Minutes of the Special Health Commission Meeting Tuesday, March 23, 2004 at 3:00 p.m. 101 Grove Street, Room #300 San Francisco, CA 94102 1) CALL TO ORDER The meeting was called to order by Commissioner Chow at 3:10 p.m. Present: Commissioner Edward A. Chow, M.D., President Commissioner Lee Ann Monfredini, Vice President Commissioner James M. Illig Commissioner Michael Penn, M.D., Ph.D. Commissioner David J. Sanchez, Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Roma P. Guy, M.S.W. Commissioner Chow introduced Commissioner Jim Illig, Mayor Gavin Newsom’s first appointment to the Health Commission. Commissioner Illig described his background and shared his priorities with his fellow Commissioners, staff and members of the public. His three priorities are: Do whatever is necessary to alleviate homelessness Focus on the health needs of all San Franciscans. While the Department has a special responsibility to care for the poor and uninsured, it must serve all San Franciscans.  Focus on results and outcomes of patients and clients, rather than institutions, employees and contracts Commissioner Illig’s perspective is one of both an outsider and an insider. He has been observing the Health Commission since 1985, when it was created. Now that he is on the Commission, he believes that government is its citizens, and public office is a public trust. As he begins his service here, he will pay attention to the public’s perspective. He looks forward to working with his fellow Commissioners, Dr. Katz and the public. 2) APPROVAL OF THE MINUTES OF THE MEETING OF MARCH 16, 2004 Action Taken: The Commission (Chow, Illig, Monfredini, Penn, Sanchez, Umekubo) approved the minutes of the March 16, 2004 Health Commission meeting. 3) DIRECTOR’S REPORT Mitchell H. Katz, M.D., Director of Health, presented the Director’s Report. Public Health Week Activities, April 5 - 11 The San Francisco Department of Public Health will observe National Public Health Week April 5th to 11th. The theme this year is “Eliminating Health Disparities, Communities Moving from Statistics to Solutions”. Planned activities include two Brown Bag Lunch presentations, one by Sandra Hernandez, M.D., Executive Director of the San Francisco Foundation and former Director of Health of the San Francisco Department of Public Health, and one by Kevin Grumbach, M.D., Chief of Family and Community Medicine at SFGH and Research Director for the UCSF Center for the Health Professions. In addition, the Health Education Training Center will present a session entitled “A Public Health Approach to Health Disparities.” For further information contact Carolyn Lieber at 255-3470 or via email at: carolyn.lieber@sfdph.org. Barry Zevin Receives Community Hero Award Dr. Barry Zevin, Medical Director of Tom Waddell Health Center, was recognized by Saint Francis Memorial Hospital as one of its 2004 Community Heroes. A $10,000 award, to be donated to Tom Waddell Health Center, accompanies the recognition. The Community Hero award is given to individuals who go "above and beyond" normal expectations to create a healthier environment for the community served by Saint Francis Memorial Hospital, especially the poor and underserved. As Medical Director of Tom Waddell Health Center, Dr Zevin has served homeless, indigent and underserved populations for many years. He is recognized as a local and national expert on health care for homeless people, HIV and hepatitis C care. Dr Zevin was instrumental in founding the first public transgender primary care clinic in the nation, planning and working with the Homeless Death Prevention and HOPE health care teams, collaborating to start the first community based medically supported residential detox program in San Francisco, and planning and implementation of the McMillan Stabilization Pilot Project. McMillan Stabilization Pilot Project Open House The San Francisco Public Health and Fire Departments along with Community Awareness and Treatment Services (CATS) are hosting a 3-day Open House from April 5 – 7 for the McMillan Stabilization Pilot Project. Invitations have been extended citywide to paramedics and emergency room physicians. The purpose of the Open House is to promote better understanding of the McMillan Stabilization Project as well as to encourage utilization. Commissioners’ Comments Commissioner Illig asked for a list of the Strategic Plan community meetings. Dr. Katz informed the Commission that there will be one meeting in each of the supervisorial districts, and all meetings are open to anyone who wishes to attend. Commissioner Chow stated that the Commission would have formal input into the Strategic Plan update process through the Joint Conference Committees. 4) CONSIDERATION OF A RESOLUTION REGARDING THE PROPOSED FISCAL YEAR 2004-05 HEALTH DEPARTMENT BASE BUDGET Dr. Katz presented the Commission new information on issues that were raised at the previous Health Commission meeting, including information on pharmaceutical co-pays, status of MediCal funding for methadone, status of the Mentally Ill Offender Crime Reduction Grant, the proposal to combine clinics, additional issues involving Walden House and the proposal to decrease administrative positions in Primary Care (see memo, Attachment A). Commissioner Illig asked how Walden House would be able to save $300,000 and reduce the length of stay, yet still keep the same number of clients. Dr. Katz replied that Walden typically has longer lengths of stay than other contractors. So there may be a reduction in the static number of beds, but in terms of the number of clients the agency serves, there should not be a reduction. Public Comment Norma Hotaling, Executive Director of SAGE, thanked the commission for retaining substance abuse programs, which is the cheapest services the department can buy. Greg Parks, Team II Clinic, said there are so many people who still need the services provided by the Team II Clinic. Angel Temple, Client of Team II, opposed to the relocation and consolidation of the clinic to the OMI Mental Health Clinic. Patients like her would fall through the cracks, and instead of saving money there would be more hospitalization of patients. Sharon Parks, patient at Team II Clinic, opposes the relocation of the clinic. It will be disruptive and reduce the quality of care. Rolando Alfonso, Citywide helped him stay clean for two years, helps him with his medication, and he has had no problem with the law for the past two years. Debbie Woods, Citywide client, said this agency saved her life. All the staff is very supportive. Billy Powell, has been incarcerated many times over the years. Citywide Clinic gives him everything he needs, and is the best type of rehabilitation he has ever had. Kinneth Bell, client at Citywide, said the program is helping him deal with depression and other problems. Please help the agency. Michael Williams, client at Citywide, has been in and out of jails and hospitals for 20 years. Citywide is helping him with his life. Please keep the program. Jay Ordman, objects to the Mayor’s request for a $50 million cut in healthcare spending, instead of raising taxes on the very wealthy and big businesses. Larry Young, client of Citywide, said the program has provided him with medication and housing. It is the first program in his life where he has had anger management, harm reduction and other programs. Please try to keep the program open. David Fariello, program director at Citywide Case Management. If this program terminates July 1st, in addition to losing 100 treatment slots, there will be negative impacts to two other partner programs that share space with Citywide. Second, although appropriate mental heath treatment is reducing jail days, the primary result has been success in getting citizens who suffer from mental health and substance abuse into treatment often for the first time in their lives. Jane Kiskiras, client of Maxine Hall Health Clinic, Maxine Hall is the best healthcare she has ever received. The staff are real caregivers. Jenelle, Team II Clinic, said the clinic provides services to a community that otherwise would not seek help. The clients will not seek services in a place they do not feel comfortable in. Let Team II remain. Kathleen Ryan, Chair of the CHN NP Professional Development Group - the group is sad and dismayed at the sudden termination of David Ofman. His dismissal leaves a void in leadership and advocacy. He has worked diligently to improve care and access for indigent patients. Dr. Ofman has been a mentor to many CHN nurse practitioners. Bruce Folsom, social worker at Southeast Mission Geriatrics. The proposed location is inappropriate for its clients. It is far away for most of the clients and is in a heavily congested neighborhood. In addition, the proposed location has had environmental problems. Arthur Bosse, National Council on Alcoholism. Substance abuse problems exist regardless of whether or not there is funding. Spending money in this area saves money in so many other areas. The Health Commission must advocate to at least maintain the level of substance abuse services. Martha Hawthorne, PHN at Castro Mission Health Center, is very concerned about the administrative cuts to Primary Care. These cuts will impact patient care and will result in the health centers serving fewer patients. Elizabeth Smith – Maxine Hall Health Center transformed her life. Do not make cuts to Primary Care. David Hall, client of Morrisania West, read from a letter he submitted to the Commission (on file). Yehiel Yisra-el, Morrisania West, said more funding is needed, and more cuts should be taken elsewhere. The Health Commission has the bully pulpit to say to the corporations and leaders, in a peaceful revolution, that these cuts are draconian. Maurice May, Morrisania West, said his job is to help teens prepare for employment and get jobs. Please say no to budget cuts to the Health Department, because the youth need these programs. Piers MacKenzie, Friends and Families of the MHRF, hopes that Commissioner Illig supports the direction of the MHRF Blue Ribbon Committee, which has been endorsed by the Health Commission. Dale Milfay, said the Commission must take a stand and demand alternative sources of revenue. We cannot continue these draconian cuts. People with mental illness cannot get better with shorter stays. Patients with poverty-level incomes should not be charged a pharmaceutical co-pay—and remember that psychotropic drugs are not generic. Debbie Lerman, Human Services Network, expressed concern about standardized indirect rates. The methodology should not be developed in a budget-cutting context, with the assumption that there will be a $1.5 million savings. Ed Kinchley, Local 790, said the Department has a commitment to culturally competent care, yet for the past three years the Commission has recommended cutting the interpreters at SFGH. It is a fantasy that bilingual staff have time to interpret in addition to their regular jobs. Tell the City that the Health Department does not have enough resources to carry out its mission. Michael Lyon, Save Public Health, is outraged at the proposed per-prescription co-pays. The plan to remove the medical director and clinic administration only indicate that the big cuts are coming. The large contingency cuts are being developed in secret. He submitted a letter written by Dr. Kevin Grumbach in 1999 on the affects of charging co-pays. Gene Hartman, Jr., client of Bayview Hunters Point Foundation, said that the agency’s services have helped him and please keep the methadone and acupuncture programs. Geoffrey Grier, San Francisco Recovery Theater and Chair of the Treatment on Demand Council – said that African Americans are going to be disproportionately affected by the budget cuts. The system is obviously broken. Primary Care needs more resources. Sasha Cuttler, R.N., provided his testimony in Spanish on behalf of his patients at SFGH who speak other languages. If the Commission does not understand what he is saying, then they understand how patients without a translator feel. The people are asking for help. How can someone talk to a nurse or a doctor if there is no one to provide translation? There are frequently waits for medical services. Please save more public health services, not less. This proposal is dangerous. Mr. Cutler then provided his testimony in English. Matt Crawford, Friends and Family of the MHRF. He thanked the Commission for saving the MHRF, and increasing the use of Buprenorphine for heroin use. His friend was prematurely released from the MHRF, and is now deteriorating and is no longer conserved. Please maintain conservatorship. And people who are severely mentally ill should not be threatened with losing their housing. Commissioners’ Comments Commissioner Chow asked for clarification that the day and evening shifts of interpreters are being maintained. Dr. Katz said last year’s budget recommended eliminating the night shift, which provided Spanish and Chinese translation. The average usage was two per night. When the Board of Supervisors restored the funding, the Department used that allocation to enhance the number of translators during the day. But, because the City almost immediately implemented a hiring freeze, DPH was never able to fill these positions. So, the positions that are recommended to be eliminated are funded but not filled. DPH does pay substantial amounts in premium for staff that is bilingual. While it is true that staff is very busy, it raises the question of whether the bilingual premium is appropriate. But this is an MOU issue. Commissioner Illig asked if the vacant translator positions are maintained in next year’s baseline. Dr. Katz said the five vacant positions are on the table to be cut. Commissioner Sanchez said there would likely be even greater oversight over Title VI, which requires adequate linguistic services. San Francisco has been one of the key leaders in this area. The Department needs to examine whether it would be vulnerable to Title VI challenges and to make sure we maintain our leadership in this area. Dr. Katz said that even with the reduction in translators, SFGH would still be far ahead of other hospitals in San Francisco. Commissioner Umekubo asked for an update on the use of video conferencing for interpretation. Dr. Katz said there is a pilot project in progress, such a system would benefit Primary Care, and would be useful for uncommon languages. Commissioner Chow suggested that the San Francisco General Hospital Joint Conference Committee continue to monitor proposed reductions in translation services, including whether the cuts are part of the final budget, what the impacts are, how the impacts could be minimized, and the status of the pilot project to use video conferencing. Commissioner Penn asked for more information about the impact of shortened stays at Walden House. Dr. Katz said that ideally a person would stay in residential treatment long enough to have a job and a home. This is not the standard of care DPH is currently providing. With utilization management, clients are examined more closely to see if patients are able to leave the program. This proposal stemmed from the fact that Walden House has longer average lengths of stay than other contractors. Commissioner Penn asked the Department to work with our contractors to explore whether other cost savings opportunities exist. Commissioner Illig said that capacity will be lost with the change to Walden House’s program, because while the same number of people are being served, there will not be as many beds in the contract. Dr. Katz reiterated that none of Walden House’s facilities would be closed. Ms. Garcia added that the Department does not have utilization review with substance abuse treatment providers, so this will be a collaborative experience. Commissioner Penn is bothered by the fact that there is no plan for indirect costs, so the Commission cannot know the impact on contractors and services. Dr. Katz said it is an across-the-board cut on agencies. In the best-case scenario, the standardized methodology would be developed without an assumption of a $1.5 million savings. Commissioner Illig said the recommendations of City’s Non-Profit Contracting Task Force, which have been approved by the Board of Supervisors, would help the Health Department and other departments develop the methodology for indirects. Commissioner Monfredini reminded the Commission that Walden House has been forced to undertake a dramatic self-assessment over the past year, which allowed them to come to the table with budget ideas. Ms. Garcia has worked tirelessly with the organization. Commissioner Penn asked for more information about the ventilation issues at the OMI Mental Health Clinic. Dr. Katz said that OMI site has had physical problems, but all have been corrected to the satisfaction of two industrial hygienists. Commissioner Penn is concerned about changes to Primary Care administration. Dr. Katz said the staff would make Primary Care work. Although the cuts are stiff, it is unusual by comparison to see clinics of this size with a full-time medical director, a full-time administrator, a full-time nurse manager and a full-time principal clerk. Commissioner Penn commended Dr. Katz for reducing his own salary. He asked his fellow Commissioners if they would be returning their meeting stipends. Commissioner Chow said Commissioners would be doing this. Commissioner Penn noted that many of the proposed cuts will disproportionately impact the African American community and he wants this reflected in the resolution. Commissioner Monfredini commended staff for developing additional alternatives in the week since the last meeting. She also recognized that 85 DPH employees will be losing their jobs, and this is difficult. She thanked Dr. Katz for looking within the Department first. Commissioner Sanchez said the proposed budget is painful. San Francisco has an unrivaled primary care system, which needs continued leadership. He asked that the change to Primary Care by monitored closely by the CHN Joint Conference Committee, as well as review of the merger of the three clinics to see that quality of services does not decline. Commissioner Umekubo said a lot of changes are being proposed, and the impact of these changes is unknown. It is critical that the Health Commission receives updates so that it is able to rectify problems next year. With regard to Primary Care, anytime changes in leadership are made, there is a discomfort on the part of staff and there needs to be constant communication. Commissioner Illig said the advocacy now moves across the street and the Commission and the public need to be taking the message to the Mayor’s Office and the Board of Supervisors that this level of cuts in unacceptable. He asked Dr. Katz to develop options for the contingency budget. He is prepared to ask the elected leaders to be excused from this next phase, at least for now. Action Taken: The Commission (Chow, Illig, Monfredini, Penn, Sanchez, Umekubo) amended the proposed resolution to add to the end of the sixteenth Whereas clause “and may reduce direct services;” Action Taken: The Commission (Chow, Illig, Monfredini, Penn, Sanchez, Umekubo) amended the proposed resolution by adding language to the eighteenth Whereas clause, so that the clause reads “Whereas, the Health Commission remains strongly opposed to service cuts that reduce safety net services, and recognizes that such cuts disproportionately affect the African American population and the mentally ill in San Francisco; ” Action Taken: The Commission (Chow, Illig, Monfredini, Penn, Sanchez, Umekubo) amended the sixth Resolved clause of the resolution so that it now reads: “Further Resolved, that the Health Commission requests that the Health Department work closely with City Administration to develop a standard policy for indirect costs that maximally protects direct services and is appropriate to the various types and sizes of non-profit contractors that the Department does business with;” Action Taken: The Commission (Chow, Illig, Monfredini, Penn, Sanchez, Umekubo) unanimously adopted Resolution #04-04, “Approving the Submission of the Department of Health’s Base Budget for FY 04-05, and Urging the Mayor and the Board of Supervisors to Develop Strategies for Avoiding Serious Cuts to the County’s Health Safety Net Services” (Attachment B), with the amendments. 5) PUBLIC COMMENT Debra Brown, Castro-Mission Health Center, spoke in opposition to the administrative cuts in primary care. There will be chaos in the system. She submitted a statement for the record (on file). 6) ADJOURNMENT The meeting was adjourned at 5:50 p.m. Michele M. Olson, Executive Secretary to the Health Commission Note: These Minutes will be adopted at the next Health Commission meeting. Any amendments to these Minutes made by the Health Commission will be recorded in the Minutes for the next Health Commission meeting.