Citing Overload, CHOC Closes Orthopedic Unit : Health care: Hospital’s clinic was deluged with indigent patients seeking routine services, officials say.

Swamped by indigent patients requesting care for fractures and congenital bone ailments, Children’s Hospital of Orange County has closed indefinitely its 26-year-old orthopedic clinic.

Dr. Greg Bruchert, the hospital’s director of ambulatory care, said the clinic was essentially “cleaning up” for other area doctors who were referring marginally insured or completely uninsured patients to the hospital for follow-up care.

“It had become an onerous situation--taking care of patients that were not our responsibility,” Bruchert said. “Our doctors are willing, but there has to be a limit.”

Although Bruchert said it is hoped the closure will be only temporary, Dr. Sanford Anzel, one of the unit’s founding physicians, said the clinic and its closure is emblematic of a local health care system “out of control.”

In the last few years, administrators and physicians said, young orthopedic patients were being dumped en masse. Many had simple fractures and few resources to pay, making it nearly impossible for the tiny volunteer staff of physicians to effectively treat the rare ailments for which the clinic was founded.

In 1991, for example, the number of patients treated at the clinic stood at 1,600, nearly double the total from the previous year. Bruchert said that about 80% of those patients sought treatment for follow-up care on simple fractures, leaving little time for doctors to treat more serious cases ranging from club feet to curvature of the spine.

Also during that period, weekly clinic enrollment was peaking at 60 to 70 patients in a setting where the ideal number used to hover between 20 and 25.

Bruchert said the caseload was placing an increased burden on the clinic’s support staff--nurses, technicians and X-ray staffers--who also serve other functions in the hospital.

Still, the unit’s closing last week has met the objections of Anzel and Dr. Samuel R. Rosenfeld, one of the two physicians who have kept the weekly clinic operating every Wednesday for the past five years.

Without the clinic, Rosenfeld said, a “catastrophic health care crisis” would begin to emerge in Orange County.

“Indigent care in Orange County does not exist,” Rosenfeld said. “There is nowhere for these people to go.”

Rosenfeld said that he and fellow clinic physician, Dr. Carl Weinert, were willing to continue running the unit but could not do so without proper staff and equipment.

He claimed the hospital could have continued the operation through funds it receives from its insurance contract with Medi-Cal but instead elected to discontinue the service.

Bruchert, however, said that the number of patients had simply become increasingly draining on the hospital at a time when rules for reimbursement through Medi-Cal were changed to require doctors to fill out the necessary paperwork--a time-consuming task previously handled by resident physicians training at the clinic.

The director said notices have been sent to hospitals and clinics throughout the county informing administrators that the unit will no longer be available for their continued referrals.

By late this week, the hospital still had not received any responses from those institutions, Bruchert said. He characterized the patients’ reaction as “nothing too dramatic.”

Most of the patients receiving continued care through the clinic have either been absorbed by the private practices of Rosenfeld and Weinert or referred to other physicians.

Rosenfeld said he has attempted to spread the word that he would continue to take on more indigent patients in his private practice.

“We do more than our share (of volunteer) work, but sometimes you run up against a brick wall,” Rosenfeld said. “If only the hospital would come around and provide the other resources.”

Bruchert said that CHOC would not turn anyone away but predicted that some patients would probably “get caught in the middle” when seeking care from some private physicians whose costs are generally not completely covered by state insurance reimbursements.

“Times are getting tougher for doctors in private practice,” the director said.

While there are plans for reopening the clinic, Bruchert said that date is at least months away. He said the hospital would attempt to reorganize the clinic to more closely adhere to its goals when Anzel founded it in 1966.

At that time, the clinic was one of the few places in the county where children could be treated for such things as club feet, curvature of the spine or cerebral palsy. Although its concentration on rare ailments was somewhat diluted by the volume of less-severe cases in the later years, Rosenfeld said the clinic remained one of the last centers in the area known for special orthopedic care.

“It’s a matter of taking care of our own patients,” Bruchert said, adding that ways must be found for redirecting the care of less-serious cases.

In its initial years, Anzel said, the clinic was treating about 10 patients during the weekly morning session.

“It used to be that a kid would come in now and then with a busted arm, and that was OK,” Anzel said. “But now everybody knows that they can send (their patients) on to CHOC, and when you get so many kids on routine fractures, access to the clinic becomes overloaded. It reflects a breakdown in the health care system.”