For more than two decades, Wanda Remo has battled one illness after another. Asthma, chronic lung disease, heart disease, high blood pressure, arthritis, depression, chronic pain, strokes. Specialists treat her lungs, her heart and her joints.
Her litany of ailments brought her to emergency rooms six times last year, between numerous additional visits to a federally subsidized health clinic in South Los Angeles.
"You are one of the million-dollar patients," her doctor, Derrick Butler, tells the 57-year-old as she leans on her walker during one appointment.
Remo and countless other chronically ill patients like her pose one of the biggest obstacles to medical professionals, hospitals and political leaders trying to rein in costs as they overhaul the healthcare system.
Starting next year, clinics in rural and urban areas will receive an influx of millions of newly insured patients — many with complex, chronic diseases — and face higher expectations to keep costs down. Many of those patients are so ill — or resistant to altering behaviors — that they repeatedly cycle through expensive emergency rooms and hospital beds.
Keeping them away from hospitals can be difficult because of patients' reliance on emergency rooms and because clinics typically lack sophisticated X-ray and laboratory equipment or the capability to perform advanced medical procedures.
Still, researchers have found that patients at community health centers are less likely to be hospitalized than those receiving treatment elsewhere, resulting in significant savings.
Despite the clinics' many successes, tracking Remo for six months demonstrates the limits of what clinic medical providers can do as they try to provide efficient, low-cost care for large numbers of seriously ill patients.
"A lot of people come here so they don't have to go to the ER," says Butler, associate medical director of To Help Everyone Clinic, known as T.H.E. "Sometimes it's beyond what we can do."
Clinics are trying to improve the odds of keeping patients healthy, including expanding weekend and evening hours and adding pharmacies so patients don't head for emergency rooms to refill prescriptions.
At T.H.E. Clinic, patient services representative Joanna Franco follows up with every client discharged from a hospital, whether the patient went in for a minor stomachache or a life-threatening asthma attack. She schedules appointments and encourages patients to come to the clinic and avoid the emergency room whenever possible.
Some patients hang up on her. Others don't keep appointments. "They aren't compliant," she says. "They wait until they are really sick and they go back to the emergency room.
"All we can do is call them and [try to] get them here."
Franco speaks regularly with Remo, who lives alone but has a visiting caregiver. She sleeps in a hospital bed, next to a nightstand covered with water bottles, medications and an ashtray full of butts. An oxygen tank and a breathing machine sit nearby.
Remo says she calls 911 only when she can't keep her medication down or control her breathing. She's been to hospitals across Los Angeles County, including Cedars-Sinai Medical Center, Hollywood Presbyterian Medical Center and Centinela Hospital Medical Center in Inglewood.
In September, she arrived at T.H.E. Clinic sweating, throwing up and hyperventilating. The clinic's driver took her to the emergency room.
Remo is covered by Medi-Cal, the public program for poor and disabled Californians. But a private insurer manages her care under a program intended to improve treatment and control costs. The company, Care1st, has assigned Remo a case manager.
In October, after her hospital stay, Remo is back at T.H.E. Clinic for a follow-up appointment. Disheveled and overweight, she moans as she pushes her walker and portable oxygen talk into the exam room. Her heart is racing, and she feels nauseated. It's a struggle to breathe.
"Please don't send me to the hospital," she tells Butler.
She needs a total hip replacement and is in horrible pain. Because of the risks of the surgery, she says, Butler and her other doctors won't approve it.
"Did you take your blood pressure medication?" Butler asks.
Remo shakes her head no.
"You know not to come in here without your medication," he says.
Butler listens to Remo's chest and orders an electrocardiogram to check her heart. If anything looks suspicious, he tells her, she has to go to the emergency room. Remo, who moves slowly and has a raspy voice, leans back on the bed and closes her eyes as a medical assistant performs the heart test. The results are normal. As she leaves, Butler reminds her to take her blood pressure medication.
A month later, Remo cancels a clinic appointment. Lying in her bed, covered with a blue knit blanket, she says, "I'm just so weak. This is not going to work today."
The winter holidays come and go. Most days Remo struggles with pain and discomfort. But she manages to avoid the hospital.
In January, she shows up for an appointment at T.H.E. Clinic wearing a gray sweat suit and her hair smoothed back into a bun. In the waiting room, she meets Eartha Brown, a patient with similar health problems.
"I used to run back and forth to the hospital," Brown tells Remo. "I don't do that anymore."
By taking her medication, showing up at her appointments and exercising, Brown says, she has slowly improved. They laugh about men and compare notes on walkers and doctors. "You call me. I see we are going to be friends," Brown says.
In the exam room, Remo is wheezing and complains that her hip is throbbing. She tells Butler she has been nauseated for days, not breathing well. But she accidentally left her inhaler at home.
Butler hooks her up to a breathing machine and medication that will help calm her lungs. "Take a nice, easy breath," he says.
As she leaves for home with refilled prescriptions, Butler urges her to rest.
The next month, Remo's case manager schedules an appointment at Pacific Alliance Medical Center, a Chinatown hospital with a special program to coordinate care for chronically ill patients. When Remo arrives, she is in pain, wheezing and nauseated. The medical staff quickly determines she needs to go to the hospital.
"Oh my Lord," she says as they wheel her to the center's hospital. "I'm hurting."
Doctors stabilize her and deliver unexpected news: They plan to schedule a hip replacement surgery. Remo is relieved. And nervous. "I don't want to take a chance and die on the table," she says.
In her hospital bed on the eve of the surgery, she signs paperwork and prepares herself. "I just want it to be over," she says.
The surgery goes well, and after several days recovering at an Inglewood nursing facility, Remo looks to be on a new path. She has stopped smoking, is up and walking and doing physical therapy twice a day. She loses 22 pounds and the pain in her hip starts to subside.
She's eager to get back to T.H.E. Clinic and see Butler and the other staff. "When I walk into his room without a walker, all of them are going to be shocked," she says.
But back home, she starts feeling ill. She's tempted to call 911 but resists and opts for more rest, hoping her condition will start to improve.
"I'm tired of hospitals," she says.