Budget Cuts Jeopardize Public Health : Medicine: Local officials scramble to patch holes and stem erosion in a system that is being pressured by growing demands and shrinking dollars.

Ventura County’s public health system--the provider of last resort for the needy--has been hit hard by budget cuts that threaten to erode the quality of medical care in every local community.

While this county is still healthier than the state as a whole, the number of poor and uninsured patients here is up dramatically. And the money to pay for their treatment is down.

Already, that has meant sharp turns for the worse on several common gauges of public health.

Infant deaths and teen-age pregnancies are increasing, while there has been a drop in early treatment of expectant mothers and the immunization of toddlers against disease.

At the same time, the number of patients at Ventura County’s public hospital and clinics has soared.

Ventura County Medical Center had 16% more patients and delivered 44% more babies last year than it did four years ago. And clinic visits have jumped almost 50,000, or 33%, during the same period.

Strong demand amid a series of state budget cuts has left local health officials scrambling to patch holes in care and to hold the line against a subtle erosion of the county’s overall health.

While Ventura County’s financial health-care crisis has hit both the private and public sectors, it is at the public level that services could be most seriously affected. And any deterioration of public health care ultimately will be felt throughout the entire county population, medical experts say.

If the public health system stumbles under its increasing load, some officials say they fear that more newborn babies will be jeopardized and that diseases now under control will spread as they do in nearby counties.

“My concern is that it will be much more difficult to respond to the outbreaks of disease,” county Health Officer Lawrence E. Dodds said. “Public health is not just care of the poor. If somebody has TB, it doesn’t matter what her social status is.”

Marilyn Billimek, county epidemiologist, added: “We’re afraid we’re going to be looking at Third-World medicine here pretty soon.”

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As more of the region’s poor and uninsured have come to its door, Ventura County’s public health system has embraced reforms that have made it a statewide model of efficiency--and the focus of dispute.

First, in the mid-1980s, it transformed the old battleship-gray county hospital in Ventura.

Tarnished by crowded 12-patient rooms one doctor calls “Civil War wards” and crippled by $40 million in debt and uncollected bills, the county hospital was almost turned over to a private company to run.

Instead, county officials revamped the hospital’s business operations, replaced its crowded wards with semiprivate rooms and gave it the sparkle of a private hospital.

And the improved quality is not just skin-deep, say doctors and hospital administrators throughout the county.

“We’re very fortunate compared to other counties,” said Daniel R. Herlinger, president at St. John’s Regional Medical Center in Oxnard, of the county hospital. “The quality of care there is as good or better than any private hospital.”

In a similar metamorphosis, three of the county’s four neighborhood medical clinics--almost closed three years ago because of a $1-million annual deficit--have been revived by turning them over to private doctors who run them for a profit. The fourth clinic is expected to be converted next year.

The semiprivate clinics, which still must care for anyone who walks through the door, are now making money and serving three times as many patients as they did before, officials said.

And counties throughout the state are calling for information about how to adopt “the Ventura model,” officials said.

Such changes have helped Ventura County cope as health-care funds have dried up or failed to keep up with inflation.

While demands for service grew, the county’s overall health-care budget shrank from $152 million to $143 million during the last year.

“The number of immigrants coming into our county who are poor is simply exceeding our ability to serve them,” said Phillipp K. Wessels, the county’s top health official. “But we are committed to providing as much access to care as possible.”

About 48,000 Ventura County residents lived in poverty in 1989, according to the U. S. Census. And since then, the number of welfare cases here has risen 68%.

In addition to the poor, an estimated 15% to 20% of county residents--more than 100,000 people--are uninsured and also depend on county facilities for medical care.

The restructured clinics in Santa Paula, west Ventura and Oxnard--all in impoverished areas with large Latino immigrant populations--are now open five days a week and some evenings, Wessels said.

Over the fiscal year ending in June, visits to the county’s community clinics and those at the hospital increased by 40,000 to more than 191,000.

But changes at the hospital and clinics have prompted critics to charge that county administrators are too focused on the bottom line.

Doctors at St. John’s Regional Medical Center say the county hospital has pulled so many beds out of operation in recent years--down from 208 to 148--that it is almost always full.

That forces private hospitals to take the overflow of uninsured and indigent patients, and suffer the financial consequences.

Philip L. Cardan, a general surgeon at St. John’s, said he has never been able to transfer a patient to the county hospital.

“The usual excuse is that they’re full,” Cardan said. “But I notice that when the patients have a Spanish surname they are particularly full (because) they have a higher chance of being uninsured.

“I’ve had the transfer nurse ask me, ‘Is the patient a citizen?’ ” Cardan said. “I said it’s not my job to ask a person’s citizenship. I’m not the Border Patrol.”

County hospital administrator Pierre Durand said he found Cardan’s comment offensive. No screening of Latino patients would be tolerated, said Durand, noting that he is a native of Peru.

The county hospital is often full or nearly full, with an occupancy rate of about 95% for the first half of the year. But that reflects only the hospital’s physical limitations after its remodeling in the mid-1980s, Durand said.

The remodeling cut available beds to 148, a reduction officials said was necessary to modernize the aging hospital. State reports show, however, that the hospital provided staff for only 143 beds on average for the first quarter of 1992, and 138 for the second quarter.

Durand said the reduction was a statistical anomaly created by the averaging, and not significant. He said a few beds are kept open in case of major accidents, because the hospital is the county’s main trauma center.

“We do receive transfers from a lot of the hospitals,” Durand said. “But when we’re full, I think it is only reasonable that the other hospitals keep the patients. It’s the moral thing to do.”

The nonprofit hospitals, such as St. John’s and Community Memorial, also have an obligation to care for the needy, because they receive a taxpayer subsidy through a property tax exemption, Durand said.

“That even raises the question about the need for them to be asking for transfers at all,” he said.

A second dispute has arisen since September, when the Board of Supervisors followed Wessels’ recommendation to cut nearly $1 million out of the Public Health Department’s $6.5-million annual budget.

The move, prompted by a last-minute loss of state funds, shifted the money to the county hospital and transferred several Public Health Department duties to the new semiprivate medical clinics.

A committee of health professionals, which advises the supervisors on family health matters, filed a letter of protest.

“(We) are horrified by the proposal to merge the Public Health Clinics with the Hospital Clinics,” wrote committee chairman Robert Skankey, an Ojai obstetrician. “This will end the Public Health model for Ventura County forever.”

The committee’s concern is that the county is saving money by cutting in exactly the wrong place, said new chairwoman Barbara Thorpe, a university nursing professor from Oak View.

The mainstays of this county’s good health, Thorpe said, are the public health programs that track communicable diseases into the home and which educate families about prenatal care, nutrition, family planning and the value of immunizations.

“These field nursing services are incredibly important,” Thorpe said. “I think it’s shortsighted of the county to cut the field services in public health. It is a major mistake.”

Dodds, the director of public health, said he is also concerned about the effect of the cuts on his department and the shift of several preventive health programs to the medical clinics. Doctors who run the clinics are more attuned to treating illnesses than preventing them, he said.

“We have ways of helping the pregnant teen-ager access the system,” Dodds said. “We help her stay in school and we teach her to nurture her child. The end result is a successful mother and a healthy child.”

Without such care, “we end up trying to pick up the pieces. If we don’t pay one year, we’ll pay another.”

Dodds said the number of public health field and clinic nurses has dropped from 33 three years ago to 26 this year, mainly because such nurses are in high demand and hard to recruit.

Two of the 22 jobs eliminated last summer were vacant field nursing positions, he said. One field nurse who was still on the job left during the cutback, he said.

Wessels said, however, that county health care was not jeopardized by cutting 16% of the Public Health Department’s 134 workers.

Eleven of the positions were already vacant and the 11 displaced workers were either supervisors or office help, said Wessels, who oversees all county health programs including the Public Health Department.

By shifting some public health services to the semiprivate clinics the county was able to keep all of its programs at current levels, Wessels said.

“I think this (dispute) is somewhat territorial,” he said. “We’re trying to mesh two entirely different mind-sets, and we’re going to have some problems. But I’d rather do that than cut entire areas of service.”

If the $1-million cut had come out of the county hospital’s budget, the result would have been fewer available hospital beds or shorter hours at hospital clinics, he said.

It may be true that the remaining public health nurses--now without the support of three supervisors, a translator and clinic assistant--have to work harder, Wessels said. “But these are tough times and we all have to roll up our sleeves and do more.”

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Public health nurse Rosa Maine says her sleeves are rolled up.

By herself, Maine covers Santa Paula, Fillmore and Piru, an area that had three nurses two years ago and two nurses until the cuts in September.

“I’m extended, way extended,” said Maine, a county nurse since 1983 and a native of Peru. “We can’t see our patients as often as we should. How can we? We cover so much area.”

Maine, who splits her time between a public health clinic and the field, said she works a caseload that has increased from 25 to 35.

The value of her labor was illustrated by a visit last week to the Santa Paula home of Maria Loyola, the nurse said.

The 23-year-old expectant mother already has three children, and since July, Maine has monitored Loyola’s pregnancy while teaching her family how to improve its diet and hygiene.

As Maine counseled the Loyola family during a visit, two other young Latina mothers with young children stopped in to ask for advice on medical care.

“When you’re in the field, that happens,” she said. “If they know you’re going by, they drop in.”

Maine said she isn’t convinced that such people can be reached solely through the Santa Paula clinic.

The clinic operates like a private doctor’s office and requires appointments for many types of care, and that has discouraged some patients, she said.

“Sometimes people are ready to go today, but not tomorrow,” she said. “And maybe they have transportation today, but not tomorrow.”

Loyola, for example, recently was refused an appointment for a prenatal examination at the Santa Paula clinic, because she missed appointments and argued with the clinic’s staff, Maine said.

“It’s sad because she lives so close to the clinic,” Maine said. “It seems like they’re punishing her . . . . And my concern as a nurse is (that) a lot of people are going to fall through the cracks.”

Nat Baumer, a doctor who runs the Santa Paula and west Ventura clinics with his physician wife, Joane, said he knew little about the Loyola situation.

Baumer, who also directs emergency services at the county hospital, said the clinic needs to schedule appointments to be efficient. But he said he would make sure that appointments do not get in the way of good patient care.

“They’re raising some valid concerns, and we’re just going to have to monitor it,” Baumer said. “Public health should be out there educating the people, getting them identified and bringing them into the clinics.

“But our philosophy is that public health care should all be provided under one roof,” he said. “Decrease the bureaucracy, streamline the operation and provide the most care for the dollar.”

Baumer’s statement is the credo of Ventura County health officials. They say they recognize that the old ways of doing business are over. They must stretch every dollar and seek every grant to replace services lost to cuts.

For example, the county’s inoculation program will begin receiving in January a $130,000 grant that could be renewed annually for eight years if goals are met, said program director Sue Hyatt.

About 59% of county children have received their full battery of shots by age 2, according to a state survey. That compares to 48% statewide and 42% in Los Angeles County.

But Ventura County is losing ground, Hyatt said.

Of the more than 11,000 babies born here in 1991, 52% of the mothers were born outside of the United States and may not consider measles a serious problem, she said. Inoculation levels in the poorest neighborhoods are perhaps 33%, she said.

“We’re not reaching a certain group of these kids,” she said. “When these families prioritize, immunizations don’t even make the list.”

But the new grant will put nurses into the community--at welfare offices, low-income housing projects and Head Start preschool sites, she said.

At the county hospital, in an innovative public-private arrangement similar in concept to the Baumers’ contract, pediatrician Chris Landon is also changing the way the county treats its young patients.

The county reimburses Landon for his rent and Landon arranges for a wide variety of pediatric sub-specialty care not previously offered here. Landon said he makes about $165,000 a year from his county contract and private consulting fees, and the county reaps a net of $500,000 in Medi-Cal payments for his patients.

“I think we all are in the business of reinventing the delivery of health care,” Landon said. “It’s capitalism with compassion.”

Ventura County’s movement away from traditional programs has put it in position to embrace a new state mandate that 20% of Medi-Cal patients be seen by private managed-care groups by 1996, Wessels said.

“The way we do things in the future is going to be greatly different than we do things now,” he said. “We have to keep expanding services with no new money. The status quo will sink us.”

Ventura County Medical Center

How Emergency Patients Pay Medi-Cal: 50% No Insurance/Self Pay: 34% Medicare: 5% Private Insurance: 5% Indigent: 4% Other: 2% *

Total Patient Discharges, Excluding Newborns 1987-88: 7,805 1991-92: 9,040 *

Births 1987-88: 2,665 1991-92: 3,835 *

Hospital and Clinic Visits 1987-88: 143,306 1991-92: 191,025

Infant Death Increase (per 1,000 births)

County Births, Infant Deaths

1987 1988 1989 1990 1991 Total Births 10,874 11,472 12,010 12,721 11,175* Infant deaths per 7.4/80 6.6/76 6.7/81 7.6/97 7.8/87* 1,000 births/total Low-weight babies 4.8/523 4.9/566 5.9/703 4.6/543 4.9/540 per 1,000 births/total Women with prenatal 77.8% 80.5% 79.8% 75.9% care in 1st trimester

* 1991 totals are preliminary and could increase

Source: Ventura County Public Health Services

Teen Age Births (As percent of total births)