Minutes of the Health Commission Meeting Tuesday, March 29, 2005 at 3:00 p.m. 101 GROVE STREET, ROOM 300 San Francisco, CA 94102 1) CALL TO ORDER Commissioner Monfredini called the meeting to order at 3:10 p.m. Present: Commissioner Lee Ann Monfredini, President Commissioner Roma P. Guy, M.S.W., Vice President Commissioner James M. Illig Commissioner David J. Sanchez, Jr., Ph.D. Commissioner John I. Umekubo, M.D. Absent: Commissioner Edward A. Chow, M.D. 2) APPROVAL OF THE MINUTES OF THE HEALTH COMMISSION MEETING OF MARCH 15, 2005 Action Taken: The Commission (Guy, Monfredini, Illig, Sanchez, Umekubo) approved the minutes of the March 15, 2005 Health Commission meeting. 3) CONSIDERATION OF A RESOLUTION CONCURRING WITH THE DEPARTMENT OF PUBLIC WORK’S RECOMMENDATION TO PROCEED WITH THE NEXT PHASE OF THE LAGUNA HONDA HOSPITAL REPLACEMENT PROJECT Michael Lane, Project Manager, Laguna Honda Hospital Replacement Project, presented a resolution allowing the Department of Public Works to proceed with construction of the South and Link buildings with no scope reduction and within budget. This resolution will also allow time to identify additional funding for future construction of the East and West buildings. Public Comment Michael Lyon asked should the city be in long-term care business? Contract it? Should the City be in the health care delivery business? We will not accept cuts in the rebuild or reduction of health services. Patrick Monette-Shaw, there are enough funds to build five of seven floors. There is $5 million more per year in tobacco settlement than expected, which is an extra $15 million over three years. Start construction now. Postpone the resolution until the Controller’s report is complete. Action Taken: The Commission (Guy, Monfredini, Illig, Sanchez, Umekubo) approved Resolution 05-05, “Concurring with the Recommendation to Proceed with Construction at Laguna Honda Hospital and Requesting that the Department of Public Health Bring Forward Options for the Completion of the Facility as Soon as Possible,” (Attachment A). 4) PRESENTATION OF THE DEPARTMENT OF PUBLIC HEALTH’S FY 2005-2006 BUDGET Mitchell H. Katz, M.D., Director of Health, presented the proposed Health Department Budget for Fiscal Year 2005-2006. Following the January 18, 2005 budget presentation, the department made various additions and revisions to regulatory issues, inflationary increases, structural issue, revenue neutral initiatives and revenue projections. New regulatory issues include reinstatement of the second phase of nurse ratio law and increased staffing at Laguna Honda as required by the State Department of Health Services. Inflationary changes include updating work orders, requesting alternate funding for Direct Access to Housing rent and others. Changes to structural issues include salary savings at MCH, interpreters’ grievance settlement, psych nurse staffing, UCSF radiology contract and Laguna Honda Hospital security, among others. Total regulatory, inflationary, structural, revenue neutral and revenue changes total $27.7 million in increased costs over last year’s budget. The Mayor’s Office gave the Department an additional $13 million, so the Department must cut $14.6 million. Dr. Katz said no dollars are currently budgeted to pay COLAs to contractors. The Mayor wants to deal with this as a citywide issue. In FY 2004-2005 the department’s budget was balanced with minimal services cuts. There were $20.44 million in cuts, 88 percent of which were administrative. At mid-year staff was unable to identify significant additional administrative reductions, so services were reduced. In this budget, Dr. Katz is proposing some reductions to administration but the majority of cuts are to service. In developing the proposed budget, staff used four guiding principles from the Strategic Plan: 1. Expand community based alternatives – Decrease need for institutional care. 2. Target populations receiving services – focus resources to those most in need and who lack options. 3. Strengthen and promote prevention. 4. Use data to reorganize, re-prioritize, reduce or eliminate services. Base Budget 1. Expand Community Based Alternatives – Antibiotic infusion and therapy services – revenue neutral State hospital bed conversion Total savings $101,028 2. Target Populations - Focus Services on those Most in Need – Administrative cuts Closure of Workers Comp. Clinic Operating Staff Reductions (LHH) Reductions in contracted services, material and supplies (LHH) Jail Health Services operating reductions Consolidate client services reimbursement Eliminate work re-entry and employment program Reduction of UCSF contract for nurse practitioners (LHH) Reduction of funding for Sheriff’s Dept. Post Release Education Program Reduction of funding for Sheriff’s Dept. Roads to Recovery Program Total savings $3,202,322 3. Strengthen and Promote Prevention: No Cuts 4. Use Data to Reorganize, Reprioritize, Reduce, or Eliminate Services – CBHS – Substance Abuse Cuts to acupuncture Cuts to outpatient Substance Abuse services – rebid Substance Abuse adult outpatient services, create 125 new methadone maintenance slots Decrease in residential substance abuse treatment (rebid and shift to supportive housing) Total Substance Abuse Services savings $2,992,597 CBHS – Mental Health Reduce funding to underutilized contracts Convert residential treatment programs to supportive housing Total Mental Health savings $1,254,514 Housing SRO Collaboration Contract Reduction (there is a high probability of continuing funding for SRO Collaboratives through another department.) Total Housing $658,333 HIV/AIDS Cut peer advocacy/treatment advocacy services/management services practical support (AIDS) Total HIV/AIDS savings of $996,272 Pharmacy Institute copay for all persons without GA Total Pharmacy savings $1,521,500 Contingency Plan DPH has been asked to propose $10 million in contingency plan reductions. The contingency plan consists of $9.5 million in cuts: UCSF Crisis Resolution Team; dialysis unit; rebid outpatient substance abuse treatment for special populations; rebid adult outpatient substance abuse services; convert mental health residential treatment to supportive housing; delete PHN Chronic care service and skilled home care services; decrease HIV prevention services; an across-the-board reduction of outpatient mental health services. Dr. Katz presented two options for reaching the contingency budget target. Option 1: Close a health center and sell a building - $2 million savings. Option 2: Operate all health centers at 80% - $2.667 million savings. Initial BOS presentation March 31. Second Health Commission meeting April 7. It should be noted that the proposed budget is posted on the DPH website at www.dph.sf.ca.us/budget/ Public Comment Valerie Ng, M.D., concerned about patients at SFGH. Make it budget priority. Underfunding of UCSF contact must stop. Affiliation agreement cannot be viewed separately from SFGH budget. Ted Miclau, M.D., SFGH is losing orthopedic surgeons because not paying enough. Trauma is in jeopardy at SFGH because cannot fill positions. Currently only four of six positions filled. Seeing 85 to 100 patients per hour. 12- to 16-month wait for new patient appointment. Allan Gelb, M.D., said the SFGH ED is the focus of these cuts. When patients cannot be seen or treated elsewhere, they come to the emergency department. There are not enough physicians to staff the ED and doctors are forced to make life and death decisions. They are at risk of losing accreditation. Dr. Gelb submitted a fact sheet on the SFGH/UCSF Partnership, which is on file in the Health Commission office. Dr. Hal Yee said there is chronic understaffing at SFGH, yet staff continues to provide compassionate care. We are rationing care. Have reached a crisis. The next GI clinic appointment is 18 months away. The next liver clinic appointment is 11 months and the next sigmoidoscopy appointment is 16 months away Dr. Shelly Marder is leaving SFGH this June. Radiology is key to many of the functions of other departments, and it is under-resourced. It is no longer viable to continue working at SFGH. No longer possible to function in this setting. Not because we do not care. Dr. Talmadge King wants the Commission to know the reality of SFGH. SFGH can no longer provide quality care. UCSF has always been a partner with SFGH. Affiliation agreement needs to be fully funded. Any more reductions mean that other people will choose to leave. Arthur Bosse, National Council on Alcoholism. He is grateful for past support. AA and 12-step programs are useful for some people, but not as effective as integrated model. Jeanna Eichenbaum, Walden House Transgender project. Housing and AA are not sufficient for the transgender population. Comprehensive services are impossible to replicate in other settings. Ahmad Sloan is a client from Walden House. Theory that there is no dual diagnosis. Without these programs they will not get the services they need to recover. Dr. Louise Foo, Jackson Street Residential Program. The program has been cut from a 25-bed to a 16-bed facility. Need services for monolingual clients. Difficult to live with mental illness, but even harder when people cannot speak the language. Stress of immigration and cultural issues. Not all well enough to live in supportive housing. Richard Heasley, Conard House, spoke against the budget proposal. $13 million in additional funds is only a down payment. Need to fund the additional $14.7 million. He urged the Commission to reject the budget and request additional funding. He is against residential treatment conversion to supportive housing. Residential treatment and supportive housing are not the same services and both are needed. Jonathan Vernick, Baker Places. Hard to respond in two minutes to elimination of eight programs. In closing residential treatment, where will people go? Don’t assume they will go to supportive housing. Continually avoid cuts to institutional care at the expense of community care. Steve Fields, Progress Foundation. Opposed to eliminating the entire modality of treatment based on one article. Need to look at local data. This will result in a backup of acute, unpaid inpatient days. With Proposition 63, it is unwise to go ahead with a competitive proposal when cutting services. Larry Nelson, Walden House. Last year 814 graduates of Walden program got into jobs and independent homes. They have built a continuum of care based on the whole person, not just their substance abuse. Can’t treat the whole person with supportive housing. Ask the Mayor for the money before we tear apart the system. Christy Nair, Sage client and former prostitute, speaking for the sexually exploited. Acupuncture treatment really works. It helps with the physical pain of knee surgery and is better than addictive pain pills. Harry Lloyd, Sage outpatient. Without help from all of these agencies, he would not be here today. Sage is a wonderful program. Working to be drug and alcohol counselor. Tom McCaffrey, Sage staff. He is new to Sage and impressed with infrastructure. It is created and staffed by consumers, and financially well run. It is important to support unique programs. Michael Wright, Walden Client. Excellent program. Without the Tenderloin drop-in center and other programs, he wouldn’t be standing here, but be in jail without these programs. Need more money in substance abuse services. Shelli Rawlings Fein said to continue harm reduction as a priority. Abstinence is safest way, but harm reduction allows providers to intervene. Cannot engage people with abstinence if it is not their goals. Residential treatment needed in addition to supportive housing. Norma Hotaling, SAGE, said she is here as a client in recovery. Was chronically homeless, was a high utilizer of services at SFGH. They have developed a highly successful program for sex workers. Partnered to create program and replicated across U.S. Francine Braae, Sage staff. Clients have been self-medicating for most of their lives. She has witnessed many miracles take place, including herself. Success rate of 53% last year. Now contributing members to society. Consuelo Bradford, Sage staff. Need to increase funding, not cut it. Celebrating 10 years drug free. She stands as a role model to clients. Sage is one solution to substance abuse problem. Cathy Lemons, Sage staff. She left the criminal justice system in 1988 as prostitute and heroin addict with no place to go. Now people have Sage, which treats the whole person. She wants to keep the doors open. It is a peer-run model and is being replicated in seven places across the country. Billie Jean Kanios, Walden staff, said NA is a self-help program, not treatment. Programs give individualized care. With this budget San Francisco will have higher incidence of HIV, more substance abuse. John Terry, Walden client, he was just released from prison after seven years. Since being in Walden, he has not been in SFGH. David Sterling, Walden client, said Walden is a good program. Taught him to be a good son to his mother and a good father. Helped him to be a good person. Walden saved his life. Marlene Cheatham, Glide Recovery services in conjunction with Haight Asbury Free Clinics, and as consumer. Did anyone call AA to see how they feel about being written into a county budget as a treatment modality? AA is self-help, not a treatment program. No professional staffing. Eve Meyer, SF Suicide Prevention, said people are being asked to believe that the only way to meet cuts is to have CBHS take the brunt of them. She believes not. Do the cuts take into account the prior cuts? She believes not. Preserve the behavioral health model. Patrick Monette-Shaw, LHH, asked why $32 million is in the budget for retirement. All retirement is paid by employees. He spoke against a number of budget initiatives. He asked that the $1.7 million revenue loss from the flow project be reexamined. The Commission needs to reject this budget. The City needs to fund public health care. Sarah Jewel, M.D., SFGH Occupational Health, regarding the proposed closure of the Worker’s Comp. clinic. Care could be contracted, but clinic provides much more including high quality care and cost effective care. Strong prevention basis to practice. The staff promotes early and safe return to work, which would be lost if the program were contracted out. Sonny Quiniquini, LHH employee, said Laguna Honda is being cited for a mistake and is asking for more money to take care of challenging behaviors from mental illness. Change in admission policy took place for a year. It should stop. Jorin Bukosky, Progress Foundation, is currently at Clay House, which is not on the cut list, but he has worked at programs slated for cuts. It is difficult to get clients ready for supportive housing. Without that time, clients won’t do well and will end up back on the streets. Mark Stanford, SEIU, said this budget basically wipes out services that we already have and jeopardizes new Prop. 63 funding. The individuals in residential treatment are not ready to be put into supportive housing. Jennifer Baity Carlin, SEIU member and MHRF staff, said to rethink cuts to residential treatment for mental health and substance abuse. Need a long-term model. She submitted a written copy of her testimony, which is on file in the Health Commission office. Janet Goy, CATS, has extensive experience with both residential treatment and supportive housing. Emphasis on supportive housing and peer-based treatment is effective for some, but not for all. For those most addicted, they would not get better. Some clients need open, supportive, and intensive services. Need the continuum of care. Proposal flies in the face of integration. Perry Zinnanti, Redwood Center: Where do we send people who need to go to residential treatment? Most clients come from the hotels where they do not make it. They need immediate behavioral changes. SROs are good for some, but not for all. Not clinically sound. Chuck Deutschman, Walden House said the statement that there were no cuts to substance abuse is not true. Last year, Walden lost funding and beds. He opposes these cuts. The cuts do not follow the strategic plan, and prevention being cut substantially. Mark Molner, Shanti, said the proposed HIV/AIDS cuts do substantial harm to special populations and people of color. These services help connect people to other services. If not funded, people go to the emergency department. Barbara Farrell, TOD Planning Council, said they have cut the number of deaths through treatment on demand. Clients who are housed and receive treatment do best. AA/NA are important adjuncts to treatment but do not replace treatment. Virgina Grant said she was addicted to crack and became a prostitute. Haight Ashbury residential treatment turned her life around. She is now a counselor at the program that changed her life. Do not cut residential treatment. Armando Martinez said do not cut acupuncture services at BVHP. This helped him not use drugs. Not a quick fix. John Carter, BVHP client. Acupuncture is a tool that use for recovery. It is located in BVHP, which is an area in need of services. Please do not cut these services. Mark Misrok, Positive Resource Center, fails to understand how the Commission can make an informed decision. People that are coming to him for treatment no longer need to lean on services. They become productive members of society. Cuts to treatment are not savings. Randy Allgaier, HIV Health Services Planning Council, said there was 5.2% cut in Ryan White funding, and San Francisco might be looking at a 21% cut in formula award. Treatment advocacy and peer advocacy are included as core services in centers of excellence. Lawrence Thibodeaux, Haight Asbury Western Addition, struggled with addiction for 40 years. He completed the Walden House program and was hired by Haight Ashbury and is living a productive life. These cuts will mean we lose the war on drugs. Karen Patterson Matthew, Bayview Hunters Point Foundation for Community for Improvement, said these are service reductions to basic health and human services. She is aware of the deficit but need to maintain basic required services. Serve primarily persons of color in a community of high need. Cuts would mean closing of three programs. There are no proposed reductions to the institutions, which we try to keep our clients out of. Reject this budget. Yuwen Liao, Bayview Hunters Point Foundation for Community Improvement, said she saw five patients between 7 am and 9 am. One client was injecting heroin without the knowledge of his wife or children and was ill from heroin withdrawal. Sees people everyday whose lives are torn apart by heroin. Reconsider cuts to outpatient substance abuse. Ben Eiland, Haight Ashbury Free Clinic, said every dollar the City gives them saves seven. The program keeps people compliant with diabetes management, psychotropic drugs, etc. The cost to SFGH will go up. Plus the cost of unemployment. Kim Tavaglione, SEIU, said California gets a lower return in federal funds than other states. How can we work together to improve that? More prisons built in California in last 20 years than schools. Larry Bevan, SEIU, said cuts might save money on the front end, but costs more on the back end. Supportive hotels work for some, but not for all. Budget will show its consequences in future years. Michael Lyon, Gray Panthers, said he couldn’t imagine what it’s like to wait 16 months for colonoscopy. All speakers have questioned the wisdom of cutting lower levels of services, which would result in people needing higher, more expensive levels of services. Ed Warshauer, SEIU 790, is growing weary of choices people are being forced to make. What’s more important: Chronic care nurses, colonoscopy, the elderly, substance abusers? Not good choices. The department can find improvements in continuum of care and administrative savings through better billing. Must unite to save public health. As important as police, fire. Need to go to the voters. The following people submitted written testimony, which is on file in the Health Commission Office: Brett Allen, supporting the STOP program. Ron Castner, Walden House, regarding the need for structural treatment. Margaret Blackman, supporting the Center for Recovery in the Western Addition Tiffany Moore, supporting Haight Ashbury Free Clinic. Commissioner’ Comments Commissioner Illig said he began his service on the Commission during budget hearings last year. Last year he went ahead and voted for the budget and believed the Mayor would reinstate the cuts. He is furious about the proposed cuts, which are in violation of the Strategic Plan. Two decisions led us to this point: the voters’ decision not to pass Propositions J and K, and the previous Mayor’s MOUs with labor unions that are now costing $32 million in guaranteed benefits and increases. The emphasis is on staff and not clients. If staff gave up one day per month of pay, it would more than make up for these cuts. He encouraged the Mayor to negotiate with labor to renegotiate contracts. Further, when the Commission is faced with major public policy decisions, such as changing the entire residential treatment sector, the Commission needs to have public policy discussions, with both sides presenting information. Commissioner Sanchez said there is a continuous dismantling of our world-class public health system that is based on training, collaboration and measured outcomes. Institutions are taking hit after hit. He reminded the Commission that MLK hospital in Los Angeles was developed after the Watts riots, and today is in deep trouble because of continued cuts and takeaways. He is seeing that happen here as well. It is getting harder and harder to retain and recruit faculty. What can we do as a Commission? We have a true crisis in public health, and need to find funding immediately to save services. He is frustrated along with his colleagues. The level of care provided at SFGH has always impressed him, and we are going to lose that. Commissioner Umekubo is frustrated with this after three years. This illustrates the underfunding of the public health system. Little by little it is being dismantled. We need to be more proactive. There are always inflationary and structural issues and the need to replace equipment and capital. These things will never change. Everyone needs to be proactive and look for more funding. Commissioner Guy supports her colleagues. The question is how does the Commission strategically address what it is faced with. The system started breaking three years ago with $20 million cuts in general funds combined with federal cuts. There have been cuts to the entire public sector. All of these cuts have health impacts. The Commission needs more than 10 days to consider this. She wants the resolution to say this is unacceptable. There needs to be further discussion about cuts in modalities. She reminded everyone that the advocacy is not over when the budget is submitted to the Mayor’s Office, and as appointees commissioners need to advocate with the Mayor and Supervisors. Commissioner Monfredini said she was speaking with the Mayor when a man came up and told the Mayor that San Francisco needs 120 more police on streets, and the Mayor could get the money by taking it from the health centers. This illustrates that everyone is looking to everyone else to save their budgets. She disagrees with Commissioner Illig about the MOUs with City workers. City workers have given back over the years, and unfortunately need more from workers this year. The Commission has a lot of work to do over the next ten days. 5) PUBLIC COMMENT/OTHER BUSINESS None. 6) ADJOURNMENT The meeting was adjourned at 6:20 p.m. Michele M. Seaton, Executive Secretary to the Health Commission Health Commission meeting minutes are approved by the Commission at the next regularly scheduled Health Commission meeting. Any changes or corrections to these minutes will be reflected in the minutes of the next meeting. Any written summaries of 150 words or less that are provided by persons who spoke at public comment are attached. The written summaries are prepared by members of the public, the opinions and representations are those of the author, and the City does not represent or warrant the correctness of any factual representations and is not responsible for the content.