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Raising Interesting Questions: An Interview with Mitch Katz, MD

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From Physician Magazine– Mitch Katz, MD, Director of LA County Health Agency is uniquely positioned to talk about what he sees as the big healthcare issues coming up in 2017 for Los Angeles. Late in 2015, the three big health agencies for LA County  – the Department of Public Health, Department of Mental Health and Department of Health Services were brought together with Katz overseeing this new single agency. We were pleased to grab some time with him just after the election to find out what people are asking him and what he thinks we should be watching for.

LACMA: The election dominated the news for months and months. What do you think the main issues for healthcare will be under the new administration and Congress?

Dr. Katz: In 2017, the dominant issue will be what the new president and Congress will do about the Affordable Care Act and how it will affect people both patients and their physicians in Los Angeles. The ACA has been dramatically effective in decreasing the number of uninsured people here and in other parts of the country. I’ve personally cared for many patients who come to our urgent care at Roybal Comprehensive Health Center and they say, “I used to be treated for hypertension or diabetes and then I lost my insurance and I haven’t filled my prescriptions for over a year, but now I got Medicaid and so I’m back.”

I think the most important role for doctors during this turbulent time is to stay focused as advocates of our patients. The most important thing to me is that people have access to going to see their medical provider. That can occur through a variety of different systems and I don’t think we have to be closed minded about what the vehicle is for paying for people to go to see their doctors. But I think to simply return to the era when people were uninsured and came into the emergency room for illnesses at the end stage would be a terrible mistake. And a terrible going back.

For 2017, the issue for all of us to watch is this – Are we talking about an alternative way of making sure people get the coverage they need? Are able to see their doctors when they are sick or are we talking about taking away the rights of people to get medical care when needed?

I can work with a variety of different mechanisms of insuring that people get the care they need. What I am against is the idea that we would just return to an era where people with chronic or acute illnesses are not able to get the care they so badly need.

LACMA: As of our press date, President-elect Trump won’t have taken office so there’s a lot we don’t know about his plans. He’s said that he would repeal ACA, but might keep parts of it. Overall, are you aware of any concrete alternatives to ACA being floated?

Dr. Katz: Again, my view is that as physicians our role is to advocate for high quality care with excellent access for our patients. That’s the standard. So the ACA has markedly improved access and quality of care and it seems to me the burden of anybody who wishes to change the system is – Okay, well how will you guarantee high quality care and access?

I’ve spent my career as a changemaker. I’m not against different ways of doing things…I feel in some ways it’s a mistake to get too deeply involved especially as physicians with the mechanics of how care gets paid for. But what we should be very focused on is what our standard is. We need to stand up for the right of people to be able to see a doctor when they’re sick or receive preventive care and against the idea of cutting off access. If people have alternative ways, then I’m all in favor of listening to how that’s going to produce the same outcome.

LACMA: Staying focused on the standard of care makes a lot of sense. That’s a clear suggestion for waiting out the limbo stage. What else should we look at for 2017?

Dr. Katz: An interesting and very topical issue on the public health side that doctors need to think about is the passage in California that will make recreational marijuana use legal. That issue has huge implications for physicians as well as the community.

I think the advocates of recreational marijuana correctly point out that when a substance like marijuana is illegal, it just pushes the substance into the underground where it cannot be regulated. It cannot be taxed. It becomes part of illegal ways of earning money. It leads to crime. So the legalization of marijuana offers us opportunity to appropriately regulate and tax this psychoactive substance.

On the other hand, the challenges it poses in terms of people who are harmed by chronic marijuana use, people who are driving under the influence of marijuana, people who are at work while they are using marijuana, the possibility that – although it won’t be for sale for minors – that greater access might make it easier for minors to get marijuana – all have quite a lot of implications for physicians. The law is now set. So it’s not a question of what if the law is set.

The job here of physicians is to recognize when our patient’s marijuana use is unhealthy and how to counsel them. How to get them to seek treatment. In that sense, as physicians we’ve always counseled people about alcohol use. In fact, small amounts of alcohol for most people who don’t have addiction issues is a positive thing, in terms of heart health if they’re drinking wine. Obviously, large amounts of alcohol are unhealthy and lead to all kinds of problems including liver disease and death.

I think this is the model that we should be thinking about with what will happen under the law change. Those states which have [legalized marijuana], have experienced increased use of marijuana. It’s unavoidable if you make it easier because people who don’t want to break the law will now not be breaking the law. The question then becomes – with easier availability, how do we make sure that it’s not harming people.

LACMA: One challenge seems to be in simply defining harm. Could you comment on that?

Dr. Katz: For young people it seems that the harm can be that marijuana does impair brain development. That is thought to be less true for older people. People who use it chronically, every day in large amounts are often impaired in other ways that need to be addressed. I think that would be a good public health issue to highlight.

LACMA: Do you think that down the road these things are going to be spelled out more? What chronic use looks like, when it’s harmful, how to counsel? Doctors have been doing these things, but they haven’t been quantified, right?

Dr. Katz: Correct, correct. In some ways, legalization makes health issues easier for doctors to talk about and to address. There’s always a reluctance to discuss and document in your medical records somebody’s illegal activity. But now if it’s no longer illegal, then that’s no longer an issue for us.

Now the issue comes, how do we deal with it. There are some very common problems. For example, many lay people may not be aware that it’s easy to diagnose someone who is intoxicated from alcohol at the job or while driving because there are alcohol tests. It is not easy to diagnose somebody who is high on marijuana while driving or at the job because there’s not a quantifiable test.

How do you decide – in the employee health point of view – you have a substance now that’s legal like alcohol, but that doesn’t mean we allow people be intoxicated while they’re at their job. And we have an objective standard for intoxication, how does that relate to then when somebody is using marijuana? An employer might say, “Well, you can’t use marijuana while you’re at the workplace.” That makes sense because we don’t generally let people drink alcohol at their workplace. But what would that mean if they used it before they came to work?

Again, you would assume that the standard would be – are you impaired? But then when you go to do an objective assessment, you don’t have a test so it’s much more complicated.

LACMA: You raise really good points. Are we close to finding answers? What else is on your radar for the upcoming year?

Dr. Katz: Well, you asked me about interesting issues so I don’t feel obligated to have answers to these questions. Sometimes I think it’s more interesting to raise questions that people don’t have the answer to.

I think two strongly related issues that you may not hear about immediately, but will be hot and have a lot of impact on doctors in the next year or two are drug prices and resistance to existing antibiotics. On drug prices, pharma has been successful at creating more and more specialized agents to address specific diseases, especially some of the new cancer drugs, some of the new rheumatological drugs, Hepatitis C drugs. But the prices are extremely high and it is unclear as the number of new agents proliferate how we as physicians will be able to continue to prescribe things, even with insured patients because ultimately, somebody has to pay.

Insurers have to be able to make money if they’re for profit or break even if they’re non-profit. That means that as the number of expensive drugs proliferate, premiums will have to go up. If premiums go up, people will be less and less able to afford insurance and will have to make other decisions.

I think as a society we’re having tremendous difficulty even deciding what do we consider to be the appropriate standard. For example, I’ve often heard people talk will say, “Can you believe that this is $20 a pill?” Well, is the standard cost per pill? Is the standard per treatment? Is the standard per benefit? Is the standard the cost for the pharmaceutical company to develop the drug? How exactly do we believe drug prices should be set?

Part of why I think this is so challenging is that there is no consensus on how drugs should be priced. How could you possibly resolve an issue where there’s not even general agreement on the basis for how to decide?

And then related is the pipeline of new antibiotics does not have a lot of new agents coming and we’re increasingly facing resistant organisms that don’t respond to the antibiotics that we have. There are some, at least short term steps, that we can take to minimize drug resistance, but they’ve been extremely hard to implement. For example, we still are treating livestock throughout the US with antibiotics, not even because of any infection but simply because livestock fed antibiotics grow fatter. So we continue to use the antibiotics in this way, for food production while compromising our future in terms of ability to deal with resistant organisms.

Also on this one, in surveys that are done of our practice, physicians continue to prescribe antibiotics for conditions such as upper respiratory infections which are shown to not benefit from antibiotics or to use antibiotics for longer than necessary for most infections. It has been challenging to get physicians to use antibiotics more sparingly.

LACMA: Thank you Dr. Katz for sharing your thoughts with us and raising some good questions. We look forward to following up with you.


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