COUNTY ON VERGE OF CRISIS SLOW PACE OF REFORMS PUTS HEALTH SYSTEM IN JEOPARDY.

Byline: Troy Anderson Staff Writer

Los Angeles County is so far behind in decentralizing its sprawling health care system that waits at the San Fernando Valley's only public hospital still can stretch for hours.

Efforts to shift unnecessary hospital care to less costly neighborhood clinics have not saved as much money as the federal government demanded five years ago in exchange for bailing out the nearly bankrupt health care system.

Time is running out for Los Angeles County, which is urgently seeking a renewal of a Medicaid waiver that would preserve health care for thousands of poor people.

On Tuesday, the county Board of Supervisors is scheduled to consider freezing new hiring across the Department of Health Services in a desperate effort to prepare for looming financial problems.

Last week, the board declared an impasse in negotiations with state and federal officials over renewal of a critical element of its $2.7 billion health care budget, the $1 billion federal Medicaid waiver that kept the system afloat but expires June 30.

The supervisors also froze payments to the 137 private health clinics with county contracts if no agreement is reached by June 30.

``We have met certain goals, but it's an entrenched old system that won't turn around on a dime,'' Supervisor Zev Yaroslavsky said last week. ``I don't think we've done enough. The reason to extend the waiver is to create a modern 21st century health care system that serves the needs of today's population.''

< Reluctant contributions

State and federal officials canceled the last two meetings with county officials and none is scheduled. The county has offered to spend $60 million of its tobacco settlement, but the state has been reluctant to contribute any of its $12.3 billion surplus.

``Efforts to get the parties to the table for meaningful, decision-making discussions have thus far proved unsuccessful,'' Yaroslavsky said. ``Frankly, we don't know what the holdup is.''

In a letter last week to U.S. Department of Health and Human Services Secretary Donna Shalala, U.S. Sens. Barbara Boxer and Dianne Feinstein said the waiver is critical for the county to ``avoid service reductions and layoffs ranging from 1,500 to 4,000 health care providers.''

Los Angeles County's dilemma comes down to a pledge it made five years ago: It would reconfigure its health-care system so that more patients received care in neighborhood clinics, except when hospitalization was needed.

The waiver saved the county from bankruptcy in 1995 when it faced an unprecedented $655 million budget deficit and supervisors were forced to lay off 2,500 health care workers.

While the health re-engineering plan saved the county $43 million in 1998-99, the projected savings this fiscal year are $71 million.

But officials say that is just not enough.

Rene Santiago, director of the county's Medicaid Demonstration Project, said the program has succeeded in cutting nonurgent visits to emergency rooms and the number of people in county hospital beds.

But more must be done, he said.

``We feel we have a lot more to do in ambulatory care expansion,'' Santiago said. ``The area the federal government has been critical of us is in meeting our savings target. Our original target savings were not realistic, and we had the chief administrative officer and auditor-controller set more realistic targets.''

Some officials are more critical of the county's progress, or lack of it.

``I would say we have fallen short and if we had a crystal ball when we introduced the waiver, there are certain things we failed to recognize,'' said Kathryn Barger, health deputy to Supervisor Michael D. Antonovich. ``We didn't achieve the numbers we originally anticipated.''

Behind the numbers are patients like Jesse Armijo, a 32-year-old Sun Valley man who suffered head injuries during a fall at a construction site last month. He came to the Olive View-UCLA Medical Center in Sylmar.

``I've been here three times,'' he said last week while waiting in the emergency room. ``It's the same thing. You wait forever and a day. They need more help and more facilities. I've been waiting here since 10 a.m. and now it's 3 p.m.''

Armijo said he didn't know the county had neighborhood clinics now, staffed with doctors who could give him follow-up care.

At the newly opened San Fernando Health Center, Panorama City resident Ana Osorio said she first went to Olive View after experiencing chest pains, but has been coming to the health center since paramedics referred her there.

``I'm very happy with the care here,'' she said.

San Fernando resident Jesus Saucedo, 31, said he chose the center when he had chest pains because it's closer to his home and cheaper.

At Olive View, the failure of the county's effort to send nonurgent cases to the clinics is clear.

``Our emergency room visits have not gone down, even though we have expanded access in the community for primary care,'' said Carolyn Rhee, chief operating officer at Olive View. ``That's probably because there was an unmet need out there.''

``When they come to the emergency room, we try to refer them for future visits to the health centers,'' she said.

The average Olive View emergency room visit dropped from seven hours in 1994-95 to five hours in 1998-99 while the number of visits to the emergency room has dropped from 85,868 in 1994-95 to 60,779 in 1998-99.

But Rhee attributes the drop in emergency room waits mostly to a campaign by private health providers to attract pregnant women and pediatric patients because of lucrative government reimbursements.

Rhee says the Northridge Earthquake skewed the emergency room visitor numbers in 1994-95 because many people sought treatment at the hospital, noting that the number of visits in 1995-96 was 68,716. She said many people didn't come back as patients after the earthquake, believing the hospital was closed because of extensive damage.

``What the waiver has done is increase the access people have to primary care centers,'' Rhee said. ``We now have more locations where people can get primary care. But that does not reduce the need for the emergency room.''

< Goals partially met

Not that there hasn't been limited success: The goal of the waiver was to cut the number of hospital beds by one-third and expand outpatient clinics with a target of 3.9 million annual visits.

Under the waiver, budgeted hospital beds have fallen 28 percent and inappropriate use of emergency rooms has dropped by 27 percent, according to county statistics.

The county has increased the number of community clinics from 45 to 170, including eight county health centers and 16 public-private partnership clinics in the San Fernando Valley.

However, the number of visits to the clinics was slightly less than 3 million in 1999-2000, missing the target.

Community activists, patients and officials alike say the county's efforts have helped a previously unserved number of uninsured people.

``The West Valley has the highest number of uninsured people in the whole county,'' said Ron Hansen, health services deputy for Yaroslavsky.

Hansen noted a number of projects and new facilities in the Valley that are making the Valley a model for the county's health care improvements. ``If the waiver was cut back, it would seriously impede the progress we have made here,'' he said.

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Photo:

Jesus Saucedo, 31, fills out paperwork as he waits with his son, Jesus Jr., for outpatient care at the San Fernando Health Center, opened to take pressure off county emergency rooms.

Gus Ruelas/Staff Photographer