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Unequal Treatment

Las Vegas tries new tactic to improve city's notorious healthcare

Hospitals and ClinicsHealthcare ProvidersLaws and LegislationDiseases and IllnessesDiabetesInsuranceMedicaid
Las Vegas clinics try a personal approach and high-tech system to track, improve health of residents
Las Vegas has critical shortage of primary care doctors, and residents are less likely to get recommended care

Teresa Garcia, weak and in pain, had all but given up on doctors when she came to a small clinic next to a former wedding chapel on the Strip.

"I never thought I would get better," the 55-year-old housekeeper said, recalling years of perfunctory physician visits that generated countless prescriptions but did little to slow the dangerous advance of her diabetes.

Today, under intense care from a team of social workers, nurses and a doctor who, like her, emigrated from Mexico, Garcia has learned to change her diet and closely monitor her disease. She has regular checkups. She has cut her blood sugar in half. She no longer needs to inject herself with insulin.

The model of medical care that is helping Garcia is built on a highly personal approach to patients and a high-tech system to track quality — something that is new for this city. A grim joke here long held that the best place to go for good healthcare was the airport.

Now, Las Vegas is emerging as a test of how much a community can improve chronically poor health by expanding insurance coverage and using models of medical care pioneered in healthier places.

"We are a prime example of what people see as problematic about the American healthcare system," said Larry Matheis, the former longtime head of the Nevada State Medical Assn. "That makes a lot of the ideas in health reform very attractive. … The challenge is going to be figuring out how to make it all work."

Starting this year, the Affordable Care Act guarantees insurance to tens of thousands of Las Vegas residents once effectively shut out of the health system. And leading hospitals, physician groups, unions and businesses are seeking to improve care by taking advantage of the coverage expansion.

The clinic Garcia visits has already inspired a similar facility in nearby downtown. And the Culinary Health Fund, a union health plan that runs Garcia's clinic, plans to build three more across the city.

Under another initiative in the city, a team of highly trained nurses is working to enhance medical care in nursing homes so fewer residents end up in the hospital.

Poverty and obesity are not as widespread here as in some of America's other least healthy communities. Nevertheless, improving care in Las Vegas is an immense task.

Before Nevada expanded its Medicaid program under the new health law, nearly 30% of working-age adults in greater Las Vegas lacked insurance. By comparison, in U.S. communities with the best health outcomes, fewer than 1 in 10 are uninsured.

The area also has a critical shortage of primary care doctors — half as many relative to the population as healthier regions of the Northeast and upper Midwest.

Las Vegas residents are far less likely than people in healthier communities to get cancer screenings, immunizations, blood-sugar tests and other recommended preventive care, even when they have a serious illness, according to data gathered by the Commonwealth Fund, a research foundation that studies healthcare systems.

They also are nearly twice as likely to die from illnesses that can be averted or controlled with timely medical care, including childhood measles, diabetes and colon cancer.

Outcomes here match those in the poorest parts of the Deep South and Appalachia, according to a review of healthcare data The Times conducted with help from public health researchers and visits to communities from Maine to Hawaii.

In a system shaped by low levels of coverage, the city's for-profit hospitals historically have sought paying patients for more lucrative care. Freeways are lined with billboards advertising short wait times at emergency rooms, a profitable way for hospitals to cash in on patients with coverage.

One doctor would call his insured patients "little ATMs," according to a physician who asked not to be identified in candidly describing a mindset he said is widespread in Las Vegas.

Medicare patients here get three times as many MRIs, CT scans and other imaging tests as patients in parts of the Midwest and New England, data show. Overuse of imaging can be harmful to patients, though profitable for providers.

"There are no controls on anything," said Dr. John Ruckdeschel, an oncologist at the University of Utah who formerly headed the Nevada Cancer Institute.

Patients shut out of the for-profit system often show up at the emergency room of University Medical Center, the city's overburdened public hospital.

Last year, state regulators exposed hundreds of cases in which private hospitals dumped uninsured and Medicaid patients onto the public hospital.

The UMC waiting room fills daily with the city's uninsured, its poor, its mentally ill, its homeless and its immigrants. A doctor who works in what was once a supply closet juggles patients with sore throats and empty prescriptions so the ER can focus on life-threatening emergencies. In a corner, the hospital runs an improvised kidney dialysis center for immigrants who are in the country illegally.

If the crowded waiting room symbolizes the medical system Las Vegas is trying to leave behind, the Culinary Extra Clinic represents what many hope will be its future.

The Culinary Health Fund, which covers about 120,000 union members and their families, built the clinic in the shadow of the 100-story Stratosphere Casino Tower after concluding that much of the community's medical care was ineffective and wasteful. By focusing on its sickest members, fund leaders believed, they could cuts costs and dramatically improve health.

Here, in a cheery medical office with the excited energy of an elementary school, doctors, nurses and social workers have turned the traditional doctor's practice on its head, delivering highly personal primary care instead of quickly churning patients.

Each morning, team members with MacBooks gather at a big table in what they call the "Huddle Room." A sign on the wall proclaims: "Never doubt that a small group of thoughtful, committed citizens can change the world," a quote from anthropologist Margaret Mead.

The team discusses the day's patients and those who have landed on the "Who needs help" list. The staff one morning debated how to help a patient with kidney trouble who was abusing drugs and another who had been controlling her high blood pressure but was back in the hospital.

Outside the Huddle Room, a wall featuring snapshots of smiling patients celebrates milestones such as quitting smoking or reducing blood pressure.

The clinic's exam rooms are designed to make conversations more relaxed. Many feature small couches instead of exam tables.

"I want to put myself at my patients' level," said Dr. Eva Snow, a primary care physician who left her practice in Las Vegas, frustrated that a traditional office didn't allow her to spend enough time with patients. "You have to find out who your patient is … because behind every diabetic, something else is going on."

Many discussions here focus on how patients can change the way they eat, exercise more or take other steps to improve their health. There is even a "health coach" who runs a yoga class.

Snow, who emigrated from Mexico, has an easy way with her many Spanish-speaking patients. She runs a diabetes class two mornings a week, something that was impossible when she was trying to make enough to pay her bills in private practice. She now has the time to talk with patients about how to manage the disease by, for example, carefully reading ingredient labels.

Garcia arrived at the clinic with dangerously high blood sugar, putting her at risk of blindness, heart disease or other diabetic complications.

On Snow's advice, she scrapped Cream of Wheat for breakfast, cut down on tortillas and reduced her blood sugar nearly to normal. Garcia said she was still surprised Snow hadn't just prescribed more medications.

"We don't want to just give you drugs," Snow told her. "We want you to have the tools to take care of yourself."

It's still early in Las Vegas' healthcare evolution.

Nevada's new online insurance marketplace, set up to handle the expansion of coverage, stumbled in its first year. And just a few miles from the new clinic sits a reminder of a previous effort to improve care in Las Vegas that failed spectacularly.

The Nevada Cancer Institute opened a decade ago with extravagant fundraisers featuring celebrities such as the Eagles. It was the vision of a casino mogul who promised a state-of-the-art center to combat high cancer rates.

It closed almost two years ago, unable to integrate itself into the city's network of hospitals and doctors.

Many community leaders are nonetheless hopeful that the new effort to build better basic care will succeed and endure.

The Culinary Extra Clinic is already helping to set a new standard.

A few blocks away, a similar clinic unaffiliated with the union opened in December. Turntable Health was built by Internet entrepreneur Tony Hsieh, founder of shoe site Zappos.com, who is using his fortune to help rebuild downtown.

Turntable aims to take advantage of the federal health law's insurance expansion to provide care to a broader section of the community. The private, for-profit clinic works closely with a new insurer, Nevada Health Co-Op, that was set up in response to the federal law.

"We really see our fate tied to the Affordable Care Act," said Dr. Zubin Damania, a former Stanford Hospital doctor who moved here to open Turntable.

The clinic is run by Iora Health, a Massachusetts firm that also operates the union clinic. It offers health coaches, 24-hour-a-day access to doctors by telephone and email and a team to help patients navigate the wider health system.

The first months have been busy, Damania said.

"We are finding this amazing pent-up demand for personalized medical care, which was unheard of before in Las Vegas," he said. "We're also seeing many patients who haven't had medical care in years."

noam.levey@latimes.com

Support for this series came from the Assn. of Health Care Journalists' Reporting Fellowships on Health Care Performance, funded by the Commonwealth Fund. David Radley at the Institute for Healthcare Improvement and Robert C. Wild and Dr. Ashish Jha at the Harvard School of Public Health assisted with data analysis.

Copyright © 2014, Los Angeles Times
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