County May Limit Shift of Patients

Los Angeles County officials are considering strict limits on the number of uninsured patients that private hospitals can transfer to county facilities as part of an effort to keep its troubled health department afloat.

As it stands, private hospitals can shift patients to county-run hospitals solely to avoid paying for their care -- a situation that is not tolerated in some other urban areas with large public hospitals.

A majority of county supervisors favors curtailing those so-called “lateral transfers,” which cost Los Angeles County millions of dollars each year. A proposal to that effect could be introduced as early as this week.

“The county taxpayers ought not to be left holding the bag, and picking up the burden of the health-care costs,” said Supervisor Mike Antonovich.

The idea of changing the transfer policy is gaining some urgency as the county’s options for paring its health-care budget appear to be dwindling.

On Thursday, a federal judge tentatively blocked the county’s plans to close its renowned rehabilitation hospital and cut 100 beds from County-USC Medical Center. Combined, those cuts would have saved the county $75 million in the first year alone.

But private hospitals, many of them mired in their own budget crises, say they would be strongly opposed to a county effort to save money by forcing them to keep uninsured patients. Administrators say they could quickly be overwhelmed financially.

In its last fiscal year, the county accepted 11,243 transfer patients, mostly from private hospitals. More than half of those were lateral transfers.

Huntington Memorial Hospital in Pasadena, which is certified to provide high-level trauma care, acknowledges that “the only reason we transfer to a county facility is because of an insurance issue,” said spokeswoman Connie Matthews.

“It can cost the hospital thousands and thousands and thousands of dollars” to care for one critically ill patient who is uninsured, she said. “It affects the bottom line, and we are really, really, really budget-conscious right now.”

Jim Lott, executive vice president of the Hospital Assn. of Southern California, said eliminating lateral transfers could “eradicate” the slim profits of small community hospitals.

“Sure, the county can do it; there’s no question about that,” he said. “By doing so, they are widening the threat of a ... meltdown beyond simply the county hospital system.”

Even if the changes were enacted, the county would continue to accept transfer patients if they needed a higher level of care than the private hospital could provide -- such as specialty treatment for trauma patients, officials said.

But Dr. Thomas Garthwaite, director of the county Department of Health Services, said the county can’t continue accepting lateral transfers from private hospitals when public hospitals are so overcrowded that some patients wait hours for care.

Recently, emergency room patients at County-USC have been forced to wait up to 16 hours to be seen by a physician, and up to four days to be transferred to a bed upstairs, according to doctors there.

County supervisors said they can’t be concerned about vexing private hospitals.

“They’re going to get a chance to feel a little bit of our pain, and we’ll see how they react under the pressure as we’ve had to deal with the pressure for the last 10 years,” said Supervisor Zev Yaroslavsky.

Supervisor Gloria Molina said changing the transfer policy is “an essential component of what we need to do.”

“In the past, we have been the safety net, and now when private nonprofit hospitals out there have someone and they are indigent, they are going to have to deal with them,” she said. “They have the same responsibility as we do.”

Molina opposed a similar policy change in 1999, calling the idea dangerous. At the time, county officials estimated that such a move would save $5 million a year, but they dropped the plan because of fierce opposition from private hospitals.

State law requires every county to “relieve and support all incompetent, poor, indigent persons and those incapacitated by age, disease or accident.” But counties throughout the state have taken various positions on what that means.

Some counties, including Orange and San Diego, don’t operate public hospitals, and instead pay private facilities a limited amount to care for the poorest of the poor. Others, such as Alameda, operate public hospitals but are tougher about transfers from private facilities.

David Kears, director of Alameda County’s health-care services agency, said Los Angeles County set itself up for difficulty by establishing a precedent of being “all things to all people.”

When the budget woes dictate that the county can no longer be that, Kears said, it becomes very hard to change.

He said Alameda County only accepts patients whose income falls below 200% of the federal poverty level, which for a family of four is $36,488. The hospital also must have a bed available, unlike some facilities in Los Angeles County that leave transfer patients waiting on gurneys in the emergency room.

“We get criticized by the private hospitals because they say we don’t take any transfers,” Kears said. But “you have to make it clear what you can do and you can’t do.”

Los Angeles County health department spokesman John Wallace said, however, that caring for the poor and uninsured is “a source of pride” for county leaders. “It’s kind of something that gets lost in all the debate,” he said.

Even in Los Angeles County, the number of transfers has dropped in recent years as public hospitals have cut the number of inpatient beds. In 1999-2000, the county accepted 14,330 patients, mostly from private hospitals. This year’s tally is on track to fall below 10,000. County officials say even that is too much to bear.

“We’ve got a balloon here -- no matter where you squeeze it, it’s going to pop up somewhere else,” said Dr. Robert Hockberger, chairman of the emergency department at Harbor-UCLA Medical Center near Torrance. “Maybe it’s a good idea to squeeze it, to offload on private hospitals until they can’t take it anymore ... and they get their private hospital lobby to come up with more money.”