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By Chester Kunnappilly
December 16, 2014

The holidays are a convenient time to take stock of our blessings and opportunities, and to consider the challenges we have overcome in the previous year. As I reflect back, I have many things to be thankful for: good health, a supportive, healthy family, colleagues I enjoy and respect, and a job that I love.

This year, the Affordable Care Act (ACA) had a profound and rapid change on my professional life as a physician who works in an institution that forms part of California’s safety net for those in need. I’m the chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. I also provide primary care in one of our outpatient clinics.

As a result of the ACA, many patients we serve in our county became newly eligible for Medi-Cal, California’s Medicaid program. With this transition, they were offered far more choices: They had access to services that were previously unavailable, such as dental services and expanded mental health services. And, instead of having to travel to our specialty clinic in the middle of the county, they could be referred to “private” specialists in their own communities. Far from luxuries, these new choices will help promote preventative care and early disease intervention; patients who in the past might have delayed a gallbladder or hernia surgery (and ended up in the emergency department with pain) can get prompt treatment with their new Medi-Cal coverage.

Before the ACA, most of our patients were either uninsured or were enrolled in a county program that only covered services at our institution; they could not seek care elsewhere. So more choice for patients means more pressure on us; as patients become eligible for Medi-Cal, they may now choose to leave our organization to seek care elsewhere. I will try to avoid clichés as I write this, but there is one that is especially appropriate here: “pressure makes diamonds.” I am seeing a spectacular gem being built around me here in San Mateo, far from flawless but beautiful nonetheless.

Competition has forced us to confront some difficult questions, such as: What is the role of the safety net in this new era when many more people are insured? Why should we, as an institution, continue to exist? Thankfully the answers to these questions came fairly easily.

As an integrated health system, we offer a range of services from outpatient to emergency services to inpatient to long-term care; we offer a distinct advantage over the traditional fragmented health care system. Embedded in the San Mateo County Health System, we can work with our colleagues in Adult and Aging Services, Family Health Services, and Public Health to better meet all the psychosocial needs of our patients. For example, our partnership with the county’s Behavioral Health and Recovery Services has allowed us to embed behavioral health experts in our primary care clinics so that they can better address the mental health needs of our patients; this partnership also expands our ability to refer patients with drug and alcohol problems.

As our patients have moved to Medi-Cal, the ACA has brought our institution some new funding. But we realize that this will be short-lived; many of the new programs of the ACA are funded by reductions to other parts of the safety net. Such pressure is not new; safety net programs are often short of resources, forcing adjustments and redesigns. But the ACA ramps up this pressure on us to innovate, to find ways to do things cheaper and more efficiently.

Fortunately, we had a head start. We began almost a decade ago by redesigning our primary care services and establishing team based care. The county implemented an electronic health record in our clinics long before there was a mandate to do so. The ACA, through its resetting of priorities and funding mechanisms, offers us an opportunity to build on this foundation. We have repurposed some staff roles and brought in new staff members with new skill sets. For example, we have staffers who are specially trained to extract information from electronic records to better manage chronic disease, and pharmacists have been added to some primary care teams to assist with medication management.

The ACA has facilitated new partnerships with other community provider, allowing us to focus on those services that we provide well while partnering to provide services that are best delivered by others. This is a transition from the past, when we were the provider of last resort, forced to provide as much as we could and living without the services we could not provide by ourselves.

One of our biggest investments has been in what we call our Lean transformation. Lean, based on the Toyota Production System, is a proven performance improvement methodology. Lean healthcare principles focus on increasing value by constantly improving quality and reducing defects and other wastes. Within the San Mateo County Health System, this transformation is being organized through our LEAP Institute. LEAP stands for Learn, Engage, Aspire, and Perfect (as a verb). As part of LEAP, we bring together teams that include line staff to observe and analyze our core processes – and then design new improved approaches that reduce waste and improve outcomes.

There is much work ahead, but much has already been accomplished. So far in 2014, we have brought almost 7,500 new patients into primary care facilitating better preventative health and chronic disease management. The majority of these patients are newly eligible for Medi-Cal. We have also seen a reduction of more than 20 percent in the number of patients leaving our Emergency Department without being seen due to long waits. We have seen an improvement in our performance on patient satisfaction surveys in a variety of areas including the Emergency and Inpatient Departments. And our pharmacy has reduced the time patients must wait for their prescriptions by about 75 percent. These are just a few of the gains. We look forward to many more.

Dr. Chester Kunnappilly is chief medical officer for San Mateo Medical Center, the county hospital and affiliated clinics in San Mateo County. He is board certified in Internal Medicine and also serves the organization as a primary care physician. He is a graduate of Dartmouth College and the University of Pennsylvania Perelman School of Medicine. He wrote this for Zocalo Public Square. Zocalo Public Square is a not-for-profit Ideas Exchange that blends live events and humanities journalism.

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