The Problem: After research showed that people infected with human immunodeficiency virus (HIV) delayed treatment and care until the disease was advanced, the challenge was to develop programs that would help them seek care in a more timely fashion.
Grantee Background: Mitchell H. Katz, MD, always lived by the mantra, “Be of use.” A graduate of Yale University and Harvard Medical School, Katz completed his residency in internal medicine in 1989 at the University of California, San Francisco, a city where for the last 20 years, he has put his mantra to practice as a leader—and now the head—of the Department of Public Health, overseeing a $1.5 billion budget, about 8,600 employees, two hospitals and nine health care centers.
Looking back, Katz credits the Robert Wood Johnson Foundation Clinical Scholars program with giving him his foothold in public health. As a Clinical Scholar from 1989–1991 at UCSF Katz conducted a study of ambulatory patients at San Francisco General Hospital that showed that many persons infected with HIV delayed initiating care until their disease was advanced. That research led him to his first position in the city’s public health department—as head of research in the AIDS Office—and launched his rise through the ranks as the director or chief of the department’s other offices—including epidemiology, emergency medical services and community health and safety—until he was named director of health in 1997. “I always wanted to be of use,” says Katz. “I loved medicine because it was a direct way to make people feel better. I became a public health official because, while practicing medicine is rewarding, the amount of difference you can make is very small. As a public health official, I try to make a difference in the lives of hundreds of thousands of people.”
Grantee Perspective: When Katz started his Clinical Scholar training, he had every intention of going into academic-based research. But then he realized that academic work was not a direct enough route to change. “The major problems of health care that we have in this country do not exist because of a lack of knowledge,” Katz explains. “They exist for a lack of will.”
He began to look at his field with an eye towards program development, not research, and points to the training in public policy and epidemiology, as well as the values of “inclusiveness, excellence in health care, and prevention” that he gained from RWJF’s Clinical Scholars program, with fine-tuning the direction of his career. “My career has been based on taking those things that I learned from my RWJF years and turning them into a body of work that can really influence how people receive care in a variety of settings,” Katz says. “What is keeping us from improving health care is not 1,000 more papers. What is keeping us from fixing that is the will. So in San Francisco, I’ve established a program to help fix the problem.”
Results: In 2007, Katz was one of several San Francisco health leaders who started Healthy San Francisco (HSF), a comprehensive medical care program for the city’s 60,000 uninsured adults. Says Katz, “I would never call it my idea. I believe that you can ferment a movement—inspire others to work with you—to accomplish goals that are meaningful together.” Katz describes HSF as an “access program” that links the uninsured to primary care providers that are all in one network, which Katz says eliminates a lot of duplication of service. “HSF is not one idea but rather a collection of best practices designed to solve a problem—the problem being the uninsured,” Katz explains.
HSF provides outpatient, inpatient, laboratory, behavioral health and pharmacy services at 14 public health clinics and a private hospital-based clinic. Fees are based on income; services can be free or as low as $20 a month based on an enrollment fee that covers a three-month period. The program has been copied in Howard County, Md., and Katz says health departments in other jurisdictions also have adopted some of its features.
“What is important is not that we have made it inexpensive but that we have made it transparent,” says Katz. “And that is based on our knowledge that this is what resulted in people delaying care. Go back to that first RWJF project (on HIV). You want people diagnosed with HIV to seek care in a timely fashion, but you have to know what they are afraid of—stigma, cost, denial—and then you design a program to deal with it. That’s the link that I have tried to work on for 20 years: Do the research, find out what the barriers are, and then develop a program. With the uninsured, it’s cost, access, knowledge of cost. Figure out what the barriers are, solve them in a program, and then you can evaluate how well you have done. That, to me, is the essential difference between the career I’ve chosen and a career more focused on academic research.”
Under federal health care reform, Katz anticipated that as many as two-thirds of HSF’s clients would be able to leave the program and get insurance. But Katz noted that the remaining one-third of HSF’s clients are undocumented immigrants who are not covered and and and who therefore will still need HSF’s services. “My proudest day would have been to roll up the welcome mat of HSF and say our program was helpful in pushing the national debate,” he says. “If San Francisco can do this, why not the rest of the country? I would have been happy to see it go away. It won’t, but it will change.”
The innovative program is only one of several created by the health department. Katz is particularly proud of another initiative that has taken more than 1,000 chronically homeless people out of shelters and placed them in supportive housing—a building not unlike a hotel with single rooms, adjoining or nearby bathrooms, access to a kitchen and on-site caseworkers. “We pay for it because—and this is going back to the helpful part of research—research shows that the health care costs of homeless people are more than twice that of housed people with the same illness. We take people directly from the street and house them and then we can address their medical needs. People can find you. You have an address. A huge issue when you are homeless and trying to get into job training is having an address.”
Katz was one of the guest speakers at the 2009 RWJF Clinical Scholars conference, where he spoke about these and other initiatives created on his watch at San Francisco’s health department. “The Foundation is increasingly about outcomes, or about trying to change the world in positive ways,” he says. “And I think that’s why they asked me to be their speaker. We need people whose careers are focused on research, and we need people whose careers take the research and develop it into programs. That’s what I’ve done. What RWJF did for me is that it bridged the gap between academic and policy development. It bridged it so much that I went to the other side.”
Since this profile was originally published, Katz has become director of the Los Angeles County Department of Health Services.
RWJF Perspective: Originally authorized in 1972, the Clinical Scholars program is RWJF’s oldest national program. It fosters the development of physician leaders by ensuring that they develop the clinical, policymaking and research skills necessary to effect change in health and health care nationwide. See the Program Results on the program and other Grantee Stories.
David M. Krol, MD, MPH, FAAP, a 2001 Clinical Scholar, director of RWJF’s Human Capital Team and senior program officer, appreciates the depth and breadth of scholars’ individual career paths as clinically active physicians, academic researchers, directors of medical school departments, health care systems and federal, state and local health agencies—and he credits the RWJF program with preparing them to function in each of these worlds.
“You learn the skills necessary to navigate the worlds of the clinician, researcher and policymaker,” says Krol. “A Clinical Scholar is able to speak fluently in those languages and translate between them. Clinical Scholars go on to become leaders in diverse areas, with critical thinking skills that can be applied widely across numerous career paths.”