April 3, 2003

To:

From:

Re:

We are writing to express our profound concern about the proposed contingency budget cuts that would reduce by 50% the general fund support of the Community Primary Care Clinics administered by the San Francisco Health Department. We recognize that the City faces a dire budget predicament, and that difficult choices must be made about funding of City services. However, the proposed reductions in Primary Care Clinic services would decimate a vital element of the Health Department's infrastructure, with catastrophic consequences for both the patients served by these clinics and the viability of the entire range of clinical services at San Francisco General Hospital.

The Department of Health's Community Health Network is built on a solid foundation of primary care clinics. This exemplary integrated system of care with a primary care foundation means that low income and uninsured patients in San Francisco receive:

** Preventive care, to avert new cases of HIV infection, diagnose cancer at an early, curable stage, avert pregnancy complications, and immunize children and adults against life-threatening infections;

** Comprehensive treatment of diabetes, high blood pressure, and other chronic illnesses, to maintain quality of life and avoid hospitalization for medical complications of these chronic conditions;

** Integrated mental health, substance use, and medical care, addressing the needs of homeless patients and other vulnerable populations and mitigating the social consequences of untreated mental illness and substance use.

The proposed contingency budget cuts for the Primary Care Clinics would cripple operations at these sites, reducing them to urgent care centers performing crisis management rather than providing comprehensive, prevention-oriented primary care. Patients would suffer from drastically reduced access to essential primary care services. The result would be greater medical disability among San Franciscans, further damaging the City's economic health and productivity.

Moreover, these services reductions at the Primary Care Clinics would also produce an ominous ripple effect at San Francisco General Hospital, compromising all hospital services including trauma care, the emergency department, and inpatient units.

Why would the proposed cuts cause a "tsunami-sized" ripple effect at San Francisco General Hospital?

** Patients unable to obtain timely appointments at the Primary Care Clinics would turn to the SFGH Emergency Department for their care. The Emergency Department would potentially face 50-100 more visits each day from patients formerly treated in the Primary Care Clinics, forcing an already overloaded Emergency Department to go on diversion at an even greater frequency.

** More patients would be hospitalized at SFGH due to deterioration of their chronic illnesses and failure to receive timely, early care in the clinic setting. Research has documented that poor access to primary care is associated with higher rates of "preventable" hospitalizations for conditions such as diabetes, asthma and heart failure. These hospitalizations would be costly to the City and stress a hospital already often operating at peak capacity, adding to the frequency of diversion of patients.

** Patients would not be able to be discharged from SFGH in a timely fashion when there is no capacity for arranging adequate primary care follow up after discharge. Short lengths of hospital stay are contingent on having coordinated primary care follow up in place. Without this capacity, lengths of stay would increase, adding to hospital costs, increasing the number of unpaid decertified days, and compounding the inpatient logjam that places the hospital on diversion.

** The shifting of care from community-based primary care clinics to the emergency department and inpatient wards of SFGH that would inevitably occur in response to the proposed cuts in the Primary Care Clinics would have a disastrous effect on the operations of SFGH. An overcrowded hospital and emergency department would compromise all hospital services. Trauma patients would lack available hospital beds for emergency admissions. Surgery would have to be cancelled due to a shortage of hospital beds to receive patients following surgery.

** The primary care cuts would also lead to reduced revenues for SFGH, precipitating further financial deterioration for the Health Department budget. Diminished access to the Primary Care Clinics would drive away clinic patients with Medi-Cal coverage -- particularly pregnant women -- who might be able to find care elsewhere. The exodus of these patients from the Community Health Network would lead to the collapse of obstetrical services at SFGH which currently depend on the patient volume and Medi-Cal revenues associated with Community Primary Care patients coming to SFGH for birthing services.

We believe that the proposed contingency budget cuts for the Community Primary Care Clinics would produce an intolerable wound in the integrity of the entire Community Health Network. At a time when concern about public safety is paramount, the cascade of events that would be set in effect by the contingency budget plan would jeopardize the ability of SFGH to effectively operate its trauma and hospital services. We respectfully urge you to reconsider the proposed contingency cuts affecting the Community Primary Care Clinics and develop an alternative approach for addressing the City's budget needs.

Cc: