Los Angeles Times: Better use of antibiotics will help reduce spread of drug-resistant ‘superbugs,’ state health official says


Dr. Kavita Trivedi, medical epidemiologist with the California Department of Public Health’s Antimicrobial Stewardship Program Initiative, answers questions after an outbreak of carbapenem-resistant Klebsiella pneumoniae in Southern California health facilities.

By Molly Hennessy-Fiske

March 28, 2011

After reports that a dangerous drug-resistant bacterium, carbapenem-resistant Klebsiella pneumoniae, or CRKP, had spread to at least 356 patients in Southern California last year, Times staff writer Molly Hennessy-Fiske spoke with Dr. Kavita Trivedi, medical epidemiologist with the California Department of Public Health’s Antimicrobial Stewardship Program Initiative, about what can be done to reduce the spread of such drug-resistant “superbugs.”

What can healthcare officials do to stop the spread of drug-resistant “superbugs”?

One of the main ways of dealing with antimicrobial organisms in hospitals is to develop an antimicrobial stewardship program. These are programs that promote the appropriate use of antibiotics. That ensures that a patient receives the appropriate agent, or antibiotic, the right dose and the correct route of administration.

What does that mean?

When patients come in to the hospital and we know they have an infection, the first day or two we don’t know what the causative agent is, but we have to give them an antibiotic. This program helps ensure that the patient then gets the appropriate antibiotic.

What is the danger of giving someone an antibiotic that’s too strong?

If you have a certain organism and I give you a broad-spectrum antibiotic like a carbapenem that covers that organism and 10 others, that organism learns how to fight off that antibiotic. So it’s much better if I give you an antibiotic that is specific to the pathogen you have.

But what if a patient shows up with a severe infection?

It may be appropriate to give a patient a carbapenem, but then maybe when you get the lab results back, you can switch to something more specific. As a clinician, it’s really hard to answer that question, because when a patient comes in, you want to give them the best option you have, and a lot of times that’s a broad-spectrum antibiotic. It’s not that doctors are doing anything wrong. They’re in this healthcare environment where you have to see patients quickly and things get missed.

What can officials at healthcare facilities do?

For example, the lab looks at how much E. coli has been isolated in patients at your facility in a given year. They can look at how many of those specimens were susceptible to a given antibiotic. You really should use that susceptibility guide to decide what will work. We want to save these broad-spectrum antibiotics that we have in our arsenal for the really, really bad infections. It is not appropriate to use antibiotics without thinking about the repercussions. What’s happening is there are a lot of places where they don’t pay attention as much and they just give a broad-spectrum (antibiotic) that may not be appropriate.

What can patients do?

It’s not right to pressure your doctor to give you antibiotics for a viral infection. We need to be cognizant about limiting the use of antibiotics, period, because we really are going to have problems. CRKP and MRSA (Methicillin-resistant Staphylococcus aureus) are the end result of us using antibiotics perhaps not as well as we should be using them. We have now developed these organisms that know how to combat even our biggest and baddest antibiotics. We cannot have these multi-drug resistant organisms running rampant. It’s a good reminder to everyone, patients and providers, that we need to be really prudent when we give antibiotics to everyone, in-patient and outpatient.

What should patients ask their doctors?

Unfortunately, the culture now in these doctors’ offices is you go in and say, ‘I have bronchitis’ and demand antibiotics. Let’s say you have bronchitis and you take [azithromycin]. Most cases are viral. If you had bacteria in your respiratory tract, they may have developed resistance. If you develop bronchitis that is bacterial, the next time you’re treated the [azithromycin] might not work. The public needs to give doctors that option to say that it’s a virus instead of demanding antibiotics. We can also help doctors understand that it’s OK to tell a patient to go home and rest and you don’t have to give them something to make them feel like they got something out of the appointment. That is the culture. What we’re trying to do with this initiative is to swing it the other way.

So patients should ask about the tradeoffs of antibiotics?

Exactly. If you initiate that conversation, that opens the door for the physician to have that conversation with you and you can develop a plan — if I don’t get better in five days, say, then I can come back and try something else.

So what does your initiative do?

California is the only state that has any legislatively mandated wording concerning using antibiotics in hospitals. Hospitals are required to have oversight of the judicious use of antibiotics. It has translated into giving many hospitals the backing that they needed to develop these programs…. It’s the lab that’s running the susceptibilities, the pharmacists who really understand the pharmacology of the antibiotics, it’s the physician, the infection control officer for the building — it’s multidisciplinary. There are many programs already in place that are very successful that have helped improve the use of antibiotics and have shown some good effects.

Los Angeles Times: Hospitals are wary of California budget plan to shift emergency funds


A move to help close California’s budget gap would shift funds used to reimburse doctors who treat emergency patients without insurance. Proponents say the move will bring in more federal dollars for Medi-Cal.

By Molly Hennessy-Fiske

March 20, 2011

California emergency room doctors are fighting to preserve a state fund that compensates them for treating poor, uninsured patients at private hospitals — money that lawmakers want to shift to the federal insurance program in order to help bridge the budget gap.

But doctors say the shift would still leave millions uninsured for the next several years, raising questions about who will pick up the tab at already strained emergency rooms.

“We can’t deny care to anybody. The hospitals that are barely making it through, this is going to make it unsustainable,” said Dr. Arturo Pelayo, an emergency physician at St. Francis Medical Center in Lynwood, where up to 20% of the nearly 70,000 emergency patients they see each year are covered by the Emergency Medical Services, or “Maddy,” fund.

That likely includes Patrick Stobie, 62, of Lynwood, an unemployed security guard who went to the emergency room for treatment recently after he was hit by a car and broke his nose.

“I’m just trying to stay healthy,” said Stobie, who lost his Kaiser medical insurance and his job in 2007 and said he had no other form of insurance. “I know the state’s broke — I don’t know what they’re going to do.”

State lawmakers want to transfer $55 million from the fund — named for Kenneth K. Maddy, the late state senator from Fresno who proposed its creation more than two decades ago — which pays doctors to care for patients such as Stobie. Moving the money to Medi-Cal, which serves the state’s poorest residents, would qualify the state for matching funds from the federal government.

Many of the patients formerly covered by the fund would be covered by a federal waiver that takes effect July 1 and by Medi-Cal as it expands under national health reform, according to Mark Hedlund, a spokesman for state Senate President Pro Tem Darrell Steinberg (D-Sacramento), who proposed the transfer along with other legislative leaders.

“That helps maintain the essential services and leverage federal money,” Hedlund said.

The “Maddy Fund” money comes from fines levied for certain traffic violations and is administered by counties. The fund included about $95 million as of the 2008-2009 fiscal year, the most recent period available, according to a recent survey by the Emergency Medical Services Administrators’ Assn. of California. Hedlund said $55 million is about half of the fund.

Dr. Andrea Brault, president of the California Chapter of the American College of Emergency Physicians, said the transfer would effectively eliminate the fund. Brault said moving the money into Medi-Cal would limit hospitals’ ability to maintain panels of on-call surgeons and specialists, increase emergency room wait times and force some emergency rooms to close.

“It’s not just about uninsured people or physicians; it’s about the safety net,” said Brault, an emergency physician at Brotman Medical Center in Culver City. “At some point when you make so many cuts to the safety net, it hurts everybody. These funds are critical to our emergency departments.”

Brault said the federal waiver would cover 500,000 patients only and national health care legislation will not expand Medi-Cal until 2014, leaving about 7 million of the state’s uninsured patients with reduced or no access to emergency medical services in the near future.

Dr. David Frankle, an emergency physician at Cedars-Sinai Medical Center who leads a Los Angeles County advisory group for the fund, said losing it would be “devastating.”

“It won’t just impact indigent people — it will impact all of us if the emergency room is overcrowded, understaffed and overwhelmed by people trying to get limited care,” he said.

Los Angeles County receives about $33 million a year from the fund, which compensates about 4,700 doctors and also helps pay for emergency responder training, emergency stroke and cardiac programs, according to Cathy Chidester, director of Los Angeles County’s emergency medical services agency.

Chidester said she fears that transferring money away from the fund would force emergency rooms to close, particularly at community hospitals such as St. Francis that serve a greater proportion of poor, uninsured patients. She said it would also likely worsen overcrowding at public safety-net hospitals.

“If the Maddy Fund goes, the line for our waiting room will be going around the block,” said Dr. Edward Newton, chairman of the department of emergency medicine at Los Angeles County-USC Medical Center.

But hospital industry officials said that rather than close emergency rooms, California hospital administrators would most likely pay extra to keep specialists on call, shifting the burden of caring for the state’s poorest patients from the state to private hospitals.

“Many hospitals will be hard pressed not to pay for the physician coverage because so much of the admission hospitals have these days comes from the emergency rooms,” said Jim Lott, executive vice president of the Hospital Assn. of Southern California.

Lott said that some hospitals, particularly those in low-income areas such as South Los Angeles, will not be able to afford to pay on-call emergency room specialists and may have to scale back services or hours. More than half of hospitals in Los Angeles are operating at a deficit, he said, and those in low-income areas are closer to the brink. Of the 17 hospitals that have closed statewide in the past 11 years, all were in low-income areas, including six in South Los Angeles, he said.

The governor’s office has not taken a position on the proposal, according to spokesman H.D. Palmer, who said “there is still a potential that there will be some changes.” However, opponents have yet to submit an alternative, and unless they succeed in negotiating changes, the proposal could pass as part of the state budget.

The Sacramento Bee: Governor may seek November ballot initiative on tax plan


By Kevin Yamamura

Mar. 23, 2011

A new Plan B for balancing California’s budget emerged Tuesday as Gov. Jerry Brown mulled the possibility of a November ballot initiative to maintain higher tax rates.

The idea, which would bypass Republican lawmakers’ opposition to a public vote, would require a signature drive under a tight timetable to put the measure on the ballot.

The Democratic governor continues to negotiate with Republican lawmakers to place tax extensions before voters in June through a two-thirds vote of the Legislature. But talks have sputtered, and state leaders are running out of time to call a June election.

Brown has repeatedly said he would seek bipartisan support for tax extensions. On Monday, however, he told a labor convention that a vote would occur “no matter what anybody says across the street.”

Republicans want pension cuts, a cap on future state spending and regulatory changes that help businesses as part of a deal to place taxes on the ballot. Democrats say some ideas are negotiable, but the most extensive changes on pensions and a spending cap are non-starters.

Democrats are also considering whether to place the tax extensions on the ballot with a majority vote of the Legislature. But Brown believes business groups are more likely to support a ballot initiative than any majority-vote maneuver.

Alternatives to Brown’s original plan have legal, political and budget hurdles. We examine them:

Why didn’t Brown gather signatures for a ballot initiative in the first place?

It typically takes months – and millions of dollars – to gather signatures to qualify a state ballot initiative. Also, heading straight to the ballot via signature spurns the Legislature’s authority, not usually a governor’s first option.

If Brown pursues this route now, the election would not occur until November, more than four months into the 2011-12 fiscal year. By that time, the state will have lost one-third of the additional sales and vehicle tax revenues it could have raised through a June election. It is also unclear how such an initiative would treat income taxes, since it would be hard to sell a retroactive income tax hike in the 11th month of a tax year.

Is it possible to qualify an initiative for November?

The timetable seems awfully tight. Proponents have to wait several weeks for the attorney general’s office to process an initiative proposal. Based on the Election Code, proponents would then have to submit signatures by late May to give election officials time to review petitions. That may leave Brown with a month or less to gather signatures. Petition companies charge top dollar to gather signatures in a short window.

Any other problems with a November initiative?

State leaders would have to figure out whether to balance the budget beforehand. Doing so with cuts would pressure districts to lay off teachers before the next school year and impose other classroom cuts. That makes education groups nervous.

If state leaders don’t balance the budget beforehand, the state will be unable to borrow cash from Wall Street without paying exorbitant rates. The state could face difficulties paying bills.

Democrats also would face huge political challenges with a November initiative. It would be difficult to portray the measure as bipartisan, though Democrats are counting on business support to win over moderates.

It would also be difficult to sell the proposal as an extension of taxes rather than a tax increase, given that all three forms of higher tax rates would have ended by November. Support drops significantly when voters perceive it as a tax hike rather than a tax extension.

What about placing the taxes on a June ballot with a majority vote?

The Legislature’s attorneys have said this route is possible under narrow conditions, such as inserting a new tax in a state tax law previously approved by voters.

Democrats have considered placing tax extensions on the ballot using majority-vote powers granted by voters last year in Proposition 25. That may open lawmakers up to criticism that they are exploiting Proposition 25, but Democrats would say they are putting the question before voters rather than raising taxes themselves.

This route would run afoul of the legislative counsel’s opinion, which said placing taxes on the ballot that way would be an unconstitutional delegation of authority. But under a different legal theory, the Legislature may argue it could delegate such questions to voters because it believes the electorate has ultimate authority. Undoubtedly, this route would face legal challenges from anti-tax groups.

Los Angeles Times: California lawmakers cut services, but contentious budget issues are still unresolved

Spending on libraries, higher ed, parks and programs for the poor is reduced while Gov. Jerry Brown searches for four Republicans to vote for his most politically difficult proposals.

By Shane Goldmacher

March 18, 2011

Reporting from Sacramento — State lawmakers continued chopping at the state’s deficit Thursday, approving more cuts in government services as Gov. Jerry Brown pressured legislators to resolve the most contentious budget issues: taxes and a plan to abolish redevelopment agencies.

While negotiators labored behind closed doors, lawmakers plowed ahead on a raft of cutbacks to close about half of California’s roughly $26-billion deficit. They slashed spending for libraries, universities and colleges, state parks, child care, and programs for the poor. A proposal to shift tens of thousands of inmates from state prisons to local jails was also approved.

The most politically difficult actions, however, still lie ahead.

“We’re in the hunt,” Brown said, walking between closed-door meetings with lawmakers, seeking votes for the rest of his spending plan.

That includes a bid to eliminate more than 400 redevelopment agencies, which subsidize development in blighted areas. Legislation to implement that fell one vote short of passage in the state Assembly on Wednesday evening and was not voted on again Thursday.

Brown is also short the votes he needs for the linchpin of his budget: a measure that would go before voters in June asking them to bless a renewal of temporary vehicle, sales and income taxes that will otherwise expire. To place the issue on the ballot, the governor needs votes from at least four Republicans, two each in the Assembly and Senate.

There was no apparent progress in those talks.

Brown faces an imminent deadline for placing the tax question on a June ballot, although officials have not said exactly when. Without the extended levies, the governor said, the volume of spending cuts would double.

“In a democracy, the people should be heard on something that’s going to affect their schools, their universities, their hospitals, their very quality of life,” he said after meeting with Senate Democrats.

Legislators approved an official budget for the coming fiscal year Thursday, but it lacked several key provisions accounting for billions of dollars. Because of that, they did not intend to send it to Brown. Instead, they planned to send him other bills necessary to enact the cuts they passed.

“We did what we set out to do today, which was to make another significant dent in the budget deficit,” said Senate President Pro Tem Darrell Steinberg (D-Sacramento).

For the first time, Democrats used a new state law, approved by voters in the fall, to pass budget legislation on a simple majority vote. Although the package includes some accounting moves, such as the deferral of certain bill payments, it also represents a marked scaling back of state government.

California’s welfare services would shrink dramatically, reducing cash grants by 8%, limiting the time allowed in the program to 48 months and slashing job-training services. Fewer families would be able to receive state-supported child care, and that program would end for 11- and 12-year-old children.

Funds for local libraries would be cut in half. And $1.4 billion would be trimmed from state colleges and universities.

Democrats said such cuts were necessary because of the depth of the state’s fiscal problems.

“I hate this bill,” Assemblyman Marty Block (D-San Diego) said several times, before casting a vote to pare back spending.

A fierce floor debate occurred over the effort to reclassify crimes in order to send inmates to local jails rather to than costlier state prisons. Republicans accused Democrats of putting the public in jeopardy by downgrading felonies; some read the list of included offenses, such as felony child abuse, aloud on the floor.

“I urge all of my colleagues, if this bill passes, to get a dog, buy a gun and put an alarm system in,” said Sen. Joel Anderson (R-San Diego).

Republicans voted against that plan and nearly all the legislation approved Thursday.

“Let it be noted, the party of ‘no’ is also the party of fear-mongering,” Sen. Mark Leno (D-San Francisco) said.

There were rare moments of bipartisanship in the Assembly on Thursday. Lawmakers on both sides of the aisle applauded when, before the voting began, children performed an Irish dance for St. Patrick’s Day.

And when Speaker John A. Pérez (D-Los Angeles) praised the service of Assemblyman Jeff Gorell (R-Camarillo), a Navy reservist who deploys on a year-long tour in Afghanistan on Friday, legislators gave Gorell a standing ovation and lined up to hug him.

The Sacramento Bee Viewpoints: Budget cut would push ERs closer to closure


By Dr. Andrea Brault

Special to The Bee

Published Wednesday, Mar. 16, 2011

Every day when I go to work as an emergency room physician, I see firsthand that California’s health care safety net is being stretched to its limit.

The patients are sicker because their access to primary care has been cut or they have lost their insurance so they tried not to come to the ER until they were just too ill to wait. There are more patients to see for the same reasons or the nearby ERs are full and have diverted the ambulances.

Through the Maddy Fund, California’s counties collect fines and reimburse emergency and on-call physicians and hospitals for treating the uninsured. This is the only source of funding to compensate for treating the uninsured, all of whom must be stabilized and treated under state law and the federal Emergency Medical Treatment and Labor Act, regardless of their insurance status or ability to pay. But it has remained an unfunded mandate since its implementation in 1986.

Without the Maddy Fund to offset these costs, emergency rooms will be pushed perilously closer to closure. Since the late 1990s more than 60 emergency rooms in California have closed. How many more can we afford to lose? The California chapter of the American College of Emergency Physicians believes emergency care is an essential public service, and emergency room physicians want to provide the very best care so the people of California will have access to high-quality, timely emergency care.

The elimination of the Maddy Fund will affect all Californians, insured or not. It equates to longer wait times for every emergency room patient, fewer doctors and fewer specialists to care for each and every one of us.

In many underserved areas throughout the state, both rural and inner-city, Maddy Funds are the only thing keeping emergency rooms open. If the state succeeds in cutting these funds, emergency rooms throughout the state could close their doors. Emergency rooms cannot survive another budget hit.

The Maddy Emergency Medical Services Fund was cut by $25 million in 2009, and other Medi-Cal, clinic and mental health cuts at the state and local levels have provided more strain to struggling emergency rooms, and this year’s budget proposes additional cuts.

By eliminating the Maddy Fund, the budget conference committee may be able to conserve $55 million for the general fund. But to what end? In reality this money amounts to pennies in the context of the multibillion-dollar deficit, but the impact on California’s emergency rooms cannot be understated, not when those pennies are the only thing standing between access for all or a closed emergency room.

While the California chapter of the American College of Emergency Physicians understands the need for legislators to find additional ways to save money for the state, this proposal will result in seriously dangerous, though unintended, consequences, which will leave California’s already fragile emergency care safety net at greater risk.

Dr. Andrea Brault is a practicing emergency physician in Los Angeles County and president of the California chapter of the American College of Emergency Physicians.

Government Health IT: Health IT Panel explores CMS online eligibility hub


By Mary Mosquera
Tuesday, March 15, 2011

The Centers for Medicare and Medicaid Services has asked a federal health IT advisory panel for feedback on potential models for an online hub that will perform verification functions in support of the exchange of eligibility information among state health and human service programs.

The exchange of program eligibility determination and enrollment information will become increasingly important as states move to build electronic health insurance exchanges required by the health reform law.

CMS is exploring the most effective model in providing these verification services, said Sam Karp, co-chairman of the enrollment work group, a panel of the Health IT Policy Committee. The work group began discussing the questions raised by CMS at a March 14 meeting and will deliver its recommendations to the policy committee at its next meeting in April.

Karp is also vice president of programs for the California HealthCare Foundation.

Last August, the policy committee endorsed the panel’s proposals that states use existing federal agency systems to verify the personal income, citizenship and legal status of those applying for health programs.

The use by states of standard Web services will help agencies make eligibility determination more efficient across various health and human services programs, such as Medicaid, food stamps and welfare.

Health insurance exchanges, which must be available by 2014, will act as e-commerce gateways, similar to those in the financial and travel industry, and offer consumers comparative information on state health insurance programs, including Medicaid, high risk pools and other public and private health plans.

CMS is considering the services that a verification hub or gateway should include. For instance, it can serve only as a pass through to channel information but not perform calculations, data aggregation or make determinations. Or the hub could perform some or all of those activities, Karp said.

The Internal Revenue Service, the Social Security Administration and Homeland Security department have Web services that states can use to help determine eligibility for health and human service programs.

The policy committee also endorsed the creation of a federal reference model, or sample application, for states to interface with the online verification hub.

“The Web services will be the transport mechanism through a standard protocol instead of each state creating their own,” Karp said.

The software would contain standards for states to verify an individual’s eligibility information from federal agencies.

CMS also is weighing whether and how the data services available at this gateway should enable the transfer of case information when the consumer moves from one exchange to another.

The Sacramento Bee: Blue Shield withdraws disputed rate hike


By Darrell Smith

Published Wednesday, Mar. 16, 2011

Blue Shield of California will not hike individual insurance rates in 2011 after all.

“Blue Shield has withdrawn its rate filing with the California Department of Insurance and the company will not increase rates to any individual or family plan member for the remainder of the year,” said Blue Shield chairman and chief executive officer Bruce Bodaken, in a statement.

Blue Shield had come under heavy criticism for plans to boost rates for some 200,000 Californians and a study commissioned by the San Francisco-based insurer and released in March that justified the rate hikes. The planned May 1 hikes for those Blue Shield customers who buy their own insurance would have been the third since October, amounting up to 59 percent in some cases.

Blue Shield filed for rate increases in October 2010 with the hikes initially to become effective in March.

But state Insurance Commissioner Dave Jones asked for a 60-day delay, later voicing “serious concerns” about the insurer’s filing.

At a press conference today, Jones said the Blue Shield announcement was a welcome relief for ratepayers.

“Californians are very upset about repeated rate hikes,” Jones said. “These rate hikes have a huge impact on people. It is noteworthy that Blue Shield made this decision. Year after year of double-digit increases are unsustainable.”

Expanding Access to Meaningful Health Coverage & High-Value Care

Building on California’s Successful Expansion of Meaningful Health Coverage 

California has been a national leader in successfully implementing the Affordable Care Act (ACA) — reducing the number of uninsured Californians by more than half. Ninety-three percent of Californians now have comprehensive health insurance and access to care.

Since the ACA’s implementation, community safety net hospitals have provided comprehensive care to 1.2 million newly enrolled Medi-Cal patients annually.  Community safety net hospitals also serve as essential community providers in Covered California’s health exchange networks.

PEACH is committed to working collaboratively at the local, state and federal levels to expand coverage to the 3 million remaining uninsured Californians, increasing affordability, and improving access to high-value, integrated physical and behavioral health care.



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