Los Angeles Health Director Dr. Mitchell Katz Talks Lessons Learned in LA That Have Improved Population Health

Mitchell Katz

[Music]

Mark Masselli: This is Conversation s on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret, it seems like we are seeing daily changes to the
narratives surrounding the Affordable Care Ac t starting with the White House .
The President announced several important changes to the health law last week
including cutting off the cost sharing reduction subsidies created by the ACA
which allows insurance companies to offer more affordable premiums to lower
income Americans purchasing health insurance on the exchanges.

Margaret Flinter: Well Mark , the President called the cost sharing reduction
payments bail outs for the insurance industry, but the reality is those payments
go directly to securing affordable coverage for low income consumers . A nd
without these CSR payments as they are called, the congressional budget office
reporting that as many as a million Americans would not be able to afford their
coverage if the subsidies are eliminated . A n d all of this with open enrolment
starting just a few days away on November 1st.

Mark Masselli: Well, a week later and there is a new wrinkle in the discussion, a
bipartisan plan was announced in the senate to continue funding the cost sharing
reduction subsidies for two years. Republican Lamar Alexander and democratic
senator Patty Murray announced they were close to a final agreement on the bill.
At first the President back pedaled it from his stance last week saying he could
get behind the short - term solution to propping up the insurance markets, one day
later though he is back saying he will not support the measure.

Margaret Flinter: The President is saying in a tweet that he cannot support
bailing out insurance companies who have made a fortune wi th Obamacare and
in the meantime, there are already a number of legal challenges being mounted
against the White House over the CSR payments and we are still waiting for
reauthorization of the Children’s Health Insurance Plan or CHIP which puts
health cove rage for 9 million American children into question, so with all this
uncertainty, one thing that is certain as that those most likely to be impacted
negatively are the most vulnerable populations.

Mark Masselli: Healthcare for the most vulnerable populat ions is something that
our guest today is a champion of. Dr. Mitchell Katz is the Director of Health for
the city of Los Angeles. His innovations in population health have earned him
many accolades. I am really looking forward to this conversation, Marg aret.

Margaret Flinter: And he has been tapped to run the New York City health
system, so we are really looking forward to hearing from Dr. Katz.

Mitchell Katz

Mark Masselli : Lori Robertson will check in with us, the Managing Editor of
FactCheck.org. But no matter what the topic, you can hear all of our shows by
going to www.chcradio.com .

Margaret Flinter: And as always if you have questions or comments, please e -
mail us at chcradio@ch c1.com or find us on Facebook or Twitter because we love
to hear from you. Now, w e’ll get to our interview with Dr. Mitchell Katz in just a
moment.

Mark Masselli: But first, here is our producer Marianne O’Hare with this week’s
Headline News.

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Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.
Confusion and compromise in Washington concerning the cost sharing reduction
payments to offset insurance cost for low income Americans, days after the
President announced in a late night memo that he was cancelling the cost
sharing reduction payments created under the Affordable Care Act that pays
funds to insurance companies, so they can significantly lower the deductibles
and out of pocket cost for lower middle income people purcha sing insurance. A
bipartisan agreement has been reached in the senate that would help stabilize
those payments for two years. Republican Senator Lamar Alexander and
Democratic Senator Patty Murray announcing the stabilization agreement,
attorney’s genera l in several states were already lining up with lawsuits against
the administration’s efforts to eliminate the CSR payments. Meanwhile, the
President’s executive order to expand the creation of health insurance buying
associations, allowing for small busi nesses to form partnerships to tap in to
insurance pools has been met with a fair degree of skepticism. President claims
this will offer an opportunity to buy cheaper options, but it has been tried before
and has failed. A number of Federal watchdog agen cies looked at these so
called association plans. Often they failed on many occasions to pay legitimate
claims for those who use them. The rules governing the management of these
association insurance plans are still being worked out. As the death toll rises in
the wake of the Northern California fires, another concern is mounting. Air
quality in the San Francisco bay area and surrounds has been rated at its lowest
level on record. The smoke cloud is covering much of the region and so many
homes, busin esses and vehicles burned in these blazes. That smoke is filled
with numerous toxins and it is being compared with the poorest level of air quality
in China’s most polluted cities. I am Marianne O’Hare with these Healthcare
Headlines.

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Mark Mass elli: We're speaking today with Dr. Mitchell Katz, Director of the Los
Angeles County Health Agency the second largest in the country overseeing the

Mitchell Katz

regions forming hospitals a network of clinics and a billion - dollar budget . B efore
that Dr. Katz served a s Director of Health for the San Francisco Department of
Public Health where he implemented the first Municipal Universal Healthcare
System in the United States . Dr. Katz earned his BA at the Yale University, his
medical degree at Harvard Medical School a nd did his residency at UC San
Francisco . H e will be leaving Los Angeles at the end of the year to take over the
New York City Health and Hospital system . Dr. Katz welcome to conversations
on healthcare.

Dr. Mitchell Katz: Thank you so much for invitin g me.

Mark Masselli: You’ve recently announced your plans to leave the LA County
Health Department where you have been nominated to run the largest Municipal
Health System in the country with a network of 11 hospitals, 70 clinics but before
we get there , you decided to realign various departments in LA to create a more
seamless process for continuum of care and I wonder if you could share with our
listeners how you approach the healthcare system challenges in Los Angeles
and how you brought about the tran sformation in the healthcare system there?

Dr. Mitchell Katz: When I came to Los Angeles , what I saw was that the patients
were not being put first . T o make any system work the people you are serving
have to be at the center of the system. I think any system that doesn't put
primary care as the linchpin for improving care is going to fail. The system that I
came to in Los Angeles , nobody had their own physician or nurse practitioner as
their provider. Patients saw who they saw . T here was no continuit y of care . I
think so much is lost if people don't have strong relationships over time with their
providers because we know that how we handle somebody who say comes with
a headache depends tremendously on what we know about that patient . If it's
somebod y who never complains and is you know cheerful and happy and then all
of a sudden , they tell you they have a terrible headache it has a different
meaning than someone for whom you have cared for, for years. So putting
primary care clinics first requiring that patients be empaneled to a specific doctor
or nurse practitioner which was quite controversial at the time I think really was
the single intervention that made the biggest difference.

Margaret Flinter: I know that you brought your training and educa tion in your
practice as a primary care physician an internist to that work, but you also
learned so many valuable public health lessons in your early 90s working as an
internist in San Francisco and a city that was a ground zero for the AIDS
epidemic . Y o u were out there trying to launch one of the country's first needle
exchange programs at a time when I don’t think it was even legal to do that, what
did you learn from your efforts in that early needle exchange initiative?

Dr. Mitchell Katz: Well , I thi nk there are really two lessons , one philosophical and
one practical. I think the philosophical one is that while I love being a doctor and
I love taking care of people , we have to recognize that medical care can’t really

Mitchell Katz

make a huge difference in most pe ople’s health. If you want to make a big
difference, you have to go upstream, and you have to address the things that are
affecting their health and in the case of needle exchange , it was recognizing that
I'm an AIDS doctor but if I really want to make a difference I need to prevent the
infection. So the needle exchange was a way of keeping people from being
infected, keeping their partners, their children from getting infected. The one
thing that makes me happiest is how much hepatitis C we prevented -- -

Margaret Flinter: Right. W e didn't know it then, yeah.

Dr. Mitchell Katz: We didn’t e ven know it, it wasn’t labeled. The practical lesson
I learned is that if something is right , then you have to pursue it . L ike when we
did needle exchange , people said that it would be against the law to fund needle
exchange and what we did is by declaring an emergency , we found a way to do it
without winding up in jail ourselves. If it's right , then we have to pursue until we
find a method of doing it.

Mark Mass elli: Certainly you bring that this is sort of a practical very
straightforward figure out what the barriers are, solve them in a program and then
evaluate how well you've done it and you've adopted a pretty innovative
approach. I wonder if you could tel l us about the program you developed to
combat chronic homelessness in Los Angeles . Talk to us a little bit about how
you shifted resources to address the issue and how that might be scaled
nationally as well?

Dr. Mitchell Katz: What I saw working in Sa n Francisco in a public hospital was
we would admit patients who were homeless . T hey would come in dehydrated or
with mental impairments and people would spend two or three days running all of
these tests and when it turned out that the person was addict ed to drugs , they
would then just discharge them to the street and I would look and say do you
know we just spent $40,000 on this person, we could have housed them for the
rest of their life and so we started the idea that we would take the sickest people,
the people who were suffering from mental illness and we would house them and
over 10 years in San Francisco we housed over a 1000 people in here and in Los
Angeles since 2012 , we’ve housed 3500 people and the big paradigm difference
was we said we will u se health dollars . I t's a good investment on health dollars
and it returns us back to the issue of social determinants what sense does it
make for me to give medications to a homeless person if they don't even have a
place that they can take it.

Margaret Flinter: Well , I think one of your many accomplishments that we've
read about in Los Angeles has been to integrate the departments of health and
public health and mental health and you know it seems kind of obvious to us that
if you integrate at the leve l of the leadership , then you ultimately have a good
chance of integrating the care and the services at the level of the patient. We
would be really interested in hearing how you've made that work in a health

Mitchell Katz

system as large as the one in Los Angeles?

Dr . Mitchell Katz: Margaret , to those of us in the field it makes total sense . Y ou
know the patients come fully integrated . T hey may present with bad stomach
pain as their expression of their mental illness . T hey themselves don't come and
say I have a me ntal health problem, I have the physical health problem, they
come, and they say that I have a stomach problem. So, the people we care for
they are fully integrated . T he problem is the clinicians have all trained in a
particular field and everyone wants to practice in their field forgetting that it ’ s
absolutely impossible for patients to have multiple different paradigms when they
are just one person. I think we can say that people are getting better care
because we have improved access and so more peopl e now who come to one of
our physical health sites with a mental health problem or are getting mental
health treatment . T he seriously mentally ill live 20 years less than people without
serious mental illness they’re dying because of sedentary lifestyle, of smoking, of
heart disease, issues the primary care providers know well how to care for.

Mark Masselli: We're speaking today with Dr. Mitchell Katz, Director of the Los
Angeles County Health Agency . B efore that Dr. Katz ran the San Francisco
Departmen t of Health . A t the end of the year , he will be taking over the New
York City Department of Health and Hospitals. Dr. Katz you are a Brooklyn
native, heading back to your home turf and after decades in the West Coast so a
very political question - San Fr ancisco, Los Angeles, New York what sports
teams are you rooting for?

Dr. Mitchell Katz: You know that’s too conscious sort of joke , I couldn’t possibly
reveal that.

Mark Masselli: But you are facing very difficult times th e looming deficit , so
where d o you anticipate your biggest challenge is going to be in the physical area
or is it really about establishing the culture?

Dr. Mitchell Katz: Well , I think the Mayor and the prior Director have already set
out the right plan to move to a much more outpa tient primary care system and I
think that's part of why they chose me, it's all in the operations - helping people .
I’ve always worked in a hospital setting to find out the joys of being a nurse case
manager in the outpatient setting. It turns out that many of the nurses who were
once working in a hospital you know have really enjoyed you know their new
practice as nurse case managers and have seen what a huge difference it can
make so what I'm hoping to do is to be adept at operationalizing that vision.

Margaret Flinter: Well , Mitch as you return to the East Coast you know have a
universe or a domain of New York but we all live in this larger context of what's
going on with healthcare and with health policy changes still so many ways the
law could be u ndermined in terms of access to health services for millions and
we of course are ever mindful that it doesn't address the needs of undocumented

Mitchell Katz

persons in this country that have no access, what are your greater concerns as
we look towards all this uncerta inty in America for people who gained coverage
as well as the millions who still aren’t covered and what are you hoping to see
this next wave of health reform play out?

Dr. Mitchell Katz: Well , the idea of taking away coverage when we really should
be ex tending coverage to people who still lack it in our country is awful . W hat I
would love to see and what we haven't seen is people trying to address how do
we improve the current system . W e can see ways that it could be improved but
what I'd really like t o see us do is move to a place where we're addressing how
do we fully extend coverage and how do we improve care. There is a reason
that the US ranks at the very bottom of the health measures for countries and we
should be actively addressing that and sad ly instead , we're trying to hold on to
the games we've gotten.

Mark Masselli: You know I just want to say as an aside here with resources of
the Affordable Care Act , you really revolutionized the public health system in Los
Angeles s o and also an exempla r for what those types of investments can lead to
and you know the health industry is going through lots of transformation in part
by the scientific advances in the areas like genomics and there's a blooming data
analytics and health data sharing environme nt out there, and I’m wondering how
important getting a hold of that information sharing is going to be part of the
platform as you think about rebuilding or improving upon the system that you are
about to inherit?

Dr. Mitchell Katz: I think information sharing is a key part . I think that at every
level , we need - we need good information when we're seeing somebody -
patients need better information themselves in order to make good decisions to
be more active as consumers of health care. My only reserva tion is that I really
believe that at its core healthcare is about healing people, and doctors heal
people and nurses heal people and pharmacists heal people, computers I’m not
sure heal people so .

Mark Masselli: They give them headaches.

Margaret Flint er: Well , Mitch I know that you have been very focused on
transforming the way primary care is organized and delivered in the LA County
Health System taking full advantage of a n integrated system where everybody's
incentives hopefully ali gn in the same di rection . Y ou must have in that LA
County system been making a huge contribution to training the next generation
of healthcare providers and workers across the board and I am curious how you
approach training the next generation to this new model of care?

Dr. Mitchell Katz : Sure w e ll first , the question needs to be what is it we're trying
to teach them. One of the most disheartening things I heard when I first came to
Los Angeles was that the residents couldn't have a panel of patients because

Mitchell Katz

after all they were residents, they were rotating, and I was like well how could
you possibly learn to be a primary care provider if you don't have the panel of
patients. So we were able to empanel them. Second when I talk to medical
students , I asked them what do you think from your mentors really smart medical
students become, and the answer is always specialists and I really remember
that too, I remember that the idea is that if you're really smart , you become a
specialist and of course my view is that the thing we most need is really smart
primary care providers whether they be doctors or nurse practitioners, physician
assistants we need the best people to go into primary care because it's the most
important and frankly it's hard to know whether or not when some body comes in
with chest pain you know whether they are having a heart attack or do they have
a broken heart, so you know I think that demonstrating the joy of primary care of
developing long - term relationships of taking responsibility for people is the be st
way to have a new generation with a similar philosophy.

Dr. Mitchell Katz : So I think that demonstrating the joy of primary care of
developing long - term relationships of taking responsibility for people is the best
way to have a new generation with a similar philosophy.

Mark Masselli: We have been speaking today with Dr. Mitchell Katz, Director of
the Los Angeles County Health Agency. He will be leading the New York
Department of Health and Hospitals in the New Year. You can learn more about
Dr. Ka tz’s work by going www.healthagency.lacounty.gov/leadership . Dr. Katz,
thank you so much for joining us on Conversations on Healthcare.

Dr. Mitchell Katz : Thank you both.

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Mark Ma sselli: At Conversations on Healthcare , we want our audience to be
truly in the know when it comes to the facts about health care reform and policy.
Lori Robertson is an award - winning journalist and managing editor of
FactCheck.org, a nonpartisan, nonpro fit consumer advocate for voters that aim to
reduce the level of deception in U.S. politics. Lori, what have you got for us this
week?

Lori Robertson: President Donald Trump issued an executive order in October
related to the Affordable Care Act . The o rder instructed the Department of
Labor, Health and Human Services and Treasury to consider proposing
regulations on Association Health Plans, Short - Term Insurance and Employer
Health Reimbursement Arrangement. The order said that those items were
alterna tive to insurance under the Affordable Care Act that is subject to
mandates. The ACA requires insurance on the individual or small group market
to cover certain benefits and limit out - of - pocket cost and the law limits how
insurers can vary pricing based o n individual factors like age. Trump’s order also
mentioned selling insurance across state lines. We looked at the issue of selling

Mitchell Katz

policies across state lines before and what impact it might have on premiums on
the individual market were those without t he employer plans or government plans
like Medicaid by their own coverage . If insurance companies could sell across
state lines and the state regulators didn’t have to follow ACA requirement, would
premiums dropped significantly?

Joseph Antos, a healthca re expert with the American Enterprise Institute told us
that while there could be some reduction, insurers would still be locked into the
cost of health services in a given geographic area. Linda Bloomberg with the
Urban Institute said that some people c ould see a big drop in premium if insurers
significantly curtailed benefit selling plan without much insurance protection to
healthy people, but that would also drive up premium for those wanting
comprehensive insurance and in states that want to have insu rance regulation.
Aetna CEO said earlier this year that the idea is outdated because insurers now
are aligned with networks of providers that they create in certain area. The
American Academy of Actuaries said this year that cost savings from negotiating
provider networks can be larger than savings glean from differences in benefit
requirements. But it may be difficult for insurers entering a new state market to
negotiate with provider and that’s my fact check for this week. I am Lori
Robertson, Managin g Editor of FactCheck.org.

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Margaret Flinter: FactCheck.org is committed to factual accuracy from the
country's major political players and is a project of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, e - mail us at www.chcradio.com . We will have FactCheck.org's Lori
Robertson check it out for you here on Conversations on Health c are.

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Mark Masselli: Each week, Conversations h ighlights a bright idea about how to
make wellness a part of our communities and everyday lives. Pregnancy is
normally an exciting time for most women, but according to the research an
estimated 10% of prenatal women experience some kind of depression s du ring
their pregnancy, and many are reluctant to treat their depression with medication
for fear of harming the fetus.

Dr. Cynthia Battle: In fact, a higher percentage are experiencing lower - grade
depressive symptoms and left untreated those mild to moder ate symptoms can
progress and in some cases lead to a more serious postpartum depression .

Mark Masselli: Dr. Cynthia Battle is a Psychologist at Brown University. She and
her colleagues decided to test a cohort of pregnant women to see if a targeted
pre natal yoga class which combines exercise with mindfulness techniques might
have a positive impact on women dealing with prenatal depression.

Mitchell Katz

Dr. Cynthia Battle: And it was a typical kind of Hatha yoga and we enrolled 34
women who were pregnant , who had c linical levels of depression and they would
come to classes and we measured their change in depressive symptoms over
that period of time.

Mark Masselli: Not only were women able to manage their depressive incidents,
they also bonded with other pregnant w omen during the program and found
additional support from their group. A larger study with control groups is being
planned with the assistance of the National Institute of Mental Health.

Dr. Cynthia Battle: Women who are depressed during pregnancy unfor tunately
do often have less ideal birth outcome. So one thing we are interested in seeing
is when we provide prenatal yoga program, can it improve mood, and then can
we even see some positive effect in terms of the birth outcomes.

Mark Masselli: A guide d non - medical yoga exercise program designed to assist
pregnant women through depression symptoms helping them successfully
navigate those symptoms without medication, ensuring a safer pregnancy, and a
healthier outcome for mother and baby, now that’s a br ight idea.

[Music]

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare broadcast from WESU at Wesleyan University,
streaming live at www.wesufm.org and brought to you by the Community Health
Center.