County toughens rules for moving indigent patients.

The financially ailing Los Angeles County Health Department, traditionally the region's medical care provider of last resort, will institute a new policy this week that is expected to reduce the number of mostly uninsured emergency room patients being transferred to its facilities from private hospitals.

The new policy makes it harder to move patients with both minor conditions and those who need higher levels of care, such as neurosurgery. This will require private hospitals to work harder to find specialists or instead transfer them to sophisticated facilities such as UCLA Medical Center.

"It could overwhelm us," said Dr. Marshall Morgan, director of emergency medicine at UCLA Medical Center. "I don't know what the magnitude will be. I don't think anyone knows."

The county's four acute-care hospitals will still take patients, but county officials say that will only happen if there is definitely an open bed--whereas in the past county doctors would often accept patients, especially those needing higher levels of care, even if there wasn't one.

"No matter how busy we were, we would figure out a way to squeeze one more patient in," said Dr. Robert Hockberger, director of emergency services at Harbor-UCLA Medical Center, a public county facility.

The county is tightening up procedures after state health inspectors found overcrowding and delays at Los Angeles County-USC Medical Center. The new policy is aimed at improving care, but it's also raising concerns among private hospitals that must now shoulder a bigger financial burden in handling uninsured or underinsured patients.

For the 2002-2003 fiscal year, the county accepted 7,420 emergency room transfers, including 3,830 patients that needed treatment the private hospitals claimed they couldn't provide.

Burden on private hospitals

This past July, transfer policies regarding stabilized patients already admitted to local hospitals were tightened up, halting transfers when there were no available beds. The policy affected patients needing routine care and those needing sophisticated procedures unavailable at local community hospitals.

Inpatient transfers to public hospitals, especially for those needing routine care, were already hard to come by. In the fiscal year ended June 30, the county accepted only 550 such patients out of 4,241 routine requests.

Hospitals say that under the new policy, it's almost impossible to get these transfers, though it has been easier to transfer inpatients needing specialized county services such as burn care.

Dr. Thomas Garthwaite, director of the county's health department, acknowledged the new emergency room policies would place a burden on private hospitals, but maintained that the county was doing all it could to minimize it.

"We continue to take the patients we feel we should but we do it with a better assessment of the overall capacity of the county hospital treating them," he said.

Specifically, as the county implements its new policy it has also hired "flow managers" to speed the movement of county hospital patients from the emergency room to operating rooms, intensive care units and ultimately to discharge.

These managers also are responsible for determining whether the hospital has room to accept a transfer. Before, transfers were handled in a haphazard manner that often involved private doctors calling county doctors who would then use their best judgment on whether there were open beds.

The new policy requires hospitals to make transfer requests via the county's Medical Alert Center, which directs requests to the county facility most likely to accept them.

Even so, private hospitals are concerned about the new transfer policy.

Dr. Mark Louden, assistant medical director of emergency services at St. Francis Medical Center in Lynwood, said the hospital takes care of uninsured patients but it has traditionally relied on the county for help.

"We do our best to take care of them in the emergency room, get them stabilized. Our next obligation is to get them continuing care but to protect the solvency of our hospital," said Louden.

Then there is the concern over the availability of sophisticated services such as heart surgery.

Mara Fellhoelter, an associate rice president at White Memorial Medical Center, an East Los Angeles facility that cares for large numbers of uninsured, said there is a limited appetite among private surgeons to come in during the middle of night to treat uninsured patients needing brain surgery.

"They are getting tired of having to pick up another cash patient (who does not pay)," she said, adding that the facility might be forced to scramble for replacement specialists.