Los Angeles April 18–20, 2006 [Report Published: August 30, 2006] Site Visit Report LA Story: Improving Care Management for the Chronically Ill and Chronically Underserved NATIONAL HEALTH POLICY FORUM FACILITATING DIALOGUE. FOSTERING UNDERSTANDING. Los Angeles Site Visit Report April 18–20, 2006 Contents Acknowledgements .............................................................4 Background ..........................................................................6 Program ................................................................................8 Impressions .........................................................................11 Agenda ...............................................................................15 Federal and Foundation Participants ................................25 Biographical Sketches Federal and Foundation Participants ..........................27 Speakers ........................................................................32 National Health Policy Forum Facilitating dialogue. Fostering understanding. 2131 K Street NW, Suite 500 Washington DC 20037 202/872-1390 202/862-9837 [fax] nhpf@gwu.edu [e-mail] www.nhpf.org [web] Judith Miller Jones Director Sally Coberly Deputy Director Monique Martineau Publications Director Site Visit Managers Eileen Salinsky Principal Research Associate Jessamy Taylor Research Associate Administrative Coordinator Marcia Howard Program Associate National Health Policy Forum | www.nhpf.org 3 Los Angeles Site Visit Report April 18–20, 2006 ACKNOWLEDGEMENTS This site visit, “LA Story: Improving Care Management for the Chronically Ill and Chronically Underserved,” was the second of two site visits made possible by the generous support of The California Endowment. The first site visit surveyed health care in California’s rural communities, while the second visit focused on the chal- lenges of providing effective, efficient care in California’s most urban locale. In light of both the number and caliber of individuals doing impressive work in LA, the Forum staff was faced with many difficult decisions in crafting the site visit agenda. The Forum is grateful to the many Angelinos who helped us under- stand how the providers of Los Angeles have struggled to deliver services to those in the community with significant health care needs. Although too numerous to mention by name, a heartfelt thank you goes to the over 100 individuals who so generously shared their time and expertise with us in preparation for the site visit. The Forum would like to extend special thanks to the many men and women who served as speakers on the site visit panels and shared their expertise and insight. Robert Tranquada, Yolanda Vera, and Jonathan Freedman provided an excellent and comprehensive overview of the county’s health and health care system. Sandra Shewry traveled from Sacramento in order to give us a candid, concise summary of Governor Schwarzenegger’s health policy priorities. Barbara Masters and Fernando Torres-Gil provided warm words of welcome at the site visit’s opening reception. In addition to these individuals, we would like to thank those who so kindly welcomed us into their facilities and helped us with countless logistical details. Tom Garthwaite, former director of the County of Los Angeles Department of Health Services (LADHS), traveled to Washington, DC, to give the group a pre- trip briefing on the LA county system. Jeffrey Guterman, Harry Furuya, and Michael Roybal welcomed us to the Edward R. Roybal Comprehensive Health Center operated by Los Angeles County’s Department of Health Services. We appreciate the efforts of everyone at Roybal who took time from their busy sched- ules to provide a tour of the facility and talk with us about their clinical respon- sibilities. Beth Lopez, John Mattison, Christine Calderon, and the rest of the staff at Kaiser Permanente’s Whittier Medical Offices also generously opened their doors to us and provided an extremely informative demonstration of their state- of-the-art electronic health record. A highlight of the trip was our visit to the Village, an integrated service provider addressing the social, medical, housing, and other needs of mentally ill, homeless persons in Long Beach. Chad Costello was instrumental in helping us make these arrangements. He and his colleagues Martha Long, Mark Ragins, Dave Pilon, and Richard Van Horn, along with many clients and dedicated staff members of the Village, helped to make a lasting impact on site visit participants. At Harbor-UCLA Medical Center, Susan Black, Robert Hockberger, Dennis Levin, William Stringer, Gail Anderson, and Miguel Ortiz-Marroquin generously took time from their pa- tient care responsibilities to allow us to observe the workings of the emergency department and discuss the pressures facing acute care providers practicing in county-run hospitals. National Health Policy Forum | www.nhpf.org 4 Los Angeles Site Visit Report April 18–20, 2006 Finally, other speakers helped “flesh out” the information provided in other set- tings. The Forum heartily thanks the following: Peter Long, who gave the group a crash course in California’s extensive early childhood development and health coverage initiatives. Anne Peters, Susan Fleishman, Hector Flores, Elisa Nicholas, and Craig Jones each gave engaging, information-packed presentations on inno- vative approaches to disease management. Jane Stafford traveled from Northern California to provide a statewide overview of the adoption of health information technology by safety net providers. Thomas Farnham presented an interesting account of one health center’s efforts to implement an electronic health record. Marvin Southard provided a concise, informative, and thoughtful overview of mental health services in Los Angeles. And Howard Kahn, Benjamin Chu, Dan Temianka, and Jeffrey Guterman closed the site visit with an insightful, provoca- tive panel discussion on the future of care management. The National Health Policy Forum is a nonpartisan research and public policy organization at The George Washington University. All of its publications since 1998 are available online at www.nhpf.org. National Health Policy Forum | www.nhpf.org 5 Los Angeles Site Visit Report April 18–20, 2006 LA Story: Improving Care Management for the Chronically Ill and Chronically Underserved BACKGROUND As the unofficial capital of moviemaking, the record industry, and other expres- sions of American popular culture, Los Angeles (both the city and the county) reflects the norms, trends, and values of the nation—in a larger-than-life man- ner. The same can be said of LA’s health care system, which provides a vivid, sometimes magnified example of both the successes and failures of American medicine. While LA is home to prestigious medical schools and premier research institutions that advance medical knowledge and technology, the county also displays profound disparities in access to life-saving services and exhibits a lack of integration that undermines optimal care management for the poor and afflu- ent alike. LA is illustrative of national health system dynamics in part because of its size, but also because of the extreme way in which health care financing and delivery have manifested there. ■ Los Angeles County’s population is large and extremely diverse, and it has grown rapidly over the last 15 years.1 With over 10 million residents, Los Angeles is the most populous county in the nation and has a larger population than that of 43 states. A majority of Los Angeles residents are members of minority groups, with just over 30 percent of the population identifying themselves as white. More than 50 percent of Los Angeles residents speak a language other than English at home and growth trends suggest that Hispanics will become the majority ethnic group by 2010. ■ Los Angeles has a large number of poor and uninsured residents.2 LA County has the largest number of persons living in poverty of any metropolitan area in the country. Over 17 percent of the population is poor and approximately 25 percent lack health insurance. An additional 18 percent are insured through Medicaid (which is known as Medi-Cal in California). ■ Los Angeles County’s governance and tax structure is complicated and highly political. The county is divided into five districts, each of which is governed by one representative who sits on the five-member Board of Supervisors. Overlaying the five-district structure, the county is also carved into eight service-planning areas (SPAs) for health care resource and planning purposes. These eight SPAs do not coincide with the five governing districts, thereby complicating advocates’ efforts to garner more resources for one SPA or another. In 1978, California voters National Health Policy Forum | www.nhpf.org 6 Los Angeles Site Visit Report April 18–20, 2006 passed Proposition 13, which significantly limited property tax assessments; about one-third of the county health system’s budget had come from property taxes, but that proportion dropped to less than 10 percent by 2001. The drop in county revenue required increases in federal and state revenues to make up the difference.3 ■ Care for the poor and uninsured is highly concentrated within the county- operated public health care system.4 Indigent care cases account for about 40 percent of patient days within the four hospitals operated by the County of Los Angeles Department of Health Services (DHS) but less than 4 percent of patient days for the 84 private hospitals in the county. DHS facilities shoulder about 40 percent of the cost associated with providing inpatient care to the county’s Medi- Cal and uninsured populations. ■ LA’s public safety net is heavily dependent on Medicaid and Disproportionate Share Hospital (DSH) funds.5 In 2001, nearly 80 percent of the over $12 billion in funding for LA County’s safety net services was linked to federal programs, including regular Medicaid (72 percent); a special Medicaid waiver, which ended in 2005, discussed in further detail below (5 percent)6; Medicaid DSH payments (4 percent); and the State Children’s Health Insurance Program (SCHIP) (2 percent). Although the county contributes half of the state match for the Medicaid program, only 3 percent of safety net funding is derived from dedicated, local contributions. LA County accounts for approximately 36 percent of California’s Medicaid program spending and receives roughly 44 percent of the state’s Medicaid DSH payments. ■ Special funding through a Medicaid demonstration waiver has allowed LA County to restructure its ambulatory care safety net and begin quality improvement reforms, but the goals of the now-expired waiver were not fully realized. In 1995, DHS faced a significant budget shortfall and secured a federal Medicaid demonstration waiver to restructure its approach to indigent care delivery. In return for this special infusion of federal financial relief, the county agreed to re-orient its efforts away from inpatient and emergency services toward an integrated, community-based system of primary, specialty, and preventive care. An extension of this waiver was granted in 1999 to continue through 2005. During this ten-year period, the county significantly reduced inpatient capacity and inappropriate emergency department utilization, diversified ambulatory care sites through contractual agreements with private sector provider groups (known as the Public-Private Partnership), and instituted initiatives to improve efficiency and quality. Although some progress has been made, problems persist. Many believe the financial underpinnings of DHS are unstable due to the high indigent care burden in the county and politically driven management decisions that impede needed reform. Malpractice scandals at one DHS-run hospital, Martin Luther King, Jr/ Drew Medical Center, have led to multiple lawsuits and have threatened the hospital’s accreditation with the Joint Commission on Accreditation of Healthcare Organizations. While other DHS facilities have not been plagued with quality of care problems to the degree reported at King/Drew, the focus of the safety net continues to be centered on crisis management in acute care settings. National Health Policy Forum | www.nhpf.org 7 Los Angeles Site Visit Report April 18–20, 2006 ■ Hospital and emergency department capacity in LA has declined while utilization has continued to increase.7 Over 20 hospitals have closed in LA County over the last decade, resulting in a decline in staffed bed capacity of over 15 percent. Admissions rose slightly during this time frame; county-wide hospital occupancy rates rose from 61 to 75 percent. Occupancy rates at DHS- operated hospitals are much higher and have held steady at approximately 95 percent. The county has lost 18 emergency departments over the past ten years, while emergency department visits have increased nearly 35 percent. Decreased capacity combined with increased demand has resulted in extremely crowded emergency departments. The likelihood of EDs being forced to divert patients to other facilities due to crowded conditions has increased sharply. Private hospitals in the county report that their emergency rooms are on diversion 27 percent of the time, whereas public hospitals are on diversion 62 percent of the time. The public, DHS-operated emergency departments provide 45 percent of all trauma care and 15 percent of all emergency services in the county. ■ Managed care has long been the dominant form of health insurance in the commercial and Medicaid markets and penetration rates are high. Over 50 percent of LA county residents are enrolled in a managed care plan, representing approximately two-thirds of all insured persons.8 Unlike in other parts of the country, integrated medical groups are the most prominent form of physician organization in LA. In the commercial market, these groups have generally assumed risk in the form of capitated payments, although recently there has been more movement toward fee-for-service reimbursement with Preferred Provider Organizations (PPOs). It appears that capitated payment is less common in the Medi-Cal managed care market. ■ Despite its image for health and beauty, LA has high rates of chronic disease. More than half of all adults in LA are either overweight or obese, and nearly 8 percent have diabetes. Mortality rates in LA exceed national averages for coronary heart disease, stroke, pneumonia and influenza, cirrhosis, homicide, and HIV/AIDS. The burden of disease is particularly high in low- income and minority groups. Taken together, these trends illustrate the broader national struggle to deliver high quality, accessible health care services at an affordable cost. While the LA county health care system continues to focus largely on acute, “crisis-management” ser- vices, providers (both public and private) are experimenting with innovative ways of retooling clinical practices to improve care management and patient outcomes. PROGRAM From April 18 to April 20, 2006, a group of 18 site visit participants and six Na- tional Health Policy Forum staff members explored care coordination for chroni- cally ill and chronically underserved patients in Los Angeles—California’s most populous, most diverse county. The site visit participants learned about the chal- lenges of providing an effective continuum of care in the context of complex (some- times counterproductive) financing incentives and an overburdened public safety net system. The site visit consisted of a mix of speaker panels convened at the National Health Policy Forum | www.nhpf.org 8 Los Angeles Site Visit Report April 18–20, 2006 headquarters hotel and excursions to several care sites throughout Los Angeles County. Although much of the program was centered on the public and private safety net system in Los Angeles, innovations from and comparisons to “main- stream” providers were interjected throughout the agenda. The program opened in the late afternoon with presentations from a panel of speak- ers given the difficult charge of summarizing LA’s health care needs, services, and funding streams in all their complexity. This context-setting overview of LA’s health care system was followed by a state-wide perspective of California’s key health policy priorities. Particular attention was given to how these priorities are likely to affect LA and how the financial crisis in LA’s safety net has influenced state-level decision making. The first day was concluded with a reception which gave partici- pants an opportunity to interact informally with the many individuals from Los Angeles who provided assistance in the development and execution of the site visit. The morning of day two began with a brief overview of efforts to expand health insurance coverage for children in California, along with a summary of state-based initiatives to support early childhood development. Attention then shifted to clini- cally driven efforts to manage chronic diseases in vulnerable populations at the point of care. The group toured the Edward R. Roybal Comprehensive Health Center, operated by DHS in East LA, which serves a predominantly Hispanic com- munity. Approximately 50 percent of its patients are uninsured and many are un- documented. The tour and overview of Roybal’s services was followed by a pre- sentation detailing DHS’s efforts to shift from an acute care, crisis-oriented ap- proach to care to a more patient-centered clinical practice across its health centers. A panel of speakers described efforts to improve diabetes care by safety net pro- viders in the private sector. Although each of the efforts used somewhat different strategies and techniques, all focused on measuring patient outcomes, improving communication with patients to facilitate self-care behaviors, and leveraging “non- medical” resources to support lifestyle changes and medical compliance. The simi- larities and differences across these care models were discussed, with a special emphasis on the demands created by patients’ socioeconomic stresses and diverse cultural perspectives. A subsequent panel focusing on pediatric asthma revisited many of these themes and also highlighted the value of utilizing health care leaders to advocate for en- vironmental changes to minimize disease triggers such as air pollution and pest infestation. Both the diabetes and asthma panels explored existing financing mecha- nisms that create barriers to effective care management, such as exclusion of nec- essary services from health insurance coverage, the volume-oriented incentives that coincide with fee-for-service payment, and the need for funding to support infrastructure development and clinical practice redesign. Over lunch the group had the opportunity to interact with promotores (community health workers), nutritionists, community outreach workers, and others to learn more about how patients’ daily lives, struggles, and priorities can both under- mine and support disease management efforts. After lunch participants toured the “Breathmobile,” a pediatric asthma clinic on wheels that visits elementary National Health Policy Forum | www.nhpf.org 9 Los Angeles Site Visit Report April 18–20, 2006 schools throughout the county to ensure that children with asthma receive appro- priate medications and care management. The group then traveled to Kaiser Permanente’s (KP) Whittier Medical Offices for a demonstration of Health Connect, KP’s cutting edge electronic health record. In addition to observing how a clinician would access and use the record during a patient encounter, the group also learned of KP’s efforts to customize the EPIC- based software, train its clinical staff, and link advances in health information technology to a broader vision for improving the quality of care received by KP members. The unique flexibility and opportunities offered by KP’s integrated de- livery system were discussed. Next, issues related to the dissemination of health information technology to safety net providers were explored. Efforts by The Tides Foundation to improve informa- tion systems in community health centers throughout the state were described and the special challenges facing safety net providers were discussed. A representative from one network of federally funded community health centers shared that organization’s experience in piloting an electronic health record and raised a variety of cautions safety net providers should heed in considering commercial software products, which are typically designed for private, mainstream medical practices. The final day of the site visit began with a focus on mental health services. The group learned about the role and structure of the Los Angeles County Department of Mental Health (DMH), its relationship to DHS, and its plan for expanding and improving publicly sponsored mental health services throughout the county through the addition of Proposition 63 (the Mental Health Services Act), which was enacted in a November 2004 referendum to provide increased funding for mental health. The group then traveled south to Long Beach to visit the Village, a nationally ac- claimed model for providing integrated services to persons with severe mental ill- ness. The group toured the Village’s facility and learned about the broad range of psychiatric, social, housing, vocational, and case management services available to homeless and formerly homeless people struggling with mental disorders and/or substance abuse issues. Funded largely by Medicaid and grant dollars from DMH, the Village seeks to help clients lead independent, fulfilling lives. Psychiatric treat- ment to reduce the distress caused by the symptoms of mental illness is just one component of a constellation of services structured around client empowerment and involvement. The services available through the Village were compared and contrasted with the outpatient mental health services generally available through DMH, and plans to expand the Village model through the state and country were discussed. The group then enjoyed lunch with Village clients and staff who shared their personal stories of recovery. Next the group traveled to Harbor-UCLA Medical Center, a 550-bed public hos- pital in Torrance that is one of four acute care hospitals operated by DHS. The visit began with an overview of Harbor’s inpatient and outpatient services and a tour of the Level I trauma center’s busy emergency department. Members of the medical staff’s senior leadership then participated in a panel discussion to explore how the crowded emergency department conditions reflect tensions in National Health Policy Forum | www.nhpf.org 10 Los Angeles Site Visit Report April 18–20, 2006 providing appropriate primary care services through an under-resourced system facing significant acute care needs. Speakers described steps that have been taken to expand access to primary care and outpatient specialty services. However, they also noted that prevailing financial incentives related to Medicaid reimbursement and DHS budgetary policies continue to focus available resources on responses to acute health crises rather than robust access to primary care and rigorous care management. They also commented that funding their teaching mission is diffi- cult because federal graduate medical education funds are distributed based on the Medicare inpatient population, although few Medicare beneficiaries seek care at Harbor-UCLA. The site visit concluded with a wrap-up panel of health care administrators re- sponsible for leading large health plans and integrated health care systems. The facilitated discussion focused on the future of care management and explored the potential of pay for performance, health information technology, outcome reporting, enhanced patient communication, consumer-driven care, and other tools for improving quality and containing costs. Speakers were hopeful regard- ing the continuing evolution of care management but were candid about the limitations of these strategies. IMPRESSIONS After the site visit, participants were asked to reflect on their experiences and obser- vations. The following are their key impressions from the presentations and tours, as well as additional insights developed during a follow-up debriefing session. Los Angeles appears to exemplify many of the challenges facing the country’s health care system, such as a rising number of uninsured persons, an increasing burden of chronic diseases, a fragmented delivery system, and misaligned financing incentives. LA is illustrative, if not on the leading edge, of the health care access challenges facing many communities across the country. Many factors make appropriate and rational service delivery a major challenge: a service-dominated economy with limited and decreasing employer-sponsored insurance coverage; a signifi- cant low-income, undocumented immigrant population; devolution of indigent care responsibility to the county paired with revenue raising constraints because of statutory barriers to taxing; and a tendency to politicize health care delivery system decisions. The state of the county’s emergency care system is tenuous at best. Emergency department crowding, boarding admitted patients in the ED until an inpatient bed becomes available, and diverting ambulances are daily occurrences. The sys- tem can barely manage day-to-day demand, much less the influx that would re- sult from a major natural disaster or terrorist event. Traffic gridlock, congestion and poor air quality from activity at the Long Beach port, and limited public trans- portation contribute to poor health status and limit access to health care services for many. Given the diversity of the population, delivering culturally and linguis- tically appropriate care is another consideration for any effort to address the delivery system problems. National Health Policy Forum | www.nhpf.org 11 Los Angeles Site Visit Report April 18–20, 2006 For the insured—few of whom seek care in the county delivery system—Medi- IMPRESSIONS care, Medicaid, and private insurance coverage continue to reward an inpatient orientation over an outpatient one. The financial incentives are misaligned on the safety net side as well. The Medicaid DSH program distributes funds based on inpatient volume; therefore, shifting to a primary care–focused system in hopes of decreasing inpatient demand would result in less safety net funding. Several site visit speakers noted that more flexibility to use DSH funds for primary care in- stead of inpatient care services would facilitate a greater emphasis on prevention and primary care. Optimizing outcomes for people with chronic health conditions requires a patient-centered approach that coordinates services and broadly supports com- pliance with both medical and non-medical disease interventions, which is diffi- cult to achieve under current conditions. Getting patients to adopt healthier behaviors and proactively manage their condi- tions is critical for improving chronic disease outcomes, but the low-tech tools for doing so, such as using community health workers to provide nutrition and exer- cise counseling, are typically not reimbursed by insurers. Sustaining successful outcomes over time, such as lowered HbA1c levels for diabetics, requires signifi- cant resources and leadership. Integrated, capitated systems like the Kaiser Permanente model or medical groups like HealthCare Partners and Family Care Specialists reap the financial benefits of an investment in these prevention strate- gies. But, for those who are insured and seek care outside these organized sys- tems, the fragmented delivery system discourages an investment in prevention because the cost savings accrue to some other provider in the system. Integrated models like the Village illustrate that services are best when coordinated and co- located. Managed care “carve outs” for mental health and the latest wave of dis- ease management contractors further stress the delivery system. Innovation is possible but requires substantial commitment, leadership, and (of- ten) targeted funding, making such innovations difficult to sustain and even more difficult to replicate. Innovation happens because one or a handful of visionary leaders who are com- mitted to creating a patient-centered culture do so, despite the delivery system’s pressures to do otherwise. A key challenge is determining how the federal gov- ernment can foster such leaders and the cultures they create and find ways to replicate them. In the case of the Village, the flexibility afforded by the optional rehabilitation service category in Medicaid is critical, yet in a time of budget con- straints, many policymakers question whether Medicaid should be paying for the social supports intrinsic to the Village model that have been demonstrated to re- duce disability and risk of relapse or hospitalization. Further cost-benefit analyses of the model would be instructive. National Health Policy Forum | www.nhpf.org 12 Los Angeles Site Visit Report April 18–20, 2006 Safety net funding appears to be inadequate to meet the needs of the poor and IMPRESSIONS uninsured and is clearly geared toward acute, inpatient services. Financing streams such as DSH and graduate medical education (GME) are not transparent and ap- pear to compound the inpatient orientation. The income disparity in LA is glaring. At once it is the home of Hollywood’s celeb- rities and burgeoning immigrant and homeless populations. The places these dif- ferent populations seek health care are as disparate as the neighborhoods where they live. Some question whether the nonprofit hospitals in the county should be doing more in the community benefit realm to take some pressure off of the county system, particularly in light of the challenges at Martin Luther King, Jr./ Drew Medical Center. The different approaches of providing insurance coverage for the uninsured versus funding the public system need to be carefully examined in the LA context. Once individuals become insured, they typically seek care outside of the county delivery system, taking that critical revenue with them. For example, Medi-Cal’s obstetrics reimbursement rates are seen as favorable by private providers, so most pregnant Medi-Cal beneficiaries receive care outside the county hospitals. Those who do stay in the city system tend to be the high-risk cases at a greater expense to the county. Likewise, few of the uninsured, once they age into Medicare, get their care through the county system; they receive it in the private system that welcomes their Medi- care coverage. Because GME dollars flow based on the Medicare inpatient popula- tion served by a facility, the county hospitals receive significantly fewer dollars per resident. Whereas the national average Medicare GME hospital payment per resi- dent is around $75,000, LA county hospitals receive less than $15,000. More than a decade after the initial LA waiver and its extension that expired in 2005, its achievements are unclear. While the Public-Private Partnership program appears to have been successful in expanding the available primary care resources for the uninsured population of the county, a lack of baseline data makes it unclear whether more people are being served than before the creation of the program. And, although the construction of a new facility for “Big County” Los Angeles County/University of Southern California Hospital will result in fewer inpatient beds, the fundamental ori- entation of the county system remains focused on acute care rather than primary care. Traditional provider training and workforce shortages (particularly for nurses, in light of California’s staff ratio requirements) also perpetuate a hospital-based, acute care model. Because training for a wide variety of health professionals, including physicians and nurses, continues to be concentrated in inpatient settings, an acute, episodic orientation to care management is perpetuated. New providers are trained and then practice in a care model that does not support long-term monitoring and integration across disciplines. Traditional roles and responsibilities are reinforced with little opportunity to modify professional expectations regarding quality of care. Labor market dynamics may also be hindering efforts to shift emphasis to pri- mary and preventive care. California is experiencing a severe nursing shortage, National Health Policy Forum | www.nhpf.org 13 Los Angeles Site Visit Report April 18–20, 2006 which has been highlighted by well publicized struggles hospitals are facing in meet- IMPRESSIONS ing mandatory staffing ratios. These staffing requirements have put pressure on hospitals to offer increasingly generous compensation packages to nursing staff. Primary care clinics and other outpatient settings report difficulties competing with these escalating salaries and are losing personnel to hospitals. This imbalance in access to a health professional workforce may contribute to the ongoing reliance on inpatient resources to deliver care, particularly in the public safety net system. Quality monitoring, pay-for-performance incentives, and health information tech- nology offer important tools for re-orienting the health care system but have lim- ited potential to be truly transformational absent other changes (such as improved integration of health care providers). In the under-resourced county system, these issues are a distraction from the day- to-day challenges of increasing demand and finite resources. For the insured and those in integrated models like Kaiser Permanente, electronic health records are an incredibly powerful albeit expensive care management tool. In the county system, no funds exist to distribute as pay for performance incentives to physicians but in the private system financial incentives do make a difference. The challenge is in identifying the right measures and ensuring that other measures do not suffer be- cause providers are practicing to the identified measures. Large financial bonuses are not necessary to make a difference, and the power of peer pressure (making public how physicians rank with their peers) should not be underestimated. It is unclear whether LA and California have too much democracy or too little. Local decision making through the five-member Board of Supervisors has contrib- uted to seemingly irrational resource allocation within the safety net. Similarly, the referendum process at the state level, while offering new funding streams like Propo- sition 63, adds layers of complexity and competing priorities to an already convo- luted delivery system. ENDNOTES 1. Robert Tranquada et al., “Sick System: A 10-Year Look at the Los Angeles Health Care System and Its Current State of Health,” LA Health Action (a project of Community Partners, funded by The California Endowment), November 2005; available at http://lahealthaction.org/library/ temp_file_LA_Health_Action_Report_Sick_System_November_2005.pdf. 2. Tranquada et al., “Sick System.” 3. Tranquada et al., “Sick System.” 4. Jeffrey Wasserman et al., “Financing the Health Services ‘Safety Net’ in Los Angeles County,” RAND Corporation, September 2004. 5. Wasserman, “Financing the Health Services.” 6. These funds were discontinued as a new, statewide waiver was approved in the place of the one formerly dedicated to LA County. 7. Tranquada et al., “Sick System.” 8. Allan Baumgarten, “California Health Care Market Report 2005,” California HealthCare Foundation, September 2005, p. 91; available at www.chcf.org/documents/hospitals/CAHealthCareMarketRep2005.pdf. National Health Policy Forum | www.nhpf.org 14 Los Angeles Site Visit Report April 18–20, 2006 Tuesday, April 18, 2006 AGENDA Afternoon Arrival in Los Angeles and check-in at headquarters hotel [Millennium Biltmore Hotel, 506 South Grand Avenue, Los Angeles] 3:00 pm Welcome and Introductions [Heinsbergen Room] OVERVIEW: THE STATE OF THE COUNTY’S HEALTH AND HEALTH SYSTEM Robert Tranquada, MD, Professor Emeritus of Medicine and Public Policy, University of Southern California Yolanda Vera, JD, Director, LA Health Action Jonathan Freedman, Chief, State Legislative Policy, County of Los Angeles Chief Administrative Office ■ What is the history of the health care delivery and financing systems in Los Angeles (LA) County? What impact have California’s strict limitations on tax increases played in health and other public programs? ■ How many county residents are uninsured? What percentage of the population receives coverage under public programs, including Medicare, Medicaid, and other programs? ■ What unusual demographic and socioeconomic features are present in LA county? How do undocumented people affect LA’s health care issues? ■ What role has the substantial presence of managed care delivery systems played in public and private systems? How influential are managed care plans, independent practice associations (IPAs), and physician groups in ensuring that high quality care is delivered? ■ How are county-provided health care services organized and financed? How are funds allocated to provider organizations within the county-based safety net? How many people depend on these services? ■ What are the unique features of Medi-Cal, California’s Medicaid program, in LA? What were the key components of the LA County 1115 waiver? How did the waiver affect the nature and structure of county and state programs that provide care to the underserved, including the Medi-Cal population? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 15 Los Angeles Site Visit Report April 18–20, 2006 Tuesday, April 18, 2006 / continued AGENDA 4:30 pm THE VIEW FROM SACRAMENTO: STATE HEALTH POLICY PRIORITIES Sandra Shewry, Director, California Department of Health Services ■ What are the State’s current priorities in health care financing and delivery? ■ What characterizes the relationship between LA and Sacramento? Is LA, because of its size and problems, the 800- pound gorilla in California health policy? ■ How did the LA waiver influence state level activities? ■ What is the status of current California 1115 waiver efforts? ■ What impact are pending state policy changes likely to have on the financing and structure of the LA county health care system? 5:30 pm Adjournment 6:00 pm Reception [Bernard’s Room] 7:30 pm Dinner on your own, if desired Wednesday, April 19, 2006 7:30 am Breakfast available [Heinsbergen Room] Video – “Understanding the Cultural Framework of Communication” 8:00 am FOCUS ON CALIFORNIA’S CHILDREN: INITIATIVES IN EARLY CHILDHOOD DEVELOPMENT AND HEALTH COVERAGE Peter Long, Director of Research and Planning, The California Endowment ■ What is California’s First Five program? How have early childhood programs evolved in the state? ■ What is the status of statewide efforts to enroll all children in health coverage programs? How did this effort get started, and how is it financed? ■ How might the movement toward universal coverage for children play out over the next few years? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 16 Los Angeles Site Visit Report April 18–20, 2006 Wednesday, April 19, 2006 / continued AGENDA 8:45 am Bus Departure – Edward R. Roybal Comprehensive Health Center [245 South Fetterly Avenue, Los Angeles] 9:15 am A COUNTY CLINIC: THE EDWARD R. ROYBAL COMPREHENSIVE HEALTH CENTER [East and West Auditorium] Harry Furuya, Administrator, Roybal Health Center G. Michael Roybal, MD, Medical Director, Roybal Health Center ■ How many patients are seen annually at the Roybal Center? What is the budget? How many providers are employed? What is the payer mix? ■ What primary and specialty services does the Roybal Center provide? ■ What is the Roybal Center’s service area? How does it fit into the overall county health care system? ■ Are capacity levels at the Roybal Center adequate to meet the needs of its service area? Is its referral network for specialty services sufficient to meet patient needs? 9:30 am Tour – Roybal Comprehensive Health Center 10:00 am REENGINEERING CLINICAL PRACTICE TO MANAGE CHRONIC DISEASES [East and West Auditorium] Jeffrey Guterman, MD, Medical Director, County of Los Angeles Department of Health Services, and Professor of Medicine, David Geffen School of Medicine, University of California Los Angeles ■ What does disease management mean? Is there a difference between disease management and care management? ■ What impedes providers from utilizing disease management programs? Are the clinical and financial incentives aligned to encourage disease management? ■ What approaches to disease management have been considered by the county, and what techniques have been most successful? ■ How is it possible to manage care effectively in a system with a diverse, low-income patient population, strained primary care capacity, limited specialty referral, and tight budgets? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 17 Los Angeles Site Visit Report April 18–20, 2006 Wednesday, April 19, 2006 / continued AGENDA 10:15 am MODELS THAT WORK: INNOVATIONS IN DIABETES CARE Anne Peters, MD, Director, University of Southern California Clinical Diabetes Programs Susan Fleischman, MD, Board Member, Venice Family Clinic and Medical Director, State Sponsored Programs, Wellpoint Hector Flores, MD, Medical Director, Family Care Specialists Medical Group ■ What are the key elements of your diabetes management program? From the provider, staff, and patient perspectives, how does care differ once disease management is implemented? ■ How many patients are enrolled, and how are they selected? ■ How do financing realities impede or boost your ability to better manage patients with diabetes? ■ How are language and culture issues addressed in the program? ■ How important is community-based health education and health promotion? ■ What role does or could health information technology (HIT) play in helping or hindering the program? ■ What health outcomes have been achieved? What challenges does the program continue to face in improving both health outcomes and the program itself? 11:15 am MANAGING PEDIATRIC ASTHMA: MOBILE OR MEDICAL HOME? Elisa A. Nicholas, MD, Executive Director, The Children’s Clinic Craig Jones, MD, Director, Allergy Immunology, Los Angeles County/University of Southern California Healthcare Network ■ What are the key elements of the asthma management program? From the provider, staff, and patient perspectives, what makes the care provided in the program different from care provided elsewhere? ■ How many patients are enrolled and how are they selected? ■ How do financing realities impact your ability to better manage asthma? ■ What are the greatest challenges the program faces in managing asthma? Do cultural issues come into play and how are they addressed? What role does technology play? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 18 Los Angeles Site Visit Report April 18–20, 2006 Wednesday, April 19, 2006 / continued AGENDA 11:15 am MANAGING PEDIATRIC ASTHMA…continued ■ What health outcomes has the program achieved? ■ To what extent do disease management efforts address environmental triggers like housing and air quality? Noon Lunch and Informal Discussions with promotores and other community workers Tour – Breathmobile 1:15 pm Bus Departure – Kaiser Permanente Whittier Medical Offices [12470 Whittier Boulevard, Whittier – First floor conference room] 2:00 pm HEALTH INFORMATION TECHNOLOGY (HIT): POTENTIAL AND PERILS Jane Stafford, Senior Program Officer, Tides Foundation Thomas Farnham, MD, Chief of Staff, AltaMed Health Services John E. Mattison, MD, Assistant Medical Director and Chief Medical Information Officer, Kaiser-Permanente, Southern California ■ What is the overall status of HIT and the use of electronic health records in California and in LA? Are there statewide initiatives, or are there active Regional Health Information Organizations (RHIO)? What is Health-e-LA? ■ How well have safety net clinics and facilities adopted information technology and electronic health records? ■ What challenges do safety net facilities encounter in developing or adopting HIT programs? Are there special initiatives to support safety net efforts? ■ What were Kaiser’s goals in developing an electronic health record system? How has Kaiser approached the development and initiation of an electronic health record system? What is Kaiser’s perspective on the return on investment for HealthConnect? 3:00 pm HIT IN ACTION: DEMONSTRATION AND DISCUSSION OF HEALTH CONNECT John E. Mattison, MD (see above) Christine M. Calderon, MD, Family Practice Physician, Whittier Medical Offices Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 19 Los Angeles Site Visit Report April 18–20, 2006 Wednesday, April 19, 2006 / continued AGENDA 3:00 pm HIT IN ACTION…continued Beth A. Lopez, Manager, Whittier Medical Offices ■ What components of HealthConnect are being used in the Whittier physician offices? How long have they been in use? What capabilities are being added in the future? ■ How have physicians reacted to the system? Patients? Nurses? Staff? ■ What type and frequency of training do you provide to providers and staff? ■ What role might HealthConnect play in helping Kaiser’s efforts to be culturally and linguistically competent providers of care? 4:00 pm Bus Departure – Santa Monica 5:00 pm Free time 6:00 pm Cocktails and Dinner – Shutters Hotel, Handlebar Room [One Pico Boulevard, Santa Monica] 8:30 pm Bus Departure – Headquarters hotel Thursday, April 20, 2006 7:30 am Breakfast available [Heinsbergen Room] 8:00 am MENTAL HEALTH SERVICES IN LOS ANGELES COUNTY: PAST, PRESENT, AND FUTURE Marvin J. Southard, DSW, Director, County of Los Angeles Department of Mental Health ■ How are mental health services in LA County organized and financed? ■ What is the relationship between the county’s Department of Mental Health Services (DMH) and the Department of Health Services? ■ What is the demographic profile of the population that uses county-sponsored mental health services? How has the county tried to meet the special needs of this diverse population? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 20 Los Angeles Site Visit Report April 18–20, 2006 Thursday, April 20, 2006 / continued AGENDA 8:00 am MENTAL HEALTH SERVICES IN LOS ANGELES COUNTY…continued ■ What proportion of the population served by DMH is homeless? What proportion of LA’s homeless population is believed to have a mental illness? ■ To what extent do private sector providers meet the mental health service needs of the uninsured or persons covered by Medi-Cal? ■ Are existing services adequate and appropriate to meet the needs of low-income and uninsured persons in the county? ■ What is “Prop 63,” and what plans are underway to use the anticipated funding from this new source? 8:45 am Bus Departure – The Village [456 Elm Avenue, Long Beach] Overview of homelessness in Los Angeles Driving tour – Skid Row area 9:30 am INTRODUCTION TO THE VILLAGE [City View Room, 3rd Floor] Martha Long, Program Director, The Village ■ What is the history of the Village? How large is the program, in terms of patients, providers, and budget? ■ What are the key features of the Village’s philosophy and service delivery? 10:00 am Tour – The Village Rotations through five stations: psychiatric services, medical services, housing, job placement, and case management 10:45 am REALITY CHECK: THE LOS ANGELES MENTAL HEALTH SYSTEM Richard Van Horn, President and Chief Executive Officer, Mental Health Association of Greater Los Angeles (MHALA) ■ To what extent is the Village representative of mental health services available through the county-based system? ■ Are existing mental health service capacity levels adequate and appropriately structured to meet current needs throughout the county? ■ To what extent will Prop 63 funding address perceived inadequacies? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 21 Los Angeles Site Visit Report April 18–20, 2006 Thursday, April 20, 2006 / continued AGENDA 11:00 am INTEGRATED MENTAL HEALTH SERVICES: BEYOND THE MEDICAL MODEL Mark Ragins, MD, Medical Director, The Village Dave Pilon, PhD, Training, Consultation and Evaluation, The Village ■ What types of services are needed to manage the care of persons with severe mental illness? How are services coordinated with providers outside the Village? ■ What are the benefits of integrating social, medical, and mental health services? Are costs greatly increased in this model? Why, or why not? ■ How has the new prescription drug benefit under Medicare influenced care management at the Village? ■ How are the diverse racial and cultural backgrounds of Village clients addressed? ■ What challenges will likely be faced in efforts to replicate the Village model? To what extent do existing financing incentives discourage broader adoption of this model? ■ What types of performance metrics can be used to ensure that integrated care leads to improved patient outcomes? 11:45 am Lunch and informal discussions with staff and consumers Introductions by Chad Costello, Director, Public Policy, MHALA 12:30 pm Bus Departure – Harbor-UCLA Medical Center [1000 West Carson Street, Torrance] 1:00 pm Tour – Harbor-UCLA Emergency Department 1:30 pm OVERVIEW OF HARBOR-UCLA [Assembly Room] Miguel Ortiz-Marroquin, Chief Operating Officer ■ How many patients are served in the hospital? By what types of providers? What is the hospital budget? What is the payer mix? ■ How does Harbor-UCLA fit into the overall county hospital and clinic system? How does the affiliation with the university affect the operations at Harbor-UCLA? ■ What are the principal challenges to providing care in this county facility? Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 22 Los Angeles Site Visit Report April 18–20, 2006 Thursday, April 20, 2006 / continued AGENDA 1:30 pm OVERVIEW OF HARBOR-UCLA…continued ■ How have problems at King-Drew Medical Center affected Harbor-UCLA? ■ How does the population of undocumented people in LA County affect the hospital, the emergency department, and specialty clinics? 1:45 pm IS IT POSSIBLE TO MOVE FROM CRISIS MANAGEMENT TO CARE MANAGEMENT? Gail V. Anderson, Jr., MD, Medical Director, Harbor-UCLA Robert Hockberger, MD, Chair, Department of Emergency Medicine, Harbor-UCLA Dennis Levin, MD, Associate Medical Director and Director of Ambulatory Care, Harbor-UCLA ■ To what extent does inaccessible or poorly managed primary care influence emergency department (ED) crowding at Harbor-UCLA? What other factors come into play? ■ What are the most common types of conditions seen in the ED? ■ What steps have been taken to reduce ED overcrowding? ■ What steps have been taken to expand and/or improve primary care capacity? Have existing financial incentives hindered these efforts? What other challenges have been faced? ■ How are specialty referrals supposed to work in the county system? Do they work as intended? ■ How does the diversity of the population served affect the provision of emergency services? In what ways has Harbor- UCLA addressed these diverse cultural and linguistic needs? ■ To what extent does Harbor-UCLA’s teaching mission influence the nature and mix of services offered? How does the teaching mission support and/or complicate Harbor-UCLA’s health care safety net mission? 3:15 pm Bus Departure – Headquarters hotel Agenda / continued ➤ National Health Policy Forum | www.nhpf.org 23 Los Angeles Site Visit Report April 18–20, 2006 Thursday, April 20, 2006 / continued AGENDA 4:00 pm IT’S A WRAP: CARE MANAGEMENT, PAY FOR PERFORMANCE, HIT, AND OTHER FUTURE DIRECTIONS [Heinsbergen Room] Benjamin Chu, MD, President, Southern California Region, Kaiser Foundation Health Plan, Inc. and Hospitals Jeffrey Guterman, MD (see Wednesday, 10:00 am) Howard Kahn, Chief Executive Officer, LA Care Health Plan Dan Temianka, MD, Medical Director, Quality Management, HealthCare Partners ■ What appear to be the most promising strategies for improving outcomes and constraining health care costs? Are these goals synergistic or mutually exclusive? ■ What is the status of pay for performance (P4P) and other quality monitoring initiatives? How should P4P incentives be structured to ensure optimal impact? What level of funding is needed to create meaningful incentives? ■ What structural changes (such as electronic medical records, enhanced patient communication mechanisms, and strengthened health education) are needed to significantly improve care coordination? What will influence providers’ willingness to make such changes? ■ Are special considerations necessary to adapt care management strategies for poor, vulnerable, and racially and ethnically diverse patients? Are the providers who serve these patients willing or ready to adopt these strategies? ■ How are the public and private delivery systems in LA likely to evolve in the future? Are these systems likely to become more or less integrated? What role are advances in health information technology likely to play in this evolution? 5:30 pm Adjournment 6:00 pm Walk to dinner at Café Pinot [700 West Fifth Street, Los Angeles] 8:00 pm Walk back to headquarters hotel Friday, April 21, 2006 Morning Check-out from headquarters hotel National Health Policy Forum | www.nhpf.org 24 Los Angeles Site Visit Report April 18–20, 2006 Federal and Foundation Participants Kathryn Allen Alice Lam Director, Health Care Presidential Management Fellow (D) Government Accountability Office Committee on Health, Education, Labor and Pensions Evelyne Baumrucker U.S. Senate Analyst in Social Legislation Domestic Social Policy Division Temina Madon, PhD Congressional Research Service 2005-2006 AAAS Health Policy Fellow (D) Committee on Health, Education, Christopher Carroll Labor and Pensions Public Health Advisor U.S. Senate Center for Mental Health Services Substance Abuse and Mental Kate Massey Health Services Administration Program Examiner Health Division David Colby, PhD Office of Management and Budget Deputy Director Research and Evaluation Linda Minamoto Robert Wood Johnson Foundation Associate Regional Administrator San Francisco Regional Office Ruth Ernst, JD Centers for Medicare & Assistant Counsel Medicaid Services Office of the Legislative Counsel U.S. Senate Katie Simons Pahner Health Insurance Specialist April Grady Medicaid Analysis Group Analyst in Social Legislation Office of Legislation Domestic Social Policy Division Centers for Medicare & Congressional Research Service Medicaid Services Deborah Greene Steve Redhead 2005-2006 Congressional Black Caucus Foundation Fellow Head, Health Services, Research, & Aging Office of Rep. Donald M. Payne (D-NJ) Policy Section Domestic Social Policy Division U.S. House of Representatives Congressional Research Service Suzanne Hassett Policy Coordinator Kenneth Serafin, JD Office of the Secretary Professional Staff Member (R) Subcommittee on Health Department of Health and U.S. House of Representatives Human Services Lisa Herz, PhD Deborah Williams Specialist in Social Legislation Professional Staff Member (R) Committee on Ways and Means Domestic Social Policy Division U.S. House of Representatives Congressional Research Service Roger Johns, MD, MHS 2005-2006 RWJF Health Policy Fellow Office of Sen. Orrin Hatch (R-UT) Committee on the Judiciary U.S. Senate National Health Policy Forum | www.nhpf.org 25 Los Angeles Site Visit Report April 18–20, 2006 NHPF Staff Christopher Loftis Eileen Salinsky Research Associate Principal Research Associate Judith D. Moore Jessamy Taylor Senior Fellow Research Associate Jennifer Ryan Marcia Howard Senior Research Associate Program Associate National Health Policy Forum | www.nhpf.org 26 Los Angeles Site Visit Report April 18–20, 2006 Biographical Sketches Federal and Foundation Participants Kathryn Allen is director for Medicaid and private health insurance issues in the Government Accountability Office (GAO, formerly the General Accounting Office). Within GAO’s body of work on health care issues, Ms. Allen directs work on Medic- aid, the State Children’s Health Insurance Program (SCHIP), long-term care, and private health insurance. GAO’s recent work in these areas has included quality of care in nursing homes, home health, assisted living facilities, and home- and community- based services; Medicaid managed care for high-risk populations, in- cluding persons with disabilities and children with special needs; and states’ imple- mentation of SCHIP. Other studies have addressed medical malpractice and access to care, retiree health coverage, small business and individual market insurance coverage, and implementation of HIPAA (the Health Insurance Portability and Ac- countability Act of 1996) and the Mental Health Parity Act. Since joining GAO in 1976, Ms. Allen has also held leadership positions in GAO’s Seattle and European field offices. From 1987 to 1988, she provided staff support to the National Commis- sion to Prevent Infant Mortality. Ms. Allen graduated magna cum laude in business administration from the University of Richmond in Virginia. She has received nu- merous awards from the GAO, including its Meritorious Service Award. Evelyne Baumrucker is an analyst in social legislation with the Domestic Social Policy Division of the Congressional Research Service (CRS). In her eight years with CRS she has worked on Medicaid and State Children’s Health Insurance Program (SCHIP) issues with a primary focus on health care coverage for families with dependent children, pregnant women, and low-income adults. She also pro- vides the Congress with expertise on Medicaid and SCHIP section 1115 waiver programs. Before joining CRS, Ms. Baumrucker earned a bachelor of arts degree from the Pennsylvania State University, and a master’s degree in administration from the George Washington University. Christopher Carroll is a public health advisor and special assistant to the director of the Center for Mental Health Services (CMHS) within the Substance Abuse and Mental Health Services Administration. Mr. Carroll has an extensive background in mental health administration, organizational management, and behavioral health systems operations. While at CMHS, he has worked on external collaborations with the Institute of Medicine, the World Bank, the National Business Group on Health, and the International Initiative for Mental Health Leadership. He is currently work- ing on a project with the Joint Commission on Accreditation of Healthcare Organi- zations (JCAHO), the National Association of State Mental Health Program Direc- tors (NASMHPD), the American Psychiatric Association (APA), and the National Association of Psychiatric Health Systems (NAPHS) for the purpose of developing a set of core performance measures for hospital-based inpatient psychiatric services. National Health Policy Forum | www.nhpf.org 27 Los Angeles Site Visit Report April 18–20, 2006 Prior to his work at CMHS, Mr. Carroll worked for the Sisters of Mercy Healthcare Network as director of operations for the behavioral health system. Mr. Carroll re- BIOGRAPHICAL ceived his master’s degree in international health economics and policy from Bocconi SKETCHES University in Milan, Italy. Participants David Colby, PhD, is the deputy director of research and evaluation at the Robert Wood Johnson Foundation. Formerly, he was the deputy director of the Health Care Group, interim team leader for the Quality Team, and team leader for the Coverage Team at the Foundation. Dr. Colby joined the Foundation in January 1998 after nine years of service with the Medicare Payment Advisory Commission (MedPAC) and the Physician Payment Review Commission (PPRC), where he was deputy director. Previously, he was with the University of Maryland–Baltimore County, where he was associate professor in the Policy Science Graduate Program and coordinator of the Masters of Policy Science Program. Dr. Colby was also a Robert Wood Johnson faculty fellow in Health Care Finance, serving in the Congressional Budget Office. Prior to his policy work, he was dean of freshmen and assistant dean at Williams College and held faculty positions at Williams College and State University College at Buffalo. Dr. Colby’s published research has focused on Medicaid and Medicare, media coverage of AIDS, and various topics in political science. He was an associate editor of the Journal of Health Politics, Policy and Law from 1995 to 2002. Dr. Colby received a PhD degree in political science from the University of Illinois, a master’s degree in administration from Ohio University, and a bachelor of arts degree from Ohio Wesleyan University. Ruth Ernst, JD, has been an assistant counsel with the U.S. Senate’s nonpartisan Office of the Legislative Counsel since 1994. She prepares and provides advice on health, welfare and social security legislation. Ms. Ernst has worked on a wide range of legislation, including the provisions of the Deficit Reduction Act of 2005 relating to the Medicaid and State Children’s Health Insurance Programs (SCHIP) and the reauthorization of the Temporary Assistance for Needy Families program, as well as the child care, child support, child welfare, and supplemental security income provisions in that legislation. She was also involved with the health insurance tax credit provisions in the Trade Act of 2002, the provisions in the Balanced Budget Act of 1997 relating to Medicaid, and the creation of SCHIP and the Personal Responsi- bility and Work Opportunity Reconciliation Act of 1996. Prior to joining the Senate Legislative Counsel’s Office, Ms. Ernst served as a law clerk to the Honorable Danny J. Boggs of the United States Court of Appeals for the 6th Circuit from 1987 to 1988, worked as an associate in a private law firm in Washington, DC, from 1988 to 1990, and was an assistant United States attorney for the western district of Michigan from 1990 to 1993. Ms. Ernst graduated cum laude from Mount Holyoke College in 1984 and obtained a JD degree from the University of Chicago Law School in 1987. April Grady is an analyst in social legislation with the Congressional Research Service (CRS). Her work focuses on Medicaid issues, including financing, admin- istration, and program integrity. Before joining CRS, she worked at the Center for Health and Social Policy at the LBJ School of Public Affairs and at Mathematica Policy Research. She holds a master of public affairs degree from the University of Texas at Austin and a bachelor of arts degree from Syracuse University. National Health Policy Forum | www.nhpf.org 28 Los Angeles Site Visit Report April 18–20, 2006 Deborah Greene is currently a fellow with the Congressional Black Caucus Foun- dation working in the office of Representative Donald M. Payne (D-NJ). Her top- BIOGRAPHICAL ics of focus include health, environment, animal, energy, telecommunications, SKETCHES banking, and internet policy issues. Ms. Greene possesses extensive practical ex- Participants perience with health delivery services, having worked with multiple Boston area charities and health delivery programs. She recently received a master’s degree in public health from Boston University. Suzanne Hassett is a policy coordinator in the Office of the Secretary of Health and Human Services, where she is responsible for coordinating policy informa- tion regarding Medicaid and the State Children’s Health Insurance Program (SCHIP). Before coming to the Office of the Secretary, Ms. Hassett worked in the Office of the Administrator of the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services), primarily on Medicaid and SCHIP issues. She also spent five years working in the office of Senator Jack Reed (D-RI). Lisa Herz, PhD, is a specialist in social legislation in the Domestic Social Policy Division at the Congressional Research Service (CRS). Her primary areas of ex- pertise include Medicaid (eligibility and benefits for children, families, and preg- nant women; financing; upper payment limits; and managed care), and the State Children’s Health Insurance Program. Prior to joining CRS in 1999, Dr. Herz was an analyst with The MEDSTAT Group, a private health care research consulting firm. She has had over 25 years of experience in the health care field. Dr. Herz holds a PhD degree from Loyola University of Chicago. Roger Johns, MD, is a Robert Wood Johnson/Institute of Medicine Congres- sional Health Policy Fellow in the office of Senator Orrin Hatch (R-UT). After medical school, Dr. Johns did an internship and residency in internal medicine and anesthesiology at the University of Virginia, followed by a clinical fellow- ship in cardiac anesthesia and a two-year research fellowship in pharmacology. In 1987 he joined the faculty at the University of Virginia as a cardiac anesthe- siologist and clinician-scientist. While at the University of Virginia, he completed an executive management program at the Darden School of Business Adminis- tration. Dr. Johns became vice chair of the Department of Anesthesiology of the University of Virginia in 1997 and assumed an acting chair position in 1998. In May of 1999, Dr. Johns accepted a position as the Mark C. Rogers professor and chairman of the Department of anesthesiology and critical care medicine at The Johns Hopkins University. Dr. Johns serves on the executive committee of the Innovations in Health Care Program at Hopkins. Recently he completed the master in health science program in health policy and management at The Johns Hopkins Bloomberg School of Public Health and is a candidate for a PhD degree in health policy and management, specializing in health services research. Alice Lam is a presidential management fellow in the Office of Legislation at the Centers for Medicare & Medicaid Services, where she is responsible for a portfolio of issues that includes Medicaid financing, the Medicare Part D low-income sub- sidy, and Medicaid coverage for special populations. As part of her fellowship, Ms. Lam is currently serving on the minority staff of the Senate Committee on Health, Education, Labor, and Pensions and covers policy issues related to HIV/AIDS, mental National Health Policy Forum | www.nhpf.org 29 Los Angeles Site Visit Report April 18–20, 2006 health, substance abuse, and disability. She has also completed rotations with the Georgetown University Health Policy Institute and the National Academy for State BIOGRAPHICAL Health Policy. Ms. Lam holds a bachelor of science degree in cognitive science SKETCHES from the University of California, Los Angeles, and a master of public administra- Participants tion degree in health policy and management from the Robert F. Wagner Graduate School of Public Service at New York University. Ms. Lam completed an adminis- trative residency at St. Vincent’s Hospital in New York City. Temina Madon, PhD, is a 2005-2006 congressional science and technology policy fellow, sponsored by the American Association for the Advancement of Science. She works on health information technology, international health, and health sci- ences issues for the minority health policy office of the Senate Committee on Health, Education, Labor, and Pensions. Prior to her fellowship, Dr. Madon worked at the University of California at Berkeley’s University Health Services department as a health services policy analyst. She completed a PhD degree in visual neuroscience at University of California, Berkeley, in 2004 and studied chemical and biomedical engineering as an undergraduate at the Massachusetts Institute of Technology. Kate Massey is a senior Medicaid analyst at the Office of Management and Bud- get (OMB). Her responsibilities include assisting in the formulation of the President’s legislative and regulatory agenda and briefing OMB and White House policy officials on current Medicaid issues. She has worked on a number of health policy issues while at OMB, including 1115 waiver policy, Medicaid reform, pro- gram integrity, private market health insurance initiatives, and Medicaid spend- ing trends. Ms. Massey received a bachelor of arts degree from Bard College and a master of public affairs degree from the Lyndon B. Johnson School of Public Af- fairs, University of Texas. Linda Minamoto has been the associate regional administrator for the Division of Medicaid and Children’s Health with the Centers for Medicare & Medicaid Services (CMS) in Region IX, the San Francisco regional office, since 1999. She is responsible for the federal administration of the Medicaid programs in Arizona, California, Hawaii, Nevada, and the Outer Pacific territories. Prior to becoming the associate regional administrator, Ms. Minamoto was a Medicaid branch manager to staff re- sponsible for overseeing, approving, and monitoring state Medicaid management information systems and Medicaid waivers. Prior to joining CMS, Ms. Minamoto held the positions of quality control chief in the Aid to Families with Dependent Children’s Branch of the Administration for Children and Families, Region IX, and deputy special studies and analysis officer in the Field Assessment Office of the Social Security Administration, Region IX. Ms. Minamoto holds a bachelor of arts degree in social welfare from the University of California, Berkeley. Katie Simons Pahner is a health insurance specialist in the Medicaid Analysis Group in the Office of Legislation at the Centers for Medicare & Medicaid Services (CMS), where she provides technical assistance on Medicaid and SCHIP policy issues. Prior to joining CMS, Ms. Pahner attended graduate school at the George Washington University (GWU), where she worked as a graduate assistant on the Government Performance Project, a comprehensive survey of all 50 state governments that is funded by The Pew Charitable Trusts. In addition to her work on the project, Ms. National Health Policy Forum | www.nhpf.org 30 Los Angeles Site Visit Report April 18–20, 2006 Pahner spent a summer interning with the Kaiser Family Foundation’s Commis- sion on Medicaid and the Uninsured. Before attending and working at GWU, she BIOGRAPHICAL was a project associate at the Council of Chief State School Officers, a national SKETCHES association representing public officials who head departments of elementary and Participants secondary education. Ms. Pahner holds a master’s degree in public administra- tion with a concentration in health policy from GWU and a bachelor’s degree in political science from Elon University in her home state of North Carolina. Steve Redhead is head of the Health Services, Research & Aging Policy Section at the Congressional Research Service (CRS), where he covers a range of health policy issues including patient safety, quality of care, and the electronic exchange of health information. Prior to joining CRS in 1992, Mr. Redhead taught zoology and physiology at George Mason University in Virginia, where he continued to teach as an adjunct faculty member until 2001. Mr. Redhead grew up in England and was educated at Cambridge University. He pursued graduate studies in com- parative anatomy and physiology at Aberdeen University, Scotland, before com- ing to the United States to study primatology at the State University of New York at Stony Brook. Kenneth Serafin, JD, is a member of the majority professional staff on the Sub- committee on Health Committee on Ways and Means Committee, U.S. House of Representatives, and he works on Medicare Part A and B issues. Previously he served as deputy chief counsel for the Pennsylvania Insurance Department and as chief counsel to a medical malpractice compensation fund. In addition to Medi- care, insurance, and medical malpractice issues, Mr. Serafin has worked on a variety of civil and criminal legal matters as an appellate court law clerk and an associate attorney in a private law practice. He also served as an adjunct profes- sor at Widener University School of Law. Mr. Serafin is a graduate of the Penn- sylvania State University and the Dickinson School of Law. Deborah Williams currently serves as member of the majority professional staff for the Committee on Ways and Means of the U.S. House of Representatives, which oversees Medicare, taxes, trade, Social Security, and welfare. For the Committee, she has worked on a broad array of Medicare national payment and coverage policy issues. Specifically, she was a lead staff member during the negotiations on provider payment issues during the Medicare Modernization Act of 2003. Ms. Williams is currently examining the issues around tax exemption. Previously, she was a senior analyst on the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare payment issues. For six years, Ms. Williams was responsible for Medicare hospital inpatient and outpatient issues for the American Hospital Association, working with government agencies, the Congress, hospital executives, and chief financial officers. In the early 1990s, Ms. Williams served as senior analyst for the Prospective Payment Assessment Commission (ProPAC, which became MedPAC). From 1986 to 1989, Ms. Williams worked as an economist for the Health Care Financing administration (HCFA), earning awards for her research. While at HCFA, she worked on the development of the national fee schedule for physicians, focusing on geographic payment issues. Ms. Williams was trained as an economist. National Health Policy Forum | www.nhpf.org 31 Los Angeles Site Visit Report April 18–20, 2006 Biographical Sketches Speakers Gail V. Anderson, Jr., MD, is the chief medical officer of the Harbor-University of California, Los Angeles (UCLA) Medical Center and professor and associate dean at the David Geffen School of Medicine at UCLA. He served as the acting chief medical officer for the Department of Health Services of the County of Los Ange- les from 2000-2002. Previously, Dr. Anderson spent 11 years as the director of the Grady Memorial Hospital Surgical Emergency Clinic. He was a director of the American College of Emergency Physicians, and he spent 16 years as an examiner for the American Board of Emergency Medicine. Dr. Anderson has been part of the medical aid teams responding to the earthquakes in Armenia, Turkey, and Pakistan and to the Guadalajara gas explosion. He also has participated in medi- cal exchange programs with countries from the former Soviet Union, particularly the Republic of Georgia. A graduate of Dartmouth College, Dr. Anderson received his medical degree from the University of Southern California and completed an internship in obstetrics and gynecology at the Los Angeles County, University of Southern California Medical Center. He completed a residency in emergency medi- cine at Grady Memorial Hospital and Emory University School of Medicine and completed a MBA program at the Emory University Business School. He is certi- fied by the American Board of Emergency Medicine, the American Board of Medi- cal Management, and the Certifying Commission in Medical Management. Christine M. Calderon, MD, is currently serving as physician in charge of the Family Medicine module at the Whittier Medical Office Building. She was origi- nally drawn to medicine as she participated in sports and enjoyed seeing the team doctors assist athletes. The ability to interact with her patients and help solve prob- lems is what Dr. Calderon really loves best about being a physician. A native of Southern California, Dr. Calderon completed her undergraduate education at the University of California at Berkeley. She attended medical school at University of Southern California and completed her residency at the Kaiser Permanente Wood- land Hills Medical Center. Dr. Calderon is a member of the American Academy of Family Physicians. Chad Costello is the director of public policy at the Mental Health Association of Greater Los Angeles (MHALA). Mr. Costello is currently working to influence the implementation of the Mental Health Services Act at the state and county levels. Using his experience as a former director of one of the MHALA Village’s case management teams, and as former director of programs for the Mental Health Association of Orange County, Mr. Costello focuses on reminding policymakers of the importance of adhering to the recovery model as well as its practical implications at the direct service level. At the Village, Mr. Costello helps instruct mental health workers from across the state and nation in the recovery National Health Policy Forum | www.nhpf.org 32 Los Angeles Site Visit Report April 18–20, 2006 model. He has provided trainings on a variety of mental health–related topics in California and across the country. He previously served as president of the Califor- BIOGRAPHICAL nia Coalition for Mental Health. Mr. Costello teaches part-time as an adjunct faculty SKETCHES member in policy at the Social Work Department at California State University, Long Speakers Beach. He also serves on the Advisory Committee for the soon-to-be initiated School of Social Work at California State University, Dominguez Hills, and on the Mental Health Advisory Group for the School of Social Work at the University of Southern California. Mr. Costello received his master’s degree in social work from the Uni- versity of Southern California. Benjamin Chu, MD, was appointed president of the Kaiser Foundation Health Plan, Inc., and Southern California Region of the Kaiser Foundation Hospitals in February 2005. Before joining Kaiser Permanente, Dr. Chu was president of the New York City Health and Hospitals Corporation (HHC), with primary respon- sibility for management and policy implementation. Previously, Dr. Chu was senior associate dean at Columbia University College of Physicians and Sur- geons. He also served as associate dean and vice president for clinical affairs at New York University Medical Center, managing and developing the clinical aca- demic hospital network. Dr. Chu is a primary care internist by training, with extensive experience as a clinician, administrator, and policy advocate for the public hospital sector. He was senior vice president for medical and professional affairs at HHC from 1990 to 1994. During that period, he also served as acting commissioner of health for the New York City Department of Health and acting executive director for Kings County Hospital Center. Dr. Chu served as legisla- tive assistant for health for Senator Bill Bradley as a 1989-1990 Robert Wood Johnson Health Policy Fellow. He has served on numerous advisory and non- profit boards that focused on health care policy issues. Dr. Chu received a master’s degree in public health from the Mailman School at Columbia University and his doctorate of medicine from New York University School of Medicine. Thomas Farnham, MD, has been affiliated with AltaMed Health Services Cor- poration in Los Angeles for 13 years, where he currently serves as chief of staff and chief medical officer. He also serves as associate medical director for sub- stance abuse services and oversees various provider quality improvement ac- tivities. Dr. Farnham has worked for 20 years in the greater East Los Angeles medical community with various community health organizations. Dr. Farnham received a bachelor’s degree in chemistry from the University of Oregon Honors College, a medical doctorate from Oregon Health Sciences University, and a master in public health degree in health services from University of California, Los Angeles. He completed his postgraduate medical training in Family Practice at UCLA. Board-certified in both Family Medicine and Geriatrics, Dr. Farnham has a special interest in advocating for and providing practical, cost-effective and culturally sensitive healthcare to the underserved. He has co-authored a chapter in a book on health care for the homeless. Susan Fleischman, MD, was the medical director of the Venice Family Clinic from 1987 until December 2004, where she was responsible for oversight of the clinical operation of the largest free clinic in the United States. Under her leadership, the National Health Policy Forum | www.nhpf.org 33 Los Angeles Site Visit Report April 18–20, 2006 clinic grew from a fledgling storefront operation to a multi-site community clinic serving over 18,000 patients in close to 100,000 visits in 2004. Dr. Fleischman also BIOGRAPHICAL provided oversight for the development of successful disease management programs SKETCHES for both diabetes and asthma. She currently serves on the clinic’s board. In 2005, Dr. Speakers Fleischman became a medical director at Blue Cross of California (now WellPoint), State Sponsored Business where she provides medical leadership to a health plan serving over 1.5 million people enrolled in publicly financed insurance programs. Dr. Fleischman is the immediate past president of the California Primary Care Asso- ciation (CPCA) and was the first physician to become the organization’s president. Dr. Fleischman continues to be active in statewide policy discussions regarding in- digent care, care for underserved populations, and chronic disease management. She is an associate clinical professor of Medicine at the University of California, Los Angeles in the Department of Internal Medicine. She is also a graduate of the Cali- fornia Healthcare Foundation Medical Leadership Fellowship. Hector Flores, MD, is medical director for Family Care Specialists (FCS) Medical Group. He is also the co-director of the White Memorial Medical Center Family Practice Residency Program. In addition, Dr. Flores serves as co-director for the Roosevelt High School Student Health Center, a school-based clinic serving stu- dents in a six-school complex. Dr. Flores is a member of the White Memorial Center Governing Board, chairs the Blue Cross of California Statewide Physician Advisory Board; and is a member of the L.A. Care Health Plan Quality Assurance and Medical Policy Committee and the California Task Force on Culturally and Linguistically Competent Physicians and Dentists. He was also a member of the University of California Medical Diversity Task Force. Dr. Flores graduated from Stanford Uni- versity with a bachelor of arts degree in history. He graduated with honors from the School of Medicine at the University of California-Davis and completed his internship and residency in family practice at the Kaiser Permanente Medical Center in Los Angeles. Dr. Flores served on the Clinton Health Care Task Force Hispanic Advisory Committee and was a member of the National Advisory Council of the National Health Service Corps. Jonathan Freedman is currently an assistant division chief in the Los Angeles County Chief Administrative Office. In this role, he coordinates a wide array of legislative issues for the county ranging from criminal justice and public works to health and welfare services. Mr. Freedman’s prior roles at the county level include director of planning for the Department of Health Services; director of the section 1115 Medicaid Demonstration Project for Los Angeles County; deputy director of Public Health Programs; special assistant to the Director of Health Services; and health, welfare, and environmental advisor to the Honorable Edmund D. Edelman, a former member of the Los Angeles County Board of Supervisors. Mr. Freedman is an alumnus of the University of California, Los Angeles, where he received his undergraduate degree in political science and a graduate degree in public health. Harry Furuya is the administrator of the Edward R. Roybal Comprehensive Health Center. Prior to joining the Roybal Center as assistant administrator, he spent 6 years working at Los Angeles County’s managed care health plan, and 11 years as a health facilities evaluator surveying health facilities. Mr. Furuya began his Los National Health Policy Forum | www.nhpf.org 34 Los Angeles Site Visit Report April 18–20, 2006 Angeles County career as a registered environmental health specialist in 1976. He received his bachelor’s degree in biology and a master in public administration BIOGRAPHICAL degree from California State University, Los Angeles. SKETCHES Jeffrey Guterman, MD, is the medical director for the Los Angeles County Depart- Speakers ment of Health Services responsible for Clinical Resource Management. Dr. Guterman is also a professor of medicine and emergency medicine at the University of Califor- nia, Los Angeles, School of Medicine. In his former role as chief of ambulatory and community medicine at Olive View-UCLA Medical Center, he was responsible for developing and operating the primary and managed care delivery systems in the San Fernando and Santa Clarita Valleys. Dr. Guterman’s research has focused on the application of information technology to enhance the efficiency and effective- ness of medical care. He led the development of the first nationally distributed program for the computerized collection of patient information for Poison Control Centers. His current research focuses on the integration of computer technology into the management of the continuum of care for patients who “present” to the emergency department. Through cooperative efforts with pharmaceutical industry leaders and health care providers, Dr. Guterman has developed medical decision support products encompassing comprehensive preventive health care, disease management programs, integrated Internet-based referral systems, and automated speech recognition patient communication systems. Dr. Guterman graduated from the University of Chicago in 1981 with a master of science degree. He received his medical doctorate in 1983 and completed his internal medicine training at Brown University. Dr. Guterman completed additional post-graduate training in emer- gency medicine and toxicology at UCLA. His recent works have been published in a broad range of peer reviewed journals. Robert Hockberger, MD, is chair of the department of emergency medicine at Harbor-UCLA Medical Center and professor of clinical medicine at the David Geffen School of Medicine at UCLA. He is a past-president of the American Board of Emergency Medicine, the organization that sets the standards for test- ing and certification of emergency physicians in the United States, and he is a national spokesperson for the American College of Emergency Physicians (ACEP), an organization that represents the 24,000 physicians that work in our nation’s emergency departments. Dr. Hockberger received the Award for Out- standing Contributions to Education from ACEP in 1995. He is also a senior editor for Rosen’s Emergency Medicine: Concepts and Clinical Practice, a 3000-page textbook for practitioners of emergency medicine. Craig Jones, MD, is director of Allergy Immunology for the Los Angeles County/ University of Southern California Healthcare Network. Howard Kahn is chief executive officer of the LA Care Health Plan. Dennis Levin, MD, is currently the associate medical director at Harbor-UCLA Medi- cal Center, a position he has held since 1989. In addition, since 2000, Dr. Levin has served as medical director of the Long Beach Comprehensive Health Center and the LA County Coastal Cluster Clinics. He holds academic appointments as associate professor of family and internal medicine at UCLA and previously held teaching National Health Policy Forum | www.nhpf.org 35 Los Angeles Site Visit Report April 18–20, 2006 positions at Wayne State University in Michigan. Dr. Levin serves on a number of committees at Harbor-UCLA, Long Beach Comprehensive Health Center, and the BIOGRAPHICAL Los Angeles County Department of Health Services. He received his bachelor of SKETCHES science and his master of public health in medical administration degrees from the Speakers University of Michigan and his medical doctorate from Wayne State University. Dr. Levin completed his residency in family practice at the University of Maryland. He holds certifications from the American Board of Family Practice and the American Board of Medical Management. Martha Long is the founding director of the MHALA Village and has guided its growth from pilot project to national model. She is the force behind making the Village a “living laboratory” that encourages new ideas and new practices that lead to positive outcomes. Recognized nationally for her expertise in integrated services, Ms. Long is a consultant, trainer, and presenter who works with public systems and organizations. She assisted mental health leaders in five states through the Substance Abuse and Mental Health Administration (SAMHSA) Community Action Grants and has consulted with mental health systems in numerous other states. She serves as a delegate to Los Angeles County’s stakeholder group to plan for implementation of California’s new Mental Health Services Act. In 2000, Ms. Long received the United States Psychiatric Rehabilitation Association’s lifetime achievement award for “outstanding contributions to the field of psychosocial rehabilitation.” She and the MHA Village’s medical director, Mark Ragins, MD, shared an American Psychiatric Association (APA) award. A Los Angeles Times editorial series on homelessness and mental illness, which won a 2002 Pulitzer Prize, commended the Village’s success in helping individuals “get…support and strive for independence.” Peter Long is the director of research and planning at The California Endowment. Mr. Long is responsible for the research, analytic, and knowledge management ac- tivities to support the development of The Endowment’s programs. He is also re- sponsible for developing information systems for strategic planning and assessing the foundation’s impact. Toward this end, Mr. Long partners with academic and other research organizations in California and nationwide to build the evidence base to inform and guide The Endowment’s programs and activities. Prior to his appointment as director of research and planning, Mr. Long was a senior program officer for the foundation’s Access to Health Services program, which aims to increase access to quality and affordable health care services for the state’s underserved popu- lations. He worked closely with the program director on the oversight of the program’s activities and served as the lead on “Covering California’s Kids,” The Endowment’s children’s health coverage initiative. Prior to joining The Endowment, Mr. Long’s work focused primarily on health policy issues. Most recently he served as an independent health policy consultant for local and national clients, including the Medi-Cal Policy Institute, the Partnership for Prevention, the Kaiser Commis- sion on Medicaid and Uninsured, the LA Care Health Plan, and the Insure the Unin- sured Project. Mr. Long received his AB degree in modern European history from Harvard University, his master’s degree in health science from The Johns Hopkins University School of Hygiene and Public Health, and he is currently a doctoral can- didate in the Health Services Department at University of California, Los Angeles. National Health Policy Forum | www.nhpf.org 36 Los Angeles Site Visit Report April 18–20, 2006 Beth A. Lopez has been with Kaiser Permanente for approximately ten years. She started with Kaiser Permanente in the sigmoidoscopy suite performing colon BIOGRAPHICAL cancer screenings. She later became an ambulatory care supervisor, then a assis- SKETCHES tant department administrator, and she is currently the office manager at the Speakers Whittier Medical Offices. Ms. Lopez began her career in nursing in 1985 with adult oncology patients, later gastroenterology, and then adult trauma and intensive care. She received her nursing education at Cerritos Community College and then received a bachelor of science degree in nursing from Holy Names College in Oak- land, California. Ms. Lopez is a member of the American Academy of Ambulatory Care Nursing. John E. Mattison, MD, currently oversees all information systems deployment in the Southern California region of Kaiser Permanente. He is also director of the $1.5 billion KP HealthConnect project. KP HealthConnect is a national initiative that is replacing every major clinical and business system throughout Kaiser Permanente with the same suite of highly integrated applications, using EpicSystems products as the core. Dr. Mattison is founder and past-chair of the HL7 XML technical com- mittee which has developed the international standard for the Clinical Document Architecture (CDA) and new messaging syntax for healthcare. He previously served as a co-chair of the California Health Policy and Data Advisory Commission and Committee to Advance Patient Privacy and Care (CAPPAC), a California legisla- tive advisory committee, and currently serves on the Executive Committee of the California Healthcare Foundation, which is developing statewide protocols for data exchange among all health care providers. Dr. Mattison is also active on mul- tiple Regional Health Information Organizations (RHIOs) in California. Dr. Mattison’s medical computing career began in 1986 when he contributed to the design of an early electronic health record. He has since participated in the design, implementation and use of eight other commercial electronic health records. From 1984 to 1989 he practiced internal medicine at Scripps Clinic and Research Foun- dation where he served as director of the Medical/Surgical Intensive Care Unit, and chaired committees on Pharmacy, Quality, and Utilization. In 1989 he began working for Kaiser Permanente in San Diego where he has practiced critical care, preventative medicine, and primary care in internal medicine. His current clinical engagements include volunteer work for Survivors of Torture International. Elisa A. Nicholas, MD, has led the growth of The Children’s Clinic, Serving Chil- dren and Their Families, a dynamic system of nonprofit community clinics in Long Beach that, since 1998, has provided over 41,000 person-to-person visits per year to a diverse and growing population. Working with community mem- bers, Dr. Nicholas implemented critical programs that include asthma coalitions, school-based health programs, and immunization awareness campaigns. Dr. Nicholas serves as the project director for the Long Beach Alliance for Children with Asthma, the American Academy of Pediatrics CATCH (Community Access to Child Health) Facilitator, an appointed member of the Los Angeles County’s Children’s Planning Council, and a member of LA Care Health Plan’s Children’s Health Consultant Advisory Committee. She is an associate professor of pediat- rics at the University of California-Irvine, and she is also an active staff member and current chief of staff at Miller Children’s Hospital where she works closely National Health Policy Forum | www.nhpf.org 37 Los Angeles Site Visit Report April 18–20, 2006 with practicing pediatricians. Dr. Nicholas graduated from the University of California, Los Angeles, and she trained in pediatrics at Yale-New Haven Hos- BIOGRAPHICAL pital. She also received a master of science in public health from UCLA while SKETCHES she was a Robert Wood Johnson Clinical Scholar. Prior to taking the helm at The Speakers Children’s Clinic, she worked in Africa on a child survival project and at Harbor-UCLA Medical Center in their child abuse center. Miguel Ortiz-Marroquin is the chief operating officer of the Harbor-UCLA Medical Center. Anne Peters, MD, is the director of the University of Southern California (USC) Clinical Diabetes Programs. She runs the USC Westside Center for Diabetes as well as the Roybal Diabetes Management Program and serves as the co-chair of the Los Angeles County Department of Health Services Diabetes Content Committee. Dr. Peters also serves as a professor of clinical medicine in the Divi- sion of Endocrinology at the USC Keck School of Medicine. She is involved in numerous professional organizations and activities and has written over 100 publications. She is a frequent lecturer and is the co-author of a book entitled Davidson’s Diabetes Mellitus, Fifth Edition and the author of Conquering Diabetes, published by Penguin Books. Dr. Peters is the principal investigator on several diabetes clinical trials, including an American Diabetes Association grant and the National Institutes of Health–funded LookAHEAD study. She is also the co- principal investigator on a grant from the Keck Foundation to study the preven- tion of diabetes in underserved areas of Los Angeles. Dr. Peters is on the edito- rial board for Diabetes Care and is on the board of directors for the American Diabetes Association Research Foundation. David Pilon, PhD, serves the Mental Health Association of Greater Los Angeles (MHALA) in a variety of capacities related to research and evaluation. He helps increase the capacity of organizations to measure their effectiveness and helps policymakers gauge the system-wide results of programs. Dr. Pilon’s outcomes studies focus on “quality of life” areas such as living, work, education, finance and social goals, the areas that often form the core of an individual’s role in the community. He developed a computerized system to collect, analyze, and re- port real-time data. Dr. Pilon continues to conduct an evaluation, commissioned by the California Department of Mental Health, for the AB 34/2034 programs, which serve individuals with mental illness who are homeless and/or at risk of incarceration. His study covers 5,000 individuals served by 55 programs in 34 California counties. Since 1996, Dr. Pilon has measured results of 15 local pro- grams for the Los Angeles County Mental Health Department. He was selected by the state to design research and evaluation in the area of employment for people with mental illness, and currently serves on the Performance Measure- ments Advisory Committee for the Mental Health Services Act, which has been charged with developing the statewide outcomes measures for services funded by the Act. In addition, Dr. Pilon serves on the research committee of the United States Psychiatric Rehabilitation Association (USPRA). In 2004, he was the re- cipient of USPRA’s annual Armin Loeb Award for outstanding research in the field of psychiatric rehabilitation. Dr. Pilon is a licensed psychologist, and he received his doctorate in social psychology from Harvard University. National Health Policy Forum | www.nhpf.org 38 Los Angeles Site Visit Report April 18–20, 2006 Mark Ragins, MD, is the founding psychiatrist and medical director at the Mental Health Association of Greater Los Angeles (MHALA) Village. He has had a lead- BIOGRAPHICAL ing role in developing the organization’s philosophy, treatment strategy, and ser- SKETCHES vice culture. Dr. Ragins is an expert on the role of the psychiatrist in recovery Speakers programs. He designed and trains in the Village’s “collaborative psychiatry” ap- proach to providing treatment, built on the belief that people with mental illness will accept help more readily if they are treated as equal and active partners in finding solutions to their needs. Through the Department of Mental Health/De- partment of Rehabilitation BEST-TAC, Dr. Ragins has trained staff and systems across California since 2000, and he was selected as a trainer for the Cooperative Program Training/Technical Assistance program in 2003. He is a regular trainer for the California Association of Social Rehabilitation Agencies (CASRA), cover- ing topics such as psychiatric diagnoses and medications. In Dr. Ragins’s newest training, the “Four Stages of Recovery,” he identifies four concepts—hope, em- powerment, self-responsibility and a meaningful role in life—that form a frame- work for helping individuals achieve their goals. A Road to Recovery, his new book, grew out of a decade of writings and workshops. In recognition of his achieve- ments, Dr. Ragins, along with Village director Martha Long, received the 1995 American Psychiatric Association’s Arnold L. Van Ameringen Award in Psychiat- ric Rehabilitation. G. Michael Roybal, MD, is the medical director of the Edward R. Roybal Compre- hensive Health Center located in the predominantly Latino community of East Los Angeles. One of three comprehensive health centers in the Los Angeles County/ University of Southern California Healthcare Network, the clinic delivers more than 130,000 patient visits per year and is a location of primary care and specialty care services delivered within the network. In addition, Dr. Roybal serves as the chair of the LAC+USC Healthcare Network’s Ethics Resource Committee. Dr. Roybal’s research interests have centered on the examination of differences in the prevention, treatment, and survival rates of colorectal cancer in the populations of Los Angeles County and California. Currently, Dr. Roybal has focused his efforts in health care delivery as it pertains to diabetes. He has been actively involved in the planning, implementation, and support of the Edward R. Roybal Comprehen- sive Health Center’s Diabetes Management Clinic. Dr. Roybal was a National Cancer Institute Post-Doctoral Fellow in Cancer Prevention at the University of Southern California Institute for Health Promotion and Disease Prevention Re- search, and he was a volunteer faculty member in the School of Medicine at USC. Dr. Roybal is a member of the American College of Physicians, the California Latino Medical Association and a Diplomat of the American Board of Internal Medicine. Dr. Roybal graduated from Harvard College with a bachelor of arts degree in en- gineering science. He next attended the University of Southern California School of Medicine in Los Angeles, California. After completing his training in internal medicine at the University of California, San Francisco, Dr. Roybal pursued and received a master of public health degree in health services from the University of California, Los Angeles School, of Public Health. Sandra Shewry is the director of the California Department of Health Services, one of the largest state departments, with 6,000 employees and a budget of $34 National Health Policy Forum | www.nhpf.org 39 Los Angeles Site Visit Report April 18–20, 2006 billion. Ms. Shewry administers public health, education, disease prevention, and health protection programs for 35 million Californians. She administers the BIOGRAPHICAL state’s Medicaid program (Medi-Cal), which provides health care services to more SKETCHES than 6 million individuals annually. Ms. Shewry has over 20 years’ experience in Speakers California state government. She began her state career with the Department of Health Services as a health planning analyst and later served as an assistant secretary at the Health and Welfare Agency. Her interests and expertise are in the areas of health care financing, insurance markets, public-private partner- ships, and health care purchasing. Ms. Shewry earned graduate degrees in pub- lic health and social welfare from the University of California at Berkeley. Marvin Southard, DSW, joined the Los Angeles County Department of Mental Health as the director in 1998, before which he served in a similar capacity in Kern County for five years. In his present role, Dr. Southard leads the largest public mental health system in the country, serving over 200,000 clients annu- ally in one of the most ethnically diverse counties in the nation with a budget of over $1 billion. He is a past president of the California Mental Health Directors Association (CMHDA) and a commissioner on the Los Angeles County Chil- dren and Families First – First 5 LA Commission. He has served as an associate clinical professor at the University of California, Los Angeles, School of Medi- cine, Department of Psychiatry and Biobehavioral Sciences; as a senior fellow in public policy at the UCLA School of Public Policy and Social Research; and as a clinical associate professor of psychiatry and the behavioral sciences at Univer- sity of Southern California Keck School of Medicine. Dr. Southard’s prior expe- rience within the Los Angeles County public mental health system includes seven years as vice president of Mental Health Programs and director of Clinical Ser- vices at El Centro Human Services Corporation, and four more years in other positions with El Centro. Dr. Southard is the 2006 Social Worker of the Year for the National Association of Social Workers–California Chapter. He is the recipi- ent of National Association of Mental Illness’s 2003 award for Excellence in Community Mental Health Services presented in recognition of his ongoing ef- forts to building a comprehensive community care mental health system in Los Angeles County. He is also the recipient of the 2003 Tom Bradley Equal Oppor- tunity award from the Los Angeles Metro Chapter of the American Society of Public Administration. A licensed clinical social worker, Dr. Southard received his master’s degree in social work from University of California, Berkeley, after which he completed his post-graduate studies in social work at UCLA. Jane Stafford is the senior program officer for the Community Clinics Initiative (CCI) a joint project of The Tides Foundation and The California Endowment. Since 2000, she has worked with CCI to create a project with the goal of building stronger and healthier communities by investing in the information systems in- frastructure of community-based clinics and their consortia. The project works to ensure that clinics have the power to use information as a means of improv- ing the health of their communities. Ms. Stafford is responsible for program de- velopment, grant making, and special programs of CCI, working on both the technology program as well as the building capacities program. Ms. Stafford brings over 18 years of executive, program, and development experience in National Health Policy Forum | www.nhpf.org 40 Los Angeles Site Visit Report April 18–20, 2006 nonprofit organizations to her work at Tides; 6 of the 18 years were spent in com- munity health care settings in the Bay Area. BIOGRAPHICAL SKETCHES Dan Temianka, MD, is a board-certified internist and the medical director of quality management at HealthCare Partners Medical Group. He also chairs their Speakers Credentials Committee and is a member of the Medical Executive Board and the Transplant Committee. Dr. Temianka also edits MedOps, the organization’s intranet website, and he is actively developing specialist templates for an elec- tronic medical record. In addition, he oversees the physician continuing medical education program, which is an accredited program. Dr. Temianka has exten- sive experience in managed care and utilization review, quality improvement, physician credentialing, risk management and peer review, and he consults on medico legal cases. Robert Tranquada, MD, is professor emeritus of medicine and public policy at the University of Southern California. He has chaired the Los Angeles County Task Force on Health Care Access since 1992 and was a member of the Christo- pher Commission (The Independent Commission on the Los Angeles Police Department) in 1991. Dr. Tranquada established and directed the Watts Health Center (now the Watts Health Foundation) from 1965 to 1969. Dr. Tranquada graduated summa cum laude from Pomona College in 1951, received his medical doctorate from the Stanford University School of Medicine in 1955, and served as a resident in medicine at the University of California, Los Angeles, Medical Center from 1955 to 1958. He served as assistant professor of medicine at the USC School of Medicine from 1959 to 1969 and was associate dean from 1969 to 1976. He was medical director of the Los Angeles County/USC Medical Center from 1969 to 1974 and regional director of the County of Los Angeles Depart- ment of Health Services from 1974 to 1976. From 1976 to 1979, Dr. Tranquada was associate dean of the UCLA School of Medicine and from 1979 to 1986 he served as chancellor and dean of the University of Massachusetts Medical Cen- ter. In 1986, he returned to USC as dean of the School of Medicine until 1991. From 1991 to 1997, Dr. Tranquada held an endowed chair in health policy and chaired the Health Administration program in the USC School of Public Admin- istration. Dr. Tranquada is a member of the Institute of Medicine of the National Academy of Sciences, and a fellow of the American Association for the Advance- ment of Science. He is chairman of the board of overseers of the Claremont Uni- versity Consortium (The Claremont Colleges), chair of the board of governors of the LA Care Health Plan, and a member of the board of directors of the Ralph M. Parsons Foundation, of the Good Hope Medical Foundation, and of the Com- munity Health Councils Project. Dr. Tranquada is chairman emeritus of the Board of Trustees of Pomona College and emeritus trustee of the Keck Graduate Insti- tute of Applied Life Sciences. He is the author of over 50 scientific and educa- tional papers and book chapters. Richard Van Horn has built the Mental Health Association of Greater Los Angeles (MHALA) into one of California’s leading nonprofit mental health organizations. Mr. Van Horn has been at the forefront of improving services for people with seri- ous mental illness through service innovation, systems design, and public policy National Health Policy Forum | www.nhpf.org 41 Los Angeles Site Visit Report April 18–20, 2006 change for over 25 years. Under Mr. Van Horn’s leadership, MHALA designed and operates the MHALA Village, which has earned recognition for its effective- BIOGRAPHICAL ness and emerged as a national model for integrated services. Started in 1990, SKETCHES the Village incorporates many types of mental health care: treatment, recovery, Speakers self-help, and family and community involvement. The MHALA Village was recognized in 2000 by President Clinton’s Committee on Employment of People with Disabilities, calling its work training and job placement program a “best practice.” In 2002, President Bush’s New Freedom Commission on Mental Health selected the Village as a model to study as the commission researched and rec- ommended “programs that work.” At the state level, Mr. Van Horn is a member of the California Adult System of Care Committee, the AB 34 Advisory Commit- tee, the Transition Age Youth Committee, and the California Coalition for Men- tal Health. He served on the Little Hoover Commission’s Adult Mental Health Advisory Committee. Mr. Van Horn has testified before Congress and California’s legislature, and is a founding member of the California Coalition for Mental Health. Recently, Mr. Van Horn took a leave of absence from MHALA to serve as principal consultant to the Mental Health Services Oversight and Accountabil- ity Commission for the new Mental Health Services Act, passed by California voters in November 2004 as Proposition 63. He has since rejoined MHALA, where he received word that he was selected by the California Chapter of the National Association of Social Workers as their 2006 Public Citizen of the Year. Yolanda Vera, JD, serves as the director of LA Health Action, a project of Com- munity Partners funded by The California Endowment. She directs The Califor- nia Endowment’s Los Angeles Access to Health Initiative, the goal of which is to increase health care coverage for uninsured, low-income children and families in Los Angeles County, to promote long-term, viable solutions to sustain the health system in Los Angeles County, and to increase access to quality health care. Ms. Vera also leads the activities of the Los Angeles Health Collaborative, a group of approximately 50 diverse private and public organizations and agen- cies dedicated to preserving and improving Los Angeles County’s health care safety net. She also serves on the Steering Committee of the Child Health Initia- tive of Greater Los Angeles. Prior to joining LA Health Action, Ms. Vera served as the senior health policy attorney of Neighborhood Legal Services (NLS). She specialized in health issues, including access to health care, Medi-Cal, and im- migrant health care and the interrelationships between health and welfare. Ms. Vera was lead-counsel in Harris v. Los Angeles County Board of Supervisors, a law- suit filed on behalf of poor uninsured families in Los Angeles County. Harris successfully enjoined the County from closing Rancho Los Amigos National Rehabilitation Center and cutting hospital beds at Los Angeles County USC Medical Center. Ms. Vera also worked for the Western Center on Law & Poverty, National Immigration Law Center, the National Health Law Program, and the Legal Aid Foundation of Los Angeles. She was recognized by American Lawyer Magazine in 1997 as one of the country’s top 45 public sector lawyers under age 45. She is a graduate of the University of California, Los Angeles, School of Law where she received the University Fellowship Award and from which she re- ceived the 2001 UCLA Law School Public Interest Award. Ms. Vera graduated from Loyola Marymount University with a bachelor of arts degree. National Health Policy Forum | www.nhpf.org 42 Site Visit Report Report Published: August 30, 2006 National Health Policy Forum Facilitating dialogue. Fostering understanding. 2131 K Street NW, Suite 500 Washington DC 20037 202 / 872-1390 202 / 862-9837 [fax] nhpf@gwu.edu [e-mail] www.nhpf.org [web]