Doctors protest county's health agency overhaul.

More than 50 doctors in the Los Angeles County Department of Health Services, many in senior positions, have sent a letter to the county Board of Supervisors asking it to take a look at ongoing reorganization and recent health department personnel practices.

The letter charged that the reorganization of the county department excludes doctor input while adding costly administrative layers.

"Physicians have been excluded from discussions (about reorganizing the department). But the department can't be designed by people with no knowledge or expertise about the work to be done or the people to be served," said Dr. Shirley Fannin, director of disease control programs for the county, and chairwoman of the ad hoc committee of concerned physicians.

Fannin added that in her 18 years with the department, "We have had five reorganizations, and each one seems to add new positions at the top."

The letter talks of the "department's disease of the spirit."

"You hired us to keep the people of Los Angeles County well," the letter stated. "But your health organization is ill and getting sicker."

Too, the letter, sent on Nov. 2, charged that Dr. Jonathan Weisbuch, former county medical director, was recently demoted because he said he would voice concerns of physicians to the county Board of Supervisors. There have been several other recent demotions of high-ranking personnel, noted the letter.

But County Health Department Director Robert Gates retorted last week that the ad hoc committee's doctors are a misinformed minority, and that physician anger stems from wrenching market changes that challenge the $2.3 billion department -- such as private-sector health maintenance organizations (HMOs, also called managed care providers) which could ultimately treat the county's indigent, perhaps rendering the county health department redundant.

"We are going to have to become a managed-care provider. We are reorganizing, trying to shake up the troops. We can't stay the same," said Gates, a 15-year veteran of the department who became director in 1984.

Some doctors can't or won't adjust to the new order, said Gates. But he declined to discuss or explain any particular demotion or transfer, stating "those are personnel matters."

Already, the state's Medi-Cal program is putting recipients into HMOs and, under Clinton's health proposals, many more Angelenos will be funneled into HMOs or other, similar "managed care" arrangements, said Gates.

Too, 115,000 Angelenos, now on general relief, are being funneled into the county HMO.

(Under managed care or HMO arrangements, the county covers patients for set monthly fees -- for example, $120 a month per enrolled patient. Under fee-for-service, the county charges per service provided, such as $1,200 to set a broken leg.)

With about one-half of the county health department's budget derived from Medi-Cal, the county has to become an HMO itself if it wishes to survive, said Gates. "We could lose the Medi-Cal contracts to other providers," he said.

The county's health care programs are huge; there are about 1.1 million visits a year to county health facilities, as well as 323,000 emergency room visits. More than 40,000 babies a year are delivered in county hospitals. The county hospitals, such as "County Med" (Los Angeles County-USC Medical Center), operate huge emergency rooms and are considered the health provider of last resort for many local residents.

In addition to hospitals and clinics, the county health department runs a public health program, concerned with epidemics (such as tuberculosis), child immunization, safety of food and water, and environmental safety. In all, the department employs 23,000.

In particular, it is the public health functions that will suffer under the county-health-department-as-a-big-HMO, said Fannin.

"HMOs are not designed to combat epidemics, check the cleanliness of restaurants," said Fannin. "The public health function will get lost in the reorganization." HMOs and other organizations geared around hospitals and billing do not give priority to tuberculosis clinics or tricky investigations of environmentally caused diseases, said Fannin.

County supervisors could not be reached for comment last week. One board staffer said that supervisors have mixed feelings about Gates, ranging from discontent to lukewarm support. Such letters as the ad hoc physicians committee sent are not daily events, but neither is the letter enough to send the board into action, said the staffer.

Both Gates and Fannin agreed that the health department is in a "crisis" because of budget cutbacks in recent years.