Q. What is the LACHS-L?
A. The USC-MFA-LACHS-L list server is a moderated e-mail forum for USC Faculty and Friends who are interested in issues that relate to the Los Angeles County Department of Health Services and USC's role in the care of County patients. Ideas for better interchange of information on related topics are welcome. It is a voluntary subscriber list maintained by the USC Medical Faculty Assembly. Further information on MFA lists and other USC Medical School lists can be found at:
http://www.usc.edu/schools/medicine/faculty/mfa/HRK029.html
Q. How do I participate?
A. Communications to the list, subscribe and unsubscribe requests should be sent to the moderator Peter Heseltine <heseltin@hsc.usc.edu>
Q. I have asked to be unsubscribed, why do I still get the messages?
A. The list server has an e-mail address for you that is forwarding your mail to another, presumably more current, account. e.g., the list sends to trojan@hsc.usc.edu, but you have arranged for your mail to be forwarded to bruin@ucla. So, when you reply using your current e-mail address, we can't figure out what your *original* e-mail address was from your new e-mail address! Send us your real name and your old e-mail address (usually at usc.edu) and we will try again :-)
Q. Can I subscribe a friend/colleague?
A No. A request to subscribe must be sent from the subscriber's valid e-mail address. But if you send us your colleague's/friend's e-mail address, we'll write to them and ask them if they want to receive the list messages.
Q. How often can I expect to get messages?
A. Unless there are "breaking stories" of great interest to the Faculty e.g., news on the CPSA "front", it's unlikely that more than two messages a week will be sent. If there are more, they will be sent as a "digest" once a week. If there is demand from subscribers, we can "digest" all messages to just once a week.
Date: Mon, 25 Jan 1999 14:00:03 -0800
Reply-To: "William Mouradian" <mouradia@hsc.usc.edu
From: "William Mouradian" <mouradia@hsc.usc.edu
To: <usc-mfa-lachs-l@usc.edu
Subject: Re: LACHS-L: County probing clinic visits
Date: Mon, 25 Jan 1999 08:25:55 -0800
Dear Sir/Madame:
I read this with interest. My experience with the ortho clinics is that they are full and run late. The doctors that staff them welcome a light day. Also, I doubt many orthopaedic residents are even aware of such things as targets. It seems likely to me that any irregularities are arising at significantly higher levels than the doctors or their immediate helpers, but, of course, I am not asserting this as factual....
Thank you for listening.
Bill Mouradian
-----Original Message-----
From: Peter Heseltine <heseltin@hsc.usc.edu
To: USC-MFA-LACHS-L@usc.edu <USC-MFA-LACHS-L@usc.edu
Date: Wednesday, January 20, 1999 9:37 AM
Subject: LACHS-L: County probing clinic visits
County probing clinic visits
By Douglas Haberman, Daily News Staff Writer
Copyright © 1999 Daily News Los Angeles
For more than a year, USC and the County of Los Angeles have been negotiating a new professional services agreement (CPSA). These services include "supplements", subcontracts for new physician services requested by the County after the original 1987 contract. The total agreement, which supports the salaries of many faculty, is worth almost $70 million to USC, approximately 19% of the School's budget.
This time, the County chose to negotiate first a "boilerplate" contract, common to USC, UCLA and Drew medical schools and then contracts specific to each school. The major difference between USC and the other schools is that at King, Harbor, Rancho, Oliveview and High Desert hospitals the physicians are salaried County employees. At LAC+USC, all are paid by USC out of the CPSA contract funds. A small number of USC faculty are paid indirectly by USC, through a "payback" to the County, who in turn pays these faculty. All were full-time employees of the County DHS prior to 1987 and most remained in this status to preserve their County retirement benefits.
A number of problems have arisen relating to the original 1987 CPSA contract: While physicians at other hospitals have been promoted through the County pay grades as their responsibilities increased, (apart from supplemental programs) USC continues to be paid only for the personnel items that existed in 1987. The performance standards of the contract have remained those of 1987 - inpatient days and a fraction of outpatient visits. This does not reflect the changes that have occurred in medical care and the County's own agreement with the Federal government (1115 waiver) which requires the County's personal health services program to emphasize dispersed outpatient services and shorter hospital stays. There are few requirements for the County to deliver an infrastructure that meets the needs of modern medicine: e.g. medical records services, up-to-date equipment, buildings or sufficient nurses and support staff. All these have been the targets of considerable cost cuts since 1987.
Cost of living and other raises have been given to County physicians at other facilities since 1987, but these increase have not been passed on to USC faculty. The reasons are controversial. As admissions and patients length of stay have fallen, the County says it owes USC less. USC says it has incurred increasing personnel costs over the ten years.
The County is self-insured for the initial $5 million of any medical malpractice liability and USC faculty practicing at LAC facilities are covered by this policy. The LAC Board of Supervisors has publicly voiced concern over some of the claims the County has had to pay, calling into question the supervision of the doctors involved. Several years ago, the BOS proposed a system where physicians would be evaluated and "disciplined" by lay administrators. Though that proposal was not implemented, one of the negotiating hurdles has been how USC will share responsibility for liability claims.
The precise details of the County's current proposal have not been made public. The USC negotiating team comprises Joe Van Der Muelen, who negotiated the original CPSA in 1987 and Jane Pisano, USC's expert executive in External Relations. They are assisted by USC's legal counsel and have met on half-a-dozen occasions over the past year with a USC Faculty CPSA Advisory Group, comprised of several chairmen of clinical departments and other faculty. The Advisory Group prepared responses to questions posed by the County and made suggestions concerning supervision, house staff, oversight and performance standards. Recently, dismayed by the general physical state of the County hospital and clinics and the proposal to move laboratories off-site, the Advisory Group has emphasized that the County must be required to meet appropriate standards to support the infrastructure of USC's medical mission at County facilities.
Although a senior official for UCLA is reported to have said their negotiation "is done", USC alone in negotiating MD salaries, struggles on. At the most recent meeting of the USC Faculty CPSA Advisory Group, it was learned that the County proposes to "take back" the remaining USC faculty who are still paid from the County's payroll and not require USC to reimburse the County for their salaries. This would result in an apparent decrease in the CPSA contract value, though no real immediate change to the County's outlay. Presumably these faculty could then be reassigned to other County facilities or their positions even eliminated - as part of down-sizing the LAC+USC Medical Center - should the County decide it necessary. While likely protected by Civil Service seniority rules from layoff, these faculty could not count on remaining at USC sites.
Recently, the MFA was informed of the results of a USC hearing of a grievance by a tenured USC faculty member who "switched over" to USC from County paid status, and though continuing to fulfill his full-time duties to the County, was paid only a fraction of his former County salary by USC. (see e-mail below from Harvey Kaslow, President MFA)
As the negotiations will almost certainly not be completed by April 1, USC is preparing a letter to all faculty dependent in part or in whole on CPSA funds, that their salaries are in doubt for fiscal 1999-2000. At last week's MFA meeting it was announced that faculty contracts, in limbo for two years, will finally be issued by USC on March 5. There will be a notable exception - the USC Department of Medicine. It was determined that the salaries of faculty in this department are too dependent on the CPSA funds to allow their contracts to be issued. This has dubious face value. The salaries of many USC faculty, tenured and non-tenured, are dependent on the CPSA. It will be recalled that two years ago, USC offered to "return" to the County those USC faculty still on full-time County paid positions. USC believed they were protected by Civil Service rules of seniority and their move would result in a "cascade" - sequential seniority job-shifting at other County facilities. The County rejected this as unnecessarily disruptive to services and agreed to a moratorium on changes to the CPSA while negotiations continued..
The actual issues stalling the negotiations with USC are further complicated by external developments. The Union of American Physicians and Dentists (UAPD) has filed a request with the County and the Labor Commission to hold an election. (See LA Times story below) This will determine if they will represent all County paid physicians in salary negotiations. Presently they represent the Mental Health professionals. The election will likely take place in May. Only a small number of USC faculty will be eligible to vote, those who hold "Physician" and "Physician Specialist" County "items"/positions. But many other physicians are eligible to vote, including most who work in the County Comprehensive Clinics now under the medical staff umbrella of USC. The County may be waiting to see the outcome of the vote before committing to physician salaries.
LAC+USC physician salaries and benefits have been negotiated for many years by faculty who are the Board of the Association of Physicians of LA County Hospital. Though not a union and comprised of USC clinical faculty, APLACH existed prior to the CPSA and has continued to negotiate pay raises since 1987. The success of the most recent raise is claimed by both APLACH and the UAPD. APLACH states it actually negotiated the raise. The UAPD asserts that the County only gave the raise to forestall the union being voted in as a bargaining unit. APLACH believes that a number of current salary benefits, usually given only to management, will be lost if the union wins. They reason that the County will not be able to treat union represented MDs differently from other represented employees. The UAPD counters that it will negotiate the same or equivalent benefits and with AFL-CIO support has the clout to do so and ensure the County does not unilaterally alter working conditions or salaries, as they can do presently.
Whoever emerges as the negotiator for the faculty, they are increasingly concerned about the conditions under which they work and the care they are able to deliver to their patients. LAC+USC will undergo an inspection by the JCAHO and State in April. This will be the first review undertaken as a healthcare network - the NorthEast LAC+USC Medical Center and associated Comprehensive Healthcare clinics - all sites where USC faculty now practice. The hospital is long overdue for replacement, but no ground has been broken or even the size agreed for the new hospital. Pre-survey inspections find the existing facility poorly maintained and still lacking many requirements for life-safety, e.g., smoke alarms. Although the immediate implementation of laboratory consolidation has receded in the face of great and reasoned opposition, the faculty are dismayed by the process - apparently more political than financial - whereby such plans are made. As in the private sector, the faculty have a decreasing say in important choices about health resource use - from drugs on the formulary to long waits for outpatient services. Despite dramatic increases in the complexity of medicine, the time required to care for increasingly sick patients (and complete the paperwork), most USC faculty have received no increase in salary for their services to the County in more than 10 years.
The County's health services are going through many of the changes that beset all other sectors of healthcare. But plans like "re-engineering" have failed dismally to move the system to one that both serves and is supported by the public. The USC faculty are uniquely positioned to continue their role as effective patient advocates for the needy and the poor, a group with very little political clout. What remains to be seen is whether their patient advocacy can survive the various political and corporate agenda. Confusion about salary negotiations serves only to distract from the important issues that relate to access to care, quality of care and good care outcomes. An increasing number of faculty are suggesting that USC employ a professional negotiator to move the stalled process along to a satisfactory conclusion. The faculty's experience, ideas and efforts are essential and must be integral to the changes and evolution that will make the system work.
*********************************************
3/4/99
From: Harvey Kaslow, President MFA
3. FACULTY CONTRACT AND THE CPSA
The MFAEB was informed that a hearing board of faculty has issued its report regarding a grievance that involved salary the University did not continue when a tenured faculty member resigned from a position of full-time employment with Los Angeles County. The MFAEB concluded that tenured faculty employed by Los Angeles County should understand the position of the University because, if as a result of a new CPSA agreement, Los Angeles County assigns tenured faculty to sites distant from campus, that assignment might prevent a faculty member from fulfilling faculty responsibilities. The faculty member might thus be put in a situation that would require them to either resign from the County position, or the faculty position.
The issue may also be of concern to tenured faculty who are not employees of Los Angeles County, because the University position might influence decisions of faculty to seek funding from other outside sources that could reimburse the University for salary expenses.
The MFAEB noted that the Faculty Contract should shed light on this issue, but that faculty in the School of Medicine have yet to receive contract documents. At the MFA meeting, the Assistant Dean for Faculty Affairs, Sandra Mosteller, announced that faculty contract documents should be available by Friday, March 5, except for the Department of Medicine. Because this department is so involved in CPSA-related work, the MFA requested the boilerplate language used in these contracts, so that faculty may better understand the situation
[For more on the MFA and the CPSA, see MFA Recommendations 1997-98-002
and -003. These recommendations can be accessed via the MFA WWW page
by clicking on the box labelled "RECOMMENDATIONS OF THE
MFA."]
***********************************************
Date: Wed, 03 Mar 1999
From: ekaptein@hsc.usc.edu
Subject: Re: USC-MFA: Budget, Fac Hbook & Contracts, Nat'l Conf.
Very interesting. Does this mean that the tenure granted to County Paid people is different that to others at USC? If so, I am very confused. The county gives all of the CPSA money to USC. Then, USC gives the money back to County to pay the "County" people. All are paid by CPSA. Why should the salaries of the USC paid people be guaranteed by tenure, and the salaries of the County paid people not be guaranteed by tenure?
****************************
3/2/99
Salaried Doctors Are Courted by Labor Union Health care: Service Employees
International's organizing effort targets physicians frustrated with managed
care.
By SHARON BERNSTEIN, NANCY CLEELAND, NICHOLAS RICCARDI, Times Staff
Writers
Times staff writer Alissa J. Rubin contributed to this report.
Copyright 1999 Los Angeles Times. All Rights Reserved
MEMORANDUM
To: Department of Medicine Faculty
From: Leslie Bernstein, Ph.D.
Date: Wednesday, March 10, 1999
Subject: Faculty Contracts
-----------
In a recent email to the faculty, Peter Heseltine stated that the Department
of Medicine faculty would not be receiving contracts although they were
being distributed to other faculty. He further stated that, "It was
determined that the salaries of faculty in this department are too dependent
on the CPSA funds to allow their contracts to be issued."
This is absolutely untrue. My office is working with the administration
of the Department of Medicine and your contracts will be delivered as soon
as they have been printed at University Park. Due to unforeseen circumstances,
the Department of Medicine could not provide the information to my office
in time for the distribution of your contracts last week.
*******************************************
Leslie Bernstein, Ph.D.
Senior Associate Dean, Faculty Affairs
AFLAC, Incorporated, Chair in Cancer Research
Professor, Preventive Medicine
USC Norris Cancer Center
1441 Eastlake Avenue, MS 44
Los Angeles, CA 90033
Research office: (323) 865-0421
fax: (323) 865-0128
Dean's office: (323) 442-1619
fax: (323) 442-1992
*******************************************
3/30/99
From : Joe Bader
Regional Administrator
Union of American Physicians and Dentists
Dr Thomas and the Department of Health Services have placed a contracting out ordinance on the agenda of the Board of Supervisors for their April 6th meeting. If passed this measure would amend the County Code to allow for more contracting out of County physicians to the Medical Schools and to private medical groups.
The UAPD is waging a vigorous fight in opposition to this ordinance change. If you would like to help us oppose this threat to the civil service, give us a call at 310-398-4038. I look forward to hearing from you.
[Mod: More information about the potential effect of this ordinance would be useful]
*********************************
3/31/99
From: Peter Heseltine
MFA Liaison to CPSA
No movement is reported in the negotiations for a new CPSA between USC Administration and LA County. The Medical School's Dean Ryan was reported as saying that he believes that the contract will be signed but when pressed, would not speculate when. Consequent to this, it is probable that the USC School of Medicine Administration will issue letters to faculty stating that their salaries are in jeopardy. These are slated to be issued if no agreement is reached by today.
The issue of contracts and the language contained therein is vexing many faculty. It appears that the language and terms are not the same for all grades of faculty or even within various academic ranks. A memorandum from Leslie Bernstein, Senior Associate Dean, Faculty Affairs to the Basic Science Chairs details some of these differences. Harvey Kaslow, President of the MFA has requested the Provost communicate to the Faculty the guiding policies governing the issue of these contracts. Although many faculty have now received contract documents and some have signed them - possibly because they were incorrectly informed there was a deadline for signature - no contracts have been issued to faculty in the Department of Medicine. According to Leslie Bernstein, this is due to "unforeseen circumstances".
The President of the USC Senate announced last week that he has set up a task force to examine the matter of contracts and among other concerns, why they have not been issued.
The contract language and fulfillment of USC's obligations to its Faculty
must be of concern to all. The new Faculty Handbook and the results of
recent grievances and court cases suggest that all faculty need to take
examine closely their contractual relationship with the University and
their continuing employment expectations. Tenured faculty, far from having
a sinecure for life are in fact under review by their peers. This difference,
removal from tenure by a peer review process, as opposed to being removed
at the say-so of a department chair or section head, is fundamental to
the difference between the corporate and an academic model. For many, it's
worth preserving as a constraint to excessive top-down management and to
encourage free academic dialogue on matters of importance to the University
community.
The following letter has been received by many faculty of the School of Medicine
**************************************************
March 29, 1999
To: CPSA-Funded Non-Tenure Track Faculty
USC School of Medicine
Dear Faculty Member;
The Professional Services Agreement with the County of Los Angeles supports the clinical work of most of our faculty. The existing CPSA will expire on June 30, 1999. We have been negotiating with the County for many months to renew it. The renewal has not yet been approved by the County, although we hope it soon will be. At this time, however, we are faced with the necessity of planning for the possible expiration of the present contract, and the possibility that the County may cease making payments to me University for services provided under the CPSA if no renewal agreement is in place by June 30.
If the CPSA is not renewed, the money the County will pay to the University for professional services may be cut off, reduced, or placed on a month-to-month basis, As a result, we must hereby give you this notice of non-reappointment under your current appointment or contract, and inform you that your last day of service under your current appointment or contract will be June 30, 1999.
After that date, whether your employment continues, and on what terms, depends upon the level of funding received from the County. If your employment continues past June 30,1999, whatever portion of your salary is based on funds that the University will continue to receive, including salary supported by contracts and grants, as well as income you derive from medical practice plans, should not be affected.
These are difficult measures forced upon us by the external source of Certain of our funds. We regret that, despite a concerted effort to avoid it and our continuing hope that agreement will be reached on a new CPSA. with the County, it is necessary to send this notification to you. We appreciate your cooperation and understanding during this time. We will keep you apprised of our efforts to obtain a contract to reaffirm the University's partnership with the County, maintain Support for our faculty and continue providing quality care for our patients. We will continue to consult with department chairs and faculty representatives on how best to face this difficult situation.
Stephen J Ryan
Dean and Senior Vice President for Medical Care
Joseph P. Van Der Meulen
Vice President for Health Affairs
Nine out of ten doctors don't want County bureaucrats mucking with your
lab tests
by Marc B. Haefele
[Moderator: Two factors were likely more responsible than the UAPD's letter, for the demise of the lab consolidation plan. Following repeated requests by the physicians for a cost study, no evidence could be presented that consolidating the laboratories would in fact save money. It was also learned that it would take more than a year to build (at additional expense) a computerized result reporting system. It's worth noting that DHS management ignored a cost saving and improvement plan put forward by the pathologists and clinicians which would have consolidated some tests and streamlined procedures.]
The recent posting at the end of last week on DHS plans for laboratory consolidation implied that DHS was no longer considering centralization of laboratories. Statements to the effect that "...the doctors' objections had derailed the lab-consolidation plans" and "...the DHS was surrendering on lab consolidation" strongly imply that DHS has aborted its plans. The information that I have is that they have only agreed with the unions to make lab consolidation a "sponsored project" which means that there will be a joint management-labor committee to oversee the project.
In this morning's mail, I received a letter from Donald C. Thomas, III, MD addressed to Hospital Administrators and Medical Directors, dated 3/25/99, stating "First and foremost, let me assure you that the Department will move forward with systemwide laboratory consolidation."
The source of the posting was the UAPD and they are in the midst of a campaign to unionize the physicians employed by DHS. Thus, it appears that UAPD has engaged in some hyperbole that goes well beyond the factual basis and any misimpression that DHS laboratory consolidation is a dead issue must be corrected.
Ed Wong
[Moderator: The following is a facsimile of a letter from Mr Finucane,
Director of Health Services to the Board of Supervisors in support of a
new County ordinance that would allow the County to contract out physician
services, if the Board finds that the services will be performed more "feasibly".
Previously, the requirement was that the services be performed more economically
by the contractor. The ordinance allows the contract to be awarded to (1)
a County affiliated educational institute, (2) an entity that would coordinate
the services between the County and an affiliated educational institution
or (3) an entity "formed and controlled by physicians employed or formerly
employed by the County". Such contracting out of services appears to be
prohibited if the services are currently being performed by County employees
who are represented by a union. Mr Finucane states in his letter that this
ordinance has an important effect on the CPSA. The letter is followed by
an analysis by County Cousel and the proposed ordinance itself.]
************************************
February 25, 1999
Honorable Board of Supervisors
County of Los Angeles
383 Kenneth Hahn Hall of Administration
500 West Temple Street
Los Angeles, CA 90012
Dear Supervisors:
PROPOSITION “A” ORDINANCE CHANGE (All Districts) (3 Votes)
IT IS RECOMMENDED THAT YOUR BOARD;
Approve the attached Ordinance to amend the County Code to allow for the contracting for services in specific circumstances when to do so is determined feasible.
PURPOSE OF THE RECOMMENDED ACTION:
The County Charter specifically permits the County to enter into a
contract for services when the Board of Supervisors finds that the work
can be performed more economically or feasibly by an independent contractor.
The County Code (“Proposition A ordinance”), however currently provides
only for the contracting pursuant to this charter authority when the work
will be performed more economically by an independent contractor.
This amendment would expand the ordinance’s authority so that it more closely
tracks the Charter by allowing the County to contract for services when
the Board of Supervisors finds that the works can be performed more feasibly
by an independent contractor. The amended ordinance enumerates the criteria
that must be met for the Board to make a finding of feasibility.
JUSTIFICATION
The Department of Health Services believes that the expanded authority
set forth in the amended ordinance is critical to its ability to provide
the highest quality of patients care, most particularly and immediately
as relates to the clinical services to be provided through the school affiliation
agreements. The current operating agreement between the County and
USC, which was approved in 1987, was done as a pilot project, due to the
difficulty in determining that the services could be performed more economically
through the University. Amending the Proposition A ordinance to include
a finding of feasibility would alleviate this difficulty and would allow
the new operating agreements to operate under the Proposition A ordinance.
The Department is coming to a close in the negotiation of a new affiliation agreements with the local medical schools. It is anticipated that these agreements will be presented to your Board this spring. Analyzing these agreements under the Proposition A ordinance, as currently written, would require the County to make a finding that the services would be provided more economically by the medical schools. However, such an analysis may not take into complete consideration factors beyond those that are purely economic and which are unique to these clinical agreements.
It would be difficult, through a traditional economic analysis, to fully capture the beneficial impact of the agreements on patient care. For example, such an evaluation may not completely recognize the costs of difficulties associated with transferring the responsibility for the services currently being provided by the medical schools, predominantly the University of Southern California and to some extent Drew university, back to the County-employed physicians. Moreover, a strict costs analysis may not take into account the replacement costs associated with shifting physicians from the university to the County payroll, particularly if these individuals chose not to accept County employment. Such an occurrence could leave the County with a significant gap in clinical coverage.
The relationship between the physicians and the medical schools has led to an increased level and quality of care provided to the patients in the County facilities. However, this enhancement would be extraordinarily difficult to quantify in economic terms. The amendment to the Proposition A ordinance, permitting the County to contract for services that could be performed more feasibly by the contractor, would allow the County to continue purchasing clinical services from its affiliated medical schools without disruption.
In addition, as systems for the delivery of healthcare evolve, such as through the managed care environment, this amendment will provide the County with the option to contract for physician services in other areas such as the Healthy Families and California Children Services programs.
FISCAL IMPACT:
The amendment to the ordinance will have no material impact on the
cost of the contract.
FINANCING:
Not applicable
FACTS AND PROVISIONS/LEGAL REQUIREMENTS:
This ordinance amends Title 2 - Administration of the Los Angeles County
Code relating to contracting with private businesses. Specifically,
it adds feasibility as a justification for contracting for services.
In determining that a contract for services is more feasible, the Boards
of Supervisors must find that:
o The services to be provided are technical or professional
services that can only be performed by persons licensed by the State; and
o If the services are being provided by County employees
at the time the contract is awarded, those employees are not represented
by a certified employee organization; and
o The department recommending the award of the contract
demonstrates facts or circumstances that support a conclusion that contracting
for such services would result in an improvement in either the administration
of the quality of the services to be provided over what would be obtained
by not contracting for such services; and
o The entity that will contract with the County
is any of the following:
1. An educational institution
which has an affiliation with the County facility at which services will
be provided;
2. An entity other
than such an affiliated educational institution, but which will serve to
coordinate the services among the contractor, the County, and any such
affiliated educational institution; or
3. A legal entity
formed and controlled by physicians employed or formerly employed by the
County.
IMPACT ON CURRENT PROGRAM SERVICES (OR PROJECTS):
This change would have the immediate effect of enabling the County
to enter into the new medical school operating agreements, and thus end
the pilot status under which the current USC agreement was enacted, thereby
ensuring the continuity of patient care. Additionally, the new agreements
are substantially different from the current contracts and provide for
greater accountability on the part of the medical schools and the physicians
employed therein. Over time, this amendment to the ordinance would allow
the Department to expand the availability of services to its patients
through both the operating agreements and an expanded network of physicians.
Respectfully submitted,
Mark Finucane
Director Health Services
MF:ak
Attachments
c: Chief Administrative Office
County Counsel
Executive Office, Board of Supervisors
Auditor-Controller
**********************************
ANALYSIS
The County Charter specifically permits the County to enter unto a
contract for services when the Board of Supervisors finds that the work
can be performed more economically or more feasibly by an independent contractor.
The County Code, however, only provides for contracting pursuant to this
Charter authority when the work will be performed more economically by
an independent contractor. The ordinance would also allow for the contracting
under this Charter authority when the Board of Supervisors finds that the
worked can be performed more feasibly by an independent contractor. The
ordinance also establishes criteria that must be met for the Board to make
a finding of feasibility.
Lloyd W. Pellman
County Counsel
by [signature]
Leela A. Kapur
Assistant Count Counsel
LAK:vc
2/26/99
************************************
ORDINANCE NO.___________________________
An ordinance amending Title 2 - Administration of the Los Angeles County Code relating to contracting with private businesses.
The Board of Supervisors of the County of Los Angeles ordains as follows:
Section 1, Section 2,121.380 is amended to read as follows
2.121.380 Award of contracts - Mandatory prerequisites.
A. No contract may be awarded pursuant to this chapter
unless all of the following requirements are met:
1. The services provided
under the contract will be either performed more economically or more feasibly
pursuant to the
criteria set forth in Section 2.121.415 by an independent contractor,
2. The county’s
ability to respond to emergencies will not be impaired;
3. The award
of the contract will not result in the unauthorized disclosure of confidential
information;
4. Alternative
resources are available so that the services can be obtained from another
source in the event of default by the contractor;
5. The
award of the contract will not infringe upon the proper role of the county
in its relationship to its citizens; and
6. The
award of the contract, if financed in whole or in part by federal or state
funds, will be in full compliance with all applicable federal and
state regulations.
B. In making a recommendation to the board of supervisors for the award of a contract, the department recommending the award shall state in writing that the requirements of this section have been met.
Section 2, Section 2.121.415 is added to read as follows:
Section 2.121.415 Contracts performed more feasibly by an independent
contractor - Board of supervisors finding required.
The board of supervisors may find that services can be performed more feasibly by an independent contractor if the board of supervisors determines that the proposed contract satisfies each of the following requirements:
A. The services to be provided are technical or professional services which can only be performed by persons licensed by the state;
B. If the services are being provided by county employees at the time the contract is awarded, those employees are not represented by a certified employee organization as defined in Section 5.04.030
C. The department recommending the award of
the contract demonstrate facts or circumstances which support a conclusion
that contracting or
such services will result in an Improvement in either the administration
or the quality of the services to be provided over what would be obtained
by not contracting for such services; and
D. The entity which will contract with the county is any of the following:
1. An educational
institution which has an affiliation with the county facility at which
the services will be provided,
2. An
entity other than such an affiliated educational institution, but which
will serve to coordinate the services among the contractor, the county
and any such affiliated educational institution, or
3. A legal
entity formed and controlled by physicians employed or formerly employed
the county.
Section 3. Section 2.121.420 is amended to read as follows:
2.121.420 Award of contracts - Board of supervisors finding required.
A. No contract shall be awarded pursuant to this chapter until the board of supervisors has made a finding that the services can either more economically or more feasibly be performed by the independent contractor;
B. The department recommending the award of a contract shall provide the board of supervisors, in writing:
1. Those
facts which support a finding that the work can be performed either more
economically or more feasibly by independent contractors;
2. A description
of the anticipated scope and cost of the work to be contrasted;
3. A statement
as to the availability of budgeted funds;
4. A statement
as to the possible impact on county tort liability, and
5. A statement
concerning the projected employee relations implications,
Section 4 This ordinance shall be published in a newspaper printed and published in the County of Los Angeles.
_____________________________
Chair
ATTEST:
_____________________________
Executor Officer - Clerk of the Board of
Supervisors of the County of Los Angeles
I hereby certify
that at its meeting of _______________, the foregoing
ordinance was adopted by the Board of Supervisors of said County of
Los Angeles by the following vote, to wit:
Ayes Noes
Supervisors
Supervisors ________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
_________________
Effective Date: _________________
________________________________
Executive Officer- Clerk of the Board of
Operative Date: _______________
Supervisors of the County of Los Angeles
APPROVED AS TO FORM:
LLOYD W. PELLMAN
County Counsel
By: [signature]
Raymond G. Fortner, Jr.
FVI-BS22 (Rev 8/98)
Chief Deputy County Counsel
[The following was received from Dr. Lawlor of the Union of American Physicians and Dentists - UAPD. In view of the impact of the ordinance on the CPSA, the Faculty may wish to make their views known directly to the UAPD. There follows an additional note from Dr. Lawlor suggesting a meeting to discuss the UAPD's issues and upcoming election. If there is Faculty interest, the MFA will facilitate the meeting. Please e-mail or call your opinions to heseltin@hsc.usc.edu or hkaslow@hsc.usc.edu]
040999
Dear LAC/USC Physician,
Just a quick update on the Board vote re: amending Proposition A to allow for increased contracting out of physician services. The vote which was scheduled for April 13th has been postponed for the 3rd time until April 20th. The UAPD is engaged in a vigorous campaign of lobbying the Board to defeat any attempt to contract out your job under any guise. We are working closely with Local 660 on this issue.
Dan Lawlor, MD
National Physician Representative
AFSCME
E-mail: UAPD@aol.com
________________________________________
March 16, 1999
Harvey Kaslow, M.D., President
Medical Faculty Assembly, USC-LAC
Los Angeles, CA
Dear Dr. Kaslow:
The Faculty Senate at UCLA-Harbor held a forum recently addressing the topic of unionization for L.A. County employed physicians. The Association of County Physicians (ACP) was invited and initially agreed to participate, only later to decline.
The discussion was about a number of issues. One issue was that of the lab consolidation proposal. The other dealt generally with the privatization of physician services (please see attached UAPD flyer "Apples and Oranges". Dr. Michael Ross coordinated this.
My assessment was that it was a useful and informational program, dealing in the particular and concrete. A majority of the program was devoted to questions and answers. A representative from ACP was present in the audience and contributed substantively to the question of unionization.
We propose that a similar program be sponsored by the MFA. Attached is a draft program agenda, following the example at Harbor.
Would you please review this and give us some feeling of the body? With an election less than two months off, this kind of presentation would help with the staff physicians at LAC-USC in their deliberations. I look forward to discussing this with you.
For the Union of American Physicians & Dentists (UAPD),
Sincerely yours,
Dan Lawlor, M.D.
The American Federation of State, County and Municipal Employees, AFL-CIO
DRAFT * DRAFT * DRAFT
Meeting Proposal
WHAT: Academic Physicians - Why a Union?
WHEN: Sometime before May 1999, Noontime?
WHO: Two Representatives from the UAPD
Joe Bader, Regional Administrator, UAPD, AFSCME, AFL-CIO
Dan Lawlor, MD, AFSCME's Physician, AFL-CIO
Representative(s) from the ACP
WHERE: Auditorium, General Hospital (LAC)
CONTENT:
The program would consist of a brief (5 - 10 minutes) report on the
progress of the union petition and upcoming election, including the election
rules. It would also address a few issues that the County Physicians have
been addressing already, including that of the plan to consolidate laboratory
services (10 minutes).
A Response from the ACP could be solicited (10-15 minutes).
Questions and Answers for remaining part of the hour.
[Moderator: From the LA Times. Hopefully Dr. Thomas' final quote was out of context and/or incomplete]
Monday, April 12, 1999
Will Union Give Relief to Doctors?
Labor: Some physicians employed by the county, contending they are becoming pawns of managed care and bureaucracy, say they will vote in May to unionize.
By NICHOLAS RICCARDI, Times Staff Writer
Copyright 1999 Los Angeles Times. All Rights Reserved
ACP Bulletin 04/15/99
ASSOCIATION OF COUNTY PHYSICIANS LOS ANGELES COUNTY
CALL TO ACTION
SAY YES TO MEGAFLEX AND THE ASSOCIATION OF COUNTY PHYSICIANS, NO TO UAPD
The Association of County Physicians (ACP) is the registered employee organization that negotiates on behalf of all Los Angeles County physicians. We represent over 1000 physicians who are employed by the Department of Health Services (DHS), and the Probation and Coroner's departments.
ACP HAS A GREAT TRACK RECORD ON BEHALF OF ITS MEMBERS
· ACP successfully negotiated the physician's participation in
the Megaflex and Flex programs.
· ACP negotiated and won the 12% raise in 1998.
· ACP defeated a Los Angeles County Human Resources proposal
to destroy your seniority rights under civil service rules.
· ACP successfully curtailed discipline plans that were designed
to apply only to physicians.
· ACP is currently monitoring the laboratory consolidation scheme
and will represent physicians in the fight to prevent this plan from being
enacted.
We, like you, are working professionals. We want what's best for our
patients, our careers and our incomes.
Now, we are facing a serious threat to one of our best and richest
benefits. If the UAPD is invited to represent us, we stand to lose more
than our independence. As your representatives, ACP strongly encourages
you to consider the following facts on
Megaflex:
PROTECT YOUR MEGAFLEX BENEFITS
· Megaflex is available only to non-represented County Employees; in fact, it's a perk reserved for management level employees only. In addition to county physicians, some lawyers and dentists also receive Megaflex. Represented employees, like UAPD physicians, are given only the "Choices" plan. Choices offers only a flat rate county contribution rather than a percentage of salary that we currently enjoy.
· With Megaflex we receive a monthly benefit contribution from the county, ranging from 14.5% of salary to 19% of salary, that can be used to:
*Purchase benefits or
*use as taxable cash.
· Also with Megaflex, either all or a portion of the county contribution is pensionable. This means that when you retire from county service, the pensionable amount is added to your final salary before your pension benefit is calculated.
It all adds up to a great benefit for you and your family. Do your own calculations. Here's an example:
FINANCIAL IMPACT
Physician moving from non-represented status
to union status
A physician specialist, Internal Medicine, with more than 14 years of continuous service, on schedule 4, Step 13 with 19% Megaflex compared with Choices (both with a family.)
Non-Represented
"MegaFlex"
Monthly Salary $9,275
Megaflex/Choices $1,762
Total $11,037
Represented
"Choices"
Monthly Salary $9,275
Megaflex/Choices $
489
Total $9,764
$11,037
- $9,764
Net Loss $1,273
The represented employee loses $1,273 per month in purchasing power
or in cash benefits. This loss would be greater for a single person or
for two persons with insurance coverage under Choices.
The Association of County Physicians has been fighting for you for
more than 25 years. We have a genuine track record of accomplishment and
our only objective is to represent the needs and best interest of our physicians.
For more information, visit us at our website: http://www.laphysicians.org. This site will contain the latest updates on issues concerning you. It also includes background on the Association of County Physicians, and how we have represented county physicians over the last 25 years. You may also send e-mail to info@laphysicians.org with any further questions.
V Protect Your Benefits
V Protect Your Career
V Support the Association of County Physicians
V SayNOtoUAPD
JOIN ACP TODAY!
Sign up today to be a part of an organization that not only understands the day-to-day issues that affect physicians like you, but can speak to government leaders on your behalf.
Unlike a union, we don't charge high dues. Ours are only $10 a month and membership is completely voluntary.
By joining ACP, you're helping to get the word out to other physicians that they can have a voice and independence while maintaining the best benefits the county has to offer.
Other benefits you will receive are:
· Regular updates of salary, benefits and working conditions
negotiations
· Our monthly newsletter, the A~P Bulletin
· An opportunity to attend monthly board of directors meetings
Take a moment now and fill out the enclosed card to begin your membership today. Please return the card to:
ACP LAC+USC Medical center
1200 N. State St., P.O. Box 111
Los Angeles, CA 90033.
Thank you for your support.
For more than 20 years, the County has attempted to recover some outpatient costs by charging patients not covered by insurance an "up-front" payment of $40 per visit. This fee included both laboratory tests and medicines prescribed during the visit. If the fee was paid before the visit, no further bill was sent to the patient. The program was ended this week with little warning.
Approximately 1500 such visits were made in March 99 at LAC+USC. The patients using the system are likely to be self-employed, but earning more than the poverty level and so ineligible for MediCal, or those who do not wish to disclose their identity to employers/family by filing insurance claims. Some may be eligible for State or other programs and an aggressive attempt has been made to divert patients with chronic illnesses (e.g., AIDS, lupus, diabetes) to apply for such programs. But there remain patients whose income, though low enough to qualify for the County program, do not qualify for State or Federal programs.
This week patients using the $40 payment scheme, who went to the LAC+USC pharmacy to pick up their medications, were told that their up-front payment no longer included medicines. Few had received any prior warning of the cut-off of medicines, which for some are essential and life-preserving. They were handed a flyer instructing them to apply for State, Federal programs. Unfortunately the flyer directed some to erroneous locations on the campus.
It seems medically and morally reasonable that patients should be given proper notice about a change in their healthcare benefits. This would have allowed them, with the help of their healthcare team, to make other arrangements. But for some, this abrupt cut-off from medicines was not only a surprise, it placed their health and future at high risk.
DHS Mission Statement: "To provide accessible, affordable, culturally sensitive healthcare, one person at a time"
DATE: 4/21/99
SUBJECT: Laboratory consolidation rolls on
FROM: Peter Heseltine
This week LAC decided, with no warning to clinical physicians or patients, to change the laboratory doing critical tests on HIV/AIDS patients and consolidate the testing at the Public Health Laboratory
Human immunodeficiency viral (HIV) load testing by PCR in combination with new drugs has changed the face of AIDS. Patients once chronically ill and wasting have had a reprieve from almost certain death. Some are back at work and many are participating in productive ways in their communities. This delicate health balance is achieved by suppressing the HIV manufactured in the patient's body with antiretroviral drugs. Many require complicated pill regimens - often up to 30-40 pills a day - and frequent monitoring that the drugs continue to work and that the virus has not become resistant to treatment. To do this the patient's blood is by a quantitative method which measures the circulating virus particles. Ideally none should be detected if the drugs are working. A change from 500 to 2500, half a log, can herald the onset of resistance and if the count rises further the drugs may need to be changed.
When the County proposed to change laboratories - the test had already been brought "in-house" to reduce costs - the physicians caring for patients with AIDS/HIV asked only that the new laboratory meet the standards that allowed judicious use of the information and drugs. NO such assurances have been given and many remain concerned that the Public Health Laboratory does not have a track record of reproducibility, technical expertise or of assuring that changes in viral counts are not due to laboratory variation. If such variation contributed to an apparent change in the viral load, drugs might be discarded or wasted.
Another concern of patients is that the change may lead to breaches in confidentiality. It's known that the Public Health Department supports reporting of all positive HIV tests. This is presently not required by law. If the Public Health Laboratory does the tests, how will confidentiality be assured?
"Re-engineering" has been abandoned by most business models as it wastes human assets. Consolidiating critical laboratory tests without meeting the needs of patients or listening to their physicians wastes drugs, time and health.
DATE: 4/22/99
SUBJECT: Update
FROM: Dan Lawlor, M.D. for the UAPD & AFSCME
____________________________________________
In case you have not seen this, [there is a] recent L.A. Times article on the physician organizing effort here in L.A. County. Television coverage in the future includes an interview with myself on KTLA with Ray Gonzales and his '"PACESETTERS" show. It will air 5/9/99 at 6 AM.
We attended the Board of Supervisors meeting yesterday. The ordinance change [amending Proposition A to allow for increased contracting out of physician services] suggested by DHS was referred back to the department. The department is embarking upon a economic study to review the economics of contracting-out schemes. We will continue to monitor the situation and keep you notified.
The ACP continues its divisive strategy to encourage a "vote no" on the union election. Its continued focus on the mega-flex benefits is incomplete. We will of course respond in kind - although we'd much rather spend our time preparing for bargaining.
If you received your contract survey, please take a few minutes and fill it out. Its important we get an understanding of your priorities.
DATE: 4/23/99
SUBJECT: ACP News
From: APLACH
Find out the latest ACP news. Now on the Web at
www.laphysicians.org
Date: Sun Apr 25 21:54:21 1999
From: "Gildon Beall, MD" <beall@HUMC.EDU
Subject: Re: USC-MFA-LACHS-L: Consolidation; ACP, UAPD Updates
You may be interested to know that Harbor has not provided pharmacy
privileges with the $40 fee for some time. Also we have been using the
Public HEalth lab for HIV-RNA for over a year. I do not have any details
on quality control but the service is acceptable and we have had no breeches
in confidentiality.
Gildon Beall, MD
Harbor-UCLA Medical Center
April 6,1999
TO: Donald C. Thomas, Ill, M.D.
Associate Director of Health Services
Director of Clinical and Medical Affairs
FROM: Roberto Rodriguez, Executive Director
LAC+USC Medical Center and Northeast Cluster
SUBJECT: RECONFIGURATION OF RESIDENCY PROGRAMS
This is to advise you that I initiated the process of reconfiguring residency programs at LAC+USC Medical Center in anticipation of the replacement project and the requisite staff realignment in a meeting today with Dr. Ronald Kaufman, Dr. Edward Wong and Dave Runke.
I have asked Dr. Wong to work with the Graduate Medical Education (GME) Committee to develop a plan that would:
Require justification for the filling of resident slots that become vacant this year (a zero-base approach).
Review and recommend elimination of Fellowship positions outside of RRC sanctioned Fellowship slots.
Develop an attrition plan beginning with next year's match (FY 2000-01) with prior notification (a zero-base approach also) to the departments of their authorized slots.
Utilize adverse ACGME/RRC reviews to right size and/or terminate programs.
Reassess the efficacy of the teaching function for all programs to ensure the appropriate level of supervision which (through internal program review and documentation) is lacking.
Once a plan is developed, the intent is to then involve appropriate
parties (ACGME, RRCs, JCIR, etc.) as necessary.
Davis, Cowell & Bowe, LLP
Cousnellors and Attorneys at Law
100 Van Ness Avenue, 20th Floor
San Francisco, California 94102
(415) 626-1880
Fax (415) 626-2860
April 21, 1999
BY UPS OVERNIGHT MAIL
Gary Robinson
Executive Director
Union of American Physicians & Dentists
5777 West Centuryt Blvd.
Los Angeles, CA
RE: Megaflex benefit plan in L.A. County
Dear Mr. Robinson:
As you know, our office is familiar with the public employee bargaining statutes and caselaw based on many years of experience in this area. It would be completely unlawful for the County to take away the Megaflex benefit plan merely because doctors voted for union representation.
I understand some doctors think this will result because the local ordinance announcing the benefit plan describes it as for non-represented employees. Such a description does not govern, because it is well-settled that the law requiring bargaining with elected employee representatives (the Meyers-Milias-Brown Act, Government Code sections 3500 et seq.) trumps local ordinances. L.A. Countv Fed'n of Labor v. Countv of Los Angeles (1984) 160 CA3d 905; L.A. Countv Firefighters v. City of Monrovia (1972) 24 CA3d 289; Prof'l Fire Fighters v. City of Los Angeles (1963) 60 Cal.2d 276.. The MMBA clearly requires that an employer negotiate with a union elected by employees before changing benefits which employees are receiving. Gov. Code section 3505; San Joapuin Countv EmDloVees v. City of Stockton (1984) 161 CA3d 813, 818 (a unilateral change in employee benefits before conclusion of negotiations with union is per so violation of MMBA); Vernon Fire Fighters v. City of Vernon (1980) 107 CA3d 802, 823 (same). Thus the terms of this local ordinance are not fixed but rather are negotiable once employees have elected union representation. People ex rel Seal Beach Police Officers v. City of Seal Beach (1984) 36 Cal. 3d 591.
Thus once elected, UAPD could demand in negotiations that Megaflex continue for its bargaining unit. If the County sought in negotiations to remove doctors from Megaflex, the County would first need to get a finding of impasse from the Employee Relations Commission and then submit to mediation before the State Mediation and Conciliation Service. Legally an "impasse" does not exist as long as there are unremedied "unfair labor practices" (violations of MMBA). Such violations are not hard to find: for example, if the employer fails to provide information requested by the union, that usually is a violation.
The physicians' current non-union status actually involves a much greater risk of loss of benefits: the County can unilaterally amend its ordinance any time they wish to remove any unrepresented employees it wishes from Megaflex, without any negotiations or other dispute resolution procedure. Ralyea v. Ventura County (1992) 2 CA4th 875.
If you have any questions, please feel free to contact me.
Very truly yours,
Andrew J. Kahn
Attorney
[From Laura Wachsman MD]
There are three items of concern to me that I think important for voting eligible doctors to consider this weekend. Perhaps you could share this information with them. It would be nice to reach all the med center physicians, as well as the comp center doctors, but I don't know how to do this.
1. EVERYONE NEEDS TO VOTE Everyone should indeed be encouraged to vote, even if they are not very interested in this matter. Every "no" vote on the issue makes the votes of the "yes" doctors less important. Apparently there are about 800 doctors who will be asked to vote. To vote in the union requires a simple majority if at least 60% of doctor's vote. This means that if everyone voted, 401 votes in favor would be required. However, if only 60%, for example, were to vote, ie 480 doctors, then only 241 votes would be needed to vote the union in. A block of votes for the union could throw the results to the positive even though less than one third of the eligible physicians wanted to be represented by the union!!!
2. It is my understanding that the California Medical Association has been in support of the JCIR, the interns and residents union, and feels that all house staff in California should belong. I think it is important to note that UAPD is in no way affiliated with the JCIR - obviously a respected union-, and that JCIR chose not to have the UAPD's organization represent them. The attending staff organization linked to the JCIR is the "USPD". UAPD has no relationship with JCIR.
Perhaps, if we are thinking about unionizing, we should be considering ALL options carefully before voting yes to the first group to lobby us. The JCIR has been very successful. It would probably be prudent to find out in more detail why that group chose not to be affiliated with the UAPD organization.
3. The union has looked into the issue of whether physicians would necessarily lose their MegaFlex benefits, if they unionize. Clearly, many doctors are concerned about the potential loss of as much as $15,000 to $20,000 per year in extra pay, if their county benefits change. Retirement income would also be significantly reduced. While it is true, as the union attests, that the county cannot just take MegaFlex away from doctors if they unionize , it is also true that MegaFlex must be considered on the table during the negotiations which would occur to get a contract between the new physician union and the county. The union would have to get the county to include MegaFlex, and other current benefits (deferred comp, 401K etc.) in the new contract that would replace the current status. There is no guarantee that they can make this happen. Indeed, over the years, the county has decreased MegaFlex benefits to new physicians whenever they could.
Mr.Louis Baker, an attorney, has assisted APLACH and the ACP in successful salary and benefit negotiations with the county for many years, (including the last time when county doctors received 2% more increase than the mental health physicians represented by the UAPD). He strongly suggests that if the union is telling physicians that MegaFlex at al would not be lost by unionizing, that it would be prudent for the doctors to have some assurance of this before joining. He believes that the UAPD should be asked to post a bond guaranteeing that no physician, as a consequence of the union representation, receive any less salary or benefits than they do now. Clearly, if the union is countering concerns expressed by the ACP in this regard by saying that no one will lose MegaFlex, they should be willing to make up any losses to the doctors if they unable to fulfill their claims and are unable to negotiate as good a package. It is important to remember that the mental health physicians whom UAPD represents do not receive MegaFlex benefits. If UAPD is so powerful and effective in protecting the interests of physician, then why are these MD's not receiving premium benefits??? The issue of obtaining an indemnity bond should be approved by UAPD, before the physicians vote so that doctors will feel protected.
Is UAPD willing to "put their money where their mouth is" as goes the
old saying. Or, are their remarks in this regard more of the same
hyperbole that some feel they resort to regularly?
[Mod (PH): The plan to move LAC DHS healthcare system to an outpatient/preventive model from a hospital based model began in 1995. Recent articles in the media have identified that the plan has not met its goals. The BOS has castigated DHS leadership for the delays, and "re-engineering" has been at least one casualty. Nevertheless, the restructuring continues, as the Federal money, a five-year waiver of the Medical/Medicaid rules (that pay mostly for inpatient/hospital care rather than outpatient care) is essential to the continuing operation of the system. The BOS will likely have to ask the Federal government for an extension of the bail-out plan, due to expire next year, to avoid a collapse similar to that avoided in 1995]
County May Seek Medicaid Waiver
Extension would permit continued health-care restructuring
By Dan Lee
Staff Writer Pasadena Star News 4/28/99
Copyright Pasadena Star News
Date: Fri, 30 Apr 1999 12:07:25 -0700
[Moderator (PH): The UAPD ballots go out this weekend and will be counted at the end of May. Dan Essin gives a perspective on his concerns and reasons for voting]
Date: Fri, 30 Apr 1999
From: Daniel Essin <essin@earthlink.net
I have given this issue a lot of thought (which has been difficult due to the paucity of substantive information that has been available). My conclusion is that there are a few basic issues:
1) Pay and job security - I am permanently disadvantaged. My specialty (Medical Informatics) is not formally recognized either by USC or by the County. I am employed and paid as if I were general pediatrician working in clinic every day. I actually engage in a number of activities that do not involve direct patient care, are highly technical, have a broad scope (the entire network) and are administrative/magerial in nature. It would be nice to think that a union could do something for me in this regard but, were they to try, the chance that the outcome would be detrimental is probably as great (if not greater) than the chance that they would secure some wonderful benefit on my account.
Furthermore, unless the USC faculty is also organized and there is collective bargaining with USC, the actions that the school takes with regard to pay will most likely cause the net compensation of an LACUSC physician to remain the same even if a union were to secure a pay raise from the County.
2) Benefits - I take great comfort from receiving the same benefits as other unrepresented classes like the board members, their deputies, the CAO and the sherrif. They all operate with enlightened self-interest and are unlikely to act to reduce their benefits.
3) Impact of management/patient care - At LACUSC, because of the CPSA, an artificial situation exists in which all physicians are perceived as working for USC even if they are on the County payroll. The reporting structure nominally flows through the department chairs to the dean and from there to the chief of staff to County administration or from the dean to DHS (depending on the issue). Unless a union also organized the USC faculty, the number of physicians represented by any union will always be small in comparison to the number of physicians for whom the dean and department chairs speak. The difficulty that we have in securing the cooperation of the medical staff in the area of chart deficiencies not only illustrates the problem that this tortured arrangement causes. It also suggests that some our colleagues are not sufficiently motivated in the area of quality to ask the union to divert itself from pay/benefit issues to focus on the care delivery environment.
4) Choice of representation/process - The impending vote combines too many issues. 1) Should the physician be organized? 2) Should they be a bargaining unit? 3) Which umbrella organization, if any, should the bargaining unit be affiliated with?
If I remember my lessons about labor organizing, it needs to have a grass-roots component. There need to be open meetings in which those who are (or may become) organized, meet and discuss the issues and decide as a collective what will be done. Were we to meet these issues could be taken in turn. As it is the last one is being taken first and we are asked to choose an umbrella organization. The assumption is that the answers to the other questions are obvious. I do not agree that they are obvious.
When the JCIR considered these issues, they decided to organize but to affiliate with a different organization. I believe that it is premature to choose UAPD without knowing more about that organization and the basis of their decision. Also , were the staff and residents to be represented by the same umbrella organization, the net effect could be greater than if each group remains separate.
There is no point (and considerable harm) in apathetically voting to allow an organization to be imposed upon you. If the collective group of physicians is not sufficiently interested in this subject to meet and discuss the issues they should not organize because they will merely be pawns of someone else's agenda.
5) Finality - Once a decision to unionize is taken it is extremely difficult to undo it. We are essentially being asked to to marry a mail-order bride in a country in which divorce is puhishable by death.
I am forced to the conclusion that I must vote no at this time. That is not to say that I would not be open to discussion and possible action in the future but the proposal on the table seems to have many more risks than benefits (no pun intended). I am not much good as an activist or perhaps I would have formed these oinions earlier and been more vocal about them.
Thank you for asking,
Dan Essin
[LA County Letterhead]
MARK FINUCANE, Director
County of Los Angeles
DEPARTMENT OF HEALTH SERVICES
(2l3) 24O-8lO3
Apn126, 1999
Dear Departament of Health Services Physician:
Recently you may have heard about proposed changes in the way in which physicians are employed by the Department of Health Services (DHS). Many of the statements being made are incorrect, and I would like to take this opportunity to set the record straight.
[Mod: Following sentence in bold print] I have never advocated, nor do I plan to propose contracting out the clinical services currently being provided in DHS facilities. There are several instances in which, as the result of preexisting agreements with the medical schools, physicians are in the employ of the university rather than the Department. These exceptions notwithstanding, County physicians are and will remain DHS employees
Rather, what I am proposing to do is increase the flexibility and earning potential of County-employed physicians by seeking changes in County rules and regulations related to timecards, the 24.hour outside employment rule, and other policies that limit the ability of DHS physicians to see non-County patients in DHS facilities when they are off the County time clock.
I have been working to change County ordinance to allow the Department to contract with physician groups, similar to the Harbor-UCLA MedicaI Foundation, Inc., that are made up of current and former County physicians for the treatment of non-County patients. By this I am referring to Medicare and private pay patients. I know that many physicians already see private patients during their off hours and I would like to make it easier for you to see these patients in County facilities, rather than require you to move from place to place.
I believe that such a change will be beneficial both to you as physicians and to the County. The end result would be increased income and flexibility for individual physicians and additional revenue for the Department.
These changes will take time, but I believe the end result will be of great benefit both to the Department and its physician employees. Please be assured that I am not working to eliminate your position, but rather to create greater flexibility for you within the County work place
Sincerely,
[signature]
Donald C. Thomas, III, MD
Director, Cclinical and Medical Affairs
[Mod: I sent this to Lisa Pratt of HRA earlier this week. She kindly distributed it on USC-CLIN-TRIAL-L. It seems that some faculty did not get it as they do not subscribe to that list. So, if you are getting this twice, sorry. But I think that the implications for the academic program at LAC+USC and the access to clinical research by the population we serve are important. I have subsequently learned that the replacement facility does not have assigned space for the USC Clinical Research Center. Renamed last year, the John Nicoloff Clinical Research Center is one of the longest funded NIH CRCs in existence and was rebuilt with a major grant from the NIH several years ago. As I recall, a condition of the grant was that the CRC remain viable in County Hospital's replacement facility.]
Date: Wed, 28 Apr 1999 21:28:19 -0700
USC-CLIN-TRIAL-L: County will not give credit for clinical research
Dear Colleagues
For the past thirty-five years, when evaluating physicians' work product for MediCal billing purposes (the Physician Time Study "Blue Books") and more recently for CPSA contract performance, the County of Los Angeles has considered patient care provided while conducting clinical research as not different, for payment purposes, from care delivered in other settings. This has allowed the development of an excellent clinical research program at LAC+USC from which the County and most importantly public patients derive great benefit. It's also generally accepted that the ability to be involved in clinical research projects has enhanced the recruitment to LAC+USC of first class physicians.
In the latest development of the CPSA negotiations, the County has offered that it will no longer "count" care provided in the course of clinical research, as work performed under the CPSA . They also maintain that this will be applied to physicians who are County employees.
This stance comes at a time when, after many years, HMOs and other organizations are agreeing to provide access to clinical research to patients as part of their benefit plans.
If successful, the County's ban on payment for time spent performing patient care as part of clinical research will have but one effect: County patients will not have access to new cancer, AIDS and other treatments. Some will no doubt successfully litigate the issue, but in the meantime we all will have been the losers. Contact Tom Buchanan at the USC CRC or John Nicoloff for more information and how you may help to reverse this anti-health and anti-academic proposal.
Peter Heseltine
I received [Dan Essin's] thoughtful analysis of the union ballot issue. If I remember Lou Baker's analysis of some years back, if unionized, the only issues for discussion are wages and working conditions. Clinical care or quality of care would not any longer be on the table.
Please do not take my praise or comment to be an attempt to influence your decision, as I am not in the categories allowed to vote, and am considered "management".
Hang in there, fellow Dorsey grad! --Rob
Date: Wed, 05 May 1999 08:44:25 -0700
From: "Thomas Berne M.D." <TBERNE@surgery.usc.edu
Subject: The meeting with Dr. Van der Muelen, 5/4/99
Mr. Rodriguez's memo to Dr. Thomas about reducing the number of house staff positions at LAC+USC MC was the major agenda item. There was a discussion regarding the reasons for Mr. Rodriguez's position on this. It was largely attributed to budget reducing pressure, probably from Mr. Finucane down. A subcommittee led by Dr. Van der Muelen and Dr. Wong was formed to respond.
The rest of the meeting was devoted to a "Draft" letter stating the intent of the DHS to set up a parallel IRB to review all research involving human subjects taking place in DHS facilities. It was clear that DHS has no concept of the magnitude, cost, or problems of delay which would result from such a system (e.g. they plan to meet once every 3 months). It was felt that this was ominous in light of their "anti-research stance" in the CPSA negotiations". A subcommittee headed by Paul Brenner (chair of our IRB) was set up to deal with this matter.
Of importance, we should IMMEDIATELY let our faculty know THAT IN THE "BLUE BOOKS" THEY ARE FILLING OUT NOW , ALL CLINICAL RESEARCH TIME SPENT IN PATIENT CARE OR SUPERVISING PATIENT CARE SHOULD BE CODED AS EITHER 1A OR 1B, NOT 1C.
From: Dan Lawlor, MD <UAPD@aol.com
Date: Tue, 4 May 1999 11:10:27 EDT
Message to: All LAC-USC Faculty
From: Dan Lawlor, MD
Subject: Privatization of Physician Services
Date: May 4, 1999
___________________
Some of you have asked us to respond to the recent missive by Dr. Thomas (April 26,1999). We should all welcome Dr. Thomas' assertion that there is no intention to privatize physician services, but we should also remain vigilant on this important issue. The fact remains that DHS has previously put their intentions in writing. The DHS memo (11/10/98) to the Board of Supervisors states:
"The Department of Health Services believes that expanded contracting authority set forth in the amended ordinance is critical ….."
The amended ordinance also clearly envisions contracting out of physician services by referring to "physicians employed or formerly employed by the county" among potential private contractors.
If you refer to these memos, you will find the texts speak for themselves (If you need copies - they've been posted to this file server or you can call the office for copies - 800-504-8273).
Regardless of the language of the memo or the ordinance, we welcome Dr. Thomas' letter and his ideas for other possible opportunities to increase the earning potential of county physicians. UAPD believes that you should be involved in the implementation of any plans that affect your future job security and earnings potential. The only way to exercise real influence is to vote for UAPD.
As a physician in the County public health system, you know the pressures that we are under both as practitioners and employees. I am sure that most county physicians support a public health care system. We are not naive about the greater economic influences of the nation's health care system. These pressures are particularly offensive in the public sector.
It is time to for attendings to create a united voice to speak on these important issues. We urge you to support UAPD in the upcoming representation election.
Date: Sun, 09 May 1999 21:27:17 -0700
05/07/99
[Moderator (PH): The following is the substance of a letter being circulated to faculty]
The County of Los Angeles has proposed reduction of the CPSA by $6,000,000 based on indications they do not want to pay for clinical research performed in the County hospital. In order to demonstrate to the County the importance of clinical research activity, departments have been requested to provide examples of approved clinical research which has a quality, outcomes or financial benefit to the County, and/or which supplies support for ancillary personnel such as nurses, secretaries, rent, equipment, medications, or supplies.
If you are a PI , co-PI, or participant in an IRB approved protocol for clinical research at LAC+USC which addresses any of the above issues, please provide [your department administrator] with the applicable IRB protocol numbers and a brief description of how the protocol addresses the above issues. If the impact of a protocol can be quantified in any way, particularly dollar value, that would be very helpful. It would also be helpful to identify which services would no longer be available to the County if the research was not being performed.
Dr. Van Der Meulen requires this information as soon as possible so
that a report can be prepared for presentation to the Board of Supervisors
next week.
Date: Mon, 10 May 1999 16:49:11 -0700
[Moderator [PH]: Dr. Julian Haywood, President of APLACH, reports that he learned at a meeting with Joe Van Der Meulen, USC Vice President for Health Affairs, last Friday (5/7/99) that the "LA County negotiators have taken the issue of no-credit towards the CPSA for patient care while doing clinical research, off the table for this year". The County claimed that 11% of faculty time was spent in clinical research. They deduced this from the Physician Time Study Books or "blue books". Consequently LAC demanded a reduction in the CPSA of $6,000,000, in line with a new policy of "not paying for physician time spent in clinical research'. Apparently, at least temporarily, they listened to the concerns raised that County patients would have no access to much needed new treatments and that the County and it's patients were greatly benefited by these treatments, which often substitute free drugs and services for standard treatments for which the County would have to pay. Dr. Haywood also believes that the County listened to the argument that going back on this policy would force a major change in USC's academic mission. As noted, the potential to change the policy remains open. This observer believes that the new CPSA should clearly define the important role of clinical research and require that County patients are not locked out of access to new treatments in keeping with the Medical School's mission and the County's obligation to provide affordable healthcare "...one person at a time". The following comments from Professor Raghaven, Chief of Medical Oncology, underscore the many benefits to our community of the USC and LA County partnership in clinical research.]
Date: Mon, 10 May 1999 14:22:45 -0700
From: Derek Raghavan <draghava@hsc.usc.edu>
Subject: County will not give credit for clinical research
....regarding the reported recent change in the position of LA County authorities with respect to Clinical Research. It is very disheartening to think that, if accurately portrayed, those responsible for the administration of a health care system can know and understand so little about some critically important aspects of that system.
In the domains of Cancer Therapy and HIV Medicine, while very important progress has been made during the past century, there are still a vast array of clinical problems that face patients. We have learned how to cure testis cancer, leukemia, lymphoma, some types of breast cancer, and a range of other malignancies, and yet cancer remains one of the leading causes of death in our community, including the community served by LA County Hospital. At the USC-LAC Medical Center, the vast majority of our cancer treatment programs are tied to objective assessment of outcome, and thus could be viewed as research-based. It is frankly impossible to separate high quality medical oncology practice from objective assessment of outcome, and we regularly learn from the work that we do. For example, I have recently seen several Hispanic patients with testis cancer (usually viewed as curable), who have had unexpectedly poor outcomes. As a consequence, we have developed an investigation to try to understand what factors have contributed to this outcome - does it relate to delayed presentation, is their a unique feature of their metabolism, or are other factors involved? We have taken on this work in the context of a malignancy that is usually regarded as curable IN ORDER TO IMPROVE THE QUALITY OF CARE OF THESE SPECIFIC, CURRENT PATIENTS. Would LA County have us separate this initiative from routine care? Should we simply say "Too bad!" and accept an unsatisfactory result? It is simply impossible for us to separate the clinical work that we do, every day, from the questions and assessments of outcome that are regularly a part of modern oncology.
In addition to the issues pertaining to service delivery, the maintenance of quality of care and outcome rests on the educative issues arising from ongoing clinical research - the tenets of clinical research ensure the meticulous review of outcomes, as well as an ongoing evaluative approach to the current state of medical practice; in this way, we train ourselves and our clinical staff to keep up to date with progress, to appreciate true progress, and to identify false leads (which can then be removed from routine clinical practice). It is thus as ridiculous to attempt to separate the clinical research process from routine practice as it is to separate ongoing or continuing medical education from standard medical care. This approach would certainly lead LA County Hospital rapidly to attain a level of medical practice usually found in the less sophisticated of the third world hospital systems.
To answer your specific question, virtually EVERY protocol at the USC-LAC Cancer Center (incorporating the Norris and LAC) is intended to improve patient care, and to increase the quality of service delivery. In a specialty in which so many questions remain unanswered, it is not feasible or logical to identify a series of Ivory-tower questions that are distinct from day-to-day practice. Even the more classically research based initiatives, such as the assessment of novel anti-cancer and anti-HIV compounds, are of life-preserving potential importance to our patients. The introduction of agents, such as gemcitabine and paclitaxel, which we have shown to be equiactive but less toxic agents (compared to conventional cytotoxics) for bladder cancer and lung cancer, has facilitated the delivery of care to the elderly, who might not otherwise tolerate life-saving or life-extending/palliative chemotherapy. In some instances, cytotoxics are provided (as part of research budgets) free of charge to LA County patients, who would not otherwise have access to these agents because of the prohibitively high costs. If those patients of LA County, who are unfortunate enough to suffer from cancer and HIV/AIDS, against a background of poverty and lack of insurance, are denied access to the basic tenets and practice of modern oncology (with the associated diagnostic and therapeutic benefits) by being separated from evaluated therapy programs (ie. clinical research), then the forces that cause that situation will ultimately be undone by the U.S. democratic process. It will remain to the leaders of organized medicine to make clear to the community at large the folly of these false economies. Please let me know if you wish me to provide further information for any up-coming dialogues on issues relating to the importance of clinical research to the patient population of LA County.
Sincerely,
Derek Raghavan MD PhD FRACP FACP
Chief, Division of Medical Oncology, USC-LAC Medical Center;
Professor of Medicine and Urology, USC School of Medicine;
Associate Director, USC Norris Comprehensive Cancer Center.
May 10, 1999
From: Julian Haywood, MD
Professor of Medicine and President APLACH
Albert Yellin, MD
Professor of Surgery and Vice-President APLACH
Edward Wong, MD
Professor of Pathology and Secretary-Treasurer APLACH
Association of Physicians of Los Angeles County Hospital
APLACH ALERT
May 3, 1999
HISTORIC VOTE: Once again the full-time physicians on the payroll of Los Angeles County Health Facilities are being asked to decide if they wish to be represented via a formal union in its negotiations with the County. In a previous election, the decision was made in favor of continuing with the Association of Teaching Physicians (now named the Association of County Physicians) as an official, unrepresented group. This has been seen in the past as providing the best of both worlds, allowing the negotiation of working conditions and benefits that were circumscribed by agreements reached with formal unions. Current efforts to recruit physicians into the United Association of Physicians and Dentists, a component of the AFL-CIO, have stressed that the climate requires a more formal and aggressive approach and has cited its own recent attempts to influence policy and ferret out information as justification for this approach. The leadership of APLACH and ACP who have participated in the bargaining over the years are highly skeptical of the Union's efforts and critical of many inaccuracies in their claims of effectiveness.
WHAT TO DO: Each, non-management level, County-paid physician who is eligible to vote will receive a ballot to be mailed on May 3, 1999. The options will be: a) vote yes in favor of union representation, b) vote no to reject union representation, c) abstain or fail to return the ballot. If the yes vote constitutes a majority of those eligible to vote, the UAPD will replace ACP as the official representatives of the physicians employed by Los Angeles County Health Facilities. The leadership of ACP and those of APLACH who serve on the ACP Board urge eligible physicians to vote NO on the ballot, believing that in the long run preserving the current gains and continuity at the LAC + USC Medical Center are best served by this vote. This will preserve the option of considering a later vote to decide whether ACP should become a certified bargaining unit (union). The costs will be lower and the gains possibly greater by retaining local control in a non-political atmosphere as has prevailed in the past. Some will vehemently disagree, as should be the case when important issues are debated!!!!
ISSUES WITH GREAT IMPORTANCE FOR THE FUTURE:
a. What is the direction of leadership at the LAC+ USC Medical Center?
b. What are the implications of the County's sudden desire to alter its position in support of clinical research at the Medical Center?
c. What are the implications of the decision to review the numbers of training slots for residents and fellows at the Medical Center.
The Los Angeles County + USC Medical Center is a great training and
patient care facility which has served the community of Los Angeles with
great distinction for a number of years. We must not stand idly by while
this great patient care facility is reduced to a shadow of itself!!!!
SUPPORT APLACH, SUPPORT AN INVIGORATED ACP, SUPPORT THE LAC + USC MEDICAL
CENTER!!!!
May 10, 1999
From: Julian Haywood, MD
Professor of Medicine
ACP BULLETIN - May 1999
Association of County Physicians
Los Angeles County
ACP SPEAKS OUT ON THE ISSUES
YOU DO HAVE A CHOICE
Make your voice heard. Beginning May 3, elections will be held to determine if physicians employed by the Department of Health Services will remain independent or be represented by a labor union.
We strongly believe that our interests and our incomes are better represented by physicians employed by Los Angeles County, rather than a multi-agenda national organization.
For more than 25 years, county physicians have been represented by the ACP.
The ACP is not a union, but a volunteer organization of physicians for physicians. We are not restricted to discussion of wages and work rules, but can deal with any and all issues of professional concern, such as patient care, outside personal income and lab consolidation.
ACP has successfully negotiated many of the benefits we enjoy today.
For example. ACP successfully negotiated:
* Megaflex, a substantial longterm benefit available only to non-represented County employees. This benefit could be at risk if the UAPD wins the election.
* The 12% salary increase. You should have already received the third of five increases in your county salary. Your ACP won these increases after months of negotiations with finance and human resources personnel.
MEET THE ACP NEGOTIATING TEAM - WORKING PROFESSIONALS JUST LIKE YOU!
Bob Bennion, MD - OVMC and President of ACP
Albert Yellin, MD LAC+USC and Vice- President of ACP
Oliver Kuzma, MD RLAMC and Secretary- Treasurer of ACP
Fred Bongard, MD Harbor-UCLA
UAPD CLAIMS CALLED MISLEADING
Dr. Robert J. Morin, chair and laboratory director, Department of Pathology, L.A. County Harbor-UCLA Medical Center, stated in a recent memo that UAPD's claims of having caused the County to drop its plans to consolidate laboratories are "misleading". He said the credits and commentaries by UAPD raise general credibility concerns (about the UAPD.)
THINK ABOUT IT!
Dr. Morin goes on to say that an even greater concern is that pensionable Megaflex benefits will be at risk if we become unionized. Dr. Morin warned that these and other issues indicate the need for careful deliberation and discussion prior to deciding your vote on unionization.
DR. THOMAS CLEARS THE AIR
In an attempt to clear up incorrect statements about contracting out, Dr. Thomas sent a letter to all DHS physicians on April 26, stating, "I have never advocated, nor do I plan to propose, contracting out the clinical services currently being provided in DHS facilities." In fact, Dr. Thomas said his proposal is to increase the flexibility and earning potential of county- employed physicians.
In his letter, Dr. Thomas said he plans to do this by seeking changes in work rules and other policies that "limit the ability of DHS physicians to see non-County patients in DHS facilities when they are off the County time clock."
The ACP is pleased that Dr. Thomas took the time to clear up the confusion being caused by an orchestrated misinformation campaign.
We agree that these changes will take time.
But, we also know that it will take a dedicated effort by ACP, working with Dr. Thomas to get the results you want. To that end, ACP Chairman, Dr. Bennion, is working on behalf of physicians on this issue and will keep you informed about progress that is being made.
Let us know what you think about the contracting out issue so that your views can be properly represented.
VISIT THE UPDATED ACP WEBSITE!
For more information or to share your views, visit us at our website: http://www.laphysicians.org. This site will contain the latest updates on issues concerning you. It also includes background on the Association of County Physicians, and how we have represented county physicians over the last 25 years. You may also send e-mail to info@laphysicians.org with any further questions.
* Protect Your Benefits
* Protect Your Career
* Support the Association of County Physicians
* SayNOtoUAPD
JOIN ACP TODAY!
Sign up today to be a part of an organization that not only understands the day-to-day issues that affect physicians like you, but can speak to government leaders on your behalf.
Unlike a union, we don't charge high dues. Ours are only $10 a month and membership is completely voluntary.
By joining ACP, you're helping to get the word out to other physicians that they can have a voice and independence while maintaining the best benefits the county has to offer.
Take a moment now and fill out the enclosed card to begin your membership today. Please return the card to:
ACP LAC+USC Medical Center
1200 N. State St., P.O. Box 111
Los Angeles, CA 90033.
Thank you for your support.
Date: Mon, 10 May 1999 18:17:13 -0700
From: "Demetrios Demetriades, M.D." <demetria@hsc.usc.edu>
Subject: Re: USC-MFA-LACHS-L: Research Update; Faculty Reply
It should be easy to respond to this new challenge: At least in the Division of Trauma we have 2-3 clinical studies which resulted in savings of millions of dollars for the hospital (Evaluation of penetrating injuries of the neck, management of gunshot injuries to the abdomen, etc). These studies have been published and are available. We can show cost savings and better patient care as a direct result of our studies.
Best regards
Dimitri
MEMORANDUM
TO: Roberto Rodriguez
Executive Director, LAC+USC MedIcal Center
Fax (323) 228-6518
FROM: Alexandra M. Levine, M.D.
Chief, Division of Hematology
DATE: April 30,1999
IN RE: RECONFIGURATION OF RESIDENCY PROGRAMS
I have a question regarding your recommendation of elimination of Fellowship positions outside of RRC sanctioned Fellowship slots. This is a mechanism to obtain additional training for our fellows, and additional clinical help for the patients at LAC+USC, from positions funded by outside sources.
As an example, I currently have a grant funded by the National Cancer Institute, which allows me to train two extra fellows each year, in the area of HIV disease. Richard Klausner, head of the NCI, became aware of the fact that AIDS malignancy is increasing in incidence. With the complexity of current treatment regimens for HIV disease, it became important to assure that adequate numbers of individuals are trained in this country in the areas of both hematology/oncology and HIV/AIDS. Additional monies were thus supplied by the NCI, to train individuals with RRC training in hematology/oncology, in the area of HIVIAIDS, with this additional training outside of the formal RRC training.
The elimination of these extra fellowship positions would serve to deplete our ability to train individuals necessary for the appropriate health care needs of our country. At the same time elimination of these positions would deplete the ability of our Medical Center to participate in this important training. Additionally the Medical Center would lose the clinical care and research opportunities that these extra fellows could provide.
Could you please tell me why you believe that these fellowship positions should be eliminated? Thanks very much.
cc: Peter Heseltine, M.D
Edward Wong, M.D
Date: Mon, 10 May 1999
From: "Juan A. Asensio, M.D. FACS" <asensio@hsc.usc.edu
Reply-To: asensio@hsc.usc.edu
Organization: University of So. California Divison of Trauma Surgery
Subject: USC-MFA-LACHS Faculty Research Update
Allow me to also respond to the challenge facing the academic faculty from USC, that labor to carry out a mission of excellence in patient care and research, by saying that the Division of Trauma has had an extensive track record of excellence in meeting this mission. An example of cost savings can be found in a paper presented during our last meeting of The American Association for the Surgery of Trauma titled "The Futility of Liberal Utilization of Emergency Department Thoracotomy. A Prospective Study". This paper, soon to be published, validated the CVRS score of the Trauma Score allowing us to select patients benefiting from this costly and risky procedure (AIDS exposure) and safely excluding those that would not, at a cost savings of $470,000. This study has sparked national dialogue amongst the community of trauma surgeons resulting in the design of evidence based guidelines under study by an ad hoc committee of the Committe on Trauma of the American College of Surgeons.
Similarly, studies on penetrating neck injuries, abdominal gunshot wounds
and our prospective studies on cardiac injuries have also led the way in
both lives saved and costs saved. It behoves those that arbitrarily make
decisions that affect science to get in touch with the impact of lives
saved versus dollars saved. Whereas it is important to be efficient
and save money, this should never be done at the expense of lives saved.
The return of an injured patient to society as a productive member versus
a permanently disabled one at the long run saves money for society, perhaps
this should also be taken into account. I shudder to think what would trauma
care be today if we had not implemented the advances made by research
.
Date: Tue, 11 May 1999 10:05:50 -0700 (PDT)
To: heseltin@hsc.usc.edu
From: jmnelson@hsc.usc.edu (Dr. Janice M. Nelson)
Subject: Disclosure
Anyone talking about the union vote whether representing themselves or representing a group, should disclose whether or not they are primarily County paid. In addition, it should be disclosed whether he or she is eligible to vote - ie. Physician or physician specialist. There are a lot of people broadcasting opinions who are not direct stakeholders in the process. The reader should have this information.
For the record, I am a physician specialist and am primarily County paid.
Janice Nelson
Date: Wed, 12 May 1999 00:38:30 -0700
From: Robert Bolan <bolan@hsc.usc.edu
Subject: Re: USC-MFA-LACHS: Faculty Research: Reply
The thought of removing research from USC+LAC is a truly chilling one.
I was recently a patient at the center. I was struck by a car while riding my bicycle in Glendale and suffered four fractured ribs, a hemo-pneumothorax, a paralyzed hemidiaphragm, and a fractured shoulder. Fortunately, at the scene, my blood pressure dropped to 80 systolic and that won me a trip to the USC+LAC Trauma Center. I say fortunately because I know I would never have received the quality of care that I did had I been taken anywhere else. Dr. Demetriades' trauma team folded me into the busy Sunday afternoon and evening array of evolving trauma emergencies with confident efficiency. The initial clinical judgment that I would probably need a chest tube "but not right now" was tempered by the decision to add a tincture of time. In time, and with frequent rechecking by members of the team, they determined that I did not need a tube. In the same way their judgment told them to watch and see whether I needed laparoscopy to determine whether I had a herniated diaphragm vs. a paralyzed one.
Obviously (to me), these judgments could not have been confidently made without orderly study of the care of trauma. Only the arrogant and foolish physician believes it is possible to practice good medicine based upon experience alone. The careful ordering of that experience is what clinical research is about--measuring this intervention vs. that one or none at all. USC+LAC is a medical center where people come with a wealth of pathology, each one hoping for the brightest doctors with the best tools and knowledge of the most effective and efficient treatments for their problem. I know I hoped that. No, I assumed it. I felt safe and in the best hands.
I believe that the USC+LAC has an obligation to perform clinical research in order to best serve its community. Those who have performed critical research here will come forward and explain how money is saved when you know what to do and what not to do. Those with an ounce of common sense should be able to figure out the value of research by themselves.
Robert Bolan, M.D.
Department of Family Medicine
Date: Wed, 12 May 1999
From: Alexandra M. Levine, M.D <hornor@hsc.usc.edu>
Subject: Research Update; Faculty Reply
Organization: University of Southern California
I am writing to express my sincere dismay regarding the possibility that clinical research might be discontinued at the LAC-USC Medical Center. As a clinical researcher, with over 20 years of experience in this area, all at the LAC-USC Medical Center, I am literally shocked at this decision. The reason for my angst relates to the fact that the patients at LAC-USC have been extremely well served by the research conducted, as has the County of Los Angeles, in a financial sense, and a humanitarian sense as well.
As an oncologist and AIDS specialist, I am constantly faced with patients for whom no standard of therapy is available. These individuals have failed traditional treatment (or no treatment at all, as was the routine during the first 8 years of the AIDS epidemic). The only option available to them is to join a clinical research protocol. The advantage of such a protocol to the patient is the possibility that morbidity and mortality from the disease may be avoided. In other words, because of the research trial, many of our patients at the LAC-USC Med Center have LIVED over the years, instead of dying.
There is another advantage to this research, however, in a societal sense. Because our patients have been willing to enter such trials, and because the faculty have been on the forefront of research in this country, the society, as a whole, has received considerable benefit. We know how to treat HIV today because our patients at LAC-USC Medical Center and elsewhere agreed to participate in the research which made these advances possible. Patients all over the world have been well served, because of the willingness and ability of our patients to participate in these numerous research trials.
If an insured or wealthy patient desires to seek experimental protocol therapy, he or she may go wherever possible, in order to join such a trial. However, if an indigent patient wishes to participate, but is not allowed to do so through the County health system, then this individual is left with no other option than to allow nature to take its course. This is fully contrary to the very mission of our Medical Center, "To provide accessible, affordable, and culturally sensitive health care, one person at a time".
My dismay also concerns the fact that enormous amounts of money have been spent by agencies outside of LA County, in order to conduct this research. Further, these substantial sums of money have been used to pay for multiple direct patient costs, which, if not covered by the protocol, would clearly be charged to the County itself. In a financial sense, it is incredible to me that the County would consider giving up these dollars, and for what purpose?
I am enclosing specific information regarding several large, ongoing studies under my direct supervision, at the LAC-USC Medical Center.
WOMEN'S INTERAGENCY HIV STUDY (WIHS): The Fiscal Benefits (yearly) are: Clinical Lab Tests $219,023; Dental Care $74,102; Clinical Personnel $679,351; Patient Transportation $15,008; Total $987,484.
AIDS MALIGNANCY CONSORTIUM: The Fiscal Benefits (yearly) are: Clinical Lab Tests $36,581; Medication $568, 489; Clinical Personnel $103,996; Total $709,066.
PHASE II STUDY OF PACLITAXEL FROM BAKER NORTON PHARMACEUTICALS IN THE TREATMENT OF AIDS-RELATED KAPOSI'S SARCOMA: The Fiscal Benefits (yearly) are: Medications $784,086; Clinical Personnel, Lab tests, etc. $288,000; Total $1,072,086.
PHASE II STUDY OF TAXOL IN THE TREATMENT OF AIDS-RELATED KAPOSI'S SARCOMA: The Fiscal Benefits (yearly) are: Medications $695,576; Clinical Personnel, Lab tests, etc. $350,000; Total $1,045,576.
LIPOSOMAL DAUNORUBICIN (DAUNOXOME) IN THE AIDS-RELATED KAPOSI'S SARCOMA (6 protocols): The Fiscal Benefits (yearly) are: Medications $1,063,520; Clinical Personnel, Lab tests, etc $606,343; Total $1,669,863.
DAUNOXOME IN HEMATOLOGIC MALIGNANCIES (4 protocols): The Fiscal Benefits (yearly) are: Medications $244,800; Clinical Personnel $125,000; Total $369,800.
Alexandra M. Levine, M.D.
Professor of Medicine
Chief, Division of Hematology
Medical Director, USC/Norris Cancer Hospital
Date: Tue, 11 May 1999 23:48:10 -0700
From: Robert Bolan <bolan@hsc.usc.edu
Subject: Fellowship training
I have a concern about fellowship training in the same context as Dr. Levine's. I have, with existing funding, managed to design a year of in depth training in HIV medicine for a Family Medicine physician who had just finished his residency. Around the country physicians like Dr. Levine and I are becoming concerned that young physicians drawn to HIV care are not guaranteed a sufficient depth and breadth of well supervised experience in their residencies to efficiently recognize and manage all the potential problems that HIV can create. If the current trend in HIV treatment continues, at best we will have fewer patients with serious opportunistic problems. But unless we want to develop a care system that is divided into physicians who can manage HIV treatment and physicians who manage sick HIV problems, we need to tend to the more orderly and in-depth training of those who are interested in the challenges of the entirety of HIV medicine. To do this we must have HIV general medicine fellowships. I am planning on seeking funding for a subsequent fellow, to begin in August or September, 2000. Obviously, I am wondering what exactly is in the wind around here and what, as Dr. Levine asks, these decisions will bode for the future of USC's contribution to training physicians for the future.
From: RSETTLAGE@aol.com
Date: Thu, 13 May 1999 00:44:34 EDT
Subject: Re: USC-MFA-LACHS-L: Disclosure
To: usc-mfa-lachs-l@usc.edu
Neither in my reply to Dan Essin, nor in Peter Heseltine's broadcast of that reply, did I disclose that I am a Senior Physician, MD, and have been a full-time County employee since 1 October 1971 (with my first full-time County job dating back to 1963--rotating intern at LACo General Hospital). I am not elgible for a union ballot.
Robert Hurd Settlage, MD, MPH
Acting Director, LACo STD Program
[Mod (PH): Although the moderator tries not to present his own views on this list without direct attribution :-), he has been a member of the LA County physician staff since 1977 and though a County employee, is not eligible to vote. He is also an elected Board member of APLACH, the MFA and an Academic Senator. The MFA Executive Board has been asked to consider whether there is a need to set guidelines for attribution/conflict of interest on the MFA list servers.]
Date: Thu, 13 May 1999 09:57:33 -0700
From: "Laura Wachsman, MD" <wachsman@hsc.usc.edu
To: usc-mfa-lachs-l@usc.edu
Subject: Re: USC-MFA-LACHS-L: Disclosure
Regarding disclosure: Dr. Laura Wachsman is a physician specialist who has been a county employee since 1977 and is eligible to vote.
Date: Thu, 13 May 1999 14:16:33 EDT
Subject: Medical Staff Bylaws Upheld By Florida Jury
From: Dfenton@aol.com
To: owner-usc-mfa-lachs-l@usc.edu
Dear Colleagues:
What the powers that be seem to forget is that there are medical staff bylaws which require due process when a physician's privileges and appointment are in any way affected. I was recently noticed that I would be "terminated without cause" with "no medical disciplinary cause or reason" from the Academic Faculty at LAC + USC Medical Center. I asked for a hearing as is my right under the Attending Association bylaws, and Dr. Ron Kaufman declined. I notified him of the information below and he still declined a hearing. The California Supreme Court opined on a case, Anton v. San Antonio Community Hospital that a hospital based physician's access to the hospital facilities is a property right which cannot be denied him or her without due process. My attorney tells me that to deny a hearing is a tort, and that any contract that is in violation of the law is an illegal contract. In other words, doctors can't be fired without cause in California and even then they have a right to a hearing and reversal of the termination if the reasons for termination are found to be invalid by an unbiased trier of fact. Centinela Hospital didn't get this and I and a co-plaintiff are taking them to trial on June 22. (Fenton, Wagener v. Centinela) Unfortunately to get some peoples attention you have to hit them on the bottom line!! I would appreciate anyone who could help me retain my job or at least get a hearing, and I hope the references I gave help many of you.
Drew E. Fenton, MD, FAAEM
Assistant Professor of Clinical Emergency Medicine
1200 North State Street - Room 1011, Los Angeles, CA 90033
Office Telephone: (323) 226-4076 Pager: (888) 610-5426
Fax: (323) 226-8101 Email: dfenton@hsc.usc.edu
The AMA Medical News reports in its May 3, 1999 issue that a Palm Beach County jury awarded $22.8 million dollars to two radiation oncologists who sued JFK Medical Center in Atlantis, FL and the University of Miami School of Medicine for entering into an exclusive contract that lead to the termination of their privileges. The doctors claimed that the medical center's decision to terminate their privileges and to enter into a new exclusive contract violated the hospital bylaws and interfered with the patient and referring physician relationships established by the doctors over the past 14 years.
"The hospital basically treated the bylaws as something that they could ignore or reinterpret or reinvent at their whim." said James W. Beasley, Jr., a West Palm Beach attorney representing the physicians.
[Mod (PH): The following memorandum was sent to the Department of Psychiatry Faculty. One should note that any extension of the contract will have to be formally approved by the LAC BOS. It will be important to learn if LAC will pay the interest (approx $4M) that would have been earned on the 1998-99 contract had it been paid at the beginning of the year, as previously. This money figures prominently as income in the USC SOM annual budget computations for 1998-99]
DATE: May 12, 1999
TO: Faculty Members, Department of Psychiatry
FROM: George M. Simpson, M.D.
Interim Chairman
SUBJECT: CPSA CONTRACT STATUS
Some of you were understandably upset at yesterday's medical staff meeting when you heard the MFA representatives' report about issues discussed in the ongoing CPSA negotiations between Los Angeles County and USC. This is to inform you that I have learned late yesterday afternoon that both parties have agreed to continue the existent CPSA contract for another year.
This means that the predictive statements that I made at the meeting yesterday about the contract for the forthcoming year were correct, i.e., there will be no 11% salary cut, there will be no transfer of faculty to county employee status, and there will be no reduction in the amount of funds in the CPSA contract. One consequence of the continuation of the existent contract is that the budget will be flat, (i.e., the School of Medicine will not be giving across the board salary increases) but I do not foresee other negative consequences
GS:mhr
From: Hdkern@aol.com
Date: Mon, 17 May 1999 11:08:13 EDT
Public Health Programs at LA County DHS has produced a really neat new
website, with links to tons of interesting information, other sites,
and DHS
hospitals and organizations (like Environmental Health).
Go to: http://phps.dhs.co.la.ca.us/
Date: Mon, 17 May 1999 17:19:47 -0800
From: "William G. Thalmann" <thalmann@rcf.usc.edu
Subject: Medical School Contracts Report
Dear Colleagues,
As you may know, some tenured faculty in the Medical School were recently offered contracts that differed from the last contract they signed in regard to the portion of their salary treated as funded by USC and guaranteed. These changes raise some difficult questions about the meaning of tenure and the protection of academic freedom in cases where the university does not guarantee full salary. An Academic Senate task force charged with gathering information about salaries and funding in the Medical School, identifying issues, and investigating options for resolving those issues has submitted its report, which is available at:
http://www.usc.edu/dept/acsen/task_force_on_contracts.html
This report is meant to be the beginning of discussions. I would welcome any comments and suggestions you may have about the report.
Greg Thalmann
William G. Thalmann
Professor of Classics
Dept. of Classics, THH 224
University of Southern California
Los Angeles, CA 90089-0352
Thalmann@Mizar.usc.edu
Date: Fri, 14 May 1999 11:53:59 -0700
To: USC-MFA-LACHS-L
From: Keith Beck <kbeck@jps.net
Subject: Micro Lab
Dear Colleagues:
I am sure you are as horrified at the deterioration of microbiology services as we are over here. I believe that the current process is leading us to destruction, and that prominent ID physicians from around the county need to work together to reverse this. It seems that the decisions are being made downtown against all the advice of physicians involved in the committee.
By comparison, I have been involved in the DHS P&T committee, and feel that we have preserved a functional formulary in the area of anti-infectives, and that the physicians have been heard and have driven the process. Obviously, this is not the case in pathology restructuring.
The latest changes have finally gotten the attention of our epidemiologist, Joel Ward, and he seems willing to be very actively involved. While I sit on the Clinical Lab committee here, that body seems relatively inert, or perhaps just overwhelmed by having to deal with the problems in all areas of Pathology.
I fear that if we do nothing now the future will only be worse. Please let me know how you think we might coordinate our efforts.
C. Keith Beck, MD
Professor of Medicine
Division of Allergy & Clinical Immunology; N-24
Harbor-UCLA Medical Center
Torrance, CA 90509
Date: Wed, 19 May 1999 15:19:52 -0700
To: usc-mfa-lachs-l@usc.edu
From: "Robert Larsen, M.D." <rlarsen@hsc.usc.edu
Subject: Re: USC-MFA-LACHS-L: Micro Lab
Dr. Beck:
The laboratory consolidation process has exempted all knowledgeable physicians at this time. The new committee structure created does not include a single practicing clinician, has no infectious disease specialists involved and has excluded the most senior and knowledgeable pathologists at our respective institutions (particularly at USC). We should be alarmed. This is not at all acceptable. I am particularly concerned that by denying access of physicians to the discussions in progress, that committee members are being mislead about the requirements essential for the provision of care. These requirements differ at each institution, as each institution has differing populations to serve. Please convey my alarm to the appropriate personnel at your institution that may be representing Harbor-UCLA. I am authorized to speak for the Department of Internal Medicine, and the Division of Infectious Diseases regarding this manner, but to no avail.
Robert A. Larsen, M.D.
Associate Professor of Medicine
Associate Program Director, Internal Medicine
To: heseltin@hsc.usc.edu
From: Kaslow_Harvey--R <hkaslow@hsc.usc.edu
Subject: UAPD web site
990601
Please inform faculty of the UAPD web site, which now links to a UAPD
article regarding the election.
see:
********
Dr. Harvey R. Kaslow
Associate Professor of Physiology and Biophysics
June 3, 1999
[Moderator (PH): The following letter originally sent to the USC Forum is reproduced with permission]
------------------------------
Date: Wed, 26 May 1999 10:15:23 -0700 (PDT)
From: "H.Richard Lamb" <hlamb@hsc.usc.edu>
To: USCFORUM-L@usc.edu
Subject: Problems in the School of Medicine
Message-ID: <Pine.GSO.4.02.9905260941560.9677-100000@hsc.usc.edu>
Dear Faculty of the University of Southern California:
In view of interest in University-wide issues arising in the School of Medicine, I am writing to add my perspective, based on my 23 years as a faculty member of the University and service to Los Angeles County.
As I see it, both the School of Medicine and the University have lost their way in understanding just why it is we have a medical school and what the priorities should be. For a few years now, the School of Medicine has been run more like a pharmaceutical company with the emphasis first and foremost on the bottom line rather than like an academic institution. I certainly do not dispute a need for prudent and responsible fiscal management of the School of Medicine, but this need must serve, not overshadow, concerns about academic excellence.
The Medical School has for many years been a cash-cow for the University. While exact figures are difficult to obtain, some examples will serve to illustrate this point. The last time I had access to a firm figure (from the previous Dean), an assessment set at 20% of direct costs of all School of Medicine contracts and grants was transferred to the University. With the large number of high-budget, multi-year NIH grants in the School of Medicine, that is a very large amount of money.
Still another source of income has been the School of Medicine's contract with Los Angeles County, the County Physicians Services Agreement (CPSA), by which the University provides physicians for the LAc+USC Medical Center. This contract is currently about 58 million dollars per year. It has been possible to make a considerable amount of money on this contract by not replacing many faculty members who have left, and requiring those new faculty who are hired to earn at least 20% of their salary in the private practice plan as opposed to paying them the full salary that their predecessors had received. According to my calculations, the School of Medicine in these ways turns a "profit" of at least 2 million dollars a year in my Department of Psychiatry alone. Still another source of considerable income is a thriving clinical medicine private practice enterprise, which, while it varies considerably among departments, has been extremely lucrative in recent years.
Despite the influx of these substantial sums of money, there have been disturbing developments. For instance, a few years ago there were many announcements from the administration about a "structural deficit" in excess of 10 million dollars. This "deficit", if it even truly existed, resulted from bad administrative and policy decisions, not poor performance of faculty. Nonetheless, to cut the "deficit" the administration's announced plan was to implement faculty salary cuts and layoffs, instead of reducing the net transfer of funds from the School to the University. Why? Wouldn't reducing taxes on the School be reasonable for a University that is in the midst of a successful campaign that will raise a billion and a half dollars?
But one of the worst parts of all this is that these actions have fueled an adversarial relationship between the administration and the faculty. When combined with actions to weaken or eliminate tenure University-wide, the result is a loss of trust. As morale sinks, grievances and lawsuits are springing up everywhere, further destroying collegiality between faculty and administration. The spirit of the University I knew when I first came here is fast disappearing.
What happens in the School of Medicine can only foreshadow developments University-wide. Nonetheless, I believe we can still alter the course of events, but it will take a University-wide effort on the part of both faculty and administration.
Sincerely,
H. Richard Lamb, MD
Professor of Psychiatry and the Behavioral Sciences
Date: Tue, 08 Jun 1999 08:17:12 -0700
From Peter Heseltine
Subject: Congratulations Elliot!!!/Today's Washington Post
LAC+USC will shortly lose the company and services of a man who was controversial and aggressive in his campaign to serve patients at a time when many administrators were more interested in cutting costs than improving services. Time and again, Elliot Johnson's brash and direct approach brought him into confrontation with the LAC bureaucracy (who consistently passed him over for promotion). He insisted that money legislated for HIV/AIDS patients be spent on no one else. He brought Federal/State Ryan White Funds to help pay for LAC patients for the first time. He nurtured commitment and professionalism among those serving AIDS patients and ensured that "County, business as usual" had no place in caring for the sick in his clinic. He helped forge a team approach between physicians, nurses and other care providers (the 5P21 model) that remains a national standard of excellence. Tirelessly, he lobbied the community, the legislature and even the Bush & Clinton Whitehouses on behalf of the patients of the LAC+USC Rand Shrader Clinic (5P21). The poor who had HIV/AIDS suddenly had a real faces for the public and a voice in Sacramento and Washington. When LAC decided to all but close its doors at the Medical Center in 1996, Elliot managed to hold onto most of the staff and facilities despite the Draconian cutbacks of "re-engineering". His argument was that today's patients might not see the new hospital and they needed full service now, as mandated by the tax payers. Elliot involved the community in the 5P21 clinic as no administrator had ever done before. It was the patients' clinic and their artwork filled the walls. This provoked controversy and disapproval from the conservative elements of LAC, but showed the patients as people with lives and passion, not just faceless men and women with a terrible disease. Elliot was the catalyst that made the clinic theirs. It was Elliot that organized church groups to support free lunches for those waiting in the clinic; it was Elliot that greeted patients personally as old friends on his regular walking rounds. But, perhaps one view of Elliot Johnson sums him up better than the immaculate suit, starched shirt and bow tie he often wears: Elliot in jeans and a stained shirt sweeping and mopping the floor late at night on a holiday with the rest of the cleaning staff as they struggled to ready the clinic for its opening after yet another move. Here is a man who speaks with his heart and works with his soul. It's been an honor to work with you, Elliot. You brought dignity and real meaning to the term public servant. We need ten more of you.
********************
Date: Tue, 8 Jun 1999 10:16:01 EDT
New Director Hired At Whitman-Walker
AIDS Program Picks L.A. Administrator
By Avram Goldstein
Washington Post Staff Writer
Tuesday, June 8, 1999; Page B04
Dear Colleagues:
As you probably know, USC's Norris Library subscribes to many on-line journals. Many are the full-text electronic versions of peer reviewed paper published journals (e.g., NEJM) and for those of you with limited office space and filing habits, they offer excellent access to the latest literature.
The problem is, if you are connecting from LAC+USC, the USC server has been programmed to view you as an "outsider" and will often restrict your access to some of these journals.
The library staff is well aware of this problem. [USC Computer Support or ISD is "stuck" in a 19 Century geographic faculty model rather than one where we are on different campus' and even off-site. No matter, USC's Computer Support is being brought kicking and screaming into the era of the abacus - but I digress.]
Here are some solutions offered by Norris Library staff:
You can try logging on through Ovid - this will give access to many journals Use your USC e-mail and password to logon (via the second button) @
http://www.usc.edu/hsc/nml/ovid/
Or if connecting by phone and using a commercial ISP, download the (unsupported) software that creates an IPsec Virtrual Private Intranet (you don't have to understand this to get it to work) @
http://www.usc.edu/isd/doc/dialup/ppp/extranet.html
Hope this helps
Peter Heseltine
PS If you work at LAC+USC or Children's Hospital or at one of a dozen sites that are connected to the USC servers, but not physically at Zonal or on the Main Campus, you might also try e-mailing
Jerry D. Campbell,
Chief Information Officer and University Librarian
Information Services Division
E-mail: jerryc@calvin.usc.edu
and tell him that you believe that defining the USC Faculty as only those that are physically on the USC Campus' is no longer appropriate and hardly in keeping with the new WWweb reality. We want the same access as our colleagues.
Date: Wed, 16 Jun 1999 08:29:35 -0700
[MOD:(PH) Ms. Brown spent a great deal of time patiently helping me to access electronically the journals I needed. Support your Norris Library colleagues!]
Date: Tue, 15 Jun 1999 04:12 PM (PDT)
From: "Janis F. Brown" <jbrown@hsc.usc.edu
To: Peter Heseltine <heseltin@hsc.usc.edu
Subject: Re: USC-MFA-LACHS: Accessing On-line journals (fwd)
Dr. Heseltine:
I received your message to the USC-MFA-LACHS-L list regarding accessing on-line journals. I'm glad that after talking with you yesterday that you were able to get the Bay Networks Extranet software to work for you.
We have been hesitant to publicize the software at this point as we are trying to assess its ease of use and also trying to work with Jerry Campbell and ISD in supporting the software. Nelson Gilman, Director, Norris Medical Library, recently sent a memo to Jerry regarding this issue.
I wanted to clear up one misconception you may have. The problem with defining who is USC faculty is not determined by Jerry Campbell nor ISD, but rather by the vendors and publishers. When licensing journals, databases, and books, we sign agreements with publishers and vendors indicating who can have access to the resources and the means for authorizing that access. Whenever possible, we have included the LAC+USC Medical Center. However, in many cases, the publishers and vendors restrict us in defining our user base. The licensing situation is very complex, and the vendors place differing requirements on us. Restrictions may be by geographic location, one Internet domain, a certain number of buildings, or may specifically exclude other institutional entities like hospitals. Publishers are trying to determine the best way to make their publications electronically accessible, while at the same time trying to make it economically viable. We will continue to license resources as inclusively as possible.
Please let us know if we can provide further information.
Thanks!
Janis
Janis F. Brown
Norris Medical Library (323) 442-1968 (voice)
University of Southern California
June 20, 1999
From: Peter Heseltine
Re: CPSA Update
An idea, that the County employ physicians who work at LAC+USC directly rather than paying them through a professional services agreement with USC (CPSA), has been raised repeatedly over the past several weeks. Dr. Don Thomas', Director, Clinical and Medical Affairs DHS, comments on this, taken from the minutes of a meeting with APLACH on May 20, 1999, are reproduced below.
"Regarding CPSA, he [Dr. Thomas] stated that CPSA will incorporate a stipend-based model with physicians returning to some form of direct employment by the County rather than the indirect employment through payment to USC and then to physicians. This should open opportunities for physicians employed by County to promote to positions that are commensurate with responsibilities they have assumed in the interval since the inception of the CPSA.The confusion over the proposed modification of the Proposition A language was discussed. DHS had sought to modify Prop A to include feasibility, in part to allow renewal of the CPSA, which could not take place under the existing Prop A language. He [Dr. Thomas] stated that the Auditor had never certified the CPSA as cost-effective. In fact the present cost of the CPSA exceeds the cost of purchasing comparable services at Harbor and Olive View by $10 million. This was part of the reason for proposing not paying for clinical research which would narrow the gap by $6 million. The merits and benefits of clinical research were discussed, but Dr. Thomas steadfastly maintained that the Board of Supervisors does not want to pay for research. "
The rationale for this approach by the County is based on an analysis of the Physicians Time Study Reports (the "Blue Books") by LAC Finance. They determined that if the approximately 20% of time reported as "1C. Patient Care - Clinical Research" was subtracted, the County could pay substantially less for physician services than it currently spends on the CPSA. If this reduction were made, it was calculated that approximately 350 positions would be needed, which on an FTE/100 beds basis is fewer than presently staff LA County's King or Harbor Hospitals. The analysis is flawed in at least two ways: (1) A single point in time, or even three or four, poorly represents the actual hours worked throughout the year by physicians at LAC+USC. (2) If a research medication or procedure, presently coded under "clinical research", is not used, other non-research treatment would likely consume the same amount of physician effort. Thus no patient care time would actually be saved by eliminating clinical research and as noted previously, many patients would be seriously disadvantaged.
The Board of Supervisors will consider at their 6/22/99 meeting the DHS proposal to "roll-over" the present CPSA agreement with USC for another year. Several of the Supervisors, notably Zev Yaroslavsky, apparently favor hiring physicians to work at LAC+USC and accomplishing this over the next year. While other Supervisors have also endorsed the concept, there have been few details of how USC physicians might become direct employees of the County. To employ anyone, the County opens "examinations" with deadlines for application. The process is cumbersome and regulated by Civil Service rules that may require the jobs be offered to others, not only to USC faculty. If substantial portions of the salaries of USC Faculty were paid by the County, they would likely not be eligible to continue in USC's TIA/CREF retirement plans. If they were employed less than 80% by the County, under present rules they would not be eligible for health and other benefits. Promotion in the County is often based on years served and prior positions held. It is unclear how prior service for USC at LAC+USC would translate into Civil Service seniority.
If USC has been unable to negotiate a renewal of the CPSA with the County, this will certainly affect all the School's Faculty. Dr. Jane Pisano, Senior Vice President, External Relations and Dean, USC School of Public Administration, who has been a key member of the negotiating team has agreed to address the next MFA Monthly Meeting on this matter. The meeting will be held on 7/6/99 at noon in the Norris Library Basement Conference Room.
[Moderator (PH) Bob Tranquada, former Dean of the SOM and one-time
Medical Director of LAC+USC has written an eloquent op-ed piece in
today's Los Angeles Times (7/5/99) supporting 750 beds for the new LAC+USC
Medical Center. Here it is, followed by a related letter from last
week]
-------------------------------------------------------------
PERSPECTIVE ON MEDICAL CARE
Just Where Will L.A.'s Sick GO?
Who will absorb the burden created by replacing County-USC's current
1,100 beds with only 600?
By Robert E. Tranquada
***************************
Letter to the LA Times
Wednesday, June 30, 1999
County Hospital
Re "Care, Not Hospital Size," editorial, June 21: In reference to the continued discussions on the merits of a 750- versus a 600-bed replacement facility for the earthquake-damaged and aging County+USC Medical Center, you frame the discussion primarily on the unfortunate public contretemps among the politicians, while making declarative statements in regard to what is best for health care delivery from the medical standpoint. However, nowhere do you take note that overwhelmingly the medical profession, including the Los Angeles County Medical Assn., the Hospital Council and two public commissions, has favored building a 750-bed facility.
The next major earthquake could render useless one or more of the very facilities that you advocate as the facilities of second resort, just as several private hospitals were severely damaged in the same earthquake that has precipitated the current debate. While economic conditions are favorable, we should invest in better health facilities for the next generation.
Experience has taught us that if the patient count goes down, there are many, many worthwhile uses for the unexpected space. The larger facility is a win-win for the future.
L. JULIAN HAYWOOD MD
President, Assn. of Physicians of L.A. County Hospital
[Moderator (PH) The following letter was received from Dr. Joseph P. Va Der Muelen, Vice President, Health Affairs during the July 6 MFA Monthly Meeting. He believes that copies will be distributed shortly to the Faculty by their Departmental offices.]
June 30, 1999
To the Faculty
University of Southern California
Schools of Medicine, Pharmacy and Dentistry
In response to inquiries about the extension of the CPSA contract for the coming year we would like to clarify the sequence of events that occurred.
The USC team had worked throughout the year advised by Ernest & Young, to negotiate a new contract with the Department of Health Services representatives. By the middle of April a rather extensive agreement had been developed and we were in the final stages of identifying the services to be provided and the amount of compensation, hoping to bring the document to the faculty and to the university administration for final approval by the end of April.
Unexpectedly, on April 16, when we arrived to finalize the document, we were notified by the County negotiators that Proposition "A" posed important legal and political barriers to the provision of clinical services by USC since the cost effectiveness of the agreement had not been demonstrated. In addition, the County was proposing to reduce the contract by $6 million for research that we had conducted as reflected in the Physician Time Allocation Modules (PTAMs).
In response to the County's Proposition "A" concerns and in an effort to obtain a contract without a $6 million reduction we suggested a process for exploring a different USC-County relationship in which clinical responsibility would revert to the County while academic responsibility would remain with the university. Pending the mutually acceptable formulation and acceptance of such a proposal the current CPSA contract would be extended with its present form and level of funding.
We believed then and continue to believe now that this was the only way in which we could get a contract by July 1st. It is our understanding from the County that any extension of the current contract required the provision of a plan for reversion to the County to avoid a Proposition "A" challenge.
This agreement was referenced in the letter to the Board as being at USC's initiative. It should be apparent that we were faced with no alternative late in the negotiations and that this had never been our intent prior to the April 16 meeting.
On June 22, the Board passed the amendment extending the contract at its current level of funding with several additional amendments directing County officials to:
(1) work with USC to develop the cost effectiveness of the various options;
(2) not initiate any action on return of clinical responsibility to
the County at this time;
(3) to conduct similar cost analyses at the other university affiliated
institutions; and
(4) to report back to the board in 30 days on the various options available.
We hope that this will clarify the situation and we will keep you informed of further developments.
[signature]
Jane Pisano
Sr. VP External Relations
USC
[signature]
Joseph P. Van Der Meulen
Vice President Health Affairs
USC
Date: Thu, 15 Jul 1999 14:11:06 -0700
[Moderator (PH) The following is from the MFA draft minutes if the 7/06/99 MFA Meeting. Full minutes will be posted on the MFA Website]
Jane Pisano, Senior Vice President, External Relations and Joseph Van Der Muelen, Vice President, Health Affairs attended the July 6, 1999 MFA Meeting and reported on the results of negotiations between USC and the County of Los Angeles Health Department (DHS) towards a new CPSA (County Professional Services Agreement). The USC negotiating team included Vice-Presidents Pisano and Van Der Muelen, Todd Dickey (General Counsel), Laura LaCorte (legal counsel), and later Carol Mauch (legal counsel). The LA County negotiating team was led by Donald C. Thomas, III, MD, Director, Clinical and Medical Affairs, LA County DHS.
The Vice-Presidents related that by April 1999 an agreement had been negotiated that contained all desired elements except overhead and three other small items. The proposal included increased accountability, a way to transition to an RV/RVU system and dollar amounts for contract program supplements (e.g., urgent care at Hudson Comprehensive Health Center) as well as the base contract.
On April 16, 1999, the County negotiators raised two new issues that were judged "insurmountable obstacles" by USC
LA County Ordinance (Proposition A) requires that all contracts between the County and another party for services be judged cost-effective to the County. In the ten years of the CPSA, no such audit or evaluation had been done.
The County had decided that it should not pay for clinical research and proposed to reduce the contract by $6 million for such clinical research that USC had conducted, as reflected in the Physician Time Allocation Modules (PTAMs). This financial assessment had been made by the County Auditor General.
USC countered by stating:
Clinical research done in the course of care for County patients had always been a part of the CPSA and was specifically addressed in the original agreement. The PTAMs were not designed to be an accurate measure of research USC would have to cut services if the contract was reduced
Subsequently, USC proposed transition to a model similar to that in force between UCLA, King Drew and LAC, where the university would provide academic services and the County would be responsible for the clinical services. USC anticipated that this transition would take place over five years, but LA County Counsel argued that to meet the requirements of Proposition A, the transition would have to be completed by the end of fiscal 1999-2000. In an exchange of letters from April through May, 1999 and in discussions during June, the parties agreed that a request would be made to the LA County Board of Supervisors to continue the present contract at the current rate (including payment for clinical research time) and that interest, owing on the prior contract would be paid. Future payments (1999-2000) would be made quarterly and include payment for lost interest, as the original annual sum was due in total every July 1 and substantial interest was earned by USC on this prepayment.
In reply to questions, the Vice-Presidents stated that the current contract may meet the requirements of Proposition A. The Los Angeles County Auditor General's "back-of-the-envelope" assessment of cost effectiveness was not conclusive. Therefore, a cost effectiveness study of the CPSA is ongoing by the Auditor General. In the view of the USC Vice-Presidents, Los Angeles County was unwilling to press the issue of revising or repealing Proposition A because the physicians were unionizing and the UAPD said that it would obtain an injunction against such action.
Academic services are not covered by Proposition A, as the County is not per se an educational institution capable of providing such services to physicians-in-training or the public.
Various measures of cost effectiveness have been used by both parties, but to date, a benchmark for cost efficacy has not been mutually agreed.
Vice President Van Der Muelen stated he had received copies of the agreements between LA County and King Drew and UCLA. Payments for units of academic service included approximately $45K per resident, $18K for program directors and $40, $75 and $115K for small, medium and large programs respectively
The Board of Supervisors has ordered that a report made to them in 30 days on the cost efficacy of the USC contract and the cost benefits of hiring USC faculty as County employees. This has been amended by Supervisor Molina to include cost efficacy reports for UCLA and King Drew as well.
Responding to a question concerning the issue of the Indemnification Clause in the original negotiation discussions that had occurred prior to April 16th, the Vice-Presidents stated there had been some discussion that USC would be responsible for current USC full-time faculty and that the County would be responsible for current and prior full-time County paid faculty.
Vice President Van Der Muelen said he was informed that the County has a number of different benefits schedules and it might be possible to develop one for returning faculty.
The Vice-Presidents also stated that though President Sample and the USC Board of Trustees had been informed of the results of the negotiations, no official opinion of position had been taken by USC.
Asked why the USC negotiators had not me more frequently with the CPSA Faculty Committee, Vice-President Van Der Muelen stated that it had been his intent to bring the contract to the group once negotiations were completed and that "we can use all the help we can get."
[From the Moderator (Peter Heseltine): The following LA Times editorial makes passing reference to the BOS "deal" to build two hospitals: one at LAC+USC and one in Baldwin Park. The resurrection of this concept (it was first proposed more than 20 years ago and plans were actually drawn up five years ago) has significant implications for USC Faculty. As the purpose of the concept is to satisfy the BOS desire to reduce expenditures on health care, by how much of the LAC+USC budget be reduced? From where will the medical staff of the Baldwin Park hospital be drawn? These are issues that must form part of this year's CPSA discussions and which need USC Faculty input to decide where the "centers of excellence" are located. Similarly, USC's plans to raise matching funds for the Keck Foundation's generous grant cannot come at the expense of USC's overall academic mission which includes teaching and public service as well as research.]
Los Angeles Times: Friday, July 30, 1999 - Medical Boons for Eastside
Date: Wed, 11 Aug 1999 17:22:02 -0700
[Moderator (PH) The following URL is a story by CBS correspondent Bill Whitaker of Sunday Morning , on the LA County doctor's vote to unionize. For those of you who missed the story on CBS it is reproduced on the web.
The central issues are: Will the doctors be able to use the union to leverage improvements in patient care and in their own working conditions? The union, the UAPD, which affiliated last year with large labor unions, now has the potential backing and experience to bargain with strength. But for what? The story quotes the new editor-in-chief of the NEJM who says that unions negotiate for money, not for "improved product". The JCIR, which has represented the interns and residents for a number of years believes that union bargaining does achieve improvements in pay and patient care. They point to the way half the residents' pay-raise is placed in a patient care equipment fund they control.
For most at LAC+USC it's wait and watch. Few are eligible to join the union as they are either USC employed or "management" position MDs. If the union were to recruit directly from the USC Faculty and represent them in contract negotiations with USC, this would obviously have a much greater impact. In the meantime, as stated by the CBS story: "Few doubt the system is sick. The question is: Are unions the cure? "]
From: "Janice M. Nelson, M.D." <4house@gte.net
While the mix-up on the time of the Sunday morning show did throw me off, I was able to find the text of the story on the CBS web site: http://www.cbs.com/flat/story_174331.html
Date: Wed, 11 Aug 1999 17:34:25 -0700 (PDT)
From: jmnelson@hsc.usc.edu (Dr. Janice M. Nelson)
Subject: Re: USC-MFA-LACHS: CBS: LAC Doctors Unionize
Although I felt this was a balanced presentation, I feel that it should have been mentioned that by the time the story aired, that Dr. Kassirer was now the former editor of NEJM having just lost his job due to differences with management. Perhaps Dr. Kassirer may now be ready to join the union (along with Dr. George Lundberg)!
Janice Nelson
Date: Sat, 21 Aug 1999 05:34:04 -0700
[From Ed Wong who now heads Graduate Medical Education at LAC+USC. Please fell free to copy this to your own department and alert the residents who are not on any MFA listserver. You will recall that we have an important site visit by the LCGME in the fall]
From: "Edward T. Wong" <edwong@hsc.usc.edu
Subject: GME Policy Manual
The GME Policy Manual is available at two web sites:
USC School of Medicine: http://www.usc.edu/medicine/. In the column on the left of the School's home page, click on "Education & Curriculum." On the next page, click on "Graduate Medical Education." On the GME page, find the heading "Program Information" and then click on "Policy Manual."
LAC+USC Medical Center's intranet: http://lacusc.org. In the right column of the Medical Center's home page, click on "Policy Manuals." On the next page, click on "GMEP Program Manual."
On both sites, the GME Policy Manual is in Adobe Acrobat pdf format, so the Adobe Acrobat Reader must be installed on the user's computer. Most will already have this program loaded and installed. However, for those who do not or who wish to upgrade their Adobe Acrobat Reader to the new 4.0 version, this is available at http://www.adobe.com. When that page opens, click on "Products" in the bar near the top of the page or in the line near the bottom of the page. The next page lists Adobe Acrobat near the top of the page. Then click on Adobe Acrobat Reader and follow the directions on subsequent pages.
The importance of the GME Policy Manual is that this contains the institutional policies that govern the conduct of graduate medical education programs (residency and fellowship programs) sponsored both by LAC+USC Medical Center and by the USC School of Medicine.