Interview: Richard Liekweg

San Diego Physician: What is the difference between UCSD’s Medical Center and the other healthcare systems in the county?

Richard Liekweg: We have a commitment to education — training the future supply of physicians, pharmacists, and other healthcare providers — and a passion for research — finding new ways to improve health and cure disease – while at the same time, providing exceptional patient care to our community and beyond. This triple mission of patient care, education, and research has allowed UCSD Medical Center to care for a broad spectrum of patients and offer a comprehensive system of services, from primary care to highly specialized care for complex cases. This includes a robust clinical research program, and several tertiary and quaternary referral centers found only at UCSD. This commitment is reflected in our vision, which is “Clinical Excellence … Through Service, Innovation, and Education.”

Because we are part of UCSD, which is world-renowned for its educational and research excellence, we have the unique ability to collaborate across campus in exciting biomedical research and educational programs that have local, national, and global impact. This synergy results in innovations in technology and treatment that can be home-grown right here in San Diego, as we’ve seen in the large number of successful start-up companies associated with discoveries coming out of UCSD. And through centers of excellence like the Moores UCSD Cancer Center, we integrate basic and clinical research and patient care on a major scale to accelerate advances in prevention, diagnosis, and treatment of disease. This means that patients can access the latest advances in the treatment of cancer that previously were only found at places like MD Anderson in Texas or Sloan Kettering in New York.

Our commitment to education, research, and patient care benefits the entire region as we attract leading researchers and clinician scholars, and the best medical and pharmacy students. Many of these students ultimately choose to stay in San Diego and contribute to the region’s ability to care for its growing and aging population.

SDP: What do you see as the biggest challenges facing UCSD Medical Center today and in the coming years?

Mr. Liekweg: As with all hospital systems, our biggest challenge is maintaining financial solvency in the face of declining reimbursements, increasing costs, unfunded mandates, and growing numbers of uninsured patients. Almost seven million people in California are uninsured, a number larger than the population of Massachusetts. UCSD has historically been a leading provider of care for the uninsured, and we are committed to continuing our role in the safety net, but we cannot take on more unfunded care than we already provide. We must generate adequate patient care revenue to cover escalating labor, pharmaceutical, and other costs; invest in facility improvements to maintain or expand access; replace or upgrade equipment and technology to deliver 21st-century medicine; install new information technology solutions to reduce human error and provide a safer environment for our patients, clinicians, and staff, and support important regional services, like our Burn Center.

In addition, as an academic center, we have some vital revenue streams supporting the university’s educational programs that are at risk at both the state and federal level. These are the direct and indirect graduate education funds that help support part of the cost of training over 500 medical and surgical residents and fellows each year. If these were to be cut, our education, research, and patient care programs would be severely impacted.

Even with a positive operating margin, we have the challenge of accumulating enough capital to address our substantial facility needs to meet the state’s seismic mandate, but also because we have an aging hospital and infrastructure in Hillcrest that requires ongoing repair, renovation, and upgrades so we can provide safe, quality care for our patients. And, as our population grows and demand for services increases, we need to expand our facilities on both campuses. As construction costs skyrocket, we must generate the income to pay for these investments and rely on community philanthropy, while making strategic decisions in regards to program and facility growth.

SDP: What do you see as the biggest challenges facing San Diego County’s physicians?

Mr. Liekweg: At the risk of sounding like a broken record, I would say it’s the reimbursement gap; it’s increasingly tough to run a successful practice when Medi-Cal, County Medical Services, and Medicare payments are inadequate to cover the significant costs of running a practice. As providers opt out of caring for Medi-Cal and unfunded patients in order to protect their income stream, those who continue to serve these populations are further impacted.

SDP: What do you see as the biggest challenges facing San Diego County’s healthcare system?

Mr. Liekweg: The biggest challenge facing the county’s healthcare system is also one of the biggest challenges for San Diego — that is, finding a way to take care of safety net patients across the continuum of care, including advocating together for better reimbursement for our region, so that no system or practice is overly burdened and access for all is preserved or enhanced. Coordination and collaboration among our hospitals, physician practices, and community clinics is vital so that we meet the needs of the underserved while ensuring that we maintain access to superb care for all patients throughout the County. The domino effect applies in healthcare. When more and more patients without insurance coverage use emergency rooms as their point of entry into the medical system, the results are overflow in the ERs and higher census in our hospitals. This creates access issues for all patients, and as we’ve seen around the state and the country, ultimately leads to financial crisis and closure for hospitals that are most impacted. Any curtailment of services by hospitals or physician practices, including the shrinking pool of specialty physicians willing to participate in the safety net, contributes further to the crisis. We must collaborate on finding solutions.
And, healthcare providers can’t solve this one alone. It will require county support beyond what has been provided to date, as well as a more rational state and federal system of reimbursement.

SDP: If you had five minutes alone with every physician in the county, what would you want them to know?

Mr. Liekweg: I have great admiration for the practicing physician at a time when our healthcare delivery system is in peril and in need of reform. I grew up in a family of physicians. My grandfather was a general practitioner and the city coroner for Washington, DC, in the early 1900s, my uncle was an obstetrician and an active leader of our community hospital’s medical staff, and my oldest brother is a retired cardiac surgeon who trained under some of the best academic heart surgeons in this country. You can only imagine the conversation at the family reunion when I announced I was going to be a hospital administrator.

While working 16 years with the Duke University Health System, I also experienced first-hand the role that an academic medical center can play in support of our community physicians and hospital partners. At Duke, we partnered with physicians and hospitals across the state of North Carolina, outside the state, and even outside the country.
We have the same opportunities here in San Diego. It’s important that many of our faculty physicians are members of the San Diego County Medical Society. Our colleagues throughout the county participate in teaching, training, and residents, partner in providing patient care, and volunteer through our free clinics and other community outreach endeavors. We serve our colleagues with continuing education and professional training, and many other important partnership opportunities. Our mutual success depends on mutual understanding and support.
My main message would be that UCSD Medical Center’s primary obligation and benefit to the community is as a premier academic medical center. This means we must maintain excellence in our patient care, research and teaching missions, invest in new technologies and programs, and recruit new faculty, in order to deliver on our commitment. I would seek support in this position from the physicians who understand the importance of making sure San Diego has a strong university medical system among its constellation of providers, as we build even stronger collaborations with community colleagues to advance patient care for our region.

SDP: Now that we’ve discussed the challenges faced by providers, what healthcare reform proposals or concepts do you favor?

Mr. Liekweg: One thing is clear: the solution, like the problem, will have to be multi-faceted. There are many successful models worth discussion as we work to develop solutions. For example, I recently visited Singapore, where they spend 4–6 percent of their GNP on healthcare. The United States spends 16 percent, and we have similar life expectancy rates. Their government subsidizes basic, affordable healthcare at public hospitals and clinics, with consumers required to pay some amount, based on their income level. Consumers can opt to pay more for higher levels of service, such as private or semi-private hospital rooms versus multi-bed wards. Those who choose not to access the government-sponsored care can purchase healthcare through a smaller network of private hospitals and providers. This model ensures access to quality, no-frills medical care for all Singaporeans, including low-income groups, in an affordable government-subsidized model, with additional amenities available through the public or private sector for additional cost.

I am optimistic that consumers are beginning to demand reform that protects their access to high-quality care, and our elected officials have taken this issue on as a priority. The proposals on the table today that appear to have the most traction are those that spread the cost of expanded coverage so everyone has skin in the game. A plan that provides coverage for primary and preventive services will be key to preventing ER overcrowding and costly interventions to treat advanced disease that should have been managed earlier.

I expect that, ultimately, we will arrive at an approach that requires not only government but employers, insurance companies, consumers, hospitals, and providers to participate. This seems rational and equitable, since we will all benefit if we can assure at least some level of coverage for everyone.

SDP: Do you think UCSD has a disproportionate share of underfunded patients in the county? Is there a problem with other systems “dumping” onto UCSD?

Mr. Liekweg: Absolutely! It is a fact that UCSD Medical Center cares for a significantly disproportionate share of underfunded patients, relative to our size. We account for only about 8 percent of the region’s total inpatient discharges, but over 36 percent of the region’s unfunded and 13 percent of Medi-Cal discharges. Almost half of UCSD Medical Center’s patient discharges are undercompensated. Whenever colleagues in the community curtail access to Medi-Cal and unfunded patients, many of these patients are told to go to UCSD as a last resort, which impacts our delicate financial balance and puts our system in jeopardy. We are seeing a greater number of underfunded patients arriving in our ERs or clinics after having been seen in another local hospital, stabilized, and discharged to get follow-up care by a physician on their medical staff. Unfortunately, many of these providers do not see Medi-Cal or unfunded patients, so they send them to UCSD.

We are fortunate that the community clinics and others concerned about the safety net are collaborating with us to help ensure these patients are getting the care they need, both primary and specialty care, through community providers, so that our hospitals and physicians are not adversely impacted. This effort takes ongoing dialogue, and a willingness by the community to participate at some level in caring for the uninsured.

SDP: Other systems sometimes say that UCSD should be the safety net institution since it receives public funds. What proportion of the UCSD Medical Center’s overall health system budget is public subsidy?

Mr. Liekweg: This is one of the most frustrating myths that we have had to confront in recent years. UCSD Medical Center does not receive special funding, other than the less than 2 percent of our hospital budget that comes from the state via the University of California to help offset the added costs of clinical teaching. The public funding we receive to help cover unfunded care is provided through the same contracts held by other hospitals and providers (such as Medi-Cal and the county’s CMS program). I can assure you that the University of California expects its hospitals to maintain a positive margin so we can cover our operating budget, and pay for our capital investments.

SDP: What projects are on the horizon for UCSD Medical Center?

Mr. Liekweg: Our strategic goals are to expand facilities and programs that best meet the needs of our growing, aging population, and to incorporate new technologies, including electronic medical records, telemedicine, and other advanced information technologies, into improving service and quality of care.

We are moving forward with expansion of the UCSD Medical Center campus in La Jolla. Construction is underway on the Sulpizio Family Cardiovascular Center, which will allow us to consolidate most of our programs in cardiovascular medicine and surgery in a state-of-the-art facility. This project will also expand our emergency department in La Jolla and provide us with additional intensive care beds and operating rooms. We have a number of projects underway in Hillcrest. Currently we are enhancing our Post-Anesthesia Care Unit, building a new inpatient MRI suite, and expanding our Neonatal Intensive Care Unit and our Labor and Delivery program. We are also planning a new inpatient bed tower in La Jolla, which will further improve access on both of our medical center campuses.