Patients Without Borders

Jose Lopez stole across the U.S. border with dreams of prosperity and a craving for adventure -- but his grand plans didn’t last long.

On his second day as a fieldworker, a car wreck left him lying in a Brawley roadway with his right leg shattered. Lopez, 19, was taken to Scripps Memorial Hospital in La Jolla, where surgeons put a rod in his leg and wired his broken jaw shut.

As Lopez recuperated at the hospital, his bill mounted by the day, and Scripps had no choice but to absorb the cost. Lopez had no money, San Diego has no public hospital to take indigent patients, and federal rules bar hospitals from releasing patients prematurely.

A novel company came to the rescue.

Nextcare, a 2-year-old firm founded by an employee in the Scripps chain, arranged to take Lopez to a Tijuana hospital dedicated, in large part, to treating indigent Mexican patients brought home from U.S. hospitals.

And after two weeks in Tijuana, Lopez was back where he started, at his mother’s one-room house in Sinaloa, 900 miles to the southeast, showing her his scars and speaking through clenched teeth.

Lopez’s journey offers a glimpse into the pros and cons of a business that many in the hospital industry expect to flourish as health costs rise.

Nextcare, believed to be the first firm of its kind, so far has contracted with five U.S. hospitals to return about 50 uninsured illegal immigrant patients to Mexico.

The American hospitals pay the company to arrange transportation and treatment south of the border -- usually at Nextcare’s Tijuana facility, Hospital Ingles. Patients must consent in writing to the transfers.

It’s a bargain to hospitals on the California side of the border -- and perhaps beyond. The average stay in a California hospital costs $1,737 a day, but Nextcare’s costs can be as low as $450 daily, the company said.

The tab for treating illegal immigrants is staggering in some areas. It was estimated at $200 million last year by U.S. hospitals near the Mexican border, according to a study of facilities in California, Arizona, New Mexico and Texas.

A study of the costs at Los Angeles County public hospitals and clinics put the total at roughly $340 million annually.

Sending such patients back to Mexico “is a responsible and inventive way of dealing with a shortage of beds for indigent patients,” said Jim Lott, executive vice president of the Hospital Assn. of Southern California. “When you talk about our border states and counties like San Diego, they’re tired of waiting for the federal government to deal with this problem.”

At the same time, the transfers are raising concern among some U.S. physicians and immigrant advocates about whether the patients receive adequate care and whether the transfers amount to de facto deportations.

“I wonder whether or not people who are being transferred are misconstruing the voluntary nature and fearing other consequences,” said Cecilia Munoz of the National Council of La Raza, an immigrants’ rights group.

Dr. Rosemarie Johnson, a San Diego physician and member of the U.S.-Mexico Border Health Commission, said the quality of hospitals in Tijuana is highly variable and most have outdated equipment by U.S. standards.

“There are a huge number of them and they range from a cottage, like a beach cottage that people claim is a hospital and have a couple of beds, to state-of-the-art places that I have visited and are up to standards,” Johnson said.

“Would I send my family there? No, not without knowing a whole lot about the quality of care.”

George Ochoa, co-founder of Nextcare, says patients receive care in Mexico that is comparable to or even better than what they would get in the U.S. The company also stresses that the transfers are voluntary, the result of an unpressured discussion between Nextcare officials and the patient.

Although hospitals are prohibited from asking about patients’ citizenship status when they arrive for treatment, Ochoa said the information often comes out in other ways -- for example, when staff members look into patients’ eligibility for government insurance programs.

“We ... say, ‘Let us take you out of this very expensive hospital and take you to our facility in Tijuana,’ ” he said. “ ‘The level of care you’re going to receive is the same, maybe even better. You’ll have a physician and nurses you understand. The food is something you’re comfortable with. The TV is Mexican. You can call your home and have your family come and visit you.’ ”

Lopez agreed to be moved mainly because he was hungry.

He’d eaten little before the accident, waiting for a payday that never came. Then his jaw was wired shut and he was reduced to imbibing liquids and oatmeal. He longed for a good meal.

In June, Ochoa’s founding partner in Nextcare, Bob Barraza, a retired businessman, visited Lopez’s room at Scripps. Barraza offered to return him to a familiar diet, language and surroundings, without compromising his medical care.

Lopez did not take much convincing. “They told me in San Diego that when I went to the hospital in Tijuana that they’d take the braces off my mouth and that the food would be my food,” he said.

He was checked out of Scripps Memorial, driven to the border, and then whisked by ambulance to Nextcare’s Hospital Ingles in the heart of Tijuana. The 17-bed facility is affiliated with 22 Mexican physicians who specialize in such areas as orthopedics, oncology and obstetrics.

It has four patients per nurse, Ochoa said, a good ratio by U.S. standards for noncritical care.

With one operating room and one room for minor procedures such as X-rays and cast removals, however, it is more of a skilled nursing facility than a hospital. Ochoa said it is prepared for emergencies but is geared to handle patients such as Lopez, who are on the mend.

The hospital is a homey place, spotlessly clean with freshly painted rooms and flowered bedclothes. Doctors bring Disney videos from home to entertain patients, and nurses run out to local restaurants for patients’ special requests. It is not a facility, however, filled with the latest in rehabilitation equipment.

Lopez’s physical therapy for his broken leg was limited to walks up and down the hallway several times a day with the help of a nurse. In the U.S., he probably would have received similar walking therapy, doctors say, but had he stayed there, physicians could have arranged for more formal physical therapy after his cast was removed to help him regain maximum strength and mobility.

His food consisted mostly of liquids, but nurses once whirred a burrito through a blender, at his request.

After about two weeks at the hospital, Lopez left Tijuana for his hometown of Escuinapa, about 90 minutes south of Mazatlan. He was on crutches and accompanied by a hospital aide who guided him through the airport, into a taxi, onto a bus and then into another taxi home.

A Mother Worries

His mother, who happened to be walking down the street as he alighted from the taxi, greeted him with calm affection. Later, in the backyard of her tiny house, Maria del Carmen Lopez explained with a sigh that it is nothing new for her son either to vanish from town or to suddenly return.

When Lopez told her about the accident, her face contorted with worry. “How will you get those off?” his mother asked, gesturing at his wired mouth.

He shrugged. At first he thought the wires were going to be removed in Tijuana, but the hospital aide explained to him and his mother that they would have to be taken off at the local hospital. He should go there as well for any emergency. The aide left town later that day.

Meanwhile, it was unclear to Lopez how he would eat. A bowl of vegetables appeared to be the only food in his mother’s home, and there was no blender.

Lopez knocked on his wrist bone and pretended to listen for the echo. He had never been heavyset -- the children in Escuinapa are lean. But now he was gaunt. “One more month like this and I’m going to disappear completely,” he joked.

Almost a month later, his gums had begun to grow over the wires and had become infected. Maria del Carmen Lopez took her son to the General Hospital of Escuinapa, a 30-bed acute care facility with a dental wing on the first floor.

Although doctors at Hospital Ingles in Tijuana told her son he would have to go to a local dentist after a month, both she and Lopez had believed they would hear from the Hospital Ingles when it was time for the wires to come off. Hearing nothing, she said, she borrowed money from family and friends and took him to General Hospital’s director of dental services.

“It’s a shame things had come to that point,” said Dr. Miguel Angel Castro Estrada. “You can tell that the bands had been expertly applied; it was a very good job.”

After removing the wires, Castro put Lopez on penicillin and gave him an antiseptic, telling him to come back in a week or two.

Lopez told a reporter he felt no bitterness toward Nextcare -- but he’d rather have avoided this pain. If he’d stayed in a U.S. hospital, he said, “I don’t think ... they would have had to tear through my mouth like that.”

In the U.S., patients who have their jaws wired shut are generally monitored for six to eight weeks afterward, said Dr. Alan L. Felsenfeld, adjunct professor of oral and maxillofacial surgery at UCLA. In treating such patients, he checks for infection every week or two, also noting whether the patient’s nutritional needs are being met and whether bones are healing properly.

After the wires are removed, Felsenfeld said, additional monitoring is recommended for the next month or two to ensure that the patient’s bite is returning.

“If a company promises equivalent care [to that offered in the U.S.], that’s not really equivalent care,” said Felsenfeld, who stressed that he did not examine Lopez or his medical records. “Is it adequate care? Possibly at the lowest level it is adequate, but it’s not equivalent.”

Arrangement Defended

Ochoa said Nextcare did all it could for Lopez: He was carefully instructed to seek help at the General Hospital, if necessary, and doctors at the Tijuana hospital had called ahead and arranged for the wires’ removal.

“The local clinic was supposed to do it at no charge,” Ochoa said.

If he had known it would not, he said, Nextcare would have kept Lopez at Hospital Ingles an extra month so the wires could be removed there.

“I can assure you, we made sure this kid was going to get the care he needed. We paid for his airplane ticket, we sent [an aide] with him. We transferred him all the way to his house. We did everything for this patient and if we would have known that somebody would charge him $45, well ... of course we would have paid that too.”

Hospital Ingles has since attempted to contact Lopez and repay his family, Ochoa said, but its efforts were unsuccessful because the family has no telephone and no formal address.

Ochoa plays a dual role, running Nextcare and holding a job at Scripps Mercy Hospital in San Diego as director of outpatient services.

He said he cleared his involvement in Nextcare with Scripps officials to ensure they saw no conflict of interest. He also said he does not use his Scripps position to identify patients for possible transfer. He sends partner Barraza, who has no Scripps ties, to speak with patients in the three Scripps hospitals that contract with Nextcare.

Ultimately, Ochoa and Barraza say, they envision expanding the patient-transfer business along the U.S.-Mexico border from California to Texas.

Some prominent health officials aren’t interested. Dr. Thomas Garthwaite, director of health services in Los Angeles County, said he could understand why a county without a public hospital would seek options such as Nextcare. He would not, however, embrace that approach, in part because Los Angeles County has a public hospital system with greater options for treating uninsured patients.

Other hospitals are thrilled to have the option. Several that have worked with Nextcare extol its services and performance. They emphasize that the transfer to Mexico ensures that patients will receive necessary health care and often be reunited with an important source of support during recovery -- their families.

“When we have patients that really need additional care” that U.S. programs can’t subsidize because the patients aren’t citizens, Nextcare “allows us to ensure they get that care,” Suzanne Purdy, vice president of patient care services at La Mesa’s Grossmont Hospital, says in a promotional video for Nextcare.

Some patients and their families also heartily endorse Nextcare.

In another promotional video, a Mexican mother says that moving her son, Roberto Tapian, from Grossmont Hospital in La Mesa to Tijuana last year was a great idea. Tapian was riding in a smuggler’s van crammed with 33 people in June when it struck four oncoming vehicles about 50 miles east of San Diego. The crash killed five immigrants and left Tapian paralyzed from the neck down.

“The representative from Nextcare has fulfilled everything they offered us,” Tapian’s mother said. “I’d like to thank them very much, because everything was perfect.”

The moment the wires were removed from his jaw, Lopez hurried home and wolfed down a ham sandwich.

During a reporter’s visit in August, he could open his mouth enough to slip in a forkful of rice and beans, but stretching it beyond that was painful.

What progress he makes from now on depends mostly on how well he cares for his mouth, said Dr. Castro of General Hospital in Escuinapa.

Lopez, who still walks with a slight limp, had not found work and probably wouldn’t until the December harvest. His mother still owed her friends and family for the visit to the dentist.

But his disastrous stay in the U.S. had receded from memory like “something from another life,” he said. With his health nearly back to normal, he said, he’d soon head north to cross the border again.

“I’m almost better now. I’ll do it once I can run,” Lopez said. “You have to be able to run if you’re going to make it to the other side.”