Cutbacks Force Clinics to Turn Away Needy

Less than two hours into his shift on a typical day last week, Dr. Richard May had turned away a dozen patients from the walk-in clinic at County-USC Medical Center, the main hospital serving the poor of Los Angeles County.

It worked out to about one out of every five patients he interviewed. All of them were sick. Some just were not sick enough to meet the leaner--and what medical staff and administrators acknowledge are meaner--criteria for care in the hospital’s adult outpatient clinics.

For the first time in the 58-year-old public hospital’s history, needy people are being turned away because of tougher criteria for care forced two weeks ago by $7.6 million in reductions to the county health services budget.

These reductions resulted from California’s fiscal crisis, partly resolved by deep cuts in state aid to counties for medical care of the indigent.

Besides County-USC, other facilities affected are Martin Luther King Jr./Drew Medical Center, Harbor-UCLA Medical Center in Torrance, Rancho Los Amigos Medical Center in Downey, and Olive View Medical Center in Sylmar. High Desert Hospital in Lancaster is not affected.

Those affected have decided to absorb the cuts by reductions in adult outpatient services that serve about 1.5 million poor residents annually. The cuts affect walk-in clinics for sick people without appointments and specialty clinics for patients with chronic problems such as diabetes, asthma or heart disease.

Faced with $4.2 million in cuts, County-USC’s goal is to reduce the number of people seen in specialty clinics by about 20% and the daily load at the walk-in clinic from 250 to 100 patients.

The screening criteria were introduced to try to get medical attention to the sickest, not just those at the head of the line, according to Richard Cordova, administrator of General Hospital, one of four hospitals in the complex and where the adult outpatient clinics are located.

May is one of the screening doctors. He said his task has made the last two weeks the saddest of his 18 years on the hospital’s staff. He tries to determine the likelihood of a person’s symptoms escalating into life-threatening or debilitating illness within the next 24 to 48 hours. He conducts only a brief interview in a room crowded with people hoping to receive care and uses a variety of subjective criteria to determine who can stay and who must go.

“The type of people who come to L.A. County are the people who have been turned away from every other hospital and now here I sit turning them away again,” he said. “It’s not what I was brought up to do in medical school.”

Across the table on this day sat soft-spoken Ismael Esquivel, 27 years old and unable to speak English. A translator told May of Esquivel’s six-year history of intense headaches that often leave his vision temporarily blurry. In the last three months, the pain has worsened, Esquivel says. He has no health insurance.

May suspects a parasitic infection of the brain common to people from Latin America, and accepts Esquivel for care. The translator explains this to Esquivel, who is directed to the end of another line, where many will wait most of the day to be examined.

Patients at the specialty clinics will have longer waits as a result of the budget cuts. Many now waiting four to eight weeks for an appointment may be put off as long as 12 weeks, county health officials have said.

In theory, reduced services should force patients with milder illnesses to find private doctors or seek care at one of the county’s five health centers or 40 public health stations. However, these facilities are already busy and are limited in the kind of care they provide. Health center patients with more complex problems typically are referred to the clinics at County-USC.

For example, it made no sense to May this particular day to tell Maria Elena Villasenor to take her nearly blind, 60-year-old brother to a health center. Reyes Garcia’s eyes, one blinded by a cataract and the other losing vision steadily, are not his only problems. He also suffers from a heart condition that requires enough medication to fill half of a grocery bag.

“I’m not turning this one away,” May said. “Near-total blindness I consider an emergency. I don’t turn elderly, frail people away either. Some of them are so confused I know they will never get to a health center if we don’t take care of them here.”

May tries to be alert to whether the patient can read. He estimates that at least 10% of those who come to the hospital clinics cannot, and therefore are not helped by the list of health centers given to those who are turned away.

One 29-year-old man puzzled over the list for different reasons as he stood in the middle of a corridor lined with the overflow of people from the walk-in clinic’s waiting room. He had waited nearly two hours to advance in the line as far as May’s interviewing table, but his problem--venereal disease--was not considered serious enough to be treated at the hospital.

He declined to give his name out of embarrassment over the diagnosis. But he was open about his other worries: no job, no money, no health insurance and no car. He had hitched a ride to the hospital with a friend. Now, he was trying to figure out by the addresses on the list whether there was a facility he could walk to.

Dr. Gerald Whelan, associate director of the hospital’s department of emergency medicine, believes many of those turned away will not go to health centers. He sees the cutbacks as forcing a “recycling” of patients from the outpatient clinics--where minor ailments could be prevented from becoming major ones--to the emergency room, where they will show up several weeks later, sick enough to require admission to the hospital.

“It is a penny-wise and pound-foolish approach,” Whelan said angrily. “The cost of that acute hospitalization wipes out whatever you’ve saved by reducing clinic visits. And the people with private insurance who think they are not going to be affected are going to find the (emergency rooms) of their hospitals full of indigent people who were turned away here.”

As administrator, Cordova’s job has been to give medical department heads the bad financial news, then work with them to implement service cutbacks as humanely as possible.

“It has translated into a lot of frustration for the staff here,” Cordova said. “Everybody out there expects the county hospital system to be all things to all people and we just can’t afford to do that anymore.”