Hospital Cuts Hit the Poor

In the first two months of a cutback, UCI Medical Center has turned away more than one in five people who called for an appointment under the county’s medical program for the poor.

UCI figures show that 21% of new patients enrolled in the county’s Medical Services for the Indigent program who sought help at the Orange hospital in August and September were referred to clinics closer to home. The result is that some clinics, especially those in the northern part of Orange County, are finding their waiting rooms filling up.

“Everybody has decided to come to our facility,” said Maggie Trejo, a patient resource worker at Sierra Health Center in Fullerton.

Even poor patients who continue to receive treatment at the medical center in Orange and its two clinics in Anaheim and Santa Ana are affected by UCI’s changes.

In the past, these patients were treated for whatever ailed them, regardless of whether the county reimbursed doctors and the hospital. But since Aug. 1, UCI has moved to a system akin to an HMO, in which treatment must be approved through a case-management system. If the county doesn’t pay for it, UCI will not provide the treatment.

As a result, close to 17% of requests for treatment for existing patients have been turned down, said Mary Owen, who heads UCI’s case-management unit. Most of the vetoed referrals have been in dermatology, gastroenterology and orthopedics, she said. A patient who needs a consultation with a cardiologist could make an appointment, but he or she could not see a specialist for a condition such as eczema, which is not life-threatening, Owen said.

Orange is one of three counties in the state, along with Sacramento and San Diego, that do not operate county hospitals. Because it is legally obligated to fund indigent health care, Orange County reimburses hospitals and doctors a portion of their costs to treat the poor.

The MSI program provides medical care for people 21 through 64 who make too much money to qualify for Medi-Cal and are not old enough for Medicare. The care is limited to services that protect life or prevent a significant disability or serious deterioration of health.

There were 17,532 MSI patients in Orange County in fiscal year 2000-01, the last year for which the county had statistics.

The county will spend $47 million for the MSI program in the current fiscal year. Health-care advocates argue that is far too little and say Orange County is among the least generous counties in the state when it comes to per-capita spending for health care for the poor.

“It’s a very bad place to be poor and sick,” said Marika Bonner, executive director of the Orange County Medical Assn.

Since Aug. 1, UCI hasn’t taken new MSI patients who live more than five miles from the hospital or two miles from its clinics. UCI officials said the medical center cannot afford to continue treating the largest portion of the county’s uninsured and that other hospitals and community clinics need to take more patients. UCI continues to treat poor patients in its emergency room.

In addition to the changes at UCI, the county reorganized the MSI program starting Oct. 1. The county will establish its own case-management system to provide cheaper alternatives to hospital care, said Jon Gilwee, vice president of the Southern California Hospital Assn. He said that in fiscal 2001, the county paid hospitals about $25 million for $190 million worth of services.

“This is the early days of the redesign,” Bonner said. “We’re all willing to take a cautiously optimistic view. It certainly wasn’t working the other way.”

Dr. Ralph Cygan, chief executive of UCI Medical Center, said it is too early to tell how the new system is working.

The most common referrals from UCI have been to Sierra Health Center in Fullerton, Nhan Hoa Comprehensive Health Center in Garden Grove and Camino Health Center in San Juan Capistrano.

The change has doubled the number of indigent patients at Sierra. Trejo, the patient resource worker, said the wait for an appointment has grown from two or three days to two weeks. Christine Ta, executive director of Nhan Hoa, the only nonprofit clinic geared toward the Vietnamese community, said the clinic is seeing about 21% more MSI patients than previously. Camino Health Center director Deb Drew would not comment.

Another important change has been that UCI specialists are not seeing patients from outside the area, forcing clinics to find other doctors who will treat their patients. Trejo said clinic physicians sent patients who needed special care, such as treatment for hepatitis C or a hernia, to specialists at UCI. “It was a lifesaver for us,” she said.

Nowadays, sometimes it is up to the patient to find the doctor.

“We can’t go through the Yellow Pages every time someone comes in here,” Trejo said. “We tell them to locate a specialist. When they do, we give them a referral so they can start treatment.”

Nancy Rimsha, director of the Health Consumer Action Center at the Legal Aid Society of Orange County, said some MSI patients won’t be able to find specialists to treat them. One of her clients can’t find an orthopedist willing to take what the county will pay, she said.

Also, Bonner said doctors worry that if they earn a reputation for accepting MSI patients, they will be inundated with the indigent. Bonner said the county is developing a network of specialists who will treat more MSI patients in exchange for a higher reimbursement.

“The specialty network is probably one of the greater hurdles to overcome,” she said.