New blood

About 700,000 mostly poor and uninsured patients cycle through the Los Angeles County healthcare system each year, visiting its hospitals, clinics and emergency or trauma units.

But what’s particularly troubling is the number of people who have cycled through the top job at the Department of Health Services. The last 10 years have seen the arrival and departure, after shorter and shorter terms of service, of three experienced, skilled and effective directors: Mark Finucane, who served for nearly five years; Dr. Thomas Garthwaite, who served for nearly four years; and now Dr. Bruce Chernof, who served for less than two years. What’s going on?

What’s going on is that the most complex of all departments is caught up in the antiquated political system that governs this enormous county. And the result is a thoroughly dysfunctional system of oversight.

The Department of Health Services is widely perceived as of significance only to the 2.5 million uninsured, while it is in reality one of the most important factors in the health of everyone in Los Angeles County. The department may run only 7% of all of the hospital beds, but it provides more than 40% of all emergency services and 15% of all trauma center services. It remains the backbone of a shrinking emergency system: 12 hospital-based emergency rooms have closed in the last 10 years, and 11 of 23 trauma centers have shut down in the last 20.

We cannot afford for the county’s broken system of governance to threaten the viability of our emergency services -- especially because there is a practical and realizable cure.

As currently constructed, the director of the Department of Health Services reports to five bosses -- the elected county supervisors -- none of whom, competent as they may be in other areas, has any expertise in healthcare. This is a seriously flawed system. The chief concern for each supervisor is to respond to the political demands of his or her 2 million constituents. The health services director, therefore, is essentially pressured to divide his efforts and budget five ways -- which is irrational because the health-services needs vary enormously among the districts. Although this problem has been somewhat offset by the recent change in the county administrative officer’s role to that of county executive officer, the political realities remain.

The cure is the creation of a public-private independent health authority, created by state statute and governed by a board whose members all have appropriate experience in healthcare. Its board members would not be political animals, and the health services director would report only to the chairman of that board.

Such a change would revolutionize the efficiency of the Department of Health Services. It would instantly free the department of the dead weight of a rigid civil service system, for starters, so it could provide employee and hiring incentives. It could seek and contract for services quickly where needed. And it would no longer have to stand in line with 30 other departments for the attention of the county counsel or other critical services.

Several successful models of independent health authorities exist. Both Denver and New York City converted their ineptly managed public medical services into efficient healthcare systems.

Locally, we can point to the remarkably successful model of the independent authority that runs the L.A. Care Health Plan. Created in 1994 by state statute, L.A. Care operates as an HMO for nearly 800,000 Medi-Cal patients and others in L.A. County. Even burdened by a level of state funding that is among the lowest in the nation, L.A. Care regularly outperforms its for-profit competition in quality of services and effectiveness. It also has been able to dedicate its operating surpluses to underwrite health insurance for thousands of children in the county and provide essential resources to dozens of community free clinics.

Creating an independent health authority isn’t a radical idea -- or even a new one. Several commissions and consultative bodies have recommended it over the last decade, including the Los Angeles County Grand Jury’s health and social services committee. It’s time for the county Board of Supervisors to let go and for the Legislature to get on board with the only hope the Department of Health Services has of getting out of crisis mode -- and maybe holding on to a director.