Committee Urges Restructuring of Health-Care Priorities for Indigent

Faced with tight times and tough issues, San Diego County moved a tentative step Tuesday toward restructuring its health-care delivery system for the medically indigent.

If the plan goes through, it would not only pare the administrative structure of the system to save $1.5 million annually but also place San Diego in the forefront nationally in setting health-care priorities.

But supervisors reacted to sweeping recommendations by an expert committee by voting to keep all their options open while still exploring the ideas.

The Select Committee on Indigent Health Care had suggested that the county throw out its multiple-contractor system for delivering the care. It also recommended establishing a Health Policy Council to help the county set consistent priorities and policies on what services it will provide, and to whom.

If necessary, the county should begin contributing general fund money--not just state health care allocations--to caring for those too poor to pay for their own health care, the panel recommended. That is an idea not likely to meet a friendly reception from supervisors who have faced a series of budget crises in recent years.

The supervisors voted unanimously to approve the panel’s report “in principle” but made clear that they aren’t endorsing any specifics.

“This motion does not mean it’s a done deal,” said Supervisor Susan Golding.

“We’re looking into it. It doesn’t mean we’ve approved the principle or the concept. It’s just that we’ve approved looking into the concept,” said Supervisor Brian Bilbray.

With those directions, the county Department of Health Services will spend through mid-October investigating the panel’s ideas further and formulating recommendations for the board.

It is a process needed to make the system more efficient and more equitable, the Select Committee said in its report to the supervisors. The panel was composed of 10 leaders in the medical community, ranging from the chief of Scripps Clinic and Research Foundation to the president of the San Diego County Medical Society.

“Not only does the county lack a clearly articulated policy for health care for the poor, but it has a de facto policy in effect whereby the private provider community is carrying the burden of undercompensated care to the indigent,” the report says.

Eligibility Cut

For instance, the county’s reaction to continuing cuts in the amount of health care funding provided by state government has been to restrict eligibility for the County Medical Services program, which covers people from 21 to 64 years old who are not on welfare but cannot afford medical insurance.

It also stopped allowing emergency room workers to determine eligibility, instead requiring the patients to visit an eligibility worker elsewhere later. Patients usually don’t follow up, and hospitals have been stuck with their bills, the hospitals complain.

More fundamentally, the county should react to its health-care funding problems by taking an active stance to lead the nation in setting health-care priorities, the report says.

A suggested question to be addressed:

Should the county be financing expensive organ transplants when, in the 12 months ending in April, 1988, there were at least 2,600 women who delivered babies in the county with no prenatal care? These babies are known to be more likely to have birth defects and lifelong learning disabilities than other children.

Such issues are seen in health-policy circles as the most volatile and most important medical issues society will face in the next few years. So far, they have been addressed by only one state, Oregon, and not at all by the federal government.

A Health Policy Council would remedy that by setting priorities for such things as “joint replacements, heart transplants, coronary bypasses, AIDS, extensive rehabilitation, prenatal care,” the report says.

“The policy exists currently, but it’s a de facto policy,” said Philip Ayres, a member of the Select Committee and chief executive officer of Hartson Medical Service. “If there’s not enough money, then it’s the physician’s decision or the emergency room’s decision not to treat. Our feeling was that should be a conscious decision by the county.”

Ayres said the panel was aware that such decisions won’t be easy, but felt that, in the absence of national or state direction, the county should act.

“We sat back and said we have to make the statement and let the chips fall where they may. In other words, (the decision) has to be made somewhere,” Ayres said.

While issues of priorities can be expected to be sticky in the long run, in the short term the committee’s recommendation to restructure administration of the County Medical Services program is proving more controversial.

Officials of agencies that contract with the county to provide services to the medically indigent objected to the proposal to finance the restructuring plan by taking $400,000 from their operating budgets in the current fiscal year.

As now organized, indigent health care is provided through four geographic service areas, in which contractors are paid to provide care at their own clinics. The system teetered on the brink of collapse in June when the North County contractor pulled out, blaming losses of $1 million a year because of underfinancing by the county.

The Select Committee on Indigent Health Care recommended scrapping that regionalized structure and instead centralizing administration under one contractor.

To do so, the county would use $400,000 for the transition next May and June, taking the money from a $700,000 increase in contractor reimbursement that had been planned, said Paul Simms, director of physical health services for the county.

Contractor Unhappy

“We object and you should object when money that you intended for patient care is retained in a bureaucracy to redesign a program that may not need redesigning,” the supervisors were told by Gabriel Arce, chief of the Community Health Group, a contractor in San Ysidro.

“Our position is that, if more monies come into the program, there is no need for restructuring,” Arce said. “But, if no more money is coming into the program, we think that there should be one contractor.”