vice president for behavioral services, described how the organization moved beyond a patient-centered approach to a customer-driven system of care. As Southcentral looked at overhauling its system of care more than a dozen years ago, they saw that nearly half of all patient encounters had a behavioral health component. As part of the complete redesign, they put behavioral health "everywhere" — across integrated teams, across their system. Today, Southcentral's model focuses on relationships. The approach has worked: Both ED and inpatient hospital utilization declined by a third between 2000 and 2015.

Reel Stories: Life and Death in the ICU

The Oscar-nominated short documentary Extremis, which was shown during this afternoon breakout session, raises critical questions about the value of aggressive medical intervention and the need for candid conversations among patients, families, and providers long before end-of-life crises occur.

After the screening, Dr. Jessica Zitter, a critical care and palliative care specialist featured in the film, and Dr. Anne Kinderman, who directs the Supportive and Palliative Care Service at Zuckerberg San Francisco General Hospital, discussed the challenge of having frank end-of-life conversations with patients and families and responded to questions from the audience, which included several palliative care physicians.



Zitter sees access to palliative care as a social justice issue. It's not fair, she said, "that a small number of people get access to palliative care and to have the kind of death that they want." Her mission, through the film, and in her new book Extreme Measures: Finding a Better Path to the End of Life, is nothing short of culture change. The session ended with wet eyes, an appreciation for the power of art to make people think, and an appetite for the conversation to continue.

Keynote: Telling the Story of What Matters to Patients

Acclaimed author, physician, and professor (and recent winner of a National Humanities Medal) Abraham Verghese closed the forum by weaving together a whirlwind tour of the history of modern Western medicine and the role of empathy in caring for patients. Verghese reminded listeners that personal connection, relationship, and ritual are powerful components of any healing interaction. Invoking the words of Harvard professor Francis W. Peabody in 1925, "For the secret of the care of the patient is in caring for the patient." Verghese cautioned the providers in attendance against an overreliance on automation during patient visits, urging vigilance (and eye contact) as a means for creating a more compassionate health delivery system. Verghese concluded his remarks by urging greater precision in understanding individual biology, population science, and the human experience of illness.

Read a Q&A with Dr. Verghese and CHCF's Senior Communications Officer Steven Birenbaum.

Watch Dr. Verghese's keynote address: