Sansum Clinic: A Legacy of Innovation

We worked with the Historical Museum of Santa Barbara to document the history of Sansum Clinic and I was amazed by how strong a role our history has played in preparing us to care for patients despite the ever-evolving changes we face in our industry. Our innovative founders established models of healthcare that have enabled us to weather the 1925 Santa Barbara earthquake, the Great Depression, World War II, the advent of Medicare and the current alphabet soup of modern healthcare – HMOs, PPO, ACA and, most recently, MACRA. The common themes from the last century closely mirror those we face today – innovation, growing to meet the needs of the community, changes in payment models, partnering for increased efficiency.

The Sansum Clinic of today – the oldest independent multi-specialty provider of outpatient healthcare services on the Central Coast, and the last remaining independent Medical Foundation in California – is actually the fascinating history of two clinics – the original Sansum Medical Clinic and the Santa Barbara Medical Clinic, both founded in 1921. Sansum Medical Clinic’s founder, Dr. William David Sansum, was the first doctor in the U.S. to use insulin to treat patients with diabetes. The underlying concept and focus of Sansum Medical Clinic was to examine and treat health problems of patients, who did not require hospitalization, with the latest research and medical advances. As it thrived and expanded, prominent patients traveled from places like Las Vegas and Mexico to receive thorough examinations without then “exorbitant price tag” of a hospital stay, back then $10 to $12 a day.

The Santa Barbara Medical Clinic was created with a new and innovative almost revolutionary approach to healthcare. Doctors Rexwald Brown, Benjamin Bakewell and Hilmar Koefod formed a group practice to make comprehensive specialty care available to all segments of Santa Barbara at a time when solo practitioners provided most of the care. Dr. Brown in particular believed in the team approach to providing higher quality healthcare more affordably by pooling resources and skills and sharing costs - a novel premise before it became the standard for excellence it is today. He was passionate about the idea that this model could make healthcare more affordable for people of moderate circumstances. This group approach to healthcare delivery was similar to the multi-specialty model of the Mayo Clinic, the first integrated group practice in the nation.

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In battlefield triage in World War I, Dr. Brown realized that a solo general practitioner could not keep up on every advancement made in all the areas of medicine and could not effectively be all things to all patients. Full-time specialists at this time comprised less than seventeen percent of all U.S. physicians. While Brown thought specialists could be in danger of having a restriction of vision and become too absorbed in their own field, he recognized a specialist could remain current in his own field, and working collaboratively with other specialists could provide optimum resources and knowledge to help a patient. After the war, other physicians with similar experiences during their military service were enthused about the concept of a group practice, and a handful of group practices were launched across the country, averaging perhaps two or three such practices per state. The Santa Barbara Medical Clinic became one of the first group practices in California.

Through the 1920s both organizations continued to grow by bringing new specialists to the area. By the late 1920s Santa Barbara had primary care as well as specialists in cardiology, gerontology, pediatrics, oral surgery, and ENT. A major earthquake in 1925 required both clinics to figure out how to provide healthcare to more people with less payments.

In the 1930s, both organizations weathered the Great Depression despite dire circumstances. At Sansum Medical Clinic, philanthropists who previously supported local healthcare initiatives were no longer funding new projects, underwriting research or donating monies for new construction. Local doctors at that time were customarily expected to provide a generous part of their practice a public charity, since this was before the era of private insurance and state and federal programs. Married couples who had been recruited to the clinic were asked to choose who would stay on payroll, physicians took substantial pay cuts, and some chose to leave to open their own office.

At Santa Barbara Medical Clinic, Dr. Rexwald Brown was envisioning health insurance as a viable means for the delivery of healthcare. He wrote a great deal about the many issues in the revision of healthcare delivery, and when President Franklin Delano Roosevelt established the Committee on Economic Security (C.E.S.) in 1934, one of its subcommittees was the Medical Advisory Committee. Dr. Brown was one of only eleven physicians in the country called to serve on this committee, a tribute to his perspective and continuing active interest in the problems and issues of accessible healthcare.

In the 1940s, staff at both clinics was reduced when the U.S. entered World War II and doctors were called to active duty. In the meantime, a Marine air base and Army hospital came to Santa Barbara, so while many local residents and some physicians left to go elsewhere to serve the war effort, large numbers of military personnel had arrived in Santa Barbara and needed medical services.

After having established Sansum Medical Clinic as the center in the U.S. for groundbreaking advances in diabetes and treatment, Dr. Sansum passed away in 1948 at the age of 67, leaving a legacy of hundreds of thousands of patients with diabetes who benefitted from his research and treatments as highlighted in the prolific number of articles and books, and demonstrated in his ground-breaking diets. Rather than dismantle the organization, Sansum’s medical successors determined to keep the clinic open and had his name memorialized. Several doctors secured funding to buy the clinic from the Sansum estate; a chairman was elected, and a business manager hired.

Coming into the 1950s, Sansum Medical Clinic saw the return of physicians from active duty from World War II and the Korean War, and these men came back armed with knowledge of the latest medical breakthroughs. Returning veterans and the postwar baby boom all added to a growing patient population into the 1960s and led Sansum to become a more diversified multi-specialty group. “Think tanks,” organizations that aggregated the best minds for problem solving, like Raytheon and Applied Magnetics attracted new residents from all over the country, and the population of SB increased fifty-five percent between 1950 and 1970. Both clinics added new physicians and more specialties to serve the needs of the community.

Along with increasing demand for medical care by the growing local population, many people living elsewhere sought out care in Santa Barbara. By the 1960s two-thirds of the patients seeking care at Sansum Medical Clinic were from out of town. This trend had started after the war, as there was a shift in the attitude of Americans who had traveled abroad and across the nation. As the country expanded with new technologies and a growing population, people now readily looked beyond the borders of their own hometowns for the goods and services they needed.

By the early 1970s, continued growth led the group of physicians at Santa Barbara Medical Clinic to consider the formation of a nonprofit foundation to ensure that local citizens and physicians would oversee the translation of healthcare dollars paid by patients and employers into the most effective care, and to allow grateful patients to give financial support to the Clinic. In 1973, physicians divested themselves of all ownership of the Clinic, its buildings and grounds and the Santa Barbara Medical Foundation Clinic was comprised of a foundation under the supervision of the Board of Trustees, and governed by the Board of Governors. Clinic surgeon, Dr. Wilton Doane, then president of the American Group Practice Association, was elected to be the founding president. To provide healthcare, the foundation contracted with the physician group, the Santa Barbara Medical Clinic, Inc., which was governed by its own Board of Directors.

This model, ideal for expansion and adaptation to the newly evolving trends in healthcare, is the same model we have to this day.

Two issues came to the forefront which had an enormous impact on the pricing and affordability of healthcare. The first was Medicare which was introduced in 1965 as a federal health insurance program designed to cover healthcare costs for people over sixty-five years of age. Soon health programs were overwhelmed with new patients. This ultimately brought about a shift in how medical care was reimbursed and led to manage care programs.

The other issue was medical malpractice cases, which were causing an unexpected and exponential increase in insurance premiums. In 1975-76 alone, Santa Barbara Medical Foundation Clinic saw its professional liability insurance jump from $72,000 to $652,000 and this was without the impact of any lawsuits. Naturally this crisis and the accompanying risk management decisions dramatically affected healthcare costs.

By the 1980s, the Santa Barbara Medical Foundation Clinic was providing care for those covered by Medicare, and those who were under HMOs, the newly developed pre-paid healthcare insurance programs offered by the big local employers, including UCSB, Santa Barbara County, and Delco. Pre-paid care produced some criticism until it became apparent that this was an inevitable change in the financing of medical care, and that large numbers of local residents were covered by such plans. The then separate Sansum Clinic did not accept HMO plans, but maintained a traditional approach with the direct physician-patient relationship paramount. Sansum did, however, make a commitment to the health of those who could not otherwise afford medical services.

Into the 1990s, the two clinics grappled with the question of how to deliver exceptional healthcare which was affordable and accessible, while dealing with the evolving business of managed modern healthcare with its “third party payers” (i.e. insurance). Eventually the conversation turned to the possibility of combining the two clinics to serve the community better through economies of scale and administrative efficiencies.

In 1998, after three years of thoughtful deliberation and careful negotiations, the Santa Barbara Medical Foundation Clinic and the Sansum Medical Clinic merged into a single outpatient healthcare institution, the complexly named Sansum-Santa Barbara Medical Foundation Clinic, which continued to operate as a nonprofit Medical Foundation, as it had for the prior 25 years. The group continued to provide care to all members of the community, whether insured with fee-for-service insurance products and traditional Medicare or whether the patients used HMO insurance models, which were very popular at the time.

Eventually it became clear that the name Sansum-Santa Barbara Medical Foundation Clinic was too cumbersome and in keeping with the names of similar institutions around the country, such as the Mayo Clinic and Cleveland Clinic, it became known simply as Sansum Clinic in 2006.

Today, Sansum Clinic is the largest private independent non-profit outpatient healthcare organization between Los Angeles and the San Francisco Bay Area, with more than 250 physicians and more than 30 specialties. It serves more than 129,000 patients, with 800,000 patient visits yearly at 22 patient care facilities, and is administered by a Board of Trustees for the benefit of the community. It is among the top dozen employers in Santa Barbara County.

In 2012 Sansum Clinic adopted a comprehensive electronic health record system, from Epic, which allows patients to have online access to their personal health records. That same year we merged with our local nonprofit Cancer Center of Santa Barbara with a vision for enhancing cancer care on the Central Coast, and today we are building a world-class regional Cancer Center slated to open later this year – thanks to the generosity of grateful patients and other donors in our community.

We have seen some of the key features of the Affordable Care Act (ACA) take effect. Since 2014, we have experienced a notable increase in new patient visits, and we have proudly adapted in an attempt to meet the community’s needs amidst this changing environment.

That year we built the Foothill Medical & Surgical Center, our first new facility in decades, which afforded us the opportunity to put specialties with similar needs under one roof, and which also created much-needed space to expand our primary care and urgent care services. This expansion will effectively double our capacity to care for patients with urgent medical care while keeping them out of the more costly hospital emergency room, while also providing capacity for same-day appointments. It also afforded the Clinic with 4 operating rooms, allowing us the ability to transition care that was only available in a more costly hospital setting to be provided in an outpatient setting. Also in 2014, a new Patient Access Department allowed us to make great strides in streamlining the scheduling and registration processes for primary care services, including Internal Medicine, Family Medicine and Pediatrics. Our new Patient Access Department has a centralized scheduling process that reduces scheduling time and increasing the efficiency and accuracy of registration, improving patients’ ability to get the right care at the right time, in the right place.

In addition to expanding capacity for Urgent Care services, the Clinic has made a dedicated effort in Disaster Preparedness for our community. As part of the expansion we are installing emergency power, which will enable us to serve the community in the case of natural disaster. Sansum Clinic joined the County of Santa Barbara’s Emergency Preparedness Program and now participates in the Disaster Healthcare Partnership Coalition which assures collaborative planning and efficient response during a disaster.

In 2015, we strengthened our partnership with CenCal Health to ensure the growing Medi-Cal patient population is served with adequate access to care, health promotion and wellness activities, care coordination and disease management, and health information technology. We continue our decades-long commitment to the health of those who could not otherwise afford medical services by providing more than $250,000 each year in free diagnostic services to patients of the Santa Barbara Neighborhood Clinics who otherwise cannot afford such services. .

We are now focused on navigating our way through the next monumental changes in healthcare: Medicare’s shift in payment models to focus on performance-based payment. One value-based model of care we are pursuing is SansumCare, a model in which a primary care doctor leads a clinical care team that oversees the care of each patient in a practice. The goal is more coordinated patient care and improved outcomes. With a team-based approach to care, all members of the clinical staff can assist with ensuring that patient’s needs are met and that valuable care is provided. Medical staff is trained to identify individual needs, whether preventive, chronic or acute and to deliver or coordinate the most appropriate care. As part of that transition, we are making great strides in measuring and reporting the quality of care our practitioners and our practice provides

As we just noted, the shift toward value-based payment models also means that we are becoming increasingly reliant on data in order to document, measure, and report our quality and cost. We must be able to report on the high-value care we provide while also monitoring it for improvement opportunities. We are making investments in our internal data warehouse and electronic health record to ensure we have the ability to meet these needs now and well into the future.

Other current efforts to improve our system include expansion of clinical hours, expansion of pharmacy services, increased use of mid-level providers (Nurse Practitioners and Physician Assistants), adding important programs like lung cancer screening, and an increased focus on patient health and wellness education.

We are proud that these efforts have earned us national recognition for medical quality, including 4.5 Medicare Stars and CAPG Elite Status.

Sansum Clinic’s vision continues to build upon the goals of the two original clinics since their founding: As a premier integrated delivery system, we provide high-value healthcare to the communities we serve, managing the population's healthcare needs, while also creating a model of care that will thrive in California's rapidly changing healthcare arena. It is a pleasure to share how our history has developed to forge what is today an exceptional healthcare provider serving our small but forward-thinking community, and how we are poised to navigate the healthcare landscape of the future.

Our predecessors practicing at “The Clinic” in the 1920 or during WWII, would not recognize the newfangled computers and technologies and interventions done every day at the current Sansum Clinic, but in other ways they would very much recognize the same dedication to meeting the community’s needs through a group practice model that started almost 100 years ago.

- Kurt Ransohoff, MD, FACP, CEO and Chief Medical Officer

(Full Noticias publication written in partnership with the Santa Barbara Historical Museum by Erin Graffy and the late Erno Daniel, MD, Sansum Clinic historian, can be found here >.)