Sigrid Bathen

Writer, Editor, Teacher

Tag: health

Former California Legislative Analyst Liz Hill, Renowned Straight Shooter, Turns Her Focus to Health Policy

LizHill

Published April 20, 2016 on the California Health Care Foundation website.

After 22 years navigating state political waters, a respected policy expert looks back on a career that depended on objective facts and data, and explains why she chose to serve on the board of the California Health Care Foundation.

Elizabeth Hill became the first woman to head the California Legislative Analyst’s Office in 1986 when she was eight months’ pregnant with her second child. For 22 years, she held one of the most important positions in state government — advising the 120-member legislature during fractious times and sometimes clashing over policy recommendations in an increasingly partisan environment beset by the passage of term limits, deep budget cuts, and recession.

Through it all, she quietly maintained a reputation as a no-nonsense, nonpartisan, data-driven, objective analyst of legislation, the state budget, and a growing number of ballot initiatives. She testified in countless hearings, was peppered with questions from legislators, state agency heads — even governors — and was always open with the news media, always on the record.

Sometimes the disagreements would devolve into invective, but Hill never wavered from her even, fact-based analysis, acknowledging that her job sometimes made her unpopular. “It comes with the territory,” she once told a reporter. At one point, she managed this mammoth, sometimes thankless responsibility with a staff of only 43.

Yet restrictions on budget and staff did not limit her ability to shape public policy, and in 2015, because of her influence on the state’s political and public developments, she was asked by the Center for California Studies at California State University, Sacramento, to be the subject of a detailed oral history (PDF) for the California State Archives.

Hill joined the LAO as a program analyst in 1976, following a steady climb from humble roots in the Central Valley city of Modesto, where she was born and raised. She earned degrees from Stanford and the University of California, Berkeley; served as a Fulbright Scholar in Sweden; and had stints with several state and local agencies. Four years after she was appointed to the top job, voters passed Proposition 140, the term-limits initiative that also cut legislative budgets and slashed the analyst’s office by 60%.

“It had a seismic effect on the office,” said Dan Carson, a former San Diego Union-Tribune Capitol bureau reporter who left journalism and joined the analyst’s office in 1995 — and stayed for 17 years. “But we found ways to develop new roles that were in keeping with the resources we had. And Liz pushed us forward on computer technology.”

Despite the cuts, Carson and others said, Hill was personally and deeply involved in day-to-day decisions, while emphasizing a collaborative approach. “Any significant fiscal issue — she personally read and edited it, as the last line of defense for us,” he said. “She was very cognizant. She didn’t phone it in.”

Her employer was the Legislature — all 120 members — and she was widely viewed on both sides of the aisle as even-handed, thoroughly prepared, and a straight shooter. “She’s a solid shot with absolute, impeccable integrity. Couldn’t be any better,” John Vasconcellos, a powerful Santa Clara Democrat in the state senate, told a reporter when Hill announced her retirement in 2008. (Vasconcellos died in 2014.)

“Everyone in that office is dedicated to the ethic of nonpartisanship,” former Republican Assembly member Roger Niello of Fair Oaks said when Hill retired, “because Liz has developed it that way.”

Echoing other legislators, Denise Ducheny, a Democratic senator from San Diego at the time, said Hill’s departure “will leave a huge hole.” During legislative ceremonies after she announced her retirement, the San Francisco Chronicle reported how “evidence of her legacy rippled through the standing ovations from both sides of the aisle.”

With characteristic humility, Hill says nonpartisanship has been a hallmark of the office since it was created in 1941. From its inception, the analyst maintains credibility through nonpartisanship, she said, “providing untainted advice that is objective,” giving lawmakers the tools to make decisions about programs and policy.

When Hill left government, she said she initially spent time “decompressing,” traveling with her husband, Larry, who retired as director of cooperative education at California State University, Sacramento. She also wanted to spend more time with their two children, Erik, 34, and Kristina, 29, and two grandchildren. Today, at 66, Hill continues to focus on public policy issues in retirement, mainly health care and higher education.

In a wide-ranging April 4 interview at her home in Sacramento, Hill spoke with veteran Sacramento journalist Sigrid Bathen about her path to becoming one of the most trusted and sought-after public policy experts in the state, and about how solid policy analysis can influence future decisions. Her recall for complex details, dates, and names is precise, razor-sharp — a quality often lauded by legislators, governors, other public officials, and her own staff. And while her long career in public policy spanned a range of issues, health care — especially access for low-income Californians — remains a major focus.

This interview has been condensed and lightly edited.

Q: Your family has deep roots in the Central Valley, and you were born and raised in Modesto. Tell us about your early years.

A: My father was born there, and my mother moved there when she was three. Both my parents went to high school in Modesto, and I attended public schools. My father was a salesman with Leslie Salt Co., and my mom was an elementary school teacher. Stone was my maiden name. Our roots are still strong in the community. My mom is 90 now and still lives in Modesto. My father died about 20 years ago. My sister, Ann Falk, who worked in local government, lives in Turlock.

Q: You were active in debate in high school, and 4H, and were strong academically, attending Stanford University on a state scholarship. You also worked in university food services during the school year and summers in a tomato processing plant near Modesto. How did those vastly different cultural and academic experiences affect you?

A: I always knew that if I was going to attend college, I would need to get a scholarship. Luckily, a guidance counselor at my high school — we still had guidance counselors in those days — was a huge help to me, just to figure out how to navigate the waters when applying for college. I was a strong academic student, and had also been on the debate team. So I had a chance to actually visit a number of campuses throughout California for debate tournaments. One of them was Stanford, and I became very interested in that as a possibility. And UC Santa Cruz was just starting about the time I was graduating from high school, and I was quite intrigued by the cluster-college model. So those were the two places I applied, and fortunately, I got in to both.

Q: And then an opportunity to study in Sweden intervened, and that became a significant experience in your life.

A: Yes. After I was accepted at Stanford, I was also accepted into the American Field Service Program (AFS), which is based in New York City and matches the interests of accepted students with families around the world. And they felt that a family up in Umeå, Sweden, which is just shy of the Arctic Circle, was the best fit for me. . . . Stanford was really terrific about it. They said that while they couldn’t guarantee me a slot for the next year, they thought that it was a wonderful idea to participate [in AFS in Sweden] and to go — and, in effect, reapply. So that’s what I decided to do.

Q: Did you know any Swedish?

A: No. I had studied Latin and Spanish. Growing up in Modesto, we had gone up to the snow once, but I had never seen snow fall out of the sky. I really didn’t understand whole sentences for quite some time. But after three months, you know, I became more conversant. It was kind of comparable to a junior college-level education, which is a difference between the system in Europe and the American high school system.

Q: And you’ve remained in touch with your Swedish family over the years?

A: It will be 50 years ago in 2018 that I went to live with them. And my children know my host sister’s children, and the next generation, our grandkids, are starting to know each other now that the world is a little smaller, with Skype and Facetime and the Internet.

Q: You remarked in the oral history that the families of some of your roommates at Stanford spent more on groceries in a week than your family did in a month. How did your different backgrounds and experiences affect your time there? How did you adjust?

A: I think the wonderful thing about growing up in California is that you’re influenced by all these different things. I had a really good public education. Then I had the opportunity to go to Sweden and learned a great deal about cultural differences, and had a different view of the United States from the outside looking in, which was really valuable. And I learned you could still have an incredible commonality with people even if your backgrounds were perhaps totally different. And I think it’s kind of driven by the Golden Rule, to be honest. Do unto others as I’d like them to do unto me, and that seemed to work out pretty well in terms of being professional and fair. At Stanford, I think that served me well. I was a bit unusual, being a scholarship student. I was very fortunate, and once the university admitted you, they sent you a strong message that they wanted you to succeed and would be helpful in seeing you through. . . . And again, I could learn from my colleagues there; I was fortunate that a new major had started when I was a freshman, called the Program in Human Biology, to try to look at folks by integrating biology and the behavioral sciences, which was actually an experimental program supported by the Ford Foundation — a nice tie to philanthropy. I just thought it was fascinating.

Q: You did food-service work at Stanford, where you held a job as a “hasher.”

A: That was what they called us in my day. I worked around 20 hours a week, and I later became the head of the hashing crew at our little part of Lagunita, which was the dorm complex where I lived. And then the human biology program had student advisors, and I was paid for that. And I worked in the summers, first at Contadina putting “eight great tomatoes in that itty-bitty can.” I also picked peaches and berries.

Q: You have said that experience gave you an appreciation for the challenges facing other workers at the Contadina plant.

A: Absolutely. The canning industry is seasonal by definition, depending on — in our case — peaches and tomatoes. And sometimes there are rains in the Central Valley in the summer. And when it rains, sometimes there are layoffs for a few days when the fruit isn’t harvested. I remember, very vividly, when we were laid off for a couple days, and I was walking behind some ladies as we left that evening, and they said, “Gee, I just don’t know how I’m going to make it without the couple days of income for that work.” And that struck me. I was earning money to be able to go to college. They were there just to make ends meet.

Q: Your major at Stanford was human biology, but you decided to focus on public policy, especially during your internship at the state Department of Transportation (now CalTrans).

A: The major at Stanford wasn’t a classic biology major, although a number of my colleagues in the major did go on to medical school and public health. Because it was a melding of biology and the behavioral sciences, there was a contingent of us who went into related areas like public policy, sociology, and psychology. It was fantastic. At first, I thought I would like to work in nutrition. And then I took my first chemistry-related course, and I realized, nope. . . . I can do nutrition, but not from the scientific point of view of a nutritionist.

Q: The program required an internship?

A: Yes, during the academic term. I became acquainted with Claire Dedrick, who later became secretary of resources under Jerry Brown during his first or second term. And I got very excited about public policy. I then had a chance to work with Assemblymember Clare Berryhill from the Modesto area who actually went to high school with my parents. I found I really enjoyed government. And the people of California had given me an opportunity to go to college with taxpayer dollars through the California Scholarship, supplemented by financial aid from the university. I was really interested in giving back through public service.

Q: After graduating from Stanford, you were accepted at the Goldman School of Public Policy at UC Berkeley, where you earned a master’s degree, working during the summer at Caltrans. After grad school, you went directly to the analyst’s office?

A: First I spent a year in Sweden as a Fulbright Scholar studying their transportation systems. Interestingly enough, when the analyst’s office had an opening upon my return, I was hoping it would be in transportation, but there was nothing available. So I ended up in criminal justice as my policy area.

Q: This was a very different policy area from transportation. Could you discuss the interrelationships among the various areas of public policy analysis — how health care, for example, is impacted by education, social services, criminal justice issues, even transportation?

A: One advantage that we had at the analyst’s office, as a small office, is that I encouraged the staff that if they thought an issue they were looking into had implications for another policy area in the office, they were supposed to walk down the hall and talk to a colleague about what the interaction was and where they could potentially partner on a potential solution. We clearly have huge health care needs in state prisons that also have some implications for the Medi-Cal budget, substance abuse, mental health. The interrelationship of those policy issues was something I really tried to emphasize during my time as legislative analyst. That’s not to say it’s easy to break down those barriers. I’m well aware that it isn’t. But that cross-fertilization I think enabled us to make some important recommendations. In 1993, for example, we made a proposal called Making Government Make Sense, and that encompassed not only health but social services, criminal justice — a whole variety of policy issues. And we were concerned about uniformity in service, particularly in health issues, so that you wouldn’t have as much variation from county to county. And so again, that kind of cross-fertilization certainly came to bear in our proposals.

Q: You clearly have a strong preference for data-driven objective analysis, while maintaining the historically nonpartisan nature of the LAO. How did the presence or absence of data and objective analysis influence policy outcomes when you headed the office?

A: A good example is our work on welfare reform. In 1997, the state had to respond to the elimination of the Aid to Families with Dependent Children’s (AFDC) program at the federal level. And we had been, of course, following social-services and welfare-related issues, cash-grant and work-related programs for many, many years. A lot of evaluations had been done of these programs. So when it came time in 1997 to assist the legislature in crafting the state’s response to the new federal requirements, one of the things we did was to point to the evaluation literature. What worked? But we also had a sense that some of the data wasn’t crystal-clear and wasn’t a full-powered evaluation, and was, frankly, more anecdotal evidence as to what might work. And so what we did in coming together with a proposal for the legislature on welfare reform was exactly to that question. . . . We thought, “Here are some really important messages coming out of this anecdotal evidence that the legislature should consider.” So sometimes, not enough work has been done to come to a conclusive decision. But you give it your best judgment, and you be explicit as to what has been “proven,” and what is instead anecdotal. And so we did that with a good deal of success in our welfare reform proposal.

Q: Do you think data-driven, objective analysis is well utilized in state government generally?

A: Objective analysis is one of many things that policymakers have to take into consideration. I think sometimes its impact may not be clear in the immediate term but becomes clearer in the long term. As local Assembly member Phil Isenberg would say, “Information is power,” and to get your facts straight and know where the weaknesses are in the information — and also the strengths. That can have a very powerful effect on decisionmakers.

Q: It must have been difficult when public officials would balk at your analyses, or sometimes yell at you or make profane comments.

A: I think when you work in the policy environment, you have to understand that analysis is one of many factors, that politics is kind of a contact sport, that my chosen line of profession was making powerful people uncomfortable, oftentimes with objective analysis. And so there were clearly going to be times that officials were not pleased. But if they knew you could be a straight shooter, be objective, evenhanded, and appreciate that they were elected to make decisions, and as staff we were employed to be advisers, not decisionmakers, it worked out. And I think sometimes folks don’t understand that difference, between advice and decision.

Q: You have told the story about the time when Assembly member Maxine Waters said she planned to vote for a budget item you were analyzing, and she told you, “I want you guys to be as hard as nails on that proposal. I want it to be improved.” Did most members have that view of your work?

A: Members who had been around quite some time understood what a neutral third-party could do for them in the policy arena. I think in the early years of a term-limited legislature, some new members had a harder time understanding how they could use the resources of the office . . . to benefit their decisionmaking.

Q: You always had an unusually good relationship with the news media during your tenure — certainly not the norm in government. How did you handle media requests, interviews?

A: We were always of the view that we had so much in common with reporters — trying to explain how state government worked, what was happening. We wanted to be as transparent and open as possible about that, and had the view that all of our staff should talk on the record and not offer their own opinions. But we also thought that the individuals who were responsible for the analysis were usually the best people for the media to talk to because they had the most expertise. I mean, you could talk to me about education, but it would be far better to talk to our education expert. We had debated, “Gee, in this media world, should we have a public information officer?” But ultimately, we decided that the way we were doing it — trying to connect media folks with our experts and talking on the record — was really important.

Q: You’ve said that health care has always been an important interest of yours. How does health policy differ from other types of policy?

A: That’s a really good question. In the analyst’s office, we were dealing with a whole variety of issues, from mental health to substance abuse to developmental services, public health, and Medi-Cal. And Medi-Cal is far and away the largest health program in California. While I didn’t do a deep dive into health [policy] in the analyst’s office, I was responsible for the overall analyses of the health budget. I think health is unique in that, while there are other policy areas that have some similarities, in health particularly it’s a partnership between the state and federal government, particularly when it comes to Medi-Cal. . . . When I retired [in 2009], roughly 6.5 million Californians were served by Medi-Cal; now that number is over 13 million. So it’s changed significantly, and largely because of the passage of the Affordable Care Act.

Q: In 2011, you decided to join the California Health Care Foundation board. What did you find appealing about that role?

A: It was right around the time that the Affordable Care Act was going in, and everybody has some health stories in their families. In my case, in the 1990s my mom had had fourth-stage fallopian tube cancer, a very rare cancer. And she, amazingly, pulled through. She was treated here in Sacramento at UC Davis — she’s 90 now. . . . And having dealt with health over the years, in all of its various permutations, I thought, “Gee, it would be really nice to do more of a deep dive.” Health affects everybody, and with the Affordable Care Act, hopefully I could be helpful to CHCF with my own state experience. I didn’t know that much about philanthropy, but CHCF was, I thought, really unique in that it was willing to work with government and find opportunities where it could be helpful to the government process, again with information, analysis, and data. And that was very intriguing to me . . . with many similarities to what we did in the analyst’s office. . . . I’ve found it incredibly interesting — great staff, great board of directors. And I think that the mission of CHCF is so important — to be sure that there is access to high-quality care for all Californians, with a particular focus on low-income individuals who often don’t have access, or the system isn’t working well for them.

Q: Have you found that your background in behavioral health, going back to your studies at Stanford in human biology, has been a factor in your work with the foundation?

A: We are really moving the foundation more into the behavioral health environment, which is a newer endeavor for us. But I think trying to see the whole person — both the physical and behavioral health ailments and the substance abuse issues that are also a part of behavioral health — that is very important, as is our continued emphasis on access to care, quality care.

Q: And end-of-life issues?

A: The foundation has done important work in that area. I’m a baby boomer, and knowing how many of us are coming, to be sure that high-quality care follows the patient’s wishes is really important. We also have a number of collaborations with other entities that are underway. We’re a fairly small foundation, and being able to collaborate with other partners to make a difference in people’s lives is really important.

Q: You utilized that collaborative philanthropic model to work with the UC Davis Comprehensive Cancer Center after your mother was successfully treated there.

A: I’ve had the opportunity as a CHCF board member to work with the Comprehensive Cancer Center at UC Davis to initiate a women’s cancer-care program. And I’m really pleased with how that’s been able to develop with a little seed money that I was able to direct their way as a director at CHCF. That happens to be where my mom got care, and I wanted to see if there were some things that we could do for other folks going forward. So it’s been an exciting time.

Q: As analyst, you emphasized the importance of field research to learn firsthand about the issues you were examining. In the oral history, you spoke of an early experience, a meeting in Los Angeles with a social worker and a client with a child in her lap trying to apply for Aid to Families with Dependent Children (AFDC). And you were struck by the complexity of the paperwork, and the challenges faced by that caseworker and her client. What did you learn from that experience?

A: That intake experience gave me a profound appreciation for what eligibility workers were facing as they were trying to manage a caseload of several hundred people, to be sure they were meeting all the requirements of federal and state law, and the client who was juggling a one-year-old on her lap as she was trying to answer all the eligibility questions and be honest and factual, and she wasn’t trying to cheat the system. . . . Ultimately, what the state budget and public service are about is understanding people’s needs and how to provide services in the most cost-efficient and beneficial way. And so it really brought it home to our little world in the analyst’s office and in explaining to members of the legislature how programs actually work, what it takes to deliver services in a cost-effective way.

Q: You went through draconian budget cuts in the LAO during your tenure. How did you maintain the quality of the work following passage of Proposition 140 in 1990, when term limits were imposed in the legislature, and your budget was slashed by 60%?

A: It was a challenging time. I think each legislative analyst has been shaped by some unique event during their tenure. Mine was certainly the Proposition 140 experience. The standards for excellence certainly predated me, and they were among the things that attracted me to the office. So when we lost 60% of our staff, we basically had to figure out how could we maintain our excellence, how could we keep the analytical focus, and how can we keep producing things that were required by statute — largely our ballot work — as well as what the legislature expected us to do on the state budget.

Q: How did you manage priorities?

A: We went from 105 to 43 employees at one point, over a two-year period — at the same time the state was in an incredible recession. I approached the legislative leadership and said, “We can’t do the same amount with 60% fewer people,” and I recommended to them that we no longer do all the bill analyses. I just didn’t see a physical way the office could do that. We still operated on a special-request basis, but we would no longer produce 3,000 bill analyses a year.

Q: What about the budget analyses?

A: In previous years, we analyzed every single item of the budget. After Prop. 140, we made a decision each year about where we were going to concentrate our efforts, but that basically, we were going to concentrate our staff resources where most of the money was, and the overall revenue and expenditures of the state. In effect, we tripled all of the analytical staff’s budget assignments as a way to make up for the loss of staff. . . . I think it is a really good case in point of the dedication of my colleagues at the Legislative Analyst’s Office who remained when a very dark cloud was hanging over our heads — and still produced solid, professional work. I think it’s a real testament to public servants.

Q: You were the first woman to be named legislative analyst, in 1986, when you were eight months’ pregnant with your second child, your daughter. How did you manage issues of work-life balance and the needs of families versus demanding careers?

A: You know, I think for all of us, the work-life balance is a constant struggle. I was very fortunate in that my husband was very supportive of me working at the analyst’s office and throwing my hat into becoming the analyst even though I was eight months’ pregnant at the time that I was appointed. He worked at CSU Sacramento most of that time, and other than May, our schedules were different enough that we could complement each other. But May was particularly trying, both for the academic and the budgetary calendar. Initially, we didn’t have any family residing in Sacramento, and so we had to rely on neighbors and friends to help with picking up children. When our children got sick, one of us would take off in the morning, and one would take off in the afternoon. Clearly, during my tenure in the office, overtime was a big component, year-in and year-out and also during tough budgetary times. The budget often wasn’t done in time for summer vacation, so that always affected things as well. So it was tough on my kids at times. But it was also my dream job, my kids were flexible, and with my husband’s support we made it work.

Sigrid Bathen, adjunct professor of journalism and communications, California State University Sacramento

The Elderly Health-Care Crisis Sneaking Up on Davis

by Sigrid Bathen published March 07, 1999


As Gov. Gray Davis relentlessly presses his education-reform agenda, other state business is seriously neglected. State department heads remain unappointed and policy in many key areas is virtually paralyzed. Many admirers and critics alike blame Davis’ legendary propensity to micromanage for the administration’s slow pace. One story has it that Davis is so obsessed with the minuscule details of his new administration that he has been known to spend 20 minutes pondering which secretary to send out on the next Federal Express run.

Perhaps nowhere is the current dearth of broad policy reexamination more apparent than in health care. Millions of children are without health care, and their elders face the daunting prospect of life in one of the state’s many substandard nursing homes, increasingly targeted by consumer activists.

This crisis in care for the state’s burgeoning elderly population could well become Davis’ health-care debacle, much as appalling conditions in state mental hospitals hammered his former boss, Gov. Edmund G. “Jerry” Brown Jr., in the 1970s. Recent reports about substandard conditions in state-licensed care facilities must have a deja-vu quality for Davis, who was frequently put in the awkward position of having to clean up the media and administrative messes in health care created by his unfocused boss. It may well be Davis’ memory of those years that infuses his achingly deliberate pace, but his caution could blow up in his face.

Last summer, the General Accounting Office (GAO), the investigative arm of Congress, issued a highly critical report on the quality of care in the state’s more than 1,400 nursing homes. Federal investigators found that one-third of them had been cited by state inspectors for “serious or potentially life-threatening care problems.” Many of the cases examined by the GAO involved the “early deaths” of elderly residents whose conditions went untreated.

The report is a sad and seemingly endless litany: patients lying in urine- and feces-soaked beds, bedsores to the bone; patients pleading for help and repeatedly ignored; nursing-home staff reporting therapy that was not provided, falsifying documents, failing to provide fluids and food, refusing to take patients to the toilet, failing to notify physicians or family members about the serious deterioration of patients.

It is troubling but familiar terrain for elder-care advocates like Charlene A. Harrington, a nursing and sociology professor at UC San Francisco. Director of licensing and certification of health-care facilities in the old state Health Department in 1975 and ’76, Harrington is doubtless remembered by Davis, who was Brown’s chief of staff at the time. Harrington was fired by Brown after she “decertified” state-run hospitals because of repeated, egregious licensing violations; parallel efforts to toughen enforcement sanctions against nursing homes were also largely ignored. She recalls that a scathing Little Hoover Commission report on nursing homes nearly a quarter-century ago came up with the same proportion of substandard nursing homes as the recent GAO report. “We’re not regulating the industry,” she says. “We’re not enforcing what is on the books now, and what is on the books is too low.” Much as she did more than two decades ago, she recommends tougher enforcement of licensing and care standards for nursing homes.

She and other elder-care advocates point to surveys showing that only about one-third of nursing-home budgets are spent on patient care, a figure the industry hotly disputes, and that CEO salaries and profits of the big nursing-home chains that increasingly dominate the industry are rising fast. (In 1997, industry revenue was about $5 billion, 70% of which was public funds.) In contrast with CEO compensation, the wages of “certified nursing assistants,” the backbone of the nursing-home industry, average just over $7 an hour. Industry officials agree that staffing and salaries must be improved, but they balk at increased fines.

But stiffer fines–the maximum is currently $25,000–and tougher enforcement are likely to command considerable legislative attention this session, as will efforts to tighten the current appeal process so that fines assessed by licensing inspectors are actually paid. “If you’re going to fine a facility for killing your mother,” says Patricia L. McGinnis, executive director of California Advocates for Nursing Home Reform (CANHR), “make it $100,000, not $25,000. My God, you can leave someone naked and tied to a wheelchair and you get a $500 fine. There are higher fines imposed for killing a dog in California.”
Recognizing the expanding universe of elder care, advocacy groups like CANHR and the American Assn. of Retired Persons are devoting more and more resources to other forms of in-home and residential care beyond the state’s nursing homes, which have beds for 120,000. As the population ages, the political climate may finally be ripe for major reform. As Californians increasingly “age in place,” that is, remain in their own homes as long as possible, services must become more available, affordable and safer. State law only recently required that nursing assistants and home health-care aides have criminal-background checks, but nonmedical, county-based In-Home Support Services personnel, funded by the state and federal governments, have no such requirement.

Criminal prosecutions involving elder abuse are increasing in frequency, and the state attorney general’s office is likely to step up such prosecutions in nursing homes through its Medi-Cal Fraud Bureau, which filed few cases under former Atty. Gen. Dan Lungren but is expected to have a much higher profile under Bill Lockyer. At the local level, prosecutors say it’s often pure happenstance when a case comes to the attention of law enforcement. Although some cases involve murder or assault by family members, other “caregivers” and nursing-home employees, more and more cases grow from financial exploitation of seniors, often in their own homes.

If stepped-up criminal prosecutions and increased state sanctions don’t stimulate nursing-home reform, civil suits and the threat they pose to companies’ bottom lines may be the spark. The California Supreme Court, in a landmark decision last week, upheld lower-court decisions awarding nearly $400,000 to the family of 88-year-old Kay Delaney, who died in 1993 at a Lake County nursing home after suffering from severe bedsores and lying in her own waste. In the unanimous ruling, justices raised the financial-liability limits of health-care providers that recklessly endanger the elderly. Also last week, the family of 75-year-old Ruth Witten, who choked to death last November in a nursing home near Sacramento, filed suit, contending that chronic understaffing at the Roseville Convalescent Hospital led to her death.

Fortunately, there are some signs that Davis is taking up health care. Early on, the governor named Grantland Johnson, a former federal health administrator and Sacramento County supervisor, as his health and human services secretary. “We have to look at tougher and more effective enforcement,” Johnson says. “We can be tough on the books, but if it’s not effective, it’s meaningless.” Johnson added, “It’s going to take us a while to settle on a methodical approach to this.”

But nursing-home and other residential care for the elderly has been the subject of countless state and federal hearings and reports over the decades. There are mountains of data pointing to horrific suffering and early deaths in nursing homes. The last thing elder-care reform needs is a “methodical” approach, which generally, in the language of government, means it will take a lot of time–a luxury Davis does not have.


Sigrid Bathen is senior editor of the California Journal, a monthly magazine about politics and government.

Out of the Snakepit, Parts 1 & 2

by Sigrid Bathen posted September 9, 2005


Rose King has seen it all.

A widely recognized expert on mental health issues, she has served in the trenches of the mental health wars for more than 30 years–even before the 1969 suicide of her husband, who suffered from what was then called manic depression. Years later, her son also committed suicide—after suffering from the same illness, known now as bipolar disorder.

She saw the emptying of the state hospitals during the 1960s–ultimately, some 87 percent of 36,000 patients were “deinstitutionalized”–that began under Gov. Ronald Reagan and continued through the 1970s by Gov. Jerry Brown. She saw the legions of homeless mentally ill roaming the streets, passing through temporary shelters and jails, victims of the state’s failure to pay for community mental health care as promised when the state hospitals were shuttered.

Today, only 4,700 mental patients remain in state hospitals.

She saw families struggling with health insurers and public mental health programs to get help from a failed system plagued by lack of money, understaffing and disorganized services. The hard lesson learned: Care is often available to the mentally ill only when they are in a state of severe crisis.

“It hasn’t really changed since my husband became ill,” says King, who lives in East Sacramento. “It remains crisis-driven, crisis-perpetuating and fragmented.”

“We turn mental health clients away and tell them to return when their symptoms are so severe and persistent that they cannot meet their own needs, and may no longer even recognize that they need care,” the Little Hoover Commission noted in a 2000 report.

But last year, voters approved Proposition 63, the landmark mental-health initiative that taxes the wealthy at 1 percent of all income over $1 million. That means Californians will now see the first major infusion of money into mental health care in decades—an estimated $1 billion a year, specifically for community mental health care.

King and other activists hope that the money will transform the wretched conditions that blight urban streets and consign millions of afflicted Californians and their families to lives of poverty and desperation.

But the story of Rose King and her family is not just a story of the struggle for mental health care. It is the story of a system so flawed that it harms the very people it is supposed to protect.

Rose and Joseph King first sought help from their health insurer–Kaiser–as Joseph began to experience frightening symptoms of depression and paranoia in 1968. Joseph “saw the doctor who had treated him for asthma, and was told there was no psychiatrist on staff in Sacramento,” Rose recalled. An urban planner who worked for regional planning agencies in California and Alaska, Joseph soon became so disturbed that he could no longer work.

Desperate, they drove to DeWitt State Hospital in Auburn–which was in the process of closing.

“They wouldn’t accept him at DeWitt,” she said. “He didn’t look ill, and they said he ‘didn’t meet their criteria.’ We had no idea where to go.” He was finally admitted “for a couple of weeks” to a mental health clinic run by Sacramento County, where his wife said he was seen by a psychiatrist twice, and sent home on a weekend pass. That night in 1969, at age 36, Joseph King killed himself.

Grief-stricken and now a single mother to 8-year-old twins and their 6-year-old sister, King, who had been a homemaker and volunteer political activist, went back to college, earning a Bachelor’s in government-journalism at California State University, Sacramento, and a Master’s in journalism at the University of California-Berkeley.

She interned in the Capitol for Democratic Sens. George Moscone and Mervyn Dymally, and worked for $25 a week in the unsuccessful 1970 gubernatorial campaign of Assembly Speaker Jess Unruh. She later worked in paid jobs for a succession of powerful Democratic legislators–including Assembly Speaker and Lt. Gov. Leo McCarthy, Senate Leader David Roberti and Assembly Speaker Antonio Villaraigosa.

But her first introduction to mental health issues had been in 1967, the year before her husband became ill, when she ran an unsuccessful but well-publicized campaign to recall Reagan, in which many of the core activists were medical and psychiatric workers infuriated by conditions for the mentally ill.

As she became more involved in the issue, she pressed politicians, pollsters and the media to lift the heavy curtain of ignorance and stigma that has long surrounded mental health policy. She helped staff a statewide task force on mental health issues under McCarthy when she was his chief of staff in the lieutenant governor’s office.

“Nobody even asked what public opinion was on the subject,” she says. “I asked Mervin Field to start putting [questions about mental health] in his surveys, and there were two statewide polls done for the [Senate] Rules Committee when I was working for Roberti in the 1980s. The importance of the subject of mental health to citizens was first in one poll, second in the other.”

In 1984, her 23-year-old son Michael was diagnosed with bipolar disorder, which is often hereditary and can surface with frightening symptoms in late adolescence or early adulthood. Years later, after battling the disease for nearly two decades, Michael committee suicde. He was 42 years old.

In 1990, King worked on an initiative to raise the alcohol tax to fund mental health care.

“It was unsuccessful, but not because people didn’t think something should be done about mental health,” she says. She was chief consultant to the Joint Legislative Committee on Mental Health Reform convened by Senate Leader John Burton in 2000 and co-chaired by former Assemblywoman Helen Thomson, author of numerous mental health measures over the years and a former psychiatric nurse who is now a Yolo County Supervisor. Thomson was termed-out of the Legislature in 2002, and King, who was principal consultant to the Assembly Health Committee that Thomson chaired, retired the same year.

King’s oldest daughter, Michael’s twin sister, does not have the condition, says King, but her youngest daughter was diagnosed with bipolar disorder at age 30, following childbirth, which can be a “trigger” for emergence of the disease. King’s youngest daughter, now 43, a college graduate with two degrees earned before the onset of the disease, “manages her condition quite well and works in her profession,” her mother says.

Recently, a teen-age grandchild has shown symptoms of the disease, and the 66-year-old King once again finds herself in the mental health trenches, seeking help from a still-fragmented system of mental health care that has bedeviled California families like the Kings for decades.

As California gears up to put Proposition 63 into effect, former Assemblyman Darrell Steinberg, who authored the measure, King and other supporters are carefully following its progress.

“I’m hopeful,” King says of the flawed, crowded mental health care system. “It’s not like we don’t know what works or what needs to be done…It’s not unusual for a case manager to have a caseload of 120, all people in crisis.”

She adds: “The system today is really no better than it was in the late 60s when my husband became ill.”

Next week: The devil is in the details: putting the voters’ will into effect.


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She has covered mental health issues for 30 years, winning several California and National Mental Health Association awards–and a Pulitzer nomination–for her mental health coverage in the Sacramento Bee and the California Journal.


New money for mental health care; Families hopes rise

by SIGRID BATHEN posted 09.08.2005


 

Darrell Steinberg, whose crusade to help California’s mentally ill culminated in the passage of the landmark Proposition 63, got an early education in the power of grass-roots advocacy.

As a law student at the University of California at Davis in 1984, he led a successful student campaign to improve access for the handicapped at the law school. Two of Steinberg’s closest friends were quadriplegics who could not access the mock courtroom in their wheelchairs, and the students successfully forced the university to install a lift.

Steinberg, a Sacramento lawyer and Democrat who is running next year for a local state Senate seat, learned a lesson that he would remember years later when he successfully pushed for Proposition 63: Get organized, then get the money.

“We organized, involved the press and found the money, which supposedly was not available,” Steinberg recalled when, as a state Assemblyman, he returned to his former law school 20 years later to deliver the commencement speech.

Now, the money for community-based mental health care will finally become available.

Approved in November and still in its planning stages, Proposition 63 represents the most important changes to California’s mental health system in decades. The changes are desperately needed: More than half of those surveyed in public opinion surveys say they have a relative or close friend with serious mental problems. For the first time, the families of the mentally ill will be directly involved in deciding how to spend the mental health funds.

Proposition 63 will provide an estimated $1 billion annually through a 1 percent tax on all annual income above $1 million. The money will go to community-based mental health care programs, which can apply for grants following Proposition 63’s strict criteria. The money can be used only for local mental health care — including housing, training, therapy and counseling — and cannot be diverted to state correctional or parole programs. So far, $24 million has been allocated for the initial planning and review of local project proposals. By the end of the current fiscal year in June 2006, some $700 million is expected to be set aside for community mental health services.

The money has been a long time coming.

“We have a once-in-a-lifetime opportunity to demonstrate to the state and the country that people with mental illness can lead productive lives, be part of our communities, live independently–and that with a decent system of supports and services, people do not have to be relegated to lives of hopelessness,” Steinberg said.

Steinberg, a former Sacramento City Council member, made mental health care one of his principal campaign platforms when he ran for state Assembly in 1998.

Shortly after he took office, Steinberg introduced AB34, which initially provided $10 million to fund pilot projects for community services to the mentally ill. The bill was the direct progenitor of Proposition 63 and marked the first significant investment in mental health in decades.

One year after the pilot projects were funded in 1999, Steinberg said, “we found that the 1,000 people helped under AB34 were showing the beginnings of real success, with decreased hospitalizations and reduced homelessness.” He points to impressive statistics from the AB34 projects: Participants had a 56 percent reduction in hospital stays, a 72 percent reduction in jail stays and a 65 percent increase in full-time jobs. The success of the pilot projects prompted Steinberg to push for more funding, and to take the matter directly to the voters during his final year in the Assembly, where he was termed-out in 2004.

Thus, Proposition 63 was born.

Steinberg and Rusty Selix, the longtime executive director of the Mental Health Association of California, led the Proposition 63 campaign, organizing a coalition of supporters who included the mentally ill and their families – people who historically were excluded from mental health policy-making. The coalition raised $5 million to place Proposition 63 on the ballot and secure its passage.

Officially called the Mental Health Services Act, it was approved with 53.4 percent of the vote. The mentally ill and their families are specifically included in the planning, implementation and staffing of the new law. Steinberg, meanwhile, chairs the 16-member Oversight and Accountability Commmission for Implementation of Proposition 63, which will be administered by the state Department of Mental Health.

Polling for the measure showed that a majority of people had a relative or friend with severe mental health problems, although the stigma against seeking care remained. “Public acceptance has been proven,” says Selix. “But the willingness to talk openly about it among average people is another matter. Not every school, nor every employer, understands.”

Clearly, after decades of neglect, the available funds will be stretched thin.

“The law was pretty specific,” says Dr. Stephen Mayberg, a psychologist who has been director of the state Department of Mental Health for 12 years. “They wanted to make sure to expand services, not to duplicate or backfill services, and specific populations are targeted.” Funding cannot be used for jail and prison or parole populations, and must avoid what Mayberg calls “the fail-first system” of previous years.

“The first time they have contact is when they are institutionalized or arrested–that is probably not a good introduction,” Mayberg says.

Mayberg’s department employs more than 10,000 people, many working in the remaining state hospitals which house some 4,700 people–mostly individuals who have been judged criminally insane or incompetent to stand trial. It is a much different population than was housed in 1961, when 36,0000 mentally ill were kept in state hospitals throughout California, before the “deinstitutionalization” of the hospitals under Govs. Ronald Reagan and Jerry Brown.

Those hospitals were plagued by scandals ranging from unexplained patient deaths to persistent reports of neglect, abuse, misdiagnosis and over-medication. But when they were closed, little was left in their place. Mental health care activists say the promise of community care has been little more than a cruel hoax on the mentally ill and their families, leaving increasing numbers of homeless mentally ill on the streets or in jail.

Proposition 63 backers hope that community care, at least, will markedly improve with significant money and staffing under the new law. The state Department of Mental Health recently added more than 80 employees specifically to work on improving and expanding community programs under the new law.

Experts say housing is the most urgent need – and the initial funding priority — for the chronically mentally ill (who often avoid shelters), as well as for families of the mentally ill and former foster kids who are kicked out of the foster care system.

“It’s very hard to provide services if people don’t have stable housing,” says Tim Brown, longtime executive director of Sacramento’s Loaves & Fishes, which does not accept government funding but has been actively involved in local planning for use of the new money. “But people need a lot of support in housing. It’s certainly preferable to their going in and out of jail.”


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She has covered mental health issues for 30 years, winning several California and National Mental Health Association awards–and a Pulitzer nomination–for her mental health coverage in the Sacramento Bee and the California Journal.

Changes in mental health care system spur new optimism

capweeklyaug2011

Changes in mental health care system spur new optimism

by SIGRID BATHEN posted 08.18.11


Massive changes in how mental health care is delivered to Californians – including abolishing or restructuring the two state departments responsible for mental health and substance-abuse programs – are being closely watched by care providers and advocacy groups.

They say they are “cautiously optimistic” that Gov. Brown’s plan will result in a coordinated, community-based system of care for the thousands of people who historically have faced a dizzying patchwork of care, or no care at all.

But advocates emphasize that mental-health care must have a prominent position in the state bureaucracy.

“We need somewhere to go to at a very high senior policy level,” said Mark Gale, chairman of the public policy committee for the California arm of the National Alliance for the Mentally Ill and the father of a mentally ill son. “We need someone at the highest level who understands core mental health policy, law and regulations, someone who has lived it. If we don’t get this right, the system will become extremely dysfunctional. If we get it right, there is great opportunity.”

Financed in part through a one-year appropriation of $861 million in the 2011-12 budget from the so-called “millionaire’s tax” approved by voters in 2004 as Proposition 63 to fund new mental health programs, the reorganization aims for a coordinated approach to mental health – and a major shift from the state to the counties for funding and managing mental-health programs, with state oversight.

Some services are being moved to the huge state Department of Health Care Services. There is talk of two new departments – one under the rubric of “Behavioral Health” or “Mental Health and Substance Abuse,” and another for “Institutions” or “State Hospitals” to administer the remaining state hospitals, which primarily house the criminally insane.  A recent spate of assaults, including the strangulation death of a psychiatric technician at Napa State Hospital last October, has prompted a series of state and federal crackdowns at those facilities, which currently house nearly 6,000 patients.

A major concern is abolishing the Department of Mental Health.

“There is tremendous fear in the mental health community about eliminating the Department of Mental Health,” said Rusty Selix, longtime executive director of the Mental Health Association in California. Selix is the co-author, with state Senate President Pro Tempore Darrell Steinberg, D-Sacramento, of the landmark Mental Health Services Act, passed by voters in 2004 as Proposition 63.

“Where are we left if the next administration doesn’t have the same level of interest?” Selix added.

Representatives of advocacy and professional groups are vocal participants in public hearings held throughout the state in August and September by the state Health and Human Services Agency and the soon-to-be defunct Department of Mental Health. The hearings solicit comments for the complex reorganization plan taking shape at the state and local level.

“There are a lot of pieces to this puzzle, and we need to look at it as a whole – courts, prisons, police, state hospitals, community programs – and re-engineer a system that works better,” said Randall Hagar, government affairs director for the California Psychiatric Association, who has followed mental health issues for decades and is the father of a schizophrenic son. He says the Brown administration’s reorganization proposals come at a critical juncture for both providers and families. “Some of the tools are there already, but we have a system that has evolved piecemeal for nearly five decades.”

Rose King, a legislative and state policy expert on mental-health issues (who is the widow, mother and grandmother of mentally ill family members), has regularly attended the ongoing “stakeholder” meetings and expresses increasing concern that the vague outlines of a new system still fail to address historic discrimination against the mentally ill, despite state and federal laws requiring parity in treatment for mental as well as “physical” health.

But she says the reorganization “has great potential” and “creates an opportunity for the integration of mental illness and substance abuse disorders” – and to close the disparities in treatment of mental  and physical health care.

Pat Ryan, executive director of the California Mental Health Directors Association, which represents county mental health directors, said the goal of the reorganization “is to get people help sooner rather than later, to avoid both incarceration and institutionalization. If you starve the system and don’t have money specifically intended for prevention and early intervention, you’re never going to get there, because you’re always going to be dealing with crises.” Like other advocates and providers, Ryan said “leadership is critical” in any new system – in which the counties will play an increasingly larger role under the Brown administration proposals and federal health care reform.

“The idea is to get the money flowing directly to counties with fewer strings and less bureaucracy,” said  Farah McDaid Ting, senior legislative analyst for the California State Association of Counties.  “It’s an opportunity for counties to take an integrated approach and offer a continuum of services. We haven’t had that opportunity before.”

Central to the reorganization are lessons learned from the tortuous implementation of Proposition 63, which levied a 1 percent tax on millionaires and provided $900 million to $1.5 billion annually in additional revenue for local mental health programs.

Hailed as the first significant infusion of state funding for mental health since the closures of decrepit, understaffed and overcrowded state mental hospitals nearly four decades earlier – dumping huge numbers of mentally ill people on communities ill-equipped to handle them – Prop. 63 became both an important harbinger of change and a bureaucratic nightmare.

Critics of its implementation – including some of those who helped write the law – say the process was plagued by red tape, glacially slow state Medi-Cal payments to counties, high consultant fees, accusations of cronyism,  and only a trickle of funds for actual programs.

While success stories emerged from communities where homeless mentally ill for the first time found coordinated housing and treatment with Prop. 63 funding, thousands more received little or no treatment, continuing on a tragic downward spiral of homelessness, institutionalization and incarceration, worsened by the severe economic downturn and draconian budget cuts.

The state required counties to jump through an array of bureaucratic hoops and “pre-approvals,” infuriating local officials.  At the same time, there were broad state and local cuts to social programs, with some Prop. 63 funds used in recent years to help balance the precarious California budget.

“The planning process went on and on,” says former Yolo County Supervisor and state Assemblywoman Helen Thomson, D-Davis, who chaired the Joint Legislative Committee on Mental Health and the Assembly Health Committee and is a former psychiatric nurse married to a psychiatrist.

“Every county hired a different kind of consultant. A lot of money was going into the Prop. 63 fund, and it was bureaucratized.” While some new Prop.-63-funded programs provided services, she said, “clinics were closing, beds eliminated.” Intended to supplement existing services and create new programs, Prop. 63 funds were used by cash-strapped counties to finance dwindling mental-health services.

Hagar says the language of the law included “something for everybody, to get everybody on board,” in order to ensure its passage. “Unfortunately, it was so diffuse that we had a lot of exemplary projects developed, doing a wide range of things – suicide prevention, school-based services – while heavy-duty services, core services for those who were homeless or not ‘engaged’ in the system,  did not receive the same level of support.”

Steinberg remains one of its most passionate proponents, and is clearly stung by what some say is the scapegoating of a landmark law.

“You can’t blame [Prop. 63] for the problems of a mental health system that has been decades in the making,” he said.  Quick to criticize the cumbersome implementation process, he is hopeful the current reorganization will address flaws in the process. “The process has been faulty, and it has gone too slowly at times. It’s been way too slow off the mark in reporting data.” Still, he added that despite setbacks, the 2004 law “remains a monumental accomplishment,” and, when fully implemented, will help provide coordinated care and keep the mentally ill out of jails and prisons.

“The fact is that we’re living through the worst recession in 50 years, and we’ve cut budgets in ways I abhor,” he added. “Prop. 63 was never intended to be the solution for all of the system’s problems. It was intended to provide comprehensive care for people with severe mental illness, with the main goal of keeping people out of the system. ”

The law included specific requirements that funds be used only for “new” services (not existing programs), and not for jails or prisons. The complex approval process that evolved, administered by the state Department of Mental Health, will likely be scrapped by 2012-13, along with the department – “reorganized” or “redirected” in state budgetary parlance – as will the state Department of Alcohol and Drug Abuse.

While state administrators are deep in a widely publicized “Public Safety Realignment,” less has been said publicly about the administration’s lower-key efforts to coordinate mental-health and substance-abuse programs with the state’s vast and costly correctional system, which faces massive court-ordered population reductions and mandated improvements to all aspects of prison health care.

Since many prisoners are also mentally ill and vast numbers are serving time for drug-related crimes, advocates say coordination of mental-health and substance-abuse services at the local level is critical to any reorganization plan, and could help avert much more expensive, sometimes deadly, arrests and incarceration.

Local officials express relief that some of the bureaucratic hoops, especially the much-maligned “pre-approval” process for Prop. 63 funding, will be eliminated, and that Medi-Cal reimbursement backlogs – which often stacked up for months, leaving counties holding the bag – will be reined in.

Newly appointed Health and Human Services Agency Undersecretary David Maxwell-Jolly, the former state Health Care Services Department director who is overseeing the reorganization with Agency Secretary Diana Dooley, said technological improvements have dramatically reduced the paperwork blizzard and Medi-Cal backlogs. He noted that state officials were “less responsive and perhaps less efficient than we could be.”

But officials are adamant that state oversight and especially “evaluation of outcomes” will be a high priority under the reorganization, and that mental health will remain high on the administration agenda regardless of its placement in the state bureaucracy.

Among those assigned to this daunting and often thankless task is a career state administrator, Cliff Allenby, recently appointed by Gov. Brown as interim director of the Mental Health Department. A veteran state Finance Department administrator who has headed several state agencies, including the Department of Developmental Services, Allenby has no illusions about the challenges inherent in reshaping a flawed and broken mental health system.

“We don’t have all the answers,” Allenby said. “We really don’t. The stakeholder process is very important – what should remain, and how that should be [reorganized].  I’m not here to prejudge, and we really will listen carefully at the stakeholder meetings to what they have to say, then prepare a proposal for the 2012-13 budget.”

“I’ve been around a long time, and Sacramento is just not the place to establish policies that work in all 58 counties,” he added, borrowing an oft-repeated anecdote from the governor’s proposals. “What works in L.A. isn’t necessarily what works in Redding.”

Many aspects of the proposed reorganization are unknown, including the specifics of long-term funding sources and state oversight of local programs. “Somehow we must have a very high-level policy visibility that is not buried in some bureaucracy somewhere,” says the Psychiatric Association’s Hagar. “The track record hasn’t been great.”  But despite sometimes heated disagreements among the various “stakeholders,” there is widespread consensus that the administration push toward coordination of mental-health services is long overdue.

Advocates and providers are hopeful that much-touted plans for “integration of services” will carry more weight than the hollow promises of decades past.  They point to the badly fragmented system  that resulted, in which the streets, jails, prisons and state mental hospitals for the criminally insane have become both the first and last resort for the severely mentally ill, who might have been helped with earlier intervention.

“The jails are full of people who are mentally ill, and hospitals are ringed with barbed wire and security guards,” says veteran mental-health advocate and former Assemblywoman Thomson.  “It’s the ‘trans-institutionalization’ of mental illness, and it’s tragic.”


Sigrid Bathen teaches journalism and communications at California State University, Sacramento. She is a former Sacramento Bee and California Journal reporter and editor who has covered mental health issues for more than 30 years.

Doctors’ drug tests: a divisive issue

Doctors’ drug tests: a divisive issue

by SIGRID BATHEN posted 10.19.2014

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On Oct. 23, 2013, San Diego physician Dr. Scott D. Greer submitted urine and hair samples to an investigator for the Medical Board of California, which oversees physician licensing and discipline.  Laboratory tests found the samples to be positive for opiates and oxycodone, but not for alcohol. Nearly one year later, on Sept. 8, according to Medical Board records, Greer was placed on probation for seven years by the board.  His license was suspended for 30 days, effective Oct. 24; he agreed to myriad restrictions and requirements, including submitting to regular, random alcohol and drug testing and monitoring.
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“If he tests positive for anything, he will be notified to immediately cease practice,” said Cassandra Hockenson, public affairs manager for the Medical Board.

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The issue of testing doctors for drug use is a key part of Proposition 46, which has become the focus of huge campaign spending — most of it spent to defeat the initiative.  The measure also would raise the cap on pain and suffering awards in medical malpractice cases, which has been $250,000 since the 1970s, to reflect cost-of-living increases. If approved, the new cap would be about $1.1 million.

The tragic deaths of two young children in 2003, killed by a drug-impaired driver who had been prescribed prescription narcotics by several doctors – a practice called “doctor-shopping” — helped spark the measure, which would also require physicians to consult a state prescription database before prescribing addictive drugs. Bob Pack, the father of Troy and Alana Pack — 10 and 7 when they were killed — left his tech job to pursue legislative solutions, and is a principal spokesman for Prop. 46.

Opponents of Proposition 46, mainly medical malpractice insurers and the powerful California Medical Association, are pulling out all stops – dumping some $57 million into the “No” campaign, roughly $50 million more than supporters of the measure, primarily consumer groups and trial lawyers.

In the case of Greer, 62, he had voluntarily sought help for his long history of alcoholism and drug use after an “intervention” by his family in 2012. He had tried to kick his decades-old habit many times before. For several years, starting in 2003, Greer participated in a beleaguered “doctor diversion” program, administered by the Medical Board and abandoned in 2008 as ineffective, failing to protect patients in the care of participating doctors.

Greer admitted to investigators that he relapsed, providing false urine samples while in the controversial diversion program, which was scrapped by the state after multiple government and independent audits revealed major flaws.

In addition to random laboratory drug-testing, a major part of Greer’s probation includes twice-daily use of the Soberlink breathalyzer test. Results are immediately transmitted with a photograph of the subject via a mobile phone attached to the device.

 “The measure as written is a mess,” says Jason Kinney, a spokesman for the No on 46 campaign. “The drug testing provision is particularly problematic.”

The Greer case marks the first use of the technology by the state board for monitoring physician compliance on probation. “It’s potentially a very powerful monitoring tool for those with alcohol problems,” said Greer’s attorney, David Balfour of Carlsbad, who specializes in physician discipline cases, “because it can provide results instantaneously, [unlike] a random urine screen, which is typically how the board has monitored [physicians].”

Details of the disciplinary actions against Greer and other physicians are posted on the state Medical Board website, www.mbc.ca.gov.

Critics of Proposition 46 say the initiative is flawed.

“The measure as written is a mess,” says Jason Kinney, a spokesman for the No on 46 campaign. “The drug testing provision is particularly problematic.”

But testing doctors for drugs is popular with focus groups and in polls of likely voters. It is privately favored by many physicians, especially those recovering from addiction issues, who argue California needs more official incentive for doctors to seek help – and liability protections for colleagues who may be reluctant to report them.

“At its peak, the diversion program had 300 to 400 participants,” says Balfour, yet the number of Medical Board enforcement actions is considerably lower. “Two-thirds are not getting treatment. In the larger context, if 10 percent of the population [has addiction issues], 12,000 doctors would need some level of help. Not having any official program is a bad outcome.”

The investigative function of the Medical Board, a so-called “self-funded” agency supported by physician licensing fees, was moved in July to the state Dept. of Consumer Affairs.

More than 128,000 physicians are licensed to practice in California, and Greer is believed by critics of the state’s doctor-discipline system to be one of hundreds – perhaps thousands — of physicians who abuse alcohol and drugs. Many may well be practicing while “impaired” and do not seek help from a patchwork physician treatment system long acknowledged by experts to be ineffectual and potentially dangerous to patients in the care of drug- or alcohol-addled doctors.

According to the Medical Board’s annual report, 394 physicians were disciplined in some way in 2012-2013, with actions ranging from license revocation (11) to probation (41) or public reprimand (47). Reasons ranged from “gross negligence” (130) to sexual misconduct (24).

Disciplinary actions for “self-abuse” of alcohol or drugs numbered only 46, with nearly half being placed on probation.

California is one of the few states in the U.S. without an official program to direct physician substance abusers into treatment and monitoring. Legislation to create a new diversion/treatment program has repeatedly failed in the state Legislature.

The investigative function of the Medical Board, a so-called “self-funded” agency supported by physician licensing fees, was moved in July to the state Dept. of Consumer Affairs after Gov. Brown signed legislation last year to reorganize board staff. In the spring of 2013, legislative oversight hearings and intense consumer-group protests over excessive physician prescribing of painkillers prompted sharp legislative criticism of the board’s failure to “protect consumers.”

The Legislature ultimately approved extending the board for four more years, but in July moved its 100-plus investigators to the Division of Investigations within the Consumer Affairs Department. The state Attorney General’s office has long had prosecutorial responsibility for board enforcement actions.

The latest legislative effort to create a physician diversion program was AB 2346 by Assemblywoman Lorena Gonzales (D-San Diego), which proposed a diversion program similar to a State Bar program for lawyers.

Julianne D’Angelo Fellmeth, administrative director of the Center for Public Interest Law at the University of San Diego Law School, has long followed physician discipline issues in California, and is a former state monitor for the Medical Board, issuing one of several scathing audits of the physician diversion program.  She often testifies in the Legislature about physician-discipline issues, and is widely regarded as an expert in the field.

“There are now three layers,” she said of the recent Medical Board reorganization. “The Medical Board, the Division of Investigations and the Attorney General’s office. We won’t know the actual impacts until after the move.” Fellmeth said she would have preferred that investigators be placed in the Attorney General’s office, to work more closely with prosecutors on enforcement cases involving physicians.

Highly critical of the diversion program, she does not favor creation of a similar successor.

“All the doctors insist that [the program] must be secret and confidential, otherwise no doctor will go into it,” she said. “So if there is a program, it [will be] secret. Patients aren’t going to find out about it.” She recalls attending a Medical Board meeting when the diversion program was in effect, when a patient appeared, uninvited, at one of the board’s public meetings, after learning that a plastic surgeon who operated on her, and several others, several years earlier, was in the diversion program.

“It was a botched plastic surgery,” Fellmeth said, “and she told the board she knew a bunch of people who had been injured by him, and they [former patients] had put up a website. Her surgery was in 2001. The physician’s license was finally revoked in 2009 for lying to investigators.”

The latest legislative effort to create a physician diversion program, Fellmeth said, was AB 2346 by Assemblywoman Lorena Gonzales (D-San Diego), which proposed a diversion program similar to a State Bar program for lawyers. “She insisted it be absolutely confidential,” Fellmeth recalled. “The State Bar program has been around for 10 years, and only 11 percent have completed it. I don’t consider that to be a successful program.”

‘A Lame Program’
“The decision to get rid of diversion was progress,” she added. “It wasn’t protecting patients, or doctors. It was a lame program. It could be gamed.”

Many hospitals require some form of drug-testing, but not all doctors have hospital privileges.

“In my experience, the problems are with doctors who don’t have privileges, who work in clinics,” Fellmeth said, citing the highly publicized 1990 case of Dr. Milos Klavana, a Valencia obstetrician who was convicted of second-degree murder in the deaths of eight infants and one fetus. The Medical Board came in for harsh criticism from patient advocates and the judge in the case for failing to intervene.

The recent Greer case is particularly instructive as a bellwether of the discipline system – and the use of high-tech, instantaneous drug testing to monitor doctors on probation.

Greer has been open about his addiction since seeking treatment in 2012, agreeing to a rigorous monitoring program and admitting to past failings. He acknowledged to investigators that he had long been abusing alcohol and drugs while still treating patients, and Medical Board public records show four DUI arrests between 1992 and 2002, with three convictions in 1992, 2000 and 2002. He entered the diversion program in 2003.

“There is no way to trace that. It’s like near-misses, like a drunk driver who has driven 300 times drunk before being caught.”

Medical Board investigators also note several brushes with San Diego law enforcement over assault allegations in 2012 involving a reported attack on a male friend, a former patient, whom Greer threatened with an ax, and an alleged “incident of domestic violence” involving a girlfriend, also a former patient, for whom he was prescribing painkillers. Neither pressed charges, according to Medical Board records, and there were no convictions, although the Sept. 8 disciplinary action by the Medical Board includes writing prescriptions for the former girlfriend without performing a required examination.

“Amazingly, there is no evidence that [Greer’s] drinking has ever resulted in any mistreatment of a patient under his care,” Dr. Mark Kalish, a psychiatrist who evaluated Greer, wrote in a report to the board. “I also don’t think there can be any question that if [Greer] continues to abuse alcohol, patient care will be compromised. The question is not if it will happen, but only when.”

Unless patients are seriously injured, or die, or file lawsuits, it is difficult to determine how many patients may have been harmed by alcohol- and drug-impaired physicians, and patient advocates blame the secrecy of the system for preventing patients from easier access to information about investigations and prosecutions. Statistics and many medical-journal articles show that physicians who do seek help, and are treated by effective programs – called Physician Treatment Programs (PTP’s) or Physician Health Programs (PHP’s) – have a very high rate of success over time, as high as 80 or even 90 percent, according to some articles.

Dr. Stephen Loyd, 47, a Tennessee physician who 10 years ago sought help for his heavy addiction to prescription pain killers through a Tennessee state program, is a frequent, albeit out-of-state, spokesman for Prop. 46. He says “nobody knows” how many patients have been harmed by drug- or alcohol-addled physicians. “There is no way to trace that. It’s like near-misses, like a drunk driver who has driven 300 times drunk before being caught.”

“I had all kinds of potential for harm,” Loyd added. “I wasn’t mean. I wasn’t psychopathic, but I harmed patients in other ways. I had a patient that I got to give me back pills one time. When he found I had gone into treatment for drug addiction, he told me he felt like he ‘caused’ me to ‘get addicted’. . .That is harm, although it didn’t dawn on me at the time that I owed him an apology. I’ve since apologized.”

For doctors who are hiding in bathrooms, they’re miserable, they’re dying. When you first intervene, they’re not going to be happy campers.”

Loyd, chief of medicine at the Mountain Home Veterans Administration Medical Center in Johnson City, Tenn., and an associate professor at East Tennessee State University Medical School, went into treatment after his father confronted him about his drug use. “I’d evaluated myself,” he said. “I was drowning, dying. I self-reported [to the state], and I was in compliance from Day One. I am one lucky SOB. I love my damn life. I get to be a doctor. I used to fuss about the check I had to write every two years for my license. I look at life differently. As bad as it was, my professional life was not suffering. But my wife had had it.”

His son and daughter were 7 and 9 when he went into treatment. His son, now a 20-year-old college sophomore, wants to go to medical school and become an addiction specialist.

Loyd said he supports Prop. 46 because, unlike Tennessee and other states, California has no official system for doctors to get help. “Assuming 2 percent prevalence, there are 2,500 to 3,000 docs who are actively addicted,” Loyd said, “but there is no mechanism, no leverage, to get them into treatment programs.” And while random drug testing of physicians – as called for in Prop. 46 — “won’t be the magic bullet,” he said, “it is an initial deterrent.”

“People look at this as being punitive,” he added. “But for doctors who are hiding in bathrooms, they’re miserable, they’re dying. When you first intervene, they’re not going to be happy campers.”

A September USC/LA Times poll showed weak support for the measure, with 50 percent opposed, 37 percent in favor and 12 percent undecided. Dave Kanevsky of American Viewpoint, the Republican pollster in the bipartisan survey team, characterized approval for the measure as “a mile wide and an inch deep.” Support “looks strong but starts to fold when voters hear both sides,” he told the Los Angeles Times. Sixty-eight percent of those polled favored the provision for drug-testing of doctors.

“We ought to be able to do as well as Alabama, where we were doing about 80 physician interventions a year, in a state with 13,000 practicing physicians.”

Dan Schnur, director of the Jesse Unruh Institute of Politics at USC, said proponents of the measure – mainly consumer groups and trial lawyers – “were very smart. They tried to cover up a controversial measure (limits on malpractice awards) with a popular one (doctor drug testing).” But, he added, “a ballot measure is only as strong as its weakest link.”

Like most legislating-by-initiative, lacking action by a state Legislature repeatedly unable to agree on workable laws to effectively regulate either physician drug use or doctor discipline, the measure is widely regarded as legally flawed – and, like most initiatives, likely to be challenged in court.  Once again pitting doctors and lawyers over malpractice caps, the measure includes provisions such as random drug testing – and a requirement that doctors consult a statewide prescription drug database before prescribing addictive drugs – which are sure to capture public interest.

California Needs Education, Intervention
According to Medical Board records, Greer had been licensed to practice since July 27, 1981. He had graduated magna cum laude in 1974 from UC-Irvine with a Bachelor’s degree in biological sciences, received a Master’s in biochemistry from California State University, Long Beach, in 1976, and a medical degree from the University of Utah in 1980. He did his internship and residency in internal medicine at Los Angeles County/USC Medical Center and a fellowship in gastroenterology at Scripps Clinic.

He entered private practice in 1985 and currently works for the Center for Family Health in San Diego. He is by many accounts a conscientious and caring physician, when he’s clean and sober, which his attorney says he has been since his family intervened and he entered treatment in 2012.

Dr. Gregory Skipper, an addiction specialist and author of many medical-journal articles on physician addiction treatment, is director of the Promises Physician Treatment Program in Santa Monica, where Greer was treated. He cannot discuss specific patients, but is quoted in Medical Board documents as one of the physicians who treated and/or evaluated Greer. Skipper has run or advised physician treatment programs in other states, including Alabama and Oregon, and says California is remiss in not having a program for doctors needing help.

“It’s such a startling fact that California doesn’t have [a program],” Skipper said. “There needs to be a program for education and intervention, which is what other states have. We ought to be able to do as well as Alabama, where we were doing about 80 physician interventions a year, in a state with 13,000 practicing physicians. We are so behind in this in California.”

“If it’s just discipline and enforcement, that’s not enough,” he added. Protection for colleagues who may want to report an impaired physician – sometimes called a “snitch law” – is necessary, he said, which requires physicians to report a colleague’s impairment, but protects the reporting physician from liability. As for drug testing, he said, “if it’s done willy-nilly, it will be unsuccessful.” He favors drug testing of physicians at key junctures in their careers — “before appointment to a hospital, for license renewal.”

And, like most physicians, he favors confidentiality for doctors receiving treatment. “It’s a medical condition,” he said. “It should be private. If doctors refuse to cooperate, they should be reported immediately.”


Ed’s Note: Sigrid Bathen, a Sacramento journalist who has frequently written about physician discipline, is a regular contributor to Capitol Weekly. She teaches journalism at California State University, Sacramento and can be reached at sbathen@csus.edu

© 2018 Sigrid Bathen

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