Foreign Visitors Put Strain on State’s Medical System : Finances: Many improperly obtain taxpayer-financed care. But officials say they cannot legally refuse treatment.

Dr. John Robertson vividly remembers the well-dressed woman from Iran who threw a tantrum at Los Angeles County’s Harbor-UCLA Medical Center because sicker patients had been scheduled for heart surgery ahead of her.

“She told me I had to do the surgery within two weeks because she had businesses to run in Iran and had to get back,” Robertson recalled. “I said, ‘Well, this is ridiculous. Are you seriously suggesting that I kick American residents out of line so you can have your surgery?’ ”

The woman, legally in the United States on a tourist visa, eventually underwent surgery to replace her malfunctioning heart valves, at a cost of about $45,000 to taxpayer-financed health programs for the poor.

Doctors at several public hospitals in Los Angeles County said the Iranian woman’s case is not unique. She is one of thousands of foreign visitors who improperly obtain taxpayer-financed medical care by manipulating health programs for illegal immigrants and other poor California residents.

State and local health officials have no comprehensive estimates of how many of these patients are using California’s publicly financed health programs, nor of the financial drain. Yet many health officials say the problem is significant, because it has placed added strain on the state’s public hospitals and has cost programs such as Medi-Cal many millions of dollars.

In Southern California, half the people caught falsifying their Medi-Cal applications are visitors from other countries. Larry Malm, chief of Medi-Cal fraud investigations for Southern California, calls that a “conservative” snapshot of the problem.

Doctors at one public hospital in Los Angeles County said such patients have accounted for as much as 20% of the monthly heart surgery caseload.

To be eligible for Medi-Cal, applicants must be California residents and poor. Some of the foreign visitors, doctors say, meet neither requirement.

Among them are patients who have arrived for treatment at Harbor-UCLA wearing expensive jewelry and driving fancy cars, only to claim poverty when confronted with the hospital bill, doctors say.

“It’s such a joke,” said Dr. Jeffrey Milliken, the hospital’s chief of cardio-thoracic surgery. “We are giving away so much for free.”

The state’s health care system cannot afford to be so generous, officials say. The lingering recession has squeezed health budgets while increasing the number of poor and uninsured Californians who depend on publicly financed medical care. In the overcrowded public hospitals, especially those in Los Angeles and other urban areas, patients often wait eight hours or more to be seen by a doctor.

Most non-resident foreign patients pay for their treatment, health officials say. Some are simply tourists or business travelers who fall ill while visiting this country. Others make special arrangements to get treatment unavailable in their own countries.

‘Gaping Loophole’

The drain on public health programs comes from those who do not pay--a problem that doctors and California health officials say has mushroomed since 1986, when Congress required states to provide certain health benefits to illegal immigrants.

Malm, Medi-Cal’s fraud investigator, said the 1986 law provided a “gaping loophole” easily exploited by legal foreign visitors who come to California for the sole purpose of obtaining free health care.

The federal law requires state Medicaid programs, called Medi-Cal in California, to cover emergency and obstetrical care for illegal immigrants. It also exempts illegal immigrants from requirements to prove their eligibility by supplying Social Security numbers or other documentation. Medi-Cal workers essentially have to take these patients at their word.

But Deputy State Health Director John Rodriguez said an undetermined amount of Medi-Cal costs attributed to California’s 1.3 million illegal immigrants goes to pay the bills of non-resident foreign patients.

Rodriguez said a new regulation requiring Medi-Cal applicants to provide proof of residency should save the state $10 million this year. But, he said, the total cost of treating foreign visitors is probably much higher. It would include bills for those who pose as illegal immigrants or provide false information about their residence and financial resources.

Some foreign visitors have received transplants of hearts, kidneys and other scarce organs, said Dr. Wayne Erdbrink, a Medi-Cal reviewer for the state.

“We see where people have recently arrived from Costa Rica, Taiwan, Russia, Israel, the Middle East, Philippines, Mexico, even Belize and Peru,” Erdbrink said. “All you’ve got to do is walk down and apply and say, ‘I am broke and I’m sick,’ and you get on Medi-Cal.”

Others enter the system through public hospital emergency rooms, taking advantage of state laws obligating these facilities to treat all seriously ill people who come to their doors.

With few exceptions, these patients are very sick, doctors say. So once they enter an emergency room, it is virtually impossible to deny them care. American medical ethics also compel treatment.

California taxpayers may foot the bill, even when these patients reveal business and other assets in their home countries, as the Iranian businesswoman did.

State health officials say they do not have the investigative resources or the legal authority to seize assets in foreign countries. And federal agencies, notably the Immigration and Naturalization Service and the State Department, say they cannot keep foreign visitors with illnesses out of the country. Officials say it would be virtually impossible to screen the millions of visitors to the United States for hidden medical conditions.

Cases under investigation by Medi-Cal suggest both the magnitude of the foreign patient problem and its complexity. And health programs are not the only services affected.

For example, Medi-Cal is investigating the case of an Israeli man who got free heart surgery in California some years ago and now has returned to the state to claim disability benefits for his heart condition.

The man is on a visitor’s visa, said Malm, the Medi-Cal fraud investigator. Yet he has somehow obtained a Social Security number and qualified for disability payments.

Southern California, with its busy international airports and proximity to the Mexican border, has been especially hard hit by fraud involving non-resident foreign patients, Malm said. Of more than 7,000 people excluded from Medi-Cal annually in the region because answers on their applications proved false, half are residents of other countries--a higher proportion than elsewhere in the state.

“I think the word is fairly widespread that Los Angeles--and Southern California in general--is the place to come,” he said. “Los Angeles has world-class hospital facilities, the doctors speak at international conferences, the hospitals promote their reputations (and) then there is the multicultural population of Southern California. It seems everyone has a relative somewhere.”

Spurred by complaints from doctors and hospital administrators, Los Angeles County conducted a brief review of medical records at two public hospitals last year and found at least $1 million in unreimbursed costs that county officials could prove were run up by foreign patients who were neither illegal immigrants nor residents of California.

‘We Open Our Arms’

County health workers privately say the actual costs are much higher. Interviews by The Times with doctors and hospital officials suggest that as well. In just one department of one county hospital--cardio-thoracic surgery at Harbor-UCLA--doctors estimate that as many as one in five heart surgery patients is a non-resident foreign visitor. At an average of $45,000 per case, that would amount to about $2.5 million each year.

“It is horrible,” said Milliken, the department head. “We open our arms to these people. We give them excellent care and we basically charge them nothing.”

Milliken and other county hospital staff say they have mixed feelings about these patients. Some are truly pitiful, brought in by family members desperate to save a loved one. Many also appear to be poor people, from countries as near as Mexico or as far as the other side of the globe.

One case involved an emaciated woman from Africa, about 20 years old, who was carried through emergency room doors by relatives.

“I went down and saw her and I couldn’t even believe she was alive,” recalled Mel Grussing, a Harbor-UCLA administrator. “We had to rush her into surgery.”

The problem was a birth defect, a hole in the heart. In the United States, babies with the condition undergo a surgical repair that lets them develop normally. The lack of such early treatment had severely stunted the young woman’s growth and left her bedridden and gasping for breath.

Grussing said the woman improved dramatically after surgery--and the family’s gratitude left the hospital staff happy to have been of help.

But other patients, such as the Iranian businesswoman, leave a bitter taste--especially now. As budget cuts threaten to severely curtail health services for the poor in Los Angeles County, resentment is building among doctors and administrators. They note that some foreign patients seem to be well coached in laws governing eligibility for free care.

“If you say, ‘Do you have any money?’ they say ‘No,’ ” said Anita Gardiner, Harbor-UCLA’s cardiac surgery coordinator. “Do you have a job? ‘No.’ Do you have any property? ‘No.’

“Then you find out later that a lot of them could pay, it seems.”

Robertson, who was chief of cardio-thoracic surgery at Harbor-UCLA from 1985 to 1990, said some of these patients arrived at his office in Rolls-Royces and Mercedes Benzes.

Other seemingly affluent patients, county hospital workers say, included a physician attending a medical convention, military and government officials, and people whose claim to poverty was belied by designer clothes, Rolex watches and pocket-size cellular phones.

Robertson, now at St. John’s Hospital in Santa Monica, said he complained repeatedly to hospital officials and tried to organize a blockade to keep foreign patients from displacing poor county residents.

But administrators, citing federal and state laws, said the patients could not legally be refused treatment if their symptoms were severe. “If the patient tells us they don’t have any money and they give us an L.A. County address and the doctors tell us they need treatment, we have no choice but to take them,” said Grussing.

Some foreign patients bring test results and referral letters from doctors in their own countries. “(The letters) are sort of amusing in one horrible sense because they represent the arrogance or misunderstanding that America is offering foreign aid within its own boundaries,” said Dr. Irwin Ziment, chief of medicine at Olive View Medical Center, the county hospital in Sylmar.

Scarce Resources

Dr. Stan Wilbur remembers a 73-year-old Bangladeshi who showed up in Olive View’s emergency room last January with advanced bladder cancer. “He brought his medical records and he had all of his CT scans and X-rays, and a box of pathology slides of his cancer cells,” Wilbur said.

The elderly man was accompanied by a local resident who introduced the patient as his father. “But,” Wilbur recalled, “the (patient) later told me he wasn’t related and had flown in the night before from Bangladesh. He even apologized to me for being tired because he had jet lag.”

Doctors say they would not begrudge treating non-resident foreigners except that they are taking resources away from other patients. “It’s just so frustrating when you can’t even get a mammogram on a woman with a lump (in her breast) for two months,” said Dr. Karen Hutchinson of Olive View.

The frustration is not confined to doctors on the front lines.

Douglas Bagley, the top administrator at Los Angeles County-USC Medical Center, asked county health officials two years ago to use their clout with federal authorities to stop seriously ill people from entering the United States. At the time, he was head of Olive View Medical Center, where the problem was growing.

The final straw for Bagley was a patient who arrived at Olive View from Cyprus, with a visa clearly labeled by the American consulate there: “For medical treatment.”

“Somehow, it does not seem right that L.A. County is obligated to provide free medical care to such a case,” Bagley wrote to county lawyers in a memo obtained by The Times. “Nor does it seem proper that INS should have granted entrance to the country for this purpose.”

Bagley’s July 1, 1991, memo led to a high-level meeting last summer of state and county health officials and INS representatives. Irene Riley, a health department finance officer, hoped to persuade the federal agency to require cash bonds of foreign visitors seeking medical care in the United States.

But the meeting did not produce the desired results. Like the loopholes foreign patients exploit in California’s publicly financed health programs, gaps in INS and State Department authority make it impossible to keep them out of the country, federal officials say.

The only way the INS could help, Riley reported in a memo to her superiors, was if Los Angeles hospitals could identify a specific pattern of abuse by visitors from a specific country.

Even so, with 32 million visitors with visas pouring into the United States each year--2.1 million of them bound for Los Angeles--screening them for hidden medical conditions would be next to impossible, INS officials told Riley.

“Pretty much, we want people to visit--we want to encourage that,” J. T. Watson Jr., an INS commissioner who attended the meeting, said in an interview. “I don’t know why we would ever question whether they were going to do something dishonest.”

Gary Sheaffer, spokesman for the State Department’s Bureau of Consular Affairs, said his agency recognizes that some people who claim to be tourists are entering the United States to obtain free medical care treatment. “It is a problem that we are quite sympathetic with, believe me,” Sheaffer said. “But we don’t have any authority” to intervene.

Even if travelers disclose their intention to seek medical treatment--as the Cypriot patient did--consulates cannot demand payment up front, he said. Visa applicants must demonstrate only that they intend to return to their home countries and that they have enough money to support themselves while in the United States. Showing evidence of property holdings and bank accounts in the home country usually satisfies these requirements, Sheaffer said.

He suggested that Los Angeles County health officials file lawsuits in these patients’ home countries to recover the cost of their medical care.

The same suggestion was made to Irene Riley at the 1992 INS meeting. She noted in her memo: “If we are able to identify financial resources for visa patients (not an easy task), obtaining payment seems to require traveling all over the globe to file papers. I think the cost-effectiveness of this effort should be considered before further actions are taken.”

There has been no action since. County health officials say their hands are legally tied.

But state officials have moved to safeguard Medi-Cal dollars. New rules, projected to save about $10 million a year, require applicants--including those seeking illegal-immigrant benefits--to provide rent receipts, drivers licenses or other documents proving California residency.

Although these rules have narrowed Medi-Cal’s obligations, the regulations do nothing to stop the influx of foreign patients into California, nor do they address the laws compelling hospitals to provide care.

Costs will still mount, county health officials say, but now it will be up to counties and hospitals to find a way to absorb them.

“It’s pass the buck,” said Robert Gates, Los Angeles County’s health director. “The state’s in an admirable position to just opt out of (financial) responsibility. But we can’t, because we have the patients.”

The state’s Rodriguez acknowledged that the new Medi-Cal rules will not solve the foreign patient problem. But he defended them as a first step toward eliminating the international “magnet effect” of California’s taxpayer-financed health programs.

“We want to send a message: Don’t come to California simply for medical services,” he said.

Easy Route to Free Care

Some foreign patients entering the United States on tourist visas are quite open about the medical nature of their visits. This is the visa of a patient treated at taxpayer expense at Los Angeles County Olive View Medical Center. The handwritten message, “For medical treatment,” was added by the State Department officer who issued the visa, according to county health officials.