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SUMMER 2019 AREA 6 AMERICAN PSYCHIATRIC ASSOCIATION VOL 37 NO 6 President s Report President Elect Report Robert McCarron DO DFAPA CPA President Mary Ann Schaepper MD CPA President Elect Reducing Vulnerability Preparing for the Future is Now Many of those suffering from mental illness will experience overall dysfunction with daily activities Depression and anxiety disorders for example often result in a marked deviation from the relatively normal aspects of life and may adversely affect relationships financial status and even one s overall health This holds especially true for those experiencing severe mental illness like schizophrenia bipolar disorder chronic depression or severe personality disorders Put another way those suffering with severe and chronic mental illness are uniquely vulnerable Psychiatrists are well positioned to advocate for patients who may be at increased risk for early demise or have excessive general medical co morbidity In fact psychiatrists may be the only lifeline for these patients The weather is hot The news is even hotter Remaining cool being informed and making wise decisions is what your CPA is all about Let me take a moment to reflect on the past few months in California First on July 4 2019 we had the beginning of the Ridgecrest earthquakes At 6 4 magnitude it was felt all over the southland Patients of mine living near the epicenter sent texts and photos of homes in disarray and businesses strewn with products covering the floors Those in treatment had some skills to address the panic Their colleagues and family members were in need of mental health services Second the Border Patrol released migrants in Blythe Continued on Page 23 Continued on Page 13 High Desert Beauty Calls to CPA The Omni Rancho Las Palmas in Rancho Mirage hosts CPA s 2019 Annual Conference showing off the finest that California s unique desert landscape has to offer Plenty of shopping hiking golf and art galleries to wander along with quality time with colleagues Join us for a weekend that will stimulate both mind and soul INSIDE THIS ISSUE Politics Science Policy Updates CMA Homeless CPA Gallery Access to Care And More

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PAGE 2 CALIFORNIA PSYCHIATRIST SUMMER 2019 This issue contains a medley of topics that are not easily woven together thematically so I thought I would focus primarily on Randall Hagar s Capitol Insight for a Cliff s Notes version of California mental health mileposts For younger psychiatrists it s important to know of the history that has resulted in some of our present conundrums and for all aged psychiatrists to attempt solutions that will steer us into the future Not necessarily in chronological order I would say understanding the Lanterman Petris Short Act is essential to understanding concepts such as least restrictive environment deinstitutionalization and the Patient Rights Movement led by Thomas Szasz that coupled with the federal Community Mental Health Act signed into law in 1963 by John F Kennedy gave Gov Ronald Reagan a reason to ultimately close many state hospitals The community level of service was not in place in most counties when this happened so that either the justice system or the social services system were left to pick up the pieces Today we see that many jails have become de facto psychiatric hospitals and many streets and shelters have become de facto homes for severely mentally ill persons Realignment was another California milestone that decentralized government responsibility for mental health proContinued on Page 12 TABLE OF CONTENTS California Psychiatric Association 921 11th Street Suite 502 Sacramento CA 95814 Office 916 442 5196 FAX 916 442 6515 Email calpsych calpsych org Robert McCarron D O CPA President Mary Ann Schaepper M D CPA President Elect Steve Koh M D CPA Treasurer William Arroyo M D CPA Immediate Past President Melinda Young M D APA CPA Area 6 Trustee Barbara Weissman M D Area 6 Assembly Rep Lawrence Malak M D Area 6 Assembly Dep Rep Lila Schmall CPA Executive Director Randall Hagar CPA Govt Affairs Director Vanessa Smith CPA Associate Executive Director Juliet Grimble Morris CPA Administrative Assistant 530 574 4139 951 271 0397 619 665 3816 213 738 6152 925 944 8880 650 573 2683 510 499 9411 916 442 5196 916 442 5196 916 442 5196 916 442 5196 Central California Psychiatric Society CCPS David Gellerman M D PhD CCPS President 916 501 9561 Chris Stockton Executive Director 888 234 1613 Northern California Psychiatric Society NCPS Smita Das M D PhD MPH NCPS President 650 493 5000 ext 62083 Adrianne Davis Executive Director 415 334 2418 Orange County Psychiatric Society OCPS David Safani M D OCPS President 310 749 1040 Karina Amaya Executive Director 949 250 3157 San Diego Psychiatric Society SDPS Benjamin Hidy M D SDPS President 916 600 0960 Michelle Gallice Executive Director 858 279 4586 Southern California Psychiatric Society SCPS Erick Cheung M D SCPS President 310 206 5361 Mindi Thelen Executive Director 310 815 3650 VOL 37 Number 6 SUMMER 2019 The President s Report 1 Robert McCarron DO DFAPA President Elect Report 1 Mary Ann Schaepper MD Editor s Notes 2 Yvonne B Ferguson MD Politics Trample Medical Science 3 William Arroyo MD APA Assembly 4 Drs Weissman Malak APA Board of Trustees Highlights Melinda L Young MD 4 Capitol Insight 5 Randall Hagar CPA Dir Gov t Affairs Residents Perspective 5 Sean Comeau MD Homeless Heritage 6 Book Review by Marc D Graff MD Access to Care 7 Joe Mawhinney MD CMA and Homelessness 9 Tim Murphy MD CPA Photo Gallery 20 DISCLAIMER The Advertisements Letters to the Editor Columns and Articles published in this newsletter state the authors opinions and do not represent endorsement of those opinions by the California Psychiatric Association Information submitted by advertisers has not been verified for accuracy by the CPA

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 3 WHO CARES WHEN POLITICS TRAMPLE ON MEDICAL SCIENCE William Arroyo M D Immediate Past President Chair of Government Affairs Committee The rhetorical statement should be a resounding we all do or should It applies to the well being of members of the general public Unfortunately there have been too many recent instances in which politics has prevailed over the health interests of the general population The following issue is just one of those where the CPA entered the fray A surge of interest has emerged among health especially public health organizations based on the increasing scientific evidence of the adverse health impacts associated with the frequent consumption of sugar sweetened beverages SSB s These include but are not limited to regular soda but not sugar free fruit drinks sports drinks energy drinks sweetened waters and coffee and tea drinks with added sugars The CDC recently issued strong cautions about these medically adverse outcomes These include weight gain obesity heart disease type 2 diabetes kidney disease non alcoholic liver disease tooth decay and gout The pattern of frequent consumption of SSB s is more prevalent among socioeconomically vulnerable populations Two national organizations namely the American Heart Association and the American Association of Pediatrics issued a joint public policy statement in April of this year outlining public policy strategies to combat the adverse impacts associated with the use of SSB s Such strategies included 1 imposition of an excise tax on SSB s following a public awareness campaign and use tax revenue to decrease health disparities 2 implementation of policies which discourage marketing SSB s to children 3 restructure of federal nutrition programs so that the consumption of SSB s is discouraged 4 easy access to nutritional information on labels menus and advertisements 5 promotion of healthier beverage options and 6 limitation of health settings such as hosCPA Annual Conference pital s accessibility to SSB s Some of these strategies Informative Important Immediate have already been implemented in different parts of By Francie Broghammer M D and Shawn Hersevoort M D the country on a very small scale For example the city of Berkeley was the first to impose an excise tax The CPA Education Committee is excited to share a in early 2015 which resulted in a decrease of SSB preview of our upcoming 32st Annual California Psysales by 9 6 and an increase in sales of untaxed bevchiatric Association Premier Conference which will be erages such as water and milk by 3 5 held at the Omni Rancho Las Palmas Resort and Spa in The California Medical Association CMA folbeautiful Rancho Mirage from September 20 22 2019 lowed suit this year by sponsoring three bills that Venue sophisticated and beautiful align with the aforementioned proposed national stratRancho Mirage is an idyllic desert town nestled in egies These bills are AB764 Bonta although it did not pass it was able to become a two year bill the heart of Coachella Valley It offers picturesque golf courses lined by palm trees breathtaking views of the Continued on Page 16 Continued on Page 13

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PAGE 4 CALIFORNIA PSYCHIATRIST SUMMER 2019 APA Assembly Working for You Barbara Weissman MD Area 6 Assembly Rep Lawrence Malak MD Area 6 Assembly Deputy Representative APA Board of Trustees Highlights Melinda L Young MD DLFAPA APA Area 6 CPA Trustee The APA Assembly of Representatives met in San Francisco during the APA Annual meeting this year at the Moscone Center With a huge agenda of over 45 action papers we were all prepared to work and get through all of the business of the Assembly Our Area 6 delegates met to review the work of committees position statements and all the papers in a marathon sprint Within our area we Dr Weissman had a healthy debate over supervision and resident training needs discussion about candidates Assembly leadership positions and about MOC lapsed diplomates and how APA and ABPN can streamline CME needs and requirements Dr Malak In the Assembly we heard from leadership including our APA President Altha Stewart MD APA CEO Saul Levin MD and the incoming AMA President Patrice Harris MD who is a psychiatrist on various issues facing medicine and psychiatry Incoming APA President Bruce Schwartz MD gave an update to the Assembly about a landmark decision here in California against United Healthcare about coverage for medically necessary care that was denied to many in need of psychiatric care As we fight for parity of mental health coverage this decision is another win against discrimination of those in need of basic mental health care In addition to these reports we heard about continued success and activities of the APA Foundation our APA PAC and several new research grants secured by the APA The Foundation also had an amazing gala fundraiser at San Francisco City Hall which was well attended by APA leadership Assembly members and general members who came together for a fun night of great food drink music and dancing in an effort to raise funds for all the good the foundation does for the community and our resident fellows Back in the Assembly we passed many papers The most recent Board of Trustees BOT meeting was held July 13 14 Archives of governance meetings including the BOT Assembly and the Joint Reference Committee JRC can be viewed HERE By the Numbers APA membership remains over 38 500 a 17 year high Net income for the first five month of 2019 remains strong and ahead of last year largely due to a higher return on investments The overall balance sheet remains strong Member Resources and Member Benefits The Ad Hoc Workgroup on Women s Mental Health AHWG presented its deliberations and recommendations to the BOT answering five questions posed to the workgroup by Dr Altha Stewart as follow up to the first workgroup that was convened one year earlier While the current AHWG recommended the formation of a new Council on Women s Mental Health the BOT referred the issue to the Finance and Budget Committee requesting a report evaluating 1 the cost of a new Council on Women s Mental Health 2 the cost of a Committee on Women s Mental Health under an existing Council and 3 the cost of directing all councils to incorporate women s mental health issues including a mechanism for tracking The Workgroup on Physician Well being and Burnout is drafting a manuscript describing findings from their 18 months survey project and examining factors associated with higher burnout scores in psychiatrists They also continue to survey and collect data focusing specifically on the issue of burnout in minority and underrepresented M UR psychiatrists Continued on Page 14 Continued on Page 8 APA Mental Health Registry PsychPRO With 2018 Merit based Incentive Payment Systems MIPS reporting completed PsychPRO staff are currently in the process of refreshing participant dashboards with 2019 data as well as onboarding new participants for 2019 Newly configured dashboards provide participants with quality measures data for tracking and improving performance throughout 2019 in readiness for reporting at the top of 2020 Participation in PsychPRO continues to grow with 570 participants from 79 practices representing

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 5 CAPITOL INSIGHT News and Views on California Mental Health Policy and Legislation Randall Hagar CPA Director of Government Relations The Challenge of Change in California s Public Mental Health System Redesigning complex systems can be a challenge particularly when strong sentiment among some segments of a system supports blowing them up and starting over as the best option The last publicly prominent enthusiast for blowing up boxes was former California Governor Arnold Schwarzenegger who tried and failed to promote a vision for fairly radical government restructuring read downsizing Governor Newsom s ambitious agenda and we should all be grateful when a Governor numbers mental health among his priorities includes trying to plug a gaping mental health leadership void in Sacramento An unintended void created by a desire to blow up some very small boxes about a decade ago Years ago the old state Department of Mental Health used to be a stand alone department The thought was to combine it and the Department of Alcohol and Drug Programs into the very large Department of Health Care Services Instantly one department formed the basis for integration of the services delivered separately through the auspices of each formerly siloed part Everybody acknowledges the value of behavioral health integration This was an early step towards that goal Enter unintended consequences Well nice theory So the sales pitch went something like this come to Sacramento and be a very small part of a huge bureaucracy and try to govern wildly disparate county mental health programs over which the state had little effective control and work for a relatively low state salary while doing so It s no wonder it took close to two years to fill the new position to run the combined mental health and substance use divisions in the DHCS Counties had headaches enough but usually paid senior management much better so incentives for the move to Sacramento were sorely lacking Today that seat vacated abruptly nearly a year ago and was only just recently filled Continued on Page 10 A Resident s Perspective on the Action Paper Process Sean Comeau MD Area 6 RFM Deputy Representative Alternate The American Psychiatric Association APA held the spring Assembly Meeting this May in picturesque San Francisco CA I had the privilege of representing resident and fellow members RFMs from the state of California as an Area 6 RFM Deputy Representative Alternate Having never participated in an APA Assembly meeting before this was a great look at what goes on behind the scenes with the reviews and discussions of proposals for APA policies and programs Over the course of the weekend issues brought up by the Action Papers were discussed in the Reference Committee Area Council various Committees the RFM Committee and lastly in the large group plenary sessions This year was a little different than most because there were 49 action papers submitted Action papers represent ideas policies or stances that may be submitted by particular members of committees or district branches as recommendations for the APA to take action There were actually several Action Papers presented that related to RFMs and some were even written by RFMs It was interesting to see firsthand the process that went into determining whether the Reference Committees would support or not support each paper First the paper was presented by the author with questions from the committee and Continued on Page 12

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PAGE 6 CALIFORNIA PSYCHIATRIST SUMMER 2019 Homeless Heritage Collaborative Social Archaeology as Therapeutic Practice Review by Marc D Graff MD Homelessness is a major topic of interest in the United States and elsewhere This book has a very different look at homelessness Rachael Kiddey Ph D an anthropologist archaeologist studied the homeless populations of Bristol and York England from 2008 to 2014 The fieldwork and documentation was called the Homeless Heritage project and it involved not only standard archaeological excavations and mapping standard anthropological evaluations such as interviews but also participant observation and ultimately the rehabilitation and perhaps even the salvation of many homeless people Dr Kiddey s decision to study this population is explained at length and she reviews the history of homelessness in England in detail beginning with the laws written during and after the Black Death thus covering legal issues in England from 1349 to the present She meets many individual homeless persons and describes them incisively and with love She learns about the experiences of mental illness which many of them had and of the problems of polysubstance abuse which almost all of them had Further Dr Kiddey learns how people survive in a world of very limited support and resources A suite of recommendations to help the homeless is provided in a clear and absorbing writing style For tools that may be applied to the US homeless crisis this book is highly recommended Rachael Kiddey Oxford University Press 2017 ISBN 978 0 19 874686 7

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 7 Access to Care Is It Too Big to Tackle or Too Important Not To Joe Mawhinney MD DLFAPA Chair CPA Access to Care Committee Barriers to access and delivery of mental health care are many and can seem overwhelming Why fight it Why not accept the complexity of the fragmented Rube Goldberg construct which we have been living with and stay in our lane Or opt out Or even join the corporate profit driven business of health care But looked at from a multi systems perspective the global health impact of disrupted delayed discontinued or inaccessible mental health care is massive and dysfunctional and cries out for healing Death by a Thousand Cuts referring to an ancient Chinese torture is experienced today by our patients and those who serve them We experience death to the timely effective and compassionate care which we know is possible In some instances we see actual preventable death In a broader view through a multi systems perspective the outcomes of our current system includes a pattern of premature death preventable disability educational failure loss of productivity and financial indebtedness and bankruptcy due to medical expenses with associated stress on relationships and family life In addition we see significant cost shifting to the justice system social services and strain on civic resources in attempting to deal with increasing homelessness Also we see the increased burden on the Physical Health Care System Yes there is a strong argument for Health Care Reform but whatever the broad stroke changes which might improve the cost effectiveness of our health care there will be no true health care reform without simultaneous and complementary focus on what is happening with our patients and the practitioners and organizations which serve them at the grassroots level The CPA Access to Care Committee is being reconstituted with broad representation among our members to shine a light on these grassroots issues and to identify collect and organize that data to put a human face on these concerns In collaboration with the CPA Government Relations Division and the CPA Council and our advocacy partners we will educate and support legislators and state administrators to invest effectively in our human resources and the global health of our society Please join us in this effort by sharpening our awareness and improving our advocacy on behalf of our patients

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PAGE 8 CALIFORNIA PSYCHIATRIST Trustee continued from Page 4 over 180 000 patients and over 2 000 000 patient encounters FIGmd PsychPRO s vendor FIGmd is the company that provides professional services to specialty societies to help with registry operations and is the vendor for the APA s registry recently released a technical solution for integration with EPIC an electric health records program the vendor of choice for many the large health systems and academic institutions nationwide The lack of an integration solution with EPIC had challenged PsychPRO in attracting participation from these important providers of behavioral healthcare With the EPIC integration solution in place other key recruitment efforts will focus on targeting large systems and academic institutions Read more about PsychPRO HERE Substance Abuse Education In June 2019 APA hosted its second annual Buprenorphine Train the Trainer program at APA headquarters Twenty five psychiatrists from across the US joined faculty experts for a two day training that will allow them to conduct medication assisted trainings MAT in their local communities Opioid Use Disorders APA serves an important role in the national States Targeted Response Technical Assistance STR TA project that provides Extension for Community Healthcare Outcomes ECHO style learning collaboratives to help physicians implement evidence based care for opioid use disorders Learning collaboratives have focused on adolescents and medication for addiction treatment telepsychiatry implementing the basics motivational interviewing and a number of additional topics Online CME Learning The Division of Education continues to expand its catalog of original leaning activities Several new modules will be launched in the coming months including a course on internet gaming disorder mental health for gay men and several modules on management of depression and bipolar disorder during pregnancy and lactation Intimate Partner Violence Education Resource In April APA released the toolkit Intimate Partner Violence A Guide for Psychiatrists Treating IPV The educational resource serves as an introductory guide that exposes psychiatrists to an array of topics and definitions that are essential in detecting understanding and treating patients who have experienced intimate partner violence It can be accessed HERE SUMMER 2019 APA Diversity and Health Equity Webpage APA Division of Diversity and Health Equity launched their updated webpage on May 17 The webpage provides members with the latest information on diversityrelated educational resources member engagement opportunities and mental health advocacy It can be accessed HERE IPS The Mental Health Services Conference The 2019 IPS Conference in collaboration with the World Psychiatric Association will take place on October 3 6 in New York Dr E Fuller Torrey founder of the Treatment Advocacy Center and associate director for research at the Stanley Medical Research Institute will give the opening address As discussed in my last report the BOT voted to not hold an IPS meeting in 2020 in order to give APA time to examine the feasibility of the meeting and because there were some challenges in contracting with a hotel for the 2020 meeting A new work group IPS Vision Group led by Dr Jacqueline Feldman has been constituted and in conjunction with APA Administration will review recommendations from a previous work group as well as focus on programmatic development for IPS 2021 and beyond Government Relations State Mental Health Parity Legislation APA developed a 50 state model parity enforcement legislation that is adapted to each state law complete with talking points one pagers and an infographic on parity for use by APA members This legislation would apply only to state regulated insurance markets APA State Government Relations is leading a state parity legislation campaign working with other mental health advocacy groups and physician specialty organizations The goal of the campaign is to have APA s model parity legislation introduced and passed in as many states as possible during the 2019 2020 legislative session Legislation has been signed into law in CO DE the District of Columbia IL NJ and TN Model legislation in CT is awaiting the governor s signature MD MN and WY also passed parity legislation that slightly differs from APA s model legislation CA FL MA MS MO MT NV and PA also introduced APA s model legislation this session and at least three states are still considering introduction later this year Seven other states are aiming for introduction in 2020 Continued on Next Page

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 9 CMA to Consider Homelessness Tim Murphy MD CMA Delegate for CPA To what extent do mental and physical health problems lead to homelessness And how does homelessness itself cause or worsen health problems How can we overcome the barriers in providing care to homeless individuals Will changes to our healthcare policies be among the strategies for reducing homelessness Homelessness will be among the issues addressed at the California Medical Association s annual House of Delegates HOD meeting in October Continuing with the format initiated several years ago the HOD will focus on a few areas of special importance In addition to homelessness topics to be presented will include cannabis addressing medical and regulatory concerns digital health AI EHRs and emerging technology and Adverse Childhood Events This last topic is of special interest to Dr Nadine Burke Harris California s first ever Surgeon General who is working to raise awareness of the links between ACEs toxic stress and serious health conditions In other news quarterly resolutions currently under consideration include proposals to advocate for the requirement of FDA approval of dietary supplements and increased regulation of nicotine vaping products Two resolutions address frustrations of physicians serving in the Workers Compensation systems where currently unfair business practices often reduce physician compensation below contracted levels and where too often the work required for reporting is uncompensated especially when physicians respond to denials modifications and delays of care In the legislature CMA is promoting a bill to limit ways in which sweetened beverage companies can use discounts and other promotions to increase sales Two other related bills have not succeeded in the current session Trustee continued from Page 8 APA Model Collaborative Care Legislation APA And the District Branches State Associations are also pursuing legislation to implement the Collaborative Care Model CoCM APA developed model legislation requires private insurance to cover CoCM codes Illinois has passed this legislation in both chambers and is awaiting the governor s signature Delaware and NJ are likely to see introduction of the legislation soon Maintenance of Certification MOC related Legislation APA is working with RI to craft legislation delinking MOC from licensure credentialing and reimbursement Safe Prescribing APA partners with District Branches State Associations on safe prescribing legislation So far this year psychologist prescribing has been prevented from moving forward in CT FL HI MT TX VT and WV Psychologist prescribing legislation has been deterred from introduction in NE and MN Oklahoma stopped legislation that would have included psychologists in the legal definition of physician Federal Mental Health Parity Legislation APA federal parity legislation has been introduced in the House and Senate based on APA s state model parity legislation Federal legislation applies to group health plans which are federally regulated under the Employee Retirement Income Security Act of 1074 ERISA

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PAGE 10 CALIFORNIA PSYCHIATRIST Insight continued from Page 5 Mental Health Czar Enter Thomas Insel MD a psychiatrist advising California Governor Gavin Newsom to inform the state s work as California builds the mental health system of tomorrow serving people whether they are living in the community on the streets or if they are in jails schools or shelters Dr Insel eschews the label is not a paid state employee has taken a leave of absence to advise and will recuse himself as necessary because of his business interests Wow when has that ever happened Dr Insel s name may be familiar to you as Director of the National Institute of Mental Health for over a decade or more recently and less publicly the three years he spent with Verily Google s life sciences division in Silicon Valley or most recently as a co founder of startup Mindstrong Mindstrong is mining the interface between digital data and mental illness to find ways to encourage adherence and prevent relapse Dr Insel also Chairs the Board of the Steinberg Institute Interesting portfolio Enter challenges Dr Insel is on an obligatory listening tour of California traveling the state s 58 counties He says there are inspiring examples of great programs out there He has also been quick to adopt a point made by many that the 58 California counties may be ungovernable as a whole each accountable to the state but having no real cohesive glue to adhere to continuums of care with common broad programmatic priorities and outcome measures Yet performance measure documentation has proliferated such that one rural county mental health director testified that 40 of clinician time is occupied in paperwork This is the California model radically decentralized compared to other states operating since funding and program authority was realigned to counties from the state in 1991 Realignment was designed as an exercise in blowing up boxes reorganizing and streamlining treatment systems bringing the locus of control over them closer to the patient It was also a fix for perennial threats to cut mental health budgets The fix dedicated funding exclusively to county mental health budgets from sales tax and vehicle license fees A permanent source of funding was created nearly untouchable but also finite There was great comfort in this accomplishment at the time after years of fighting and often loosing annual budget battles over SUMMER 2019 mental health funding But realignment has been problematic too With regularity the state requires counties to assume more responsibilities while at the same time does not provide more money with which to carry them out obligating them to care for medically indigent individuals Former Governor Brown also became enamored of the concept of rea Dr Thomas Insel lignment because it offered him an opportunity among other things to satisfy federal courts over constitutionally deficient care for the mentally ill in California prisons successfully pushed Public Safety realignment in 2011 Since poor care was in a sense a proxy for overcrowding in state prisons 2011 realignment released non violent non serious non sexual crime charged prison inmates to counties and shifted the locus of authority for less serious crime to county facilities and supervision The rationale was that locals will know best how do deal with locally based offenders and leave the serious stuff to the state Counties while they had gained significant local control over criminal justice health and mental health issues through the 1991 and 2011 realignments were still feeling fiscally vulnerable and ended up negotiating a constitutional amendment in Proposition 30 that guaranteed that the state would pay for any new program or service mandates Enter state helplessness over shaping local programming California has all of the above 40 million customers and a series of interlocking reforms over 50 years that add layers to the problem of envisioning and implementing change Among the layers Medicaid Medi Cal reforms available to California include a possibility of using Federal funds to underwrite the costs of inpatient psychiatric care Federal policy 50 years ago mostly forbade this use as a way to dis incentivize institution based care in the form of the old state hospitals and in favor of community based care The acute end of the spectrum of care has been starved of financing since then New federal funding could reverse the trend of downsizing psychiatric units and loss of beds generally California has lost nearly 30 of the beds it had in 1995 a drop of 2 650 beds to 6 702 in 2016 This against a backdrop nationally of a 96 5 decrease in the US since the 1950 s and internationally against a number of advanced first world countries which averaged 68 beds Continued on Page 15

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PAGE 12 CALIFORNIA PSYCHIATRIST SUMMER 2019 Ferguson Continued from Page 2 www scvmc org www sccmhd org PSYCHIATRIST 253 600 329 700 annually 7 weeks of annual leave Full benefits retirement Above annual salary includes additional pay for Board Certification and Acute Settings Santa Clara Valley Health and Hospital System a public healthcare system in the heart of Silicon Valley is seeking BE BC psychiatrists PGY III IVs for a variety of clinical settings including emergency psychiatric services inpatient psychiatric services outpatient behavioral health clinics and custody health programs Opportunities for additional moonlighting also exist within our healthcare system As the largest public health care system in northern California we offer comprehensive healthcare resources to a large and diverse patient population Psychiatrists are part of a robust team of staff that work in collaboration with other medical specialties to provide integrated health care to patients Psychiatrists are eligible for numerous benefits including 7 weeks of annual leave 1 week of educational leave 12 holidays 4500 educational funds health benefits life insurance and CalPERS retirement plan If you are interested in working in a dynamic and collegial work environment please submit a CV and letter of interest directly to Dr Tiffany Ho Behavioral Health Medical Director tiffany ho hhs sccgov org 408 885 5767 The County of Santa Clara is an Equal Opportunity Employer gramming for the indigent without the necessary funding and in 2011 passed the solution to constitutionally deficient care of mentally ill inmates and overcrowding in state prisons on to counties by releasing non violent non serious non we have a governor who sexual crime charged believes mental health to prison inmates to county facilities for be within his purview treatment and supervision Public Safety Realignment Not until Prop 30 was the state made liable for paying for such service mandates Now we have a governor who believes mental health to be within his purview and has appointed a mental health advisor who has some monumental challenges ahead Notwithstanding his credentials Resident Perspective continued from Page 5 then individuals in the audience had the floor to support or oppose the paper The author would then be allotted time to answer specific questions presented As you can imagine this process takes some time which is why the 49 actions papers were split between 5 Reference Committees Afterwards the Reference Committees would deliberate on each action paper to present their position to either support the paper support with changes or not support the paper These decisions were then presented to each of the Area Councils and various Committees for deliberation The Action Papers were then presented in the plenary sessions imagine the intergalactic senate from Star Wars and voted on after discussion from the floor It has been an invaluable experience to participate in the national APA Assembly but one does not have to be involved at the national level to have an impact on the future of psychiatry I encourage residents and fellows to get involved in organized psychiatry your local district branch is a great place to start There are Assembly Representatives eager to serve as mentors and help you develop an action paper for next year s Assembly

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 13 President s Report Continued from Page 1 This was the view of a colleague who worked with underserved patients in California s Central Valley He believed in treating the whole person and not merely a disease This psychiatrist routinely conducted targeted physical examinations on patients as part of his psychiatric assessment For many of his patients he was the only physician providing medical care This was done out of a sense of duty and for the betterment of his many patients After diligently providing this type of care for about two decades he was informed by his employer his services were no longer needed He was fired for completing physical examinations on his patients Months later my colleague was notified the California Medical Board was acting on a complaint filed by his former employer The complaint was that he inappropriately conducted a physical examination in his role as a psychiatric clinician The action taken was a probationary medical license for five years This psychiatric physician a CPA member lost his job and had his right to practice medicine in the State of California restricted because he completed a physical examination on a patient under the auspices of his role as a licensed and board certified psychiatrist I realize some psychiatrists may not feel comfortable routinely addressing general medical conditions or performing targeted physical examinations For those who do it is critically important to support this practice Psychiatrists are physicians first We are trained to prevent and even address some general medical illness This type of medical practice can make a difference and meaningfully reduce health care disparities and vulnerabilities in those who have severe mental illness The CPA is supporting my colleague during this difficult time More importantly the CPA is supporting the right or in some cases the expectation that psychiatrists will appropriately treat their patients and complete physical examinations when indicated As a long time CPA member I once again see the value of advocacy in this situation and am proud to see our busy Legislative and Government Affairs Committees take the lead by protecting those who are delivering excellent care to those most in need Arroyo Continued from Page 3 AB 765 Wicks which failed to get out of the Health Committee and AB 766 Chiu which failed to get out of the Health Committee The CMA requested that all medical specialty organizations join forces with CMA on these bills The CPA Government Affairs Committee agreed that this package of bills should have the support of the CPA in light of the fact that many of our patients are at risk of developing a similar array of medical problems due to additional risk factors of physical immobility especially for those with severe mental illness and side effects of some psychotropic medications especially antipsychotic agents among other risk factors that coupled with adverse effects associated with SSB consumption serve only to increase potential health risks When it became evident to the SSB industry that CMA was pursuing major policy changes the SSB industry reportedly mobilized its resources in very strategic ways First the American Beverage Association ABA largely funded by Coke Pepsi and Doctor Pepper Snapple industry tripled its spending for lobbying in the State capitol the first three months of this year as compared to last year A former aide and advisor to five previous assembly speakers was hired to lead the government affairs unit of the ABA One such Speaker Toni Atkins now heads the Senate There were junkets sponsored by the ABA to Sacramento Kings games as one prong of its political strategy An additional prong was to underscore the notion to a democratic controlled legislature that such new policies would result in the loss of jobs by many union members Furthermore similar arguments were used by the National Association of Theater Owners who argued against a bill that would force theaters to use smaller soda containers adding that customers would simply refill their containers These politics are quite sobering when one considers the potential morbidity associated with SSB s The costs of medical care for such morbidities has yet to be succinctly addressed in the anti SSB narrative As with the anti tobacco movement this anti SSB effort may have to be sustained over several years before it demonstrates signs of success

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PAGE 14 CALIFORNIA PSYCHIATRIST SUMMER 2019 Assembly continued from Page 4 including action papers by Area 6 members on topics including a position statement on universal health care coverage improved education of family medicine residents in psychiatry efforts to better understand the psychiatric impact of climate change and how to support state PACs across the country including our own Other papers that generated healthy debate were around topics of patient safety supervision of residents by non physicians and the process in which we elect Assembly Leadership positions of Recorder and Speaker Speaking of elections the Assembly did elect Joe Napoli from New Jersey as the new Speaker and Mary Jo Fitz Gerald MD from Louisiana as the new Recorder Our own Adam Nelson ran a strong campaign against Dr Fitz Gerald and will no doubt find his way into another leadership position in the future The Assembly workgroups met as part of the assembly to look closely at important issues of Maintenance of Certification Access to Care Voter Turnout Practice Guidelines and Public and Community Psychiatry For a full recap please see the Assembly Notes link HERE created by our own Dr Adam Nelson who works hard to create these notes for us at every Assembly The Assembly Executive Committee met as always at the conclusion of the Assembly and will meet again shortly in July At that meeting in Washington D C the plan will be to focus on several of the papers that passed this May but also on how we communicate with one another via listserves emails and other communication platforms The full Assembly will reconvene in November in Washington D C and the deadline for Action Papers will be in September If you have any ideas for papers or positions that you think need an action paper or discussion at the APA Assembly please contact you District Branch leadership or any Assembly Representative including the two us so we can have your ideas heard

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 15 Insight Continued from Page 10 per 100 000 individuals 2011 while California rated 14 1 beds per 100 000 2016 The Lanterman Petris Short Act LPS provides standards of care like the 5150 for involuntary civil commitment of individuals living with a mental illness The LPS was designed to provide prompt short term community based intensive treatment minimizing the loss of personal liberty to individuals who are dangerous to themselves or others or who are gravely disabled Yet the Act is 52 years old and has not been evaluated and would seem ripe for updating An audit by the state auditor has been ordered by the California Legislature based on a proposal that the CPA helped to construct The legislative intent of the Act in particular to provide prompt evaluation and treatment of persons with mental disorder is still valid but the Act s ability to deliver and not delay or prevent care has been questioned in an environment where intractable problems of severe mental illness coincide with burgeoning homelessness News articles now regularly toll the numbers of homeless individuals who are dying of treatable health conditions The audit will try to assess what s working and what s not working in the LPS in light of conditions that could not have been anticipated when the Act was drafted Other layers include the fact that there is no articulated framework for a uniform continuum of care systems of care services are only available to the extent that resources are available Proposition 63 the millionaires tax i e the Mental Health Services Act hasn t worked the way it was intended incidents of homelessness and arrest and incarceration of persons with a severe mental illness are continuing to trend higher on top of already high numbers These challenges are formidable yet paralysis is not inevitable I am hopeful I will be meeting with Dr Insel soon I ll let you know how that turns out

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PAGE 16 CALIFORNIA PSYCHIATRIST Conference Continued from Page 3 San Jacinto Mountains botanical gardens and even a Living Desert Zoo and Gardens Overall Rancho Mirage allows for the perfect mix of exploration and relaxation Tripadvisor com can help research any of your shopping or exploring needs Pre conference Experts from elite CA universities This year the fourth annual CPA Clinical Updates in Psychopharmacology Pre Conference on Friday September 20th featuring some of the state s leading experts in psychopharmacology In two talks Dr Jonathan Meyer UCSD will explore research and new clinical updates on the use of lithium clozapine and pimavanserin Dr Allison Remnick UCSD will discuss the intricacies of safe prescribing in pregnancy and Dr Nolan Williams Stanford will present the latest research on ketamine and esketamine So that you can also engage with the content and our speakers this portion of the conference will feature 60 minute presentations followed by 30minute questions and answer sessions The concluding remarks will coincide with the opening of the CPA 32nd Annual Premier Conference Conference Great presentations meals and camaraderie The CPA Annual Premier Conference will open on Friday at 5 PM with the President s Reception in the exhibit area followed by dinner please purchase tickets in advance After dinner Friday Night at the Movies features Finding Traction the inspirational story of ultra runner and conference speaker Nikki Kimball s quest to become the fastest person in history to run the 273 mile Long Trail Through Nikki s incredible journey racing towards a dream and against time this film has a new perspective on what we all share in terms of endurance and the human spirit Saturday will open with the traditional 7 00 SUMMER 2019 AM Fun Run at right followed by breakfast in the exhibit hall The Women in Psychiatry and Senior Psychiatrists Caucuses will run concurrently At 8 00 AM will be opening remarks from CPA President Robert McCarron DO and the Education Committee team The Saturday program follows with a med psych update Paul Summergrad MD neuromodulation TMS Robert Bota MD legal and legislative updates Randall Hagar CPA Government Affairs exercise and depression John Onate MD and how to create an exercise plan for patients Nikki Kimball Special for Early Career Psychiatrists a Career Planning Symposium from 8 15 AM 12 00 PM hosted by Education Committee Vice chair Francie Broghammer MD The afternoon and evening events include Legislative Luncheon at 12 15 PM the Political Action Committee PAC Reception at 5 45 pm and the Resident Fellow Member Early Career Psychiatrist RFM ECP Reception at 7 PM Sunday will open with 7 AM breakfast and the Resident Fellow Member Psychotherapy and Residency Training Director Caucuses Sunday s topics include recovering after physician impairment Katie Hirst MD and EMDR Patrick Gannon PhD We encourage residents and fellows to attend the CPA conference Please contact Lila Schmall CPA Executive Director at lila schmall calpsych org to get information on CPA travel stipends for trainees Please email the Education Committee team Francie Broghammer MD fbrogham uci edu Shawn Hersevoort MD shawnhersevoortmd gmail com with any questions about the conference We very much look forward to seeing you in beautiful Rancho Mirage on September 20th Register now and book your reduced rate 169 per night hotel room soon

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PAGE 18 CALIFORNIA PSYCHIATRIST SUMMER 2019 2019 CPA Conference REGISTRATION Pre Conference Clinical Updates in Psychopharmacology The 32nd Annual Premier Conference 2019 Rancho Mirage CA September 20 22 2019 Full Name___________________________________________Degree____________________ Mailing Address_________________________________________________ City State Zip___________________________________Phone_________________ Specialty_______________________Email__________________________ Required to send Confirmation Friday Pre Conference Only Non members CPA APA Members Resident Members Annual Conference Only Non members CPA APA Members Resident Members Attendance at both Pre Conference Annual Conference Non members CPA APA Members Resident Members 235 185 100 APA CPA members reimbursed this fee upon completion 455 365 100 APA CPA members reimbursed this fee upon completion 595 495 200 APA CPA members reimbursed this fee upon completion Yes_____ No_____ Attending the Early Career Mentorship and Career Planning Symposium Cancellation Fee of 120 after September 1 2019 Tickets for the Legislative Luncheon included in your registration fee All other tickets must be ordered paid below ______ of Tickets for Friday Night Buffet 60 00 each ______ of Guest tickets for Legislative Luncheon 55 00 each CPPAC Major Donor Reception ______ 250 minimum contribution required to attend ECPs 125 RFMs 50 Or contribute online HERE ______ of Guest tickets for CPPAC Major Donor Reception 40 ______ SPONSOR A RESIDENT MEDICAL STUDENT Register and pay online at www calpspych org conferences OR Please make checks payable to California Psychiatric Association or charge your VISA or MasterCard by calling CPA at 800 772 4271 or by filling in the information needed below and return this form to California Psychiatric Association 921 11th Street Suite 502 Sacramento CA 95814 916 442 5196 1 800 772 4271 FAX 916 442 6525 Check Enclosed for Total Amount of _______________ Please Charge My _______VISA_________MasterCard Credit Card ______________________________________ Expiration Date ___________________________ CHECK OUT THE EXCITING CPA CONFERENCE SCHEDULE HERE

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 19 HOTEL RESERVATIONS Omni Rancho Las Palmas Reservations made be made by calling 760 568 2727 directly to the resort Rancho Mirage CA 92270 866 423 1195 Omni Hotels Resorts Reservations Reservations may be made online by using the reservation link Book your group rate for California Psychiatric Association 2019 Guests unable to use the online reservation system can make reservations by calling 1 866 423 1195 If you call make sure to let them know you are with the California Psychiatric Association to get the special rate Premium guestroom rate is 169 00 Single or Double Occupancy per night Hotel room rates are subject to applicable state and local taxes in effect at time of check in The conference rate applies to 3 days before and 3 days following the conference based on availability only There is very limited availability for additional days Please let the hotel know as soon as possible if you are interested in additional days and specify that you are with the California Psychiatric Association RESERVATIONS MUST BE MADE PRIOR TO SEPTEMBER 2 CHECK IN 4 00 P M CHECK OUT 11 00 A M Reservations must be guaranteed with one night s advance deposit by credit card or personal check at the time reservation is made Unconfirmed reservations are subject to cancellation All individual guestrooms must be cancelled at least seven 7 days more prior to arrival All early departures no shows and late arrivals will be charged the contracted nightly rate for each night the reserved room is not occupied by the individual All reductions to guest s length of stay must be received 48 hours or more prior to arrival or the guest will be required to pay for the full original length of stay Omni Rancho Las Palmas 41000 Bob Hope Drive Rancho Mirage CA 92270

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PAGE 20 CALIFORNIA PSYCHIATRIST SUMMER 2019 CPA Gallery A look back at CPA s 2018 Annual Conference Amid the serious work and communication that happens at CPA s Annual Conference is a good measure of fun One of the most anticipated events is the Fun Run launched by Dr Romer pictured at above awarding last year s first place to Dr RaflaYuan Inset is Dr Jessica Thackaberry having a windy Marilyn moment Below is Dr McCarron with Sen Moorlach the CPA s 2018 guest speaker and a group of fresh faced medical students who were special guests at the Conference

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SPRING 2019 CALIFORNIA PSYCHIATRIST Top and clockwise are residents awaiting a session Assemblymember Anthony Portantino who put his great sense of humor on display at the evening reception The Conference also hosted meetings for several caucuses including the Senior Caucus and the Womens Caucus Dr Fouras backed by Randall Hagar emphasizing the importance of financial support for CPA s voice to be heard in the State Capitol SUMMER 21

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PAGE 22 CALIFORNIA PSYCHIATRIST SUMMER 2019 More CPA Quick Pix Above Dr Cap Thomson and wife Helen celebrate his special CPA Mentorship and Teaching Award with grandsons Emit and Eno At left Dr Arroyo and Dr Shaner catch up on news at the close of the successful conference

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SUMMER 2019 CALIFORNIA PSYCHIATRIST PAGE 23 President Elect Continued from Page 1 Riverside County starting April 19 2019 Five hundredplus persons including children have been sent from the border at Yuma to this small desert town to await direction a potential destination and eventual asylum Riverside Behavioral Health and heroic volunteerism from people around this state and others helped the By the Seventh day Adventist Church open its doors and receive these people for basic food and shelter The first responders were heroic and they reported a need for relief as the stress and stories of those they serve are overwhelming The migrants need more than food and shelter We know this Third it is hot All over the state we are in high fire alert times Friends in Chico who gave shelter to 5 families after the Camp Fire in Paradise in November 2018 experienced firsthand loss and devastation Fire destruction and loss is not a one time event How do we as psychiatrists respond to these disasters whether natural or man made Each of us are welltrained in the diagnosis and treatment of depression anxiety adjustment disorders panic and acute stress disorder One on one we do well We count on other systems of care to address basic needs Five hundred plus persons including children have been sent from the border at Yuma to this small desert town That I have experienced in the past was when I or as a group member with attending and resident physicians came to offer our help in an acute time of need Neither we nor the system were fully prepared to be of help Since that time members in our district branches have independently or in small numbers sought training either with the American Red Cross or the Los Angeles County Surge Unit to be able to quickly respond to the public mental health needs in an emergency Southern California Psychiatric Society SCPS under the leadership of Anita Red MD the immediate Past President has elect ed to have a member from council Danielle Chang MD join the California Disaster Mental Health Coalition a multidisciplinary coalition of mental health professionals who prepare mentor each other for disasters and help to deploy prepared professionals CPA is the state organization that has the expertise to not only counsel our state and local government on emergency mental health but to train and prepare our members to be ready to respond when the situation arises I urge you to write me your thoughts and ideas on this Your leadership members from each of the district branches along with the executive leadership will meet August 10 2019 for our summer council meeting Call your district leadership and let your voice be heard I do look forward to seeing you and talking with you in person September 20 22 2019 at the Premier Annual Conference in Rancho Mirage where it will be hot and we will stay cool and will be informed and continue to make wise decisions for our profession

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