County Begins Rejecting Ill; Hospitals Brace for Impact

Financially stricken county hospitals and health clinics began rejecting new patients Friday as private hospitals across Los Angeles readied their emergency rooms for an expected deluge of low-income people with no medical insurance.

With drastic cuts to the county’s $2.5-billion health system hitting the public for the first time, county officials refused transfers of indigent patients from private hospitals and turned away new clinic patients

“It’s very distressing,” said Ernest Espinoza, a county health department administrator in Van Nuys. In the San Fernando Valley, he said, 70 people were turned away Friday morning from eight clinics.

Private hospitals are hiring more doctors and nurses and enlarging emergency rooms to cope with thousands of poor people expected to arrive as public medical facilities are closed to ease an unprecedented budget crisis. The effect of the transfer policy could increase patient loads at private hospitals by about 1,000 a month, health officials estimate.

But private hospital staffers warn that they may be unable to cope for long with waves of extra patients. They said physicians eventually will refuse to treat “no pay” patients, forcing some hospitals to close their emergency rooms and producing gaps in the region’s trauma care network that will endanger the middle class and wealthy as well as the poor.

“If the volume is anything like it could be, we won’t be able to hold out for more than a month or two,” said Dr. Brian Johnston, director of emergency services and chief of staff at White Memorial Medical Center in East Los Angeles. “Bad things will begin to happen. I think people will begin to die.”

Struggling to bridge a $1.2-billion budget shortfall, county supervisors voted last month to close 34 of 45 health centers and clinics, as well as most hospital outpatient services, on Oct. 1. The facilities each year provide hundreds of thousands of poor residents with prenatal care, immunizations against childhood diseases, AIDS testing and treatment for contagious diseases such as syphilis and tuberculosis.

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In anticipation of closures, clinics Friday began refusing to accept new patients or make new appointments for current patients. Clinic workers handed clients long lists of local medical providers who accept patients covered by Medi-Cal, the state’s insurance program for the poor, and flyers in English and Spanish detailing symptoms of common ailments such as high blood pressure.

County officials also clamped a 60-day ban on patient transfers to public hospitals, except for people with critical injuries or who belong to the county’s health maintenance organization.

County health czar Burt Margolin said the transfer limits were imposed because of “massive disruptions” occurring within county medical facilities, where 5,000 employees are expected to lose jobs.

“We need to have a smaller patient population to manage,” he said.

County officials said the clinic and outpatient shutdowns will produce an “unmet need” of 1.3 million medical-office visits per year. Transfer limitations will leave private hospitals caring for many non-paying patients who normally would be sent to county hospitals as soon as they are stabilized. Last fiscal year, 16,790 people were transported from private to county hospitals, many suffering from stroke, epileptic seizure, appendicitis, drug and alcohol withdrawal or broken bones.

Besides adding staffers, some Catholic hospitals in low-income areas are sending nuns into schools and housing projects to urge residents to stay calm and not flood their facilities.

“We’re telling them we’ll do as much as we can and we’ve been adding staff to care for their needs,” said Will Mallari, president and chief operating officer of Santa Marta Hospital, a Catholic institution in East Los Angeles. “But we’re also telling them we’re not the only hospital in town.”

Private hospital executives said their most immediate concern is doctors who serve on hospital “call panels,” standing by in case they are needed at hospitals to treat critically injured patients. After emergency room physicians stabilize a badly hurt patient, on-call doctors perform neurosurgery and other specialized operations and admit patients.

But no law requires on-call physicians to answer emergency room summonses and, several observers said, it is just a matter of time before they begin refusing to show up at emergency rooms to treat the poor.

“If you’re up all night taking care of an indigent, and you have to cancel your private [paying] patients the next day, they can’t and won’t accept that,” said Virginia Hastings, director of the county’s Emergency Medical Services agency. “Their recourse will be to go and say, ‘I can’t take calls.’ ”

“Some doctors, unfortunately, have a word for indigent patients; they call them ‘gomers,’ which stands for ‘get out of my emergency room,’ ” said David Langness, a spokesman for the Healthcare Assn. of Southern California, whose members are primarily private hospitals. “I had a doctor tell me last week, ‘I don’t want a patient load of 200 gomers in my office with 50 paying patients. Why? It’s going to drive me out of business.”’

Mass refusals by on-call physicians, said experts, could force some hospitals to close their emergency rooms, sending ambulances scrambling for an open ER, a treatment delay that would endanger critically ill people of all socioeconomic classes.

Hastings predicted that some smaller hospitals will begin filing applications to curtail emergency room operations within a month.

She compared the situation with the crisis that swept Los Angeles in the late 1980s, as hospitals certified as trauma centers began closing their emergency rooms because many on-call doctors would not show up to take care of uninsured patients.

But Dr. Daniel Higgins, director of emergency care at St. Francis Medical Center in Lynwood, said private physicians cannot be blamed for not wanting to stay up “night after night after night after night,” taking care of one uninsured patient after another who typically is “a belligerent, drunk, angry person who has HIV and a bullet wound.”

Given state and federal laws against “dumping” the uninsured, medical authorities said, private hospitals are unlikely to simply reject low-income people with truly life-threatening problems. But, they said, many of the poor will be unable to get adequate follow-up care after they are discharged or treated for chronic conditions that could flare out of control.

Many of those who now use county health clinics have chronic ailments like diabetes and high blood pressure, and get medication free at county outpatient units. But with those facilities closed, and with little money of their own for prescription drugs, many such people will only get sicker, eventually winding up in an emergency room.

“We’re going to see strokes, we’re going to see kidney failure, we’re going to see long-term complications of treatable disease,” said Johnston, of White Memorial. “They have to choose between taking medication or eating. What are they going to do? They’re going to eat.”

Facing long waits to get into crowded private emergency rooms, many poor people, especially the homeless and those with drug or alcohol problems, are unlikely to have the patience or persistence to get care, experts said.

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In an effort to fend off large numbers of low-income patients, many private hospitals in Los Angeles have submitted bids to take over the county health clinics. By keeping clinics open themselves, they believe they can prevent patients from inundating their emergency rooms, where care is far more expensive.

But Margolin, the health czar, has warned that some bids are flawed and that it remains unclear how much of the clinic network can be maintained under private management.

Beth Zachary, chief operating officer of White Memorial, owned by the Seventh-day Adventist Church, said the added cost to her nonprofit hospital of taking care of county patients “could easily be in the millions.”

Langness, of the health care association, said private hospitals will have to absorb 1,000 new patients a month because of the county’s patient transfer limits alone.

Shutting down county clinics could add thousands more, he said, comparing the patient load to that experienced by hospitals during the Northridge earthquake. About 82 private hospitals in the county have emergency rooms.

Langness said the financial burden could push some hospitals into bankruptcy. Many hospitals, squeezed by recession and cost-cutting linked to managed care, are in the red.

“We’re in a state of great chaos and fear,” said Langness. “No one knows what the impact of all this will be. . . . We’re bracing for an onslaught of new patients.”

Aside from financial anxiety, hospital staffers worry that all the extra patients will wear them out, leading to mistakes that could further hurt the sick.

“I’m worried we’ll misdiagnose or delay care to the point where the patient is harmed,” said Johnston. “My goal is to make sure that doesn’t happen in any area that I’m responsible for, but I think it’s inevitable.

“There’s an underlying mood of anxiety because we don’t know what’s going to be demanded of us, or if we’ll be able to do it,” he said. “And lives are at stake.”

Times staff writers Jeffrey L. Rabin and Douglas P. Shuit contributed to this story.