Last February, a consultant hired by Ventura County concluded that the county's six public clinics were choked by red tape and burdened with too many administrators and an inept billing system. The consultant recommended a major overhaul.
Eight months later, change has yet to sweep the clinics, despite numerous committee meetings and pleas from clinic doctors who say they spend too much time doing paper work and too little treating patients.
Ventura County Health Care Agency administrators, however, say improvements are just around the corner. A committee formed about 5 months ago is considering an innovative proposal to let doctors run their own clinics, much as they would in private practice.
Shift of Responsibility
Physicians would assume responsibility for hiring and firing, day-to-day operations and many of the administrative tasks now handled by the Ventura-based health-care agency.
The plan, which may come before county supervisors as soon as next month, is expected to be tested during a 6-month to 1-year pilot program at West Ventura Clinic, said Dr. Richard Ashby, the assistant medical director for the Ventura County Medical Center.
"This could really make the clinics more effective and provide better patient care," said Dr. Katherine Stewart, of the Colonia clinic in Oxnard. "The way the clinics are run, there are little inefficiencies that add up every day."
The "semiprivate clinic" proposal is the latest attempt by Ventura County to improve its public health-care system, which suffered a severe blow last year when county officials discovered a $12-million health-care agency deficit. The agency's annual operating budget is $173 million.
That deficit was later blamed on years of poor management, sloppy accounting and computers too antiquated to handle the volume and diversity of billings.
At the time, the county considered dismantling key parts of its public health system--including its satellite clinics in Ventura, Oxnard, Moorpark, Simi Valley and Santa Paula that served as the chief source of medical help for thousands of elderly, disabled and indigent residents.
Instead, the Health Care Agency cut its patient load 8% by pruning 200 of its 1,200 jobs and trimming 35 of the Medical Center's 145 beds. It also upgraded its computer system in an effort to collect overdue bills.
Officials say the measures worked. By spring, the county congratulated itself for averting a crisis and said it expected to post a $1-million operating surplus for 1988.
But while the figures indicate a full recovery, clinic doctors and nurses say there have been hidden human costs. Clinic patients today face longer waiting times, fewer doctors and slightly steeper prices.
And medical professionals say there may be another, more dangerous cost that is not visible to health-care finance officials.
"I see people waiting a longer time to come in for a problem," said Dr. Joanne Baumer, one of two doctors at the West Ventura Clinic. "I see people letting urinary tract and vaginal infections go for weeks. They say, 'I can't come in--it costs too much.' "
Baumer recalled a young woman with a urinary tract infection who asked for a prescription by telephone so she could avoid the office visit fee. Baumer refused. Two weeks later, the woman finally came in, but by this time the infection had spread to her kidneys and could have caused serious damage if it had gone untreated, Baumer said.
Or the family with "big, weeping sores," one of the worst outbreaks of impetigo that Baumer had seen. The father noticed blisters on the face of his 4-year-old son but did not bring him in because it was too expensive, Baumer said. Ten days later, the father showed up at the clinic with two other sons in tow. All four were then infected.
"This is a very easily and cheaply treated disease," Baumer said.
A standard clinic visit runs from $40 to $50, Ashby said, which is comparable to fees at private urgent-care clinics that demand payment with service. Most patients at the public clinics are subsidized by Medicare or Medi-Cal, and some lack insurance coverage. In any event, doctors say even a $5 increase can be enough to deter the very poor from seeking treatment.
When the West Ventura Clinic opened in 1983, an office visit cost $35 to $45, and Baumer believes the modest increase now keeps some poorer patients away. She and Dr. John Ford, the only physicians in the modular building on Ventura Avenue, the main artery in the county's poorest census tract--have urged the Health Care Agency to establish a sliding scale for medical services. The system would reduce costs for simple, routine procedures and raise costs for more complicated and time-consuming ones.
At another county clinic, a registered nurse who did not want to be identified agreed with Baumer's assessment and suggestions.
The higher rates "create hardships. With private-pay patients, they tend to hesitate to seek health care," the nurse said. She said her clinic can only see 25 to 40 patients daily, but that the demand for services is twice that. Patients often are sent to other clinics or the Medical Center, she said.
Kay Maloney, the manager of ambulatory care nursing for the clinics, contends that no patients are ever turned away and that medical care is available to all who seek it. But she and Ashby concede that last year's health-care crisis has made obtaining medical treatment more difficult for some of the people who need it most:
Patients now face up to an 1 1/2-hour wait before seeing a doctor, up from a 30-minute average wait before last year.
The South Oxnard Clinic--in one of that city's poorest areas--has lost one of its two full-time physicians and two of its five nursing-support staffers. The county has no plans to replace that doctor or the staff members.
The Medical Center's family care training center, which is staffed by residents, now sees about 100 fewer patients per month because it lacks the nursing support to treat its usual caseload.
The Medical Center's neonatal care department has lost a nurse and a nursing assistant. Ashby said the department has been reorganized and that nurses now take patient histories of groups of women at the same time instead of conferring with them individually.
In addition, the clinics committee is still studying a cost-cutting recommendation by Peat Marwick--the accounting firm hired to assess the satellite clinics--that would consolidate the clinics in Simi Valley and Moorpark into one facility and do the same with the clinics in South Oxnard and La Colonia, Oxnard's barrio.
Ashby said clinic consolidations are unlikely. And he added that a number of improvements will soon streamline existing operations.
He said the Health Care Agency intends to consolidate all patient charges on a "superbill." Currently, clinics must fill out separate bills for office visits, medication, treatments and lab fees--a time-consuming process for everyone involved.
The Health Care Agency also expects to improve its access to financial records Nov. 1, when a more than $1-million computer is to go on line. Medical administrators estimate that the clinics run up a $700,000 annual deficit, but they say they are not certain about profits and losses at individual clinics.
The new computer is also expected to streamline clinic billings, which now are muddled.
"We have constant complaints about people's bills being inaccurate or inappropriate," Baumer said. She noted that her own hospital bill, incurred 18 months ago when she had a baby, arrived only recently for payment.
The county is also looking at several proposals that would make life easier for clinic patients who do not drive or are not able to walk. For instance, before seeking treatment, some patients must now visit the Medical Center in Ventura--a round trip of nearly 100 miles for some east county residents--for an "eligibility interview," which tells them what benefits are available.
This could be solved, Ashby said, by allowing clinics to conduct their own eligibility interviews on site. Another proposal is to allow the clinics to collect fees as they treat patients. Currently, patients cannot pay their bills at the clinic, but must send payment to the Health Care Agency.