Wrong Rx

The most stunning aspect of the latest report on Los Angeles County’s healthcare system is not the budget shortfall of $195 million, or even the prospect of that deficit ballooning to $331 million if the economy and decision-makers in Sacramento and Washington don’t cooperate. A financial hit of that magnitude promises a continuing meltdown of the county’s health network, but elected officials and healthcare professionals have seen it approaching for months. They are sobered but unsurprised.

Last week’s real shock came from the county Department of Health Services’ preliminary recommendations to the Board of Supervisors on how to deal with the crisis. The department proposes transferring or closing 11 of the county’s 12 clinics and, perhaps, all six of its comprehensive healthcare centers. Transferring them to public-private partnerships operating under county contracts is an acceptable, even a smart, move; closing any would threaten to stand more than a decade’s worth of county health policy on its head. The board will no doubt demand details; it also should insist on alternatives, even those -- such as cutting hospital budgets -- that would certainly meet intense political and bureaucratic resistance.

Since the mid-1990s, the Board of Supervisors has refocused healthcare from hospitals to walk-in clinics, where patients can be seen cheaply and early, before small ailments grow into costly medical problems requiring inpatient hospital care. It has not been easy, and it required the Clinton administration to agree to two temporary waivers of the federal reimbursement rules that otherwise encourage counties to emphasize hospitals, because that’s where they get the most Medicaid money.

Today, virtually everyone in the healthcare establishment agrees that preventive and outpatient treatment is the proper model. But hospital care is still where the federal money is, and the county health department, although ostensibly onboard with the outpatient policy, still follows the money.

Health department officials insist that their proposal, which is to be heard by the supervisors today, is not a deviation from county policy but a continuation of it. If that’s true, they must make clear that closing clinics is off the table. Privatization, on the other hand, means many things to many people. The move could keep the county on course while cutting per-patient costs virtually in half -- but only if handled very carefully. Transfer can’t be rushed. Hasty deals, brokered to achieve quick savings, will leave patients without walk-in preventive or primary care. Shuttering a county clinic and contracting with a private operator five miles away to pick up the slack is not a transfer, it’s a closure.

If it takes more than a year or two to reach an agreement that will best serve patients, so be it. That may mean the county must find some money to tide it over, and that means pain. Again, so be it, even if the pain comes in the form of tighter hospital budgets or in the Proposition B trauma care parcel tax that voters authorized in 2002 to prevent the county system’s collapse.