Outpatient Clinics Crippled by Cutbacks

When a young man hobbled into an examining room at Olive View Medical Center recently, the diagnosis was simple.

The man’s dislocated ankle might need surgery, said Dr. Pramod Gan, as he peered at the swollen, discolored leg that had been set and put in a cast a few days earlier. “He really needs to see an orthopedic surgeon.”

Yet he was told that nobody at Olive View could help him. Instead, he was handed a yellow referral sheet and a map to help him find County-USC Medical Center 24 miles away. He was dumbfounded.

“I don’t know if I can make it,” pleaded the man who said he had no one to drive him to County-USC.

But he had no choice. He had arrived at Olive View on Aug. 23, the day the county-run medical center shut its orthopedic clinics. The orthopedic surgeons had been told not to show up. No one had told the patients, however, and they waited in vain with bandaged feet and aching limbs for someone to unlock the blue clinic door.

The walking wounded were the victims of Los Angeles County’s latest health crisis. Faced with a $7.6-million deficit, the county’s Department of Health Services decided to reduce services at the outpatient clinics at Olive View and its four other major hospitals. At the other medical centers, hours at specialty clinics, such as urology, ophthalmology and oral surgery, have been shortened. Waiting times in some cases will double, and at County-USC, some new patients will be turned away.

The cuts were a setback for Olive View, which was already treating tens of thousands of patients more than they were receiving funding for.

Even before the belt-tightening, it was taking 144 days for a child diagnosed with an orthopedic problem to see a doctor. A new gynecology patient was waiting 94 days. A person with a skin rash was waiting 118 days for a first visit. The initial appointment for a person with hypertension took more than four months to schedule. A newly diagnosed AIDS patient had to wait five weeks to be seen.

An immediate consequence of the new cuts will be that patients will wait even longer.

“It becomes an administrative nightmare. Who decides who’s going to get help and who’s going to wait?” said Maple Gray, Olive View’s assistant administrator.

“We’ve just got to make clinical judgments and see the sickest ones,” said Administrator Douglas Bagley. “Then on a relative scale decide who are less acute and try to defer them or see them less frequently.”

In the cramped clinics, physicians typically treat people who are not sick enough to be hospitalized. The doctors try to keep these patients out of hospital beds, where the costs of treatment are exorbitant.

Last year, 203,500 people passed through the emergency room and the clinics, which are scattered along a confusing maze of corridors on the hospital’s second floor. The clinics’ popularity has soared since three years ago, when 145,000 visits were logged at the newly reopened hospital in Sylmar.

To save nearly $1 million, Olive View physicians are supposed to eliminate 7,600 patient visits in the next 10 months.

The dental and orthopedic clinics were shut down immediately, though administrators later decided to restore 40% of orthopedic services. Still, 161 patient visits a month will be eliminated. Many other clinics, including those specializing in pediatrics, skin disorders, spinal deformities, kidney ailments, podiatry and neurology, will be open fewer hours.

When possible, physicians are being asked to spend less time with patients and to delay booking new appointments. A patient who normally would return in three months, for instance, might be given enough medicine for six months instead.

Those with medical problems needing immediate treatment will always be squeezed in, physicians emphasized. But some less-urgent problems will go untended longer.

Those who will suffer most will be the elderly, children and the working poor who use Olive View and its noisy, crowded waiting rooms. Most have no private insurance or they are covered by Medi-Cal, the state’s medical insurance for the indigent. But many private physicians shun Medi-Cal because they say the program’s reimbursements are laughably low.

Dr. Gino Iovine, Olive View’s associate medical director and director of outpatient services, said he has instructed physicians to see more patients by speeding up exams without sacrificing quality. But he acknowledged that the task will be difficult.

“If you reduce a 20-minute examination down to 10 minutes, it becomes very difficult to decide what to do,” Iovine said. “If a patient has a headache, it’s easy to check and say there is nothing wrong with them. But, on the other hand, you don’t want to miss a brain tumor.”

Physicians lament that they long ago cut out bantering with patients. In the cancer clinic, where most of the patients are dying and terrified, Dr. Harry Griffith said he feels more like a “technocrat.” He only has time to ask people how they feel, tell them their blood count and ask about their chemotherapy.

“I would prefer to sit and discuss some of their concerns and beliefs and thoughts about how they want to die, but we don’t have time,” Griffith said.

Doctors predict that trying to slow the stream of people into Olive View will backfire.

“You can’t play the shell game with patients,” insisted Dr. Robert Galli, an emergency room physician who, like many of the hospital’s physicians, is affiliated with UCLA. “If they aren’t seen in one area, they will go to another area of the hospital to be seen.”

That’s what happened after the orthopedic clinics closed. Dr. Susan Tully, head of the pediatric clinic, one day found five infants with possibly dislocated hips in her waiting room. She spent hours on the phone trying unsuccessfully to persuade orthopedic surgeons at County-USC to see the infants. Ultimately, physicians at the private Orthopaedic Hospital near USC agreed to take them.

“This ortho business has caused a tremendous mess,” grumbled Tully, who added that cutting back patients in her clinic is probably impossible because worried parents will continue to bring in children who just need chicken soup. “You spend so much time trying to send them away, you might as well see them,” she said.

At least initially, the adult orthopedic patients bound for County-USC weren’t as lucky as the babies. The day that physicians tried to persuade the man with a dislocated ankle to go to County-USC, another of the patients they referred was sent back to Sylmar. Hospital administrators said that is no longer happening.

“There were a tremendous amount of people out there who were sent adrift,” said Dr. Martin Morris, a private Mission Hills physician who ran one of Olive View’s closed orthopedic clinics.

Some physicians worry that delaying care will only aggravate health problems for patients who usually postpone getting help anyway. In fact, it’s already happening, Galli said. Once or twice a week, someone suffering from diabetes, angina or hypertension ends up in the emergency room because they ran out of medicine before their next clinic appointment.

Administrators acknowledge that the emergency room will become more congested as access to the clinics tightens. The emergency room, where gurneys are separated by pin-striped curtains, is expected to have an influx of 3,700 more people this year than last year, said Tony Rodgers, associate hospital administrator.

With no money to hire extra emergency room staff, the wait to see a doctor, which can now last several hours, will be even more unbearable.

That prospect frightens the nurses in the hospital’s busiest waiting area. They decide in what order people will see doctors in the emergency room or the walk-in clinic, where less seriously ill people are seen without appointments.

One or two “triage” nurses sit behind a counter with a plastic barrier erected to protect them from spitting patients, flying soda cans and medical clipboards. While most patients are appreciative of any help at all, the long waits sometimes cause tempers to boil.

“You are being cussed out constantly, attacked and spit at,” complained Yvonne Estrada-Heinrich, a registered nurse in the emergency room.

Like the emergency room, not all clinics can postpone treating patients. In the cancer clinic, for instance, patients with malignant tumors must be seen quickly and often. Consequently, 60 cancer patients are often scheduled to see physicians on clinic days--a 100% increase in recent years, said Dr. Nancy Feldman, who oversees the oncology clinic.

With so many patients, the chemotherapy area is jammed. To create more space, the two chemo nurses have sometimes resorted to laying a board across a trash can to make a support while inserting a needle into a patient’s arm. There is only room for two reclining chairs for chemo patients, who are often medicated to prevent nausea when the drugs are administered. The unlucky ones must sit in straight-back chairs in the hallway. On a recent day a man with colon cancer, who was feeling well enough to read the National Enquirer, was asked to give up the recliner for a frail, partially bald Korean woman.

The high-risk prenatal clinics could also pose problems for administrators trying to lower patient counts. Most of the poor pregnant women with diabetes, high blood pressure and other complicated problems in the San Fernando Valley end up receiving prenatal care at Olive View. Considering it a high priority, the county has provided the obstetricians with extra staff and money.

But the opportunity to receive quality care has each year attracted a record number of mothers. This year, physicians will see 10% to 20% more women than last year’s record number, said Dr. George Mikhail, head of the obstetrics and gynecology department.

Some physicians privately worry that the pregnant women will drain more and more money away from the other clinics.

“We are overburdened, but no more than anybody else,” Mikhail said. “I wouldn’t trade places with other departments. I get a lot of responsive ears.”

WAITING TO SEE A DOCTOR

Waiting times for first appointments for certain illnesses:

Gynecology: 94 days

Gynecological cancer: 34 days

Skin problems: 118 days

Cleft palate: 47 days

Cancer: 5 days

Children’s blood disorders: 61 days

Children’s orthopedic problems: 144 days

Hypertension and other ailments not requiring a specialist: 127 days

AIDS: 35 days