County to Weigh Creating Health Agency

Los Angeles County supervisors thought the dangerous overcrowding of County-USC Medical Center’s psychiatric emergency room was one problem that could be quickly fixed.

In response to reports by The Times and grand jury, the board two months ago gave its health department two weeks to devise a plan to open up 39 beds in another county hospital to accommodate the overflow.

Two months later, the beds at Olive View Medical Center remain closed and the County-USC psychiatric emergency room is so dangerously packed with psychotic patients that employees there say medical staff last week tried to turn away mentally disturbed people brought in by police.

The inability of the supervisors to relieve overcrowding at the psychiatric emergency room bolsters critics who argue that the board needs to cede control of the Health Department to a public authority of medical professionals.

Supervisors for years have resisted relinquishing their power. But their opposition has softened since federal spending cuts created a looming $884-million deficit in the health care budget and several reports criticized conditions in public hospitals.

At their regular meeting today, the supervisors will hold their first formal discussion about creating a health authority. They will receive a report from their staff on various models for a new health department and could order an additional study.

If Los Angeles County takes the dramatic step of moving to a health authority, it will join an increasing number of public health agencies nationwide that have tried to take the politics out of health care.

Larry Gage, executive director of the National Assn. of Public Hospitals, said a health authority’s appeal is partly in having “a full-time governing board that doesn’t have to worry about the jails and the police and the fire [department] and the other issues” that demand the attention of county supervisors.

But Gage and others caution that a new organizational structure for Los Angeles would not solve the dire budget problems the county faces. “Governance changes by themselves are not panaceas,” he said. “They’re not going to generate another half-billion dollars in revenues overnight.”

Some question whether a health authority would do any good. Supervisor Mike Antonovich, for example, has said such an idea would simply create “another layer of bureaucracy.”

The way Los Angeles County deals with health care has long been subject to criticism.

The county Health Department provides medical care for the county’s nearly 3 million uninsured residents through its six public hospitals and numerous clinics. It has a bevy of other responsibilities, from protecting against outbreaks of disease to managing the region’s emergency medical network.

The county health director reports to the five-member Board of Supervisors. As a result, the Health Department is a highly politicized institution. A hospital was built in every supervisor’s district. The county’s public hospitals operate as virtually independent institutions, not even sharing patient records with one another, and supervisors historically look after the interests of their hospitals rather than the system as a whole.

The sprawling system is perpetually wracked by crises, from medical mishaps to chronic budget woes. It has repeatedly failed to reform itself. When the federal government rescued the county from bankruptcy in 1995, the Health Department vowed to funnel more patients to cheaper outpatient clinics and cut costs. It did not do so at the promised pace.

Overcrowding Shows Agency’s Problems

The slow pace of change in the Health Department is demonstrated by the County-USC psychiatric emergency room.

Since last year, doctors and nurses there have warned that the room where families or police bring disturbed patients is so dangerously overcrowded it puts both patients and staff at risk. The hospital has been unable to ease the crowding because of a shortage of beds for uninsured psychiatric patients.

After a Times story on the problem in July, supervisors directed their health staff to present them with a plan to fund the Olive View beds. Dr. Gail Anderson Jr., the county’s medical director, said in an interview last week that it has taken longer than expected to figure out how to expand the psychiatric services.

“It’s a pretty complicated matter,” Anderson said.

Anderson said health staff are still studying the cost, as well as the logistics of transporting potentially dangerous patients from County-USC in Boyle Heights to Olive View in Sylmar. And finally, the county must assess whether it could hire the nurses needed to staff the beds in the midst of a nationwide nursing shortage.

“It’s one thing to have the physical space,” Anderson said. “You’ve got to find out if you even have a realistic chance of getting” the needed nurses.

The county has had difficulty competing with the private sector for nurses because of the more complex and burdensome process of hiring county workers. Advocates of a health authority say that sort of problem can be solved with a switch in governance.

“The process of government doesn’t lend itself to the rapid decision-making required in health care,” said Dr. Patricia Grabow, the medical director of Denver Health, which is cited as an example of the benefits of switching to a public authority. “Health care is an extremely competitive business in America. You have to be agile and free to quickly move.”

New employees of Denver Health, created in the late 1990s, no longer enjoy civil service protections, allowing swifter hirings and firings. Purchasing and leasing also have been streamlined. Grabow recalled that it took the city 26 years to buy the agency’s headquarters, but the new department snapped up a parcel of land for another building in only a few months.

Not All Authorities Have Been Successful

While there are several examples of successful health authorities, there are also failures. Chicago in the 1970s formed a health authority but dissolved the entity because of political infighting. Public health there is still controlled by county commissioners. In St. Louis, the creation of a health authority allowed city leaders to cut funding for public medical care, resulting in the closure of the city’s public hospital.

“For every horror story there are multiple success stories too,” said Gage, of the public hospital association. “So much depends on how you do it and how you address the complexities of your local situation.”

Creation of a public health authority in Los Angeles would probably require state legislation, years of uncoupling the health system from other elements of the county bureaucracy and possible pitched battles with unions seeking to protect their wages and benefits. The county’s administrative office says the transition alone could take three to five years--the time during which the deficits will appear.

A health authority can take a number of forms, from a county commission composed of experts who deal with daily medical matters and report to political leaders, to a full-fledged nonprofit corporation that has contracts with local government for funding but otherwise runs like a business.

In Alameda County, supervisors in 1995 created a health authority to run the county’s three public hospital facilities and five community clinics. The supervisors there give the agency a stipend to care for indigents and appoint board members, but have no other authority.

Elected Officials Lack Ties to Health System

Health officials there cite improved efficiency and flexibility. But they also worry about creating a system in which elected officials do not have a direct connection to the local health care system. Budget shortages this year have them considering closing their long-term-care facility and begging county supervisors for more money.

“We are not perceived of as the county responsibility,” said Melinda Paras, chairwoman of the authority. “If we choose to eliminate our long-term-care facility, that could appear to be our fault, that of voluntary trustees, and not that of the board of supervisors, which has some public accountability.”

She cautioned Los Angeles about putting its hopes in a health authority approach. Closing the looming deficit will require the direct involvement of influential county politicians to get more health funding from Sacramento or Washington, Paras said.

“Los Angeles faces a huge financial crisis a year or two down the road, and this will not fix this,” she said.