By Robert Moore, MD, MPH, MBA, Chief Medical Officer

“It is easier to build strong children than to repair broken adults”

– Frederick Douglas, American abolitionist and orator

While most healthcare leaders and policy makers are focusing attention on responding to cuts in Medi-Cal enrollment and funding, three California assemblymembers have proposed legislation to address three major public health issues affecting teens and tweens: a spike in injuries associated with use of motorized bicycles, a dramatic increase in nicotine vaping, and an increase in mental illness caused by social media and mobile phone use.

The most successful public health campaigns started with data gathering and analysis and progressed to educational interventions, which gradually reframed the issue, ultimately culminating in legislation that included penalties for non-compliance. Examples in the last 50 years include mandatory use of car seats, motorcycle helmets, bicycle helmets for children, broad prohibitions around cigarette smoking in public locations, mandatory use of seat belts, and requiring new cars to have air bags. At the time each of these was introduced, there was much debate and disagreement, especially as it relates to mandating our ruggedly individualistic population to do something they are not inclined to do on their own. Now, young people can’t imagine a world without car seats, seat belts, motorcycle helmets, etc.

During the COVID pandemic, there was not sufficient time to gradually build consensus or reframe the interventions that help contain a pandemic; well-meaning policy makers and public health professionals who depended on the mandate playbook for business closures and vaccination mandates inadvertently eroded trust in public health activities. Lack of trust in public health has created a harmful ripple effect of vaccination rates falling for children and adults and vaccine preventable illnesses emerging and spreading.

Are we in California now ready for legislation for e-bikes, vaping, and social media in children?

The data showing the harm of these three exposures is compelling.

• Recent results reported by The Mineta Transportation Institute through San Jose State University Hospitalizations and Emergency Department visits for motorized bicycle injuries in children have skyrocketed in the last few years, especially for children ages 10-15.
• An anonymous survey in Modoc County schools found vaping rates of over 80%, with the youngest children reporting vaping at age 10. Parents were largely unaware of their children’s vaping. These rates are much higher than those found by the California Student Tobacco Survey, probably due to either methodologic differences (how anonymous do children believe the CSTS really is?) or local variation.
• Jonathon Haidt’s book The Anxious Generation, presents a large body of evidence from countries around the world for the negative effects of excessive use of social media, mobile phones, video games, and online pornography on the emotional and intellectual development of children.

Are legislative mandates to promote safety among children excessive? Shouldn’t we rely on educational interventions alone?

Adults and teachers who educate children recognize a key element of their development is to protect them from dangers that they are developmentally unable to fully understand. However, this doesn’t mean we should be over-protective of children, avoiding all potential sources of pain and stress that actually promote learning and development. In the last chapters of the The Anxious Generation, Jonathon Haidt (who also wrote an entire book on this topic, called the Coddling of the American Mind) gives concrete advice to parents and teachers on how to gradually and steadily increase responsibility and grow confident and thinking teens and young adults. If you have school age children, I really can’t underemphasize how important the ideas in this book are to you.

The art of policy that seeks to change behavior is to synchronize with the beliefs and framing of a critical mass of adults, so that any mandates are generally accepted by most people. If mandates are pushed prematurely, they can lead to widespread ignoring of the mandate, with breaking the law on the mandate becoming the norm. It is better to stick with narrow mandates initially, to support this re framing, and progressively phase in more stringent mandates. This was the strategy used for first second-hand smoke and then indoor smoking in California.

When evaluating legislation intended to address public health issues, we need to consider all these issues! Is the harm proven? Are people believing the evidence around this harm? Will the proposed legislative solutions be accepted and adhered to? If the lift is too heavy, is there an intermediate, smaller step is better to aim for this year?

With these questions in mind, here are summaries of four bills currently before the California Legislature to consider. Talk them over with your families and colleagues! If you think they need changes, contact the lead staff member at the legislative author’s office and offer your suggestions. As health care professionals, your views on public health issues carry considerable weight.

Bike Safety

AB-2346 (Wilson) Vehicles: Electric Bicycles and Speed Limits.
This bill would require all class 1 and class 2 electric bicycles manufactured, sold, or offered for sale on or after January 1, 2029, to be equipped with a speedometer. The bill would also require all electric bicycles on or after January 1, 2029, to be equipped with an integrated front lamp and a rear lamp. The bill would also require manufacturers and distributors of electric bicycles to include a written description of California’s electric bicycle laws with the bicycle’s packaging to be provided to the consumer. The bill would also require sellers and distributors of electric bicycles to provide specified disclosures at or before the point of sale. The bill would make a violation of these provisions punishable by a civil penalty not to exceed $15,000 for a first violation and not to exceed $50,000 for each subsequent violation. This bill would authorize a local authority to set a speed limit on a bicycle path of 15 or 20 miles an hour or on a multiuse trail to 10, 15, or 20 miles per hour, subject to specified signage requirements. The bill would also prohibit a person under 16 years of age from riding an electric bicycle at a speed greater than 15 miles per hour on a highway or a bicycle path. This bill is being actively supported by the California Medical Association, the California Chapter of the American Academy of Pediatrics, and the California Association of Family Physicians. Assemblymember Lori Wilson started her career as an accountant, served as mayor of Suisun City and represents Solano County.

Youth Nicotine Use

AB-1884 (Hadwick) Interscholastic athletics: drug testing: suspensions: nicotine use. Would require the governing boards of school districts to establish drug testing programs for pupils in grades 7 to 12, as part of their policies regarding participation in extracurricular and cocurricular activities. The bill requires programs to include nicotine testing for athletic extracurricular activities, authorizes testing to also include alcohol and other controlled substances, and authorizes testing to apply to other non-athletic extracurricular activities. Assemblymember Heather Hadwick is a former schoolteacher who witnessed the effects of vaping in schools, first hand and is passionate about finding remedies. She is a businesswoman from Modoc County and represents the rural corner of Northeastern California.

AB-2667 (Hadwick) Vape products: household hazardous waste: advertising

Prohibits the sale of cannabis or tobacco vape products that conceal the nature of the vape product, use branding known to appeal to minors, or include interactive videogame capabilities; requires the Department of Toxic Substances Control (DTSC) to evaluate and make recommendations relating to the confiscation of vape products from students by schools; and authorizes household hazardous waste (HHW) collection facilities to disassemble vape products.

Social Media Addiction

AB-1700 (Lowenthal) Covered platforms: age restriction: e-Safety Advisory Commission. Would require covered platforms – based on the “addictive internet-based service or application” definition from the Protecting Our Kids from Social Media Addiction Act to prevent minors under age 16 from having accounts, using the device-based age verification system created by the Digital Age Assurance Act. The bill does not prevent minors from accessing social media to find information and resources; it simply prohibits them from having a personalized account. The bill would require the eSafety Commission to craft regulations to enforce the ban. The commission would be established within the State Department of Justice and advise the Attorney General on which platforms are covered under the law. Assemblyman Josh Lowethal is a former teacher and tech businessman from the Long Beach area, with three school-aged children.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The best management is a true science, resting upon
clearly defined laws, rules, and principles.”

– Frederick Winslow Taylor, American mechanical engineer

In medicine, we tend to measure what we can see: labs, vitals, outcomes. When Google, one of the world’s most data-driven organizations, applied the same rigor to management, the results revealed worthwhile lessons. Project Oxygen may have originated in Silicon Valley, but its findings translate with striking clarity to the halls of a hospital or a busy primary care practice.

In the early 2000s, Google’s founders held a view common among tech-minded leaders: managers were, at best, a necessary inconvenience. The hypothesis was that talented engineers performed better when left alone and that hierarchy got in the way. In 2002, Google tested this by briefly eliminating all manager roles. The experiment failed quickly. Without management, communication broke down, priorities blurred, and staff were left without support or direction.

This failure planted a serious question: not just whether managers matter, but what specifically makes a manager effective. In 2008, Google’s People Innovation Lab launched Project Oxygen to find out, beginning with the goal of proving management quality had no impact on team performance. Instead, the data proved exactly the opposite.

The methodology behind Project Oxygen was rigorous and multi-modal. Researchers analyzed over 10,000 data points drawn from performance reviews, employee engagement surveys, and nominations for Google’s internal Great Manager Award. They also conducted hundreds of hours of structured interviews with employees across the organization. Statisticians were brought in to evaluate the differences between the highest and lowest-rated managers, looking for patterns, not anecdotes.

The findings were unambiguous: teams with highly effective managers consistently outperformed those with poor managers. They had lower turnover, higher satisfaction scores, and stronger overall results. The research identified eight core behaviors initially, which were refined and expanded (following an updated employee survey in 2018) to the ten behaviors recognized today. Crucially, the updated list of ten was even more predictive of team outcomes than the original eight.

For clinician leaders in primary care and hospital settings, there is an important parallel here. Just as evidence-based medicine replaced intuition with data, Project Oxygen replaced assumptions about leadership with proof. The behaviors that emerged aren’t soft, unmeasurable ideals; they are specific, observable, and trainable.

Google has a proprietary process for assessing their managers for weaknesses and specific trainings for addressing these. See this 2013 Harvard Business Review case study for details. As a non-proprietary shortcut, we can do an honest self-assessment of each, or ask a trusted colleague reporting to you to rate you on each of these.

Every one of us has something from this list that we can work on; start with just a few.

Here are the 10 behaviors, with a brief description of each:

1.  Is a Good Coach — Ask before you answer.

Great coaches resist the urge to solve problems immediately. Instead, they use challenges as teachable moments: asking questions, drawing out the team’s own thinking, and building long-term problem-solving capacity. In clinical settings, this looks like a charge nurse who asks, “What do you think we should do?” rather than issuing orders at every turn.

2.  Empowers Team — Does Not Micromanage — Delegate authority, not just tasks.

Effective managers grant autonomy that matches the skill level of their team. They distinguish between someone who needs direction and someone who simply needs support. For a primary care group, this means trusting clinicians to manage their patient panels without constant oversight, while remaining available when needed.

3.  Creates an Inclusive Team Environment — Safety before solutions.

Google’s research confirmed that psychological safety, the belief that one can speak up without fear of embarrassment or retaliation, is essential to team effectiveness. In healthcare, where hierarchy runs deep, this behavior directly impacts error reporting, care quality, and staff retention. Inclusive leaders actively invite quieter voices into the conversation.

Interestingly, in follow-up research, Google’s Project Aristotle identified psychological safety as the most important trait of high functioning teams.

4.  Is Productive and Results-Oriented — Focus on outcomes, not activity.

High-performing managers prioritize ruthlessly and keep their teams oriented toward meaningful outcomes. In clinical leadership, this means distinguishing between metrics that matter (patient experience scores, readmission rates, staff turnover) and the noise of administrative busywork. They model urgency without generating chaos.

5.  Is a Good Communicator — Listens and Shares Information — Information is oxygen for your team.

Great managers are conduits, not gatekeepers. They share context, explain the ‘why’ behind decisions, and actively listen in return. For clinician leaders navigating organizational change (e.g. new EHR systems, staffing shifts, policy updates) keeping communication flowing prevents the rumor-driven anxiety that derails teams.

6.  Supports Career Development and Discusses Performance — Grow your people or watch them leave.

Effective managers invest in the futures of their direct reports, not just their current performance. They hold regular one-on-ones, set clear expectations, and address problems early and honestly. In healthcare, where burnout and workforce shortages are systemic issues, career investment is also a retention strategy.

7.  Has a Clear Vision and Strategy for the Team — If you don’t name the destination, no one can get there.

Teams perform better when they understand where they’re headed and why their work matters. Clinician leaders who articulate a compelling vision, even for a small primary care panel, give their team a shared purpose that transcends the daily grind of a busy schedule. Usually this vision is linked to the organizational mission and vision.

8.  Has Key Technical Skills — Clinical credibility still matters.

Google’s data showed that managers don’t need to be the most technically skilled person on the team, but they do need enough fluency to be taken seriously and to provide meaningful guidance. For clinician leaders, this means staying current enough in your clinical domain to support your team, even if your primary role has shifted toward administration.

9.  Collaborates Across the Organization — Leadership stops at your team’s edge, unless you build bridges.

This behavior reflects the growing complexity of organizational work. Cross-functional collaboration (between primary care and specialty teams, between clinical and administrative leaders, between departments) is now a core leadership competency, not an optional soft skill.

10.  Is a Strong Decision-Maker — Decide with confidence, revisit with humility.

This behavior recognizes that indecision is itself a decision, and often a costly one. Strong managers gather relevant input, make timely calls, communicate the rationale, and remain open to adjusting course with new information. In fast-paced clinical environments, decisiveness paired with transparency builds deep team trust.

Final thoughts

Project Oxygen’s deepest finding — the qualities defining great management are primarily relational, not technical — should resonate with anyone trained in patient-centered care. The skills making a physician or nurse practitioner effective with patients (listening, coaching, clear communication, trust[1]building) are the same skills making them effective leaders of teams.

The 10 behaviors are not a checklist, they are a continuous practice, best approached the way we approach clinical quality improvement: with honest assessment, iterative refinement, and the willingness to be accountable to evidence. Managerial excellence, like clinical excellence, is always a work in progress.

For the past decade, I have posted a list of the core behaviors near my desk, where I can ponder them from time to time. (If you look closely, you will see Google combined some behaviors together to keep the list to a manageable number of 10.)

In case you also want to print these out and post them, here is the adapted version I use:

Ten Behaviors of High Functioning Managers

1. Be a Good Coach
2. Empower the Team; Do Not Micromanage
3. Create an Inclusive Team Environment
4. Be Productive and Results-Oriented
5. Be a Good Communicator: Listen and Share Information
6. Support Career Development and Discuss Performance
7. Have a Clear Vision and Strategy for the Team
8. Maintain Key Technical Skills
9. Collaborate Across the Organization
10. Be a Strong Decision-Maker

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Current models of health care funding, which treat health care as a service for an individual rather than as infrastructure for a population, are innately biased in favor of large populations.”

– Janice Probst, Jan Marie Eberth, and Elizabeth Crouch in Health Affairs, December 2019

Preface: Just as the COVID-19 infections began to spread in December 2019, a seminal article was published in Health Affairs, coining the term: structural urbanism.  

In the article Structural Urbanism Contributes to Poorer Health Outcomes for Rural America, the authors define structural urbanism as “elements of the current public health and health care systems that disadvantage rural communities.”

The COVID-19 pandemic consumed our attention for several years, contributing to changes in the way we think, teach, learn, work, and act on public policy. In the Spring of 2020, a series of police killings sparked national protests seeking greater racial equity and a governmental and corporate focus on racial justice. As rural hospital obstetric unit closures continued and Glenn Medical Center closed altogether in 2025, it has become more significant that the Partnership counties reframe the way we think about rural health policy.

To re-ground us in this reframing of rural health policy in February 2026, I present my January 2020 lead newsletter article on this topic, lightly edited and updated. The Health Affairs article referenced above is available online for free and is highly recommended for reading. The reflections below become an inspiration on how structural urbanism impacts Partnership and our rural clinicians and members.

Enjoy!

In January 2019, the California Department of Health Care Services (DHCS) decided that all providers that contract with Partnership HealthPlan of California and other Medi-Cal managed care plans must apply to the state of California and be accepted as official Medi-Cal providers. Previously, Partnership could contract with specialists outside the state in Oregon and Nevada, which is closer to our members that live in border counties. These out-of-state specialists are excellent physicians to partner with and are recognized by Medicare and the state Medicaid organizations in which they practiced. The DHCS decision was not required by the federal government, but it was based on administrative convenience. The needs of Medi-Cal beneficiaries in border regions were not considered sufficient enough to alter the policy.

This is an example of structural urbanism.

This can include policies and regulations, such as the rule on out-of-state specialists which limits access to care for those in rural communities.

It can also include the fee-for-service payment methodology, which pays hospitals based on volume. Smaller rural hospitals have far more fixed costs per admission, so an “equal” payment arrangement becomes a disadvantage for smaller rural hospitals, contributing to financial instability and hospital closures. This is yet another example of structural urbanism.

It can also extend to state grant programs, like the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. This specific program designated payments to public hospitals, which are all situated in counties with large urban populations. While some version of this may be adapted to smaller counties, at best, only medium-sized counties have the infrastructure to access these funds, and yet again, serves as another example of structural urbanism.

Structural urbanism impacts county social services infrastructure which, in turn, affects health status.

Structural urbanism affects primary care access. National Health Service Corps loan repayment eligibility is dependent on the Health Professional Shortage Area score (HPSA score), which supposedly measures the relative need for physicians in a particular area. The score in parts of urban Los Angeles County is higher than many rural areas in Northern California. While urban health centers serving low-income areas need providers, the providers are able to commute from areas with higher average income. In contrast, rural California health centers need to convince new clinicians to move to a new area. The scoring methodology does not account for this, which is another example of structural urbanism.

Decades ago, sociologists coined the term “structural racism” to describe the historic, political, and social structures that perpetuate racial inequality. Structural racism contributes to persistent health disparities experienced by marginalized racial and ethnic communities. Opposition to a structural racism framework often centers on the belief that persistent inequities stem from individual choices, reflecting the assumption that personal motivation alone can overcome systemic barriers.

Racism is not always just structural, resulting from implicit bias, but is sometimes explicit. Similarly, we may encounter examples of explicit urbanism. Here are three examples:

With today’s political polarization and the increased association of rural areas with support of conservative voting patterns (including in California), some policymakers are explicit in not wanting to prioritize rural areas in any way due to political affiliations.

In the medical field, I have encountered Obstetrician / Gynecologist (OB/GYN) specialists and OB nurses who believe that becoming pregnant while living in rural areas is a high-risk choice for women rather than a policy challenge to rectify. (This explicit urbanism is not universal. Many other OB/GYN specialists and OB nurses have expressed understanding and support for policy and structural solutions to ensure rural OB services are available and safe given inevitable volume and distance influences.)

In state government, we have heard a policymaker remarking on rural specialty access challenges with the suggestion that people who need specialty care should move to large metropolitan areas (indicating a deep lack of commitment to restoring robust specialty access to rural areas).

There is a conceptual similarity between structural racism and structural urbanism. Health outcomes in rural populations have complex and interrelated structural factors. Are worse health outcomes due to the “choice” to live in rural areas? Are they due to poverty itself? If so, why do low-income populations in urban and suburban communities have better outcomes than low-income populations in rural areas? How does differential access to social services, charitable organizations, and health care providers associated with rural areas contribute to differential outcomes? These many factors are the manifestations of structural urbanism.

We can measure worse health outcomes in rural counties. Each year, after conducting our annual audit of the Health Effectiveness Data Information Set (HEDIS®), we stratify the results based on the demographic information we have available. Specifically, we are looking for different outcomes associated with any race, ethnic or language group, and geography. Since 2014, we have found outcomes vary by geography more than race, ethnic or language groups, with the exception of outcomes in the Black and Tribal populations.

Studies suggest rural health inequities are driven by several factors, including less availability of health care and social services, higher poverty levels, higher rates of substance use disorders (SUD), and different health beliefs and practices. These are incompletely balanced with resiliency factors associated with living in small, tighter knit communities.

HEDIS® outcomes in rural areas have improved gradually year over year, but the geographic disparities remain.

How do we achieve better outcomes for rural counties? How do we overcome structural urbanism?

The Health Affairs review article mentioned above has several recommendations:

Access: Maintain and increase availability of health care providers and institutions in rural areas.

Conceptualization: Change the conception of the provision of health in rural areas from being a service to being infrastructure. Decades ago, rural hospitals were funded by the federal government as infrastructure and were able to grow and thrive. Since the conversion to a fee-for-service environment, rural hospitals are closing and quality measures for rural hospitals (which previously were equal to urban hospitals, in aggregate) have steadily declined.

Resources: Additional financial resources can help reduce rural inequities. The National Health Service in England created such a financial redistribution method in the 1970s and 1980s to provide additional resources to rural areas, resulting in decreased access disparities from 22% to 6% in a 12- year period.

Partnership is dedicated to addressing structural urbanism at multiple levels: interventions to increase provider access; leveraging funding mechanisms to provide differential support to rural health care providers; and addressing social issues which impact health (like housing instability, substance use, and justice-involved status). We will also strive to give policy input and feedback from a rural perspective to DHCS and other state agencies, whenever possible.

Correcting many other contributors to structural urbanism will require legislative and regulatory changes at the state and federal levels. Defining a prioritized policy agenda will require us to work together with our partners in rural areas.

Acting on a rural policy agenda is challenging, as organizations working in rural areas often have fewer staff and less resources available to do advocacy compared to urban organizations. For example, compare the organizational structure and capacity of the Consortium of Clinics of Los Angeles County with the California State Rural Health Association (CSRHA). These differential capabilities are also examples of structural urbanism, but organizations representing rural health policy interests are arguably the key to changing the discussions around rural health.

We need organized, effective advocacy to promote rural health equity.

Organizations such as the CSRHA, the California Rural Indian Health Board, and the California Critical Access Hospital Network need more active members and leaders to build infrastructure and generate the policy influence to counteract structural urbanism.

The boards of state-wide organizations like California Health Care Foundation (CHCF), The California Endowment, and the Blue Shield of California Foundation need vocal rural representation to help vet priorities and proposals from a rural lens.

It takes a stronger effort for leaders living in rural areas to engage personally in such organizations, compared to their urban colleagues. This is partly due to travel time, but additionally, rural hospitals and clinics may have a smaller core leadership team who also need to optimize care and operations locally.

Building rural health care leadership is thus a key prerequisite.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Leaders should be ‘trustees of how people spend their time’ and ensure efforts aren’t ‘spread thin like peanut butter on a slice of bread,’ but concentrated on impactful work.”

– Robert Sutton & Hayagreeva Rao, Professors, Stanford Graduate School of Business

What are the leadership practices that make large organizations and government bureaucracies most effective?

This is a central question I have considered as Partnership has grown from a small health plan covering fewer than 100,000 members in one county to a large organization that covers about 900,000 members in 24 counties. During this time, I have also had a front-row seat for viewing how the state and county government institutions sometimes seem to operate at a crawl while at other times a sprint.

Business schools in the United States (and particularly in California) spend a lot of time and energy on teaching the entrepreneurial process, which has arguably been a key contributor to American economic power. Conversely, business schools in other countries tend to spend more time on teaching operations, people management, and labor relations. Some aphorisms reflecting this U.S. focus on moving fast are: “Ready, aim, fire,” a mantra of startups, and “Go for it,” which encourages pursuit of a goal without hesitation or planning. This philosophy has spread to the California state government, flooding several unproven ideas written into legislation and policy in the past five years, with the hope that the good intentions behind these initiatives will be sufficient to make them work.

The balance between speed and deliberation is something you confront in medical offices and health centers. Leaders are frequently asked to weigh how much analysis to do before beginning a new initiative, such as whether or not to run a pilot or small test of change first and how much to focus on stabilizing current systems versus building something new. On the opposite side of the spectrum, humans tend not to think about what can be subtracted to make things work better; our mindsets and social and workplace rewards are based on pushing a new initiative forward.

With these leadership time-sinks weighing down many of us in the health care sector, I was pleasantly surprised to hear about a new way of framing these tradeoffs. In their book titled The Friction Project: How Smart Leaders Make the Right Things Easier and the Wrong Things Harder, Stanford business professors, Robert (Bob) Sutton and Hayagreeva (Huggy) Rao, address both the problems caused by too much friction, causing inefficiency and delays, as well as too little friction, causing precipitous decisions with adverse consequences. The role of the leader is to learn how to address both!

Seven years in the making, the book is filled with case studies, stories, and examples drawn from organizations in the past five to 10 years, integrated with key learnings from behavioral economics and psychology from the preceding 30 years. The storytelling is compelling, and the messages are not overly complex. They encourage us as leaders to become “friction fixers:” adding or subtracting friction, as well as speeding up or slowing down, depending on what the situation calls for.

In an example of reducing friction, Michigan Social Services reduced the 42-page application for food stamps and Medicaid (just about impossible to decipher and fill out accurately) to just eight pages. In an example of increasing friction, Google sped up its hiring process by requiring only four interviews per candidate to reach an 86% confidence level in a hiring decision; any additional interviews need executive approval. The authors dissect the friction framework further, discussing barriers to friction fixing including “jargon monoxide” (asphyxiation from unintelligible jargon), “addition sickness” (never considering subtraction of processes to fix problems), and “power poisoning” (senior leaders exerting their will without input from their team).

The principle of aiming for an optimal amount of friction has many implications at Partnership, ranging from program design to prior authorization requirements, to structuring pay-for-performance programs to be most effective. One example is the application that is part of our grant-making process. The application should be as short and clear as possible, with each question reflecting either key information needed to evaluate the organization and grant proposal or to track / categorize the grant after it is awarded. The decision of which procedures to assign prior authorization requirements is another example of balancing friction in terms of staff time and system complexity, with the cost of the procedure and the staff cost for performing these reviews.

It is also a framework that may help you achieve balance in your work leading clinicians and health centers. For example, in attempting to get universal depression screening, you will consider how to do this while minimizing friction to clinicians, by having the screening be automated, or having medical assistants trained to do the screening.

Sutton and Rao’s work in formulating their framework was influenced by two other books with intriguing titles, likely to offer additional insights:

• Sludge: What Stops Us from Getting Things Done and What to do About It by Cass Sunstein, based on his work in taming the federal bureaucracy in the Obama presidency.
• Subtract: The Untapped Science of Less by Leidy Koltz, about harnessing the power of removing processes, people, etc. to solve business and personal problems.

Considering friction as a continuous variable of policy implementation is helpful to create mental flexibility, considering novel policy approaches and not prematurely locking-in on a particular approach as being the “best” approach. I encourage you to consider the principles of the Friction Project and work to become a “friction fixer” in your own environment!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I believe in evidence. I believe in observation, measurement, and reasoning, confirmed by independent observers. I’ll believe anything, no matter how wild and ridiculous, if there is evidence for it. The wilder and more ridiculous something is, however, the firmer and more solid the evidence will have to be.”

– Isaac Asimov, Author and Biochemistry Professor at Boston University

Six years ago, California’s first Surgeon General, pediatrician Dr. Nadine Burke Harris, secured legislative approval to create a supplemental payment for providers to screen adults and children for Adverse Childhood Experiences (ACES) – traumatic events in childhood that can include violence, neglect, abuse, and growing up in a home with substance use and/or mental health challenges. To be able to be paid the $29 reimbursement for screening, clinicians needed to complete a standardized training, which includes some basics on a related topic: trauma-informed care.

The rollout of the ACES screening has been turbulent. However, a moderate amount of screening state-wide has been done, with 29% of the overall Medi-Cal population and 12% of Partnership members having been screened since January 1, 2020. There are different billing codes for low-risk (scoring 0-3 on the ACES screen) and high-risk screening results (scoring 4-10). This allows the Department of Health Care Services (DHCS) to report on the proportion of those who are screened with different risk scores. This year, they reported that 7% of children and 18% of adults had ACES scores of 4 or higher across all Medi-Cal-managed care plans.

The Surgeon General’s program, ACES Aware, also funded several studies and implementation projects. Ostensibly, these grants were supposed to develop an evidence base for the effectiveness of interventions to address ACES and potentially mitigate their effects. In practice, these many studies brought forth many interesting insights, anecdotes, and ideas around ACES and trauma-informed care, but little evidence on outcomes.

One of these studies – which documents a series of interviews of clinicians working in Tribal health centers – notes that the ACES screening tool is not very helpful for Native American populations (Garrow & Wimsatt, 2021). This is because certain kinds of trauma, such as historical trauma, transgenerational trauma, and efforts at cultural erasure, are pervasive undercurrents experienced by our Tribal communities and are not covered in the ACES screening tool. The ACES screening tool was first designed in the late 1990s by Kaiser San Diego for insured adults in an urban setting. The Suscol Intertribal Council offers an excellent online course that encompasses the vital nature of California’s history through the lens of our California Tribes and the effects of colonization through the Native American Historical Trauma and Traditional Healing Project.

Despite the lack of studies showing benefits of ACES screening, ACES Aware and the DHCS websites both authoritatively assert that ACES screening is a vital component of addressing underlying trauma. In addition, DHCS considers ACES screening as an option for a standardized risk assessment expected to be performed by primary care providers on their patients, evaluated as part of the triennial Partnership Medical Review process.

The other options are routine screening for Social Determinants of Health and performing a standardized cognitive health assessment for members aged 65 and older.

Other national organizations are more skeptical. The US Preventive Services Task Force and the Cochrane Collaborative have no recommendations about ACES screening or trauma-informed care. These organizations have endorsed screening for intimate partner violence and depression based on evidence screening, which can lead to interventions and improve outcomes. In January 2022, American Academy of Family Physicians (AAFP) recommended a “universal precautions” approach to trauma-informed care with no screening requirement:

“Providing trauma-informed care does not require individuals to disclose their specific trauma history. Family physicians should approach trauma-informed care itself as a universal precaution by utilizing trauma-informed practices in all patient interactions, even if a patient’s experiences with trauma are unknown. The AAFP urges its members to understand and incorporate trauma-informed care into clinical practice.”

In an effort to review the evidence base more systematically, the US Agency for Healthcare Research and Quality commissioned a study sponsored by the National Institute of Health, released in 2025, titled “Trauma Informed Care: A Systematic Review.” A summary of this study can be found in the November edition of the American Family Physician Journal, Trauma-Informed Care: Evidence and Pragmatic Approaches on page 474.

The summary found that the studies that were reviewed had a high risk of bias and high variability of interventions. The studies were not structured to disprove the null hypothesis: that ACES screening and trauma-informed care have no effect. Partly for this reason, the investigators concluded, “the evidence was insufficient to reach any conclusions about the effects of trauma-informed care for any outcome (Nguyen-Feng, et. al, 2025, p. 9).”

Of course, the absence of evidence is not the same as evidence that something doesn’t work. However, the amount of money and effort dedicated to a particular intervention deserves to be linked, at least somewhat, to the level of evidence behind that intervention.

In the last decade, it seems many well-intentioned researchers who believe a particular fact have been negligently unaware of how their biases affect their study design and validity. Economist Ronald Coase once said, “If you torture the data long enough, it will confess.” Following this logic, we cannot insist on “following the evidence” for the effectiveness of vaccines and the safety of acetaminophen in pregnancy, for example, while following a different standard about interventions that address the important issue of ACES screening and trauma-informed care.

With the absence of outside studies showing a benefit, I encourage you to consider analyzing your own experience. If you are regularly performing ACES screening, consider gathering your own data on the follow-up of this screening. If positive outcomes are being observed, understand the sequence of activities that led to these outcomes. If you find unintended negative consequences, embrace the opportunity to dive deeper into the drivers of these consequences. Make every effort to follow the data to whatever conclusions they reveal.

In the meantime, the AAFP-recommended approach – assuming that any given patient may have trauma impacting their care experience – of providing universal trauma-informed care seems patient-centered and sensible (although this too is not rigorously supported by evidence). The benefit of universal ACES screening itself remains unproven, although perhaps learning about the association between a high ACES score, chronic disease, and poor health outcomes can help motivate our teams to study and understand the principles of trauma-informed care more diligently. Additionally, the $29 per screening in supplemental income from universal screening can help subsidize counseling and staff education around trauma-informed care.

To conclude, I leave you with some final words of wisdom on this topic by Partnership medical director and family physician Dr. Marshall Kubota:

“Maybe it’s the long-term relationships that family physicians (and other primary care physicians) develop over time with their patients (past trauma and other life events) that inform us as doctors, that are threatened by the lack of continuity and time with patients, and cannot be replaced by AI. On the other hand, I don’t know if we can ever really know our patients that well. We might be fooling ourselves that a questionnaire or trauma history would give us the sympathy/empathy that would be needed, especially as it is transmogrified by our own personal history and culture.”

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“In the fields of observation, chance favors only the prepared mind.”

– Louis Pasteur, Chemist, Pharmacist, and Microbiologist

As leaders in primary care medicine, many of us have seen studies stating remote patient monitoring (RPM) improves outcomes for chronic conditions, reduces hospitalizations, and enhances patient engagement. The evidence is compelling, yet when primary care providers (PCPs) in our service area try to implement RPM for blood sugar, blood pressure, and weight measurement in our practices, the results fall short of those glowing published reports. Why does that happen?

The Implementation Gap
The disconnect between research and reality stems from a fundamental resource challenge: discretionary energy. Published studies typically involve motivated research teams with dedicated support staff, structured protocols, and patients selected for their engagement. This is a common reason why pilots and studies are not replicable at scale in the real world.

Early RPM systems overwhelmed care teams with alerts, data streams, and fragmented workflows. While vendors have worked to reduce this noise through better algorithms and smarter notifications, a core challenge remains: one still needs to review data, respond to alerts, and adjust care plans. This requires time, attention, and mental bandwidth that many care teams in real-world practice do not have.

One option that does not burden primary care teams is to turn over disease management to an outside organization. Several PCPs in the Partnership service area have tried this. If the outside organization is integrated with the PCP’s electronic health record (EHR), communications disruption can be mitigated. However, practice patterns and clinical decision-making are often different between the PCP and the case management vendor. This creates friction and a paradoxical increase in clinician discretionary energy often leading the PCP to drop the vendor – particularly if the vendor relies on the PCP to actually implement the orders / changes recommended by the vendor.

Even when an RPM launch is successful, another problem emerges: adherence decay. Both patients and providers tend to disengage over time. Patients tire of daily measurements and app interactions. Clinicians, lacking time to consistently review and act on data, begin to tune out alerts. What starts as an innovative intervention gradually becomes abandoned equipment and unused subscriptions.

This is a predictable outcome when new technologies are layered onto already overburdened systems without removing other work or adding adequate support.

The Path Forward
The future of effective RPM likely lies in patient empowerment rather than clinical surveillance. Imagine AI-powered systems that automatically motivate patients at individualized intensity levels, gently activating them toward better self-management. These tools would reach patients through multiple channels – text, email, app notifications, even voice calls – meeting them where they are rather than requiring constant app engagement.

Such systems could reduce the burden on care teams by helping patients develop better self-management skills before problems escalate. The clinician becomes a consultant and troubleshooter rather than a daily data reviewer.

Making RPM Work Today
If you’re an enthusiastic clinician wanting to use RPM effectively right now, the literature shows you can make an impact. However, you need to be realistic about the requirements. Success demands either personal investment of extra time or allocated resources that include dedicated staff support as well as protected time for data review and patient outreach.

In our current environment of constrained access and projected reimbursement cuts, securing those additional resources will be challenging. Most practices are already stretched thin, struggling to meet basic access needs.

RPM works — but not automatically. The published success stories are real, but they reflect specific conditions that may not match your practice’s reality. Before implementing RPM, honestly assess whether your team has the discretionary energy to make it effective. If not, wait for (or even try out early versions of) next-generation tools that truly optimize rather than add to team burden. If you proceed now, ensure that support structures are built in from day one, and don’t be surprised when implementation proves harder than the literature suggests.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“It is the first responsibility of every citizen to question authority.”

– Benjamin Franklin

The October in-person convening of the California Medical Association (CMA) brought two major categories of recommendations to the House of Delegates (HOD) for discussion and debate.

The first category was a series of recommendations responding to the current threats to public health, access to health care, and interference with the delivery of health care to patients. The greatest debate among these was the degree to which the CMA should advocate for immigration policies, which indirectly affect the health status and mental health of the patients they serve. Led by amendments from the student and resident caucus, with moving testimony from many physicians – some of whom were immigrants – the final resolutions contained more specific language on immigration policy changes for which the CMA should advocate and referred these recommendations to the American Medical Association (AMA) to take national action.

The second category of action was a series of recommended changes to the CMA bylaws, which returned more deliberative responsibility to the CMA HOD while maintaining some regional medical society responsibilities for the appointment of national delegates.

In the last 30 years, the CMA has mirrored many state and national legislative bodies in changing rules to decrease the time and effort taken for deliberation and granting more authority for decision[1]making to a more powerful executive and/or legislative leadership.

For the CMA, this meant shortening the annual HOD meeting from five days to two, eliminating the reference committees deliberating on resolutions before sending them to the HOD, and moving approval of resolutions from the HOD to the Board of Trustees. CMA made these changes 20 years ago to make the process more efficient and less time-consuming for physician leaders. The consequence was that a very small group of physician leaders (the Board of Trustees) did the majority of the deliberating and then customized the recommendations as they saw fit. This resulted in many neutralized resolutions being submitted to the board with milder statements of principles, rather than resolutions that had previously come from the raucous democratic body of the HOD; the CMA Board of Trustees amended these resolutions to be more palatable and less controversial.

After a two-year process of membership engagement by the CMA Governance Reform Technical Advisory Committee (GTAC) – a sort of CMA Constitution convention – a series of bylaw changes were debated and ultimately passed by the HOD. These changes will create a policy review process in between the old way (five-day HOD meeting with reference committees and every resolution debated) and the more recent way (all resolutions go to the Board of Trustees, with one or two major topics of discussion / collections of related resolutions brought to a two-day HOD). Going forward, resolutions submitted year-round will be sorted for consideration by the Board of Trustees or the HOD, with the latter meeting twice per year.

Unrelated to the GTAC recommendations, the Board of Trustees submitted a request to the HOD to change the way the CMA delegates to the AMA were selected. These changes to bylaws would remove regional selection of a portion of AMA delegates, allowing the Board of Trustees to have final say in selecting all delegates and filling all vacancies. After spirited debate with testimony noting the importance of democracy for promoting productive dissent, inclusiveness of minority viewpoints, and preventing centralization of power, the HOD voted down these proposed changes by a nearly two[1]thirds vote. Despite the dissent, the HOD discussion remained respectful and appreciative of those who proposed the unadopted change.

In the face of vigorous and passionate deliberation, it was inspiring to witness the level of respect shown among colleagues who hold different viewpoints expressed toward each other. The discourse reminded me that for a democratic body to thrive, it needs to be engaged and reflective; it needs to debate differences respectfully, drawing upon logic and principles. While many of us may disagree with some decisions of our leaders in organized medicine, the organizations themselves are worthy of our pride and membership.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Half of science is asking the right questions”

-Francis Bacon, father of empirical science

The recent troubling activities by the U.S. Food and Drug Administration (FDA) and the Advisory Committee on Immunization Practices (ACIP) are part of a larger pattern of drawing conclusions based on unacknowledged cognitive biases.

Charles Piller, an investigative journalist of the prestigious journal, Science, recently authored “Doctored: Fraud, Arrogance, and Tragedy in the Quest to Cure Alzheimer’s,” which meticulously catalogues a huge volume of falsified images and data related to the nature of Alzheimer’s disease. Piller’s work has led to the retraction of numerous scientific papers going back more than three decades and a cessation of National Institutes of Health (NIH) grants to the neuroscientists associated with these studies, several of which are well-documented in Piller’s New York Times guest essay, “The Devastating Legacy of Lies in Alzheimer’s Science.”

Piller’s book narrates the story of an individual whistleblower who reported evidence of fraud to the NIH, FDA, individual universities, and academic journals starting in 2021. The overlapping interests of those not wishing to expose the irregularities and potential fraud led to little response. It was not until the details were revealed to the wider press and in Congress that several actions were taken in 2024.

Prior to publicizing the results, Piller offered every researcher suspected of doctoring results the opportunity to review the evidence and comment or be interviewed. Those who accepted the offer were most often the co-authors of the papers publishing results of experiments performed by others. For each researcher who was found to have fabricated the results, there were several co-authors, many world-famous, whose biases led them to ignore negative experimental results incongruent with “groundbreaking” results, potentially yielding them wealth and fame — confirmation bias in action.

Piller identified one professor who routinely berated graduate students whose lab experiments did not produce desired results, which could disprove the theory. Conversely, the professor showered praise and privileges on graduate students whose results favored the preferred theory. Although the professor did not explicitly tell students to falsify the results, the culture of the laboratory created an environment lacking integrity to the scientific method in favor of obtaining particular results.

Significant financial conflicts of interest were also a major driver, enticing scientists to look the other way when fabricated results or poor-quality studies made a particular drug look promising. In such cases, the scientists or pharmaceutical company leaders would overzealously promote the promise of a drug if it served their personal financial interests. Scientists who favor a particular result plainly reveal their bias towards that result, and extra caution is warranted before accepting any results at face value.

In the area of Alzheimer’s disease research and drug development, precious resources and research dollars were siphoned away from legitimate Alzheimer’s research projects and granted to those whose papers were based on fabricated results. In retrospect, these were dead-ends, and the totality of harm is immeasurable.

Piller’s book focuses on and reveals misbehavior in scientific research. Insights into the behavioral economic origins of this misapplication of the scientific method can also be applied to the area of health policy.

In an ideal world, health policy decisions would be made based on an understanding of science and statistics. Policies would also apply the principles of quality improvement: iterating repeated small[1]scale pilots before mandating state-wide implementation of a new approach, rather than using a compliance policy approach for lofty aspirational goals better suited to incentives.

Well-crafted policy relies on several principles in common with good scientific research: humility and willingness to test new ideas objectively and acknowledge failure as we learn, so we can make the next attempt better. Having a pre-conceived bias or propensity for a particular policy approach, coupled with an unwillingness to logically consider scientific and statistical arguments, will lead to policy that is ineffective at achieving its goals.

While we do need to have visionary leaders with charisma and energy, this should ideally be coupled with an understanding of the importance of keeping the scientific method and quality improvement methodology at the forefront in the policy development process.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“When the pressure is on, we don’t rise to the occasion, we fall to the highest level of preparation.”

– Chris Voss, Author and Former FBI Negotiator

At the end of residency training, what knowledge do clinicians retain, and what tends to fade quickly over time?

Knowledge is often retained when clinicians experience a high-stakes clinical syndrome firsthand – watching it unfold, making difficult decisions, and later second-guessing whether those decisions were correct. In contrast, information is often forgotten quickly when it comes to reading about a topic they have never personally encountered.

Memories are stronger when the neuronal connections associated with that memory are more myelinated and have redundant pathways. Memories become stronger with repetition, when memories are attached to emotion, if the memory involves multiple learning modalities (listening, reading, watching, and doing), if the information is repeated over time, and if it is associated with other memories.

Some clinical scenarios are rare, but the consequences of decisions are particularly impactful. Some examples include unexpectedly being a clinician responsible for the care of a person with cardiopulmonary arrest, major trauma, status epilepticus, or obstetrical emergency.

Being relatively calm and effective in these cases depends on the level of preparation and knowledge one has gained before being confronted with an emergency. The more automatic our actions are, the faster and more accurate they will be.

Simulations and case studies are two helpful resources to help prepare for high-stakes situations. If the scenario requires a manual skill, watching a video or practicing the actual skill with some repetition is essential (simulation). If the scenario involves high-stakes decision making, a deeper and more considered thought process is helpful (case studies). Watching attentively as one of our peers struggles with the manual skills or cognitive processes of an emergency also reinforces the neural pathway; so, learning as a team is better than learning alone.

What sort of emergencies might you encounter in an outpatient practice? One of the most common is a patient who unexpectedly loses consciousness or nearly loses consciousness. First, we must quickly assess the situation to determine the underlying severity of the situation. Is it a vasovagal reaction, a hypoglycemic episode, or a cardiopulmonary arrest? Subsequently, or sometimes simultaneously, promptly initiating treatments that will help or resolve the situation is key.

Training together as a team offers other major benefits, such as: deepening trust with teammates, developing shared mental models so that the actions of others can be anticipated, and strengthening communication to be as efficient as possible in an emergency situation. In the past several months, Partnership has been sponsoring trainings in obstetrical emergencies for hospital teams and found that the enhanced team effectiveness was a major unexpected benefit highlighted by the hospitals afterwards.

Unfortunately, as our health care delivery system has moved to the convenience of online training for Advanced Cardiovascular Life Support (ACLS), Basic Life Support (BLS), etc., this becomes a missed opportunity to develop our team effectiveness, particularly with new staff. We might consider alternating or augmenting our online training with in-person scenarios to help the material resonate better and build team effectiveness. Another best practice could be to combine an in-person BLS training with clinic-specific customizations, such as treatment of vasovagal reactions, seizures, and hypoglycemia.

One final best practice is what our outgoing Physician Advisory Committee chairman, Dr. Steve Gwiazdowski, calls “high frequency, low fidelity” practice. Finding ways to do quick refreshers on key scenarios or skills every three months or so, has been proven to keep this knowledge fresh. The Banner Hospital system, with small rural hospitals throughout the rural western states, has institutionalized such quarterly re-trainings for their nursing staff and found that this approach improves both outcomes and teamwork. To better prepare for emergencies, please consider ways to incorporate these types of quick refreshers into your clinical setting.