PNHP

Aetna eliminates markets with high-cost patients

Aetna eliminates markets with high-cost patients

Aetna
Press Release
February 11, 2003
Aetna Reports Fourth Quarter And Full-year 2002 Results

“In 2002, Aetna improved its financial performance,” said John W. Rowe, M.D., chairman and CEO. “This success was built on a seven-point reduction in the medical cost ratio (MCR), as well as lower administrative costs. This decline in MCR was driven by three factors: reduction of membership with historically higher MCRs … (premium increases)… (and changing contracts and benefits).

Full-year 2002 results for Health Care show operating earnings, excluding other items, of $361.6 million, compared with an operating loss, excluding other items, of ($161.9) million for full-year 2001, primarily reflecting improved underwriting results, driven by an increase in the premium yield and a decline in the medical cost trend, combined with continued reductions in operating costs and a decrease in amortization of intangibles.

“Aetna delivered on its promises in 2002, and we believe the company is now firmly re-established as a top-tier competitor in the health care arena,” President Ronald A. Williams said. “Our broad operational goal for 2003 and beyond is to build on our competitive advantages and grow profitably.”

http://www.aetna.com/news/2003/pr_4thquarter2002_earnings.htm

Comment: Building success on reduction of membership with higher medical cost ratios, and increasing the premium yield with a decline in medical cost trends was accomplished by withdrawing from high cost markets and pricing plans with high cost patients out of the market. Eliminating beneficiaries that actually need health care will allow Aetna to fulfill its goal of building on their competitive advantages and grow profitably.

Should we criticize a corporation for reducing losses and improving profits? No. It is their obligation to their shareholders to do precisely that.

Should we criticize health care policymakers for insisting that we continue to build on this system that thrives by excluding from coverage those with the greatest health care needs? No, criticism is not enough. We need to dismiss them and replace them with policymakers that will design a health care funding system that has a mission of actually meeting the health care needs of all of us.

Reinhardt responds to Socoalar on price disparities

Uwe Reinhardt responds to Deborah Socolar on her comments about price disparities:

In connection with price disparities in health care, I wonder what Deborah Socolar means when she uses the term “free market” in her sentence:

“If it were a free market, competition would mean prices would tend to converge (as happens with, say, prices in pizza parlors).”

A distinguishing characteristic that sets pizzas apart from, say, coronary bypasses is that the former can, in principle, be resold among customers while a CABG cannot. Absent a resale market for CABGs (and most other health services), the stage is set for price discrimination, that is, charging different customers different prices for the same thing.

Now, if CABGs and other health services were perfectly standard commodities that are purchased in a national market (i.e., Jones does not care whether his or her CABG is procured in Holy Mercy in San Diego or Apex Hospital, Inc. in Dallas or Womens and Brigham in Boston), then there might still be price convergence. That is why hotel rates quoted to conventions tend to converge across areas with similar climatic and other characteristics.

But CABGs and other health care are not at all perfectly standard commodities and they are not traded competitively over large national markets. Price convergence in a “free” (unregulated?) market would be unlikely to obtain.

Only in highly regulated market with either administered prices set more or less unilaterally by the buy side (Medicare, Medicaid) or uniform prices negotiated by large bodies representing individual buyers and seller, respectively, (Germany) would price discrimination disappear. Even then price might or might not reflect costs.

Uwe Reinhardt

A weak apology for the poetry spam

To Quote of the Day list members:

It should not have surprised me to receive the responses that objected to the poetry expressing opposition to the war, but it did. I mistakenly believed that those who support health care reform would also support activities designed to prevent the premature death and suffering characteristic of a war that most of the citizens of the world believe is avoidable.

For those that did complain, I wish to thank you for being willing to express your thoughts on this highly controversial topic. I also wish to apologize in advance for the fact that my comments to follow will not end the controversy.

I sent the message out after the Bush administration announced a second condition for preventing the war, a regime change in Iraq. Since it seems that we are only days away from war, I believed that our stridency must increase. I believe that an effort to prevent this war must be the first priority of everyone at this moment. Our work on health care reform can continue, but it is a task that will never be completed though, hopefully, we will have major breakthroughs such as the eventual establishment of a universal single payer.

The decision to send the poems to the Quote of the Day list was mine and mine alone. Although I am president of Physicians for a National Health Program, and most of the messages are posted on the PNHP website, technically they are my personal project and not a project of PNHP. It is appropriate that PNHP publishes my comments since my personal views coincide precisely with the policies developed and supported by PNHP. I’m not saying that I’m always right on target since I’m only human, and I have no staff to critique my views before I send them out. But I am saying that, to those who were offended, please direct your ire exclusively toward me and not to PNHP.

Because I sent the anti-war message to a list that is for health policy issues, I certainly can be criticized for having sent out spam. And for that I do sincerely apologize.

Although I erred in my selection of the forum in which to express my views, I did not err in my expression of those views. For speaking up on this issue, I cannot apologize.

Many undoubtedly were offended by the particular poems that I selected from the thousands on the Poets Against the War website. The poems suggested that the president’s decision-making process on the issue of the war is no more sophisticated than that of a young child. With all of the options available, our president is down to a list of only two. Either Saddam Hussein walks, or we attack. Even a child can understand that expanded inspections until hell freezes over would be a much better option, but that has already been rejected by President Bush.

Ardent supporters of Mr. Bush might be expected to be offended by my remarks. But I am more offended by their callous disregard of the people of Iraq and disregard of our standing in the international community. No political personality is worth protecting at that price.

I will not use the Quote of the Day list for any further comments on the war. I intend to limit the list to health policy issues. But for those of you who believe that I have already exceeded my bounds to the degree that you want off the list, you can unsubscribe at http://two.pairlist.net/mailman/listinfo/quote-of-the-day, or you can send me an e-mail directly at don@mccanne.org.

For those who agree with me, more stridency please!

Don McCanne

D. Socolar on health care price disparities

Deborah Socolar, MPH, Co-Director, Health Reform Program, Boston University School of Public Health, comments on price disparities, using the example in the comments about the deficiencies of health reimbursement arrangements:

Here’s one thought on a issue you touch on. Some might quibble with saying that this is an $85,000 procedure — “out-of-pocket expenses for the patient of a total of $84,240. That is quite a tab for an $85,000 procedure” — since one place is CHARGING $108K and the other $56K. It would of course also be quite a tab for even a $108K procedure.

But further — the price disparities help highlight the point that in today’s unfree market, where big buyers have the market power to negotiate discounts, charges tend to bear little relationship to costs, and the uninsured and those in smaller plans face big cost-shifts, subsidizing those who could often afford to pay more. If it were a free market, competition would mean prices would tend to converge (as happens with, say, prices in pizza parlors). Of course today’s such wild disparities in prices make it absurd to think that people can do very much to price the care they think they might need in the coming year and estimate their o-o-p costs to help decide on plan/”level” of coverage, etc…even assuming no major changes in health status. (Obviously folks just all need comprehensive coverage…)

And in a rational system, although I hope we’d pay for much care through global budgets, prices in cases where we do pay for individual services would bear a close relation to costs.

Health Reform Program, Boston University School of Public Health: http://www.healthreformprogram.org/

Single payer bill introduced in California

California State Senate Bill Number: SB 921 February 21, 2003

SB 921, as introduced, Kuehl (Sen. Sheila Kuehl). Single payer health care coverage.

This bill would establish the California Health Care System to be administered by the newly created Health Care Agency under the control of an elected Health Care Commissioner. The bill would make all California residents eligible for specified health care benefits under the California Health Care System, which would, on a single-payer basis, negotiate for or set fees for health care services provided through the system and pay claims for those services.

http://info.sen.ca.gov/pub/bill/sen/sb_0901-0950/sb_921_bill_20030221_introd uced.html

Comment: Sen. Kuehl’s bill is based on the findings of the California Health Care Options Project which demonstrated that all residents of Californian could have affordable, comprehensive health care coverage merely by eliminating the administrative excesses of the current system and establishing a single, publicly administered payer for health care services.

Sen. John Burton is also introducing a pay-or-play employer mandate which apparently is receiving the support of AFL-CIO and the California Medical Association.

Another measure (AB 30, Richman) would “reduce state funding for county hospitals and safety net providers” and transfer those funds to the Medicaid and SCHIP programs. Another proposal (AB 293, Daucher) would allow small businesses to provide insurance to employees working a minimum of 40 hours per week, using an hour of overtime to help pay for health care coverage.

Obviously, the debate in California will be between single payer and an employer mandate. Although the leadership of AFL-CIO and CMA may be attracted to the “politically feasible” employer mandate model, union members and physicians need to take a careful look at both proposals. They will see that the single payer program will not only provide greater benefit for all patients in California, but it will also provide greater benefit for union members and physicians. Union members will have greater health and financial security, and physicians will have freedom and the resources to provide the care that their patients need.

EASY AS PIE

Although this message seems to be a departure from the topic of health policy, what could be more unhealthy than war?

On March 5, 2003, about 15,000 poems will be presented to members of Congress By Poets Against the War. The poems are available at: http://www.poetsagainstthewar.org/

David Budbill

EASY AS PIE

The Emperor divides the world
into two parts:
the Good and the Evil.

If you don’t want to accept that,
The Emperor says
you are Evil.

The Emperor declares himself
and his friends:
Good.

The Emperor says as soon as
Good has destroyed Evil,
all will be Good.

Simple as one, two, three.
Clear as night and day.
Different as black and white.

Easy as pie.

_______________________________________________

Bruce Arthurs

This Is The Day

This is the day.
This is his Big Day.
This is the Biggest! Bestest! day
of his life.

This is the day
he will be remembered for.
This is the day
his father’s folly is erased.

This is the day
the naysayers are silenced.
This is the day
their numbers could not stop.

This is the day
the missiles will fly.
This is the day
when ancient cities burn.

This is the day
collaterals are damaged.
This is the day
that Jesus will applaud.

This is the day
his name becomes immortal.
This is the day
he finally shows them all.

This is the day.
This is his Big Day.
This is the Biggest! Bestest! day
of his life.

Wrong diagnosis, wrong Rx

BY KAY MCVAY
Special to The Examiner
    TENNESSEE Sen. Bill Frist is undoubtedly a good surgeon and a handy provider of roadside emergency medical service, but the plan he and President Bush are cobbling together for Medicare contains neither a useful diagnosis of the country’s current healthcare infirmity nor a prescription for getting us out of our current healthcare blind alley.

    The Bush-Frist approach will hardly move us any closer to a genuine solution. In a hospital setting, to prescribe a spinal adjustment when radical surgery is called for is to ignore the injunction to first of all do no harm.

    Although the full details of the president’s Medicare plan are yet to be revealed, it is evident that the administration seeks to “promote competition” in Medicare and eventually turn it into a program looking more and more like private healthcare insurance.

    To most Americans, anything that sounds like more HMO-healthcare is going to be immediately suspect, but the White House and some in Congress imagine such an aversion can be overcome by linking a broad scheme to profoundly revamp Medicare with the popular appeal of adding prescription drug coverage.

    The core of the argument is that competition for enrollees between regular fee-for-service Medicare and private insurance will result in lower costs for healthcare coverage.

    However, with the costs of drugs and other elements of healthcare delivery skyrocketing, the readily available instrument enabling private insurers to “hold down costs” is diminishing services.

    The history of the managed care “revolution” — which the White House would now superimpose onto Medicare — is one of drive-through mastectomies, restricted access to specialists, physician speedup, decreased skilled nursing care and shuttered inner-city and rural medical facilities.

    Without some action to harness healthcare costs, they will only continue to rise.

    The only significant change under the Bush plan would be that Medicare funds would be channeled through — and siphoned off by — private insurers.

    Moreover, HMO bureaucracies, advertising expenditures and enormous executive compensation arrangements will remain major contributors to spiraling healthcare delivery costs.

    Managed care and health maintenance organizations were supposed to make healthcare more accessible and affordable.

    Nothing of the sort has happened. Costs continue to rise, far outstripping the general rate of inflation; out-of-pocket expenses for insured patients continue to increase; personnel cutbacks are undermining care quality; and 44 million people have been priced out of healthcare insurance.

    The way out of the crisis and past these smoke and mirror “reform” proposals is recognition that the private insurers are superfluous. That is, they are not needed.

    Most of the industrialized world and much of the not-so-industrialized world has been able to do without them for quite a while. They have also been able to impose and enforce controls on healthcare cost inflation.

    Of course, this has meant no profits to be reaped in a healthcare “market.” In the weeks and months ahead, those currently rewarded handsomely by the healthcare industry will be all over Washington and in our faces continually extolling the virtues of consumer “choice” and healthcare “competition” as they line up support for the Bush-Frist plan to get rid of Medicare as we known it.

    It was a tremendous accomplishment for our country to enact legislation in 1965 to guarantee that the elderly in retirement would no longer have to be in a state of continual insecurity when it comes to healthcare.

    Medicare is a successful and very popular program. People who have paid into the program over their working lives have every reason to expect the benefits will be there when they need them.

    What we need now is a plan for shoring up and expanding Medicare, adding a provision for full prescription drug coverage coupled with a thoroughgoing discussion of what we need in a healthcare system and how to get there.

    For many of us, this will lead in the direction of a comprehensive, universal “single-payer” type system that guarantees healthcare as an entitlement.

    Comment: letters@examiner.com

    Kay McVay, R.N., is president of the California Nurses Association.

http://www.examiner.com/opinion/default.jsp?story=op.mcvay.0221w

Affordable premiums, unaffordable care

Washington Post
February 11, 2003
AARP Offers a Plan, but Experts Aren’t Buying It

AARP, in partnership with UnitedHealth Group, has launched an insurance plan for people too young for Medicare. Called the Medical Advantage Plan, it’s open to people between 50 and 64 who live in any of 10 states.

The two partners call the product “an affordable alternative to major medical insurance.” Unlike major medical policies, the plan does not, for example, guarantee to cover all or a certain percentage of hospitalization costs. Instead, the plan pays a fixed amount for a variety of small and large health items: …up to $7,856 for a coronary-artery bypass operation, and so on.

Marilyn Moon, a senior fellow at the Urban Institute, said she asked a colleague how much the tab was for his recent triple bypass heart surgery. About $80,000, he said — far more than the AARP plan would pay for such an operation.

“Trying to provide people in this age range” with insurance options “is very important,” Moon said, but buying this policy might “lure people into thinking they have a lot of protection.” Those with little to spend, she said, “should spend it on major medical [coverage] and not on this.” With traditional coverage, she said, at least you “protect yourself from major expenses.”

Julie Alexis, AARP’s manager of member health products, acknowledged that the plan is “not comprehensive in any way, shape or form,” but “we had to make something available [to] people who are going without coverage” because they cannot afford to buy individual insurance or to fully pay for their employer-sponsored group coverage after leaving their jobs.

“They shouldn’t call it health insurance,” said Karen Pollitz, project director of Georgetown University’s Institute for Health Care Research and Policy. “This is a supplement [that] could help you fill in the cost-sharing” demanded by many major medical policies, she said, but if it is your only coverage, “it will not protect you from financial ruin.”

http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&node=&contentId=A5 4433-2003Feb10&notFound=true

Comment: In the individual market for health insurance, premiums increase with age. For people between 50 and 65 who are not eligible for a group plan, finding affordable coverage can be difficult. This AARP/UnitedHealth Group plan demonstrates that products designed with affordable premiums for this age group fail to provide adequate coverage. Those with significant medical needs will face financial ruin in spite of this coverage.

The only way we will ever provide satisfactory coverage for this sector is to include them in a universal risk pool with the rest of us. Why do we keep fighting this inevitable conclusion?

J. Kahn on affordability of premiums or of health care?

James G. Kahn, MD, MPH, a professor at the Institute for Health Policy Studies at the University of California, San Francisco, responds to the comments on the Kaiser poll on the desire for affordable health care:

Don – you are so right. I would add that the respondents’ focus on affordability means that they are ripe for believing reforms that appear to control costs (premiums, anyway) by (quietly, surreptitiously) restricting benefits and/or excluding the sickest from coverage. – Jim

Comment: Jim’s point is absolutely crucial. Much of the discussion about affordability in health care has centered around the affordability of premiums. That is a very different issue than the affordability of health care.

Employers, individuals and even the government (FEHBP, Medicare + Choice, etc.) have directed attention to keeping premiums affordable. This can be done only by reducing coverage, through a reduction in benefits, an increase in patient cost sharing, or through measures to exclude high risk patients from coverage.

As Jim mentions, the control of premium rates is frequently engineered through quiet, surreptitious manipulations. Defined contribution programs, tiering of services, providing options of streamlined (i.e., bare bones) coverage, and offering low premium, high deductible coverage with some form of health reimbursement arrangement (similar to MSAs) are only a few of the manipulations that are designed to make premiums more affordable. The problem, of course, is that they do nothing to make HEALTH CARE more affordable. They merely shift costs to those with the greatest health care needs.

In our debates over the model of health care reform that should be adopted, we must diligently challenge those that claim affordability when they are referring only to controlling premiums. Those supporting employer mandate or individual mandate models of “universal” coverage will claim that they are controlling costs when, in fact, their current models will only control premiums. These models make health care UNaffordable by shifting costs to individual patients.

A universal, publicly administered program can make global health care costs affordable through mechanisms such as global budgeting, reduction of administrative waste, rate negotiation, and bulk purchasing. And with equitable funding, whether you call it an income-related premium or a tax, health care can be truly affordable for everyone.

Commercial insurers unable to control administrative costs

BlueCross BlueShield Association News Release February 21, 2003 New BCBSA Report Shows Health Insurer Administrative Costs Rising Slower Than Premiums

Health plan administrative costs contribute to rising premium costs, but not as much as you might think. A new report from Milliman USA (Milliman), commissioned by the Blue Cross and Blue Shield Association (BCBSA), shows that administrative costs for America’s health insurers are growing, but at a rate slower than the growth of premiums overall.

Milliman studied national health insurance administrative cost trends from 1998 to 2002 and found that while premiums for commercial business increased by an average of 7.4 percent annually, administrative costs grew at a much slower average rate of 4.6 percent annually. The report shows that in 2001, an average of 85.7 percent of commercial premiums went to pay medical claims with 11.6 percent going to administrative costs and 2.7 percent going to profits. In comparison, an average of 86.5 percent of commercial premiums among Blue Cross and Blue Shield Plans went to medical claims in 2001, with 11 percent going to administrative costs and 2.5 percent going to profits.

“This report clearly demonstrates that the majority of premium dollars are being spent on healthcare services – as they should be,” said Scott P. Serota, BCBSA president and CEO.

“To keep healthcare affordable, we must know more than just how much we are spending. We need to know how well we are investing our healthcare dollars,” Serota said. “This research, like BCBSA’s previous research on healthcare cost-drivers, helps all of us – insurers, hospitals, physicians, employers, drug companies, consumers and government – find ways to eliminate unnecessary costs and improve quality. That’s the only way we as a nation are going to be able to keep healthcare affordable.”

For the press release: http://bcbshealthissues.com/relatives/20445.pdf?PROACTIVE_ID=cecfcbcec8c9c7c

Comment: BCBSA attempts to put a positive spin on these numbers by showing that medical claims grew more than administrative costs, but by the deceptive method of expressing them as a lower percentage increase compared to the higher percentage increase in actual health care costs. At a time when the health plans are under scrutiny for perpetuating excessive administrative waste, they wish to show that they are controlling administrative costs. But they aren’t. Administrative costs grew at a rate of 4.6% annually, in excess of the rate of inflation. In fact, the very nature of the middleman business model of health plans makes it impossible for them to ever control these administrative costs.

The 14.3% of commercial premium dollars that is being burned up in administrative costs and profits is only a small part of the problem. The administrative burden of our fragmented system of multiple private plans, public programs and no programs at all further increases the diversion of funds from patient care to wasted public and especially private administrative excesses. And this does not include the impact of the flawed system of allocating our resources, a system in which some entities and regions receive 30% more funds without any improvement in health care outcomes.

A single, integrated system of funding health care would dramatically reduce these administrative excesses, and would provide a basis for more rational allocation of our resources. Bruce Bodaken, Chairman, President and CEO of Blue Shield of California, recently called for universal coverage, but his model only expands on the current flawed system, perpetuating inequities and waste.

Instead of turning to Milliman for advice on how the egregious administrative waste can be hidden, we should move ahead with change that will minimize the waste, and utilize those resources more effectively, assuring affordable access to comprehensive care for everyone. Unfortunately but understandably, the BlueCross BlueShield Association apparently does not want to lead that charge.

L.A.'s critical condition

Posted on Wed, Feb. 26, 2003

L.A.’s critical condition
The needs of L.A.’s uninsured are overwhelming emergency rooms. Could this be the future for all of California?
By Barbara Feder Ostrov
Mercury News

It’s a routine day at Los Angeles County’s Harbor-UCLA Medical Center’s emergency room: By 3 p.m., every bed is filled. The waiting room is packed with an additional 60 patients. An elderly man on crutches says dejectedly that he’s been waiting 17 hours to see a doctor.

More than 100,000 patients will appear at Harbor-UCLA’s ER this year. Most won’t have health insurance, or doctors of their own. They turn to Los Angeles emergency rooms like this one for basic care — to such an extent that on any given day, 40 percent of the county’s 81 emergency rooms must divert incoming patients and ambulances to less crowded hospitals.

“We are a pitcher of water that can’t be filled any more,” the ER director, Dr. Robert Hockberger, said. “It’s just overflowing.”

Look hard at emergency rooms like this one. As patients around the state see their health care options shrink, the struggle in Los Angeles hospitals could be the future for health care throughout California.

In Los Angeles, the traditional emergency-room patient — the heart attack victim, the person with a broken arm — increasingly collides with California’s newer emergency: millions of people with no health insurance.

Both groups need help quickly, often from the same place. There aren’t enough doctors or beds in the public health system to care for them all. Here, the gap between the Beverly Hills executive pulled from a fender-bender and the flu-stricken laborer from East L.A. is erased: Neither can be sure of how quickly they will see an emergency-room doctor.

The shock of that convergence, combined with a severe budget deficit in Los Angeles County, has pushed the health care system here to the edge. The financial collapse has already forced the closing of two of the county’s six public hospitals and 16 of its 40 health clinics. A move to shut down two other hospitals — including Harbor-UCLA — galvanized Los Angeles voters in November to approve a rare property tax increase. For now, the two hospitals are saved.

But the breathing room gained by that tax does nothing to address the underlying problem: that about 20 percent of Los Angeles County’s population has no health insurance, compared with just 8 percent in the Bay Area, and that the needs of the uninsured are overwhelming the entire health system.

“Everybody’s all maxed out,” said Kazue Shibata, executive director of the Asian Pacific Health Care Venture clinic in West Los Angeles, where the wait for appointments has doubled and new patients are being turned away. “It’s a very stressful time.”

Is the rest of California headed the way of Los Angeles? Some experts think so, if other parts of the state begin to mirror Los Angeles’ large numbers of poor, uninsured patients.

Rising health care costs, an increasingly sick population, and more people without insurance certainly aren’t unique to Los Angeles. As the numbers of uninsured grow throughout the state, Los Angeles’ plight — however extreme — looks more and more like California’s fate.

“We’re all on the same highway,” said Bob Sillen, who oversees Santa Clara County’s public health system. “It’s merely a question of timing.”

The following dispatches explore the travails of a health care system shaken to the core, and its implications not only for Angelenos, but the rest of us.

`Lurking danger’

Crowded emergency rooms are the most visible symbol of Los Angeles County’s health care crisis — and the one that most concerns everyone, rich and poor alike.

“I think people know there’s a lurking danger that when they clutch their chests, they’re going to have a hard time getting into an ER and a hospital bed,” said Dr. Michael Karpf, who directs UCLA Medical Center and Santa Monica Community Hospitals, both private hospitals.

“This is not just a problem for the poor,” he said. “The health care crisis in California transcends class. It covers everybody.”

The critical factor is “diversion,” when an emergency room gets so crowded it starts turning away patients. Ambulance drivers must often radio hospital after hospital looking for an ER willing to accept a patient, and then sometimes drive long distances to deliver patients to an open bed. The county’s hospitals are on diversion status 40 percent of the time.

Just after 6 p.m. on a Friday night, the emergency room at UCLA-Harbor Medical Center is already chock-full, and so is its waiting room. In the entire hospital, only two beds are open.

By 8:15 p.m., as paramedics deliver a 20-something drunk driver with a four-inch gash on his scalp, only four of the county’s 81 emergency rooms are accepting new ambulance patients. The others are on diversion.

With a click of a mouse, Harbor-UCLA joins them. “It’s time,” said nurse Russ Wright. “We’re just too full.”

Jennifer Davis, who is 30 and lives in Paramount, was one of the ones who made it in. She had come to the ER to attend to a broken arm that fractured again after a fall. At Arby’s restaurant, where Davis and her husband make sandwiches for $7 an hour, only managers are offered health insurance.

Davis waited only three hours this time. Two days earlier, trying to get her arm cared for, she waited seven hours.

“I was irritated,” she said, “but there are a lot of people that are sicker than I was.”

As Davis leaves at 12:45 a.m., Conan O’Brien, on TV, is failing to entertain dozens of sleepy, frustrated patients. An announcement comes over the ER loudspeaker.

“Will patient number 97 please go to Window 5.”

Preventive care

Los Angeles’ public health system cares for 800,000 people a year, equivalent to nearly the entire population of San Jose.

Most are uninsured. Many are poor, sick and unable or unwilling to change their lives in ways that might make them healthier.

In the 1990s, county health officials tried to save money by paying community clinics to provide preventive care to thousands of uninsured or underinsured patients who previously went to county emergency rooms and clinics.

Doctors tried to do the right thing. At free clinics like the one in South Central operated by the University Muslim Medical Association, primary-care physicians identify problems they are not equipped to treat. They send those patients to specialists at the county’s King-Drew Medical Center.

“The treatment we get at the UMMA clinic is fantastic,” said Kathy Windley, a longtime patient there.

But that “fantastic” care is a key part of the reason the public health system is facing a crippling $710 million deficit over the next four years. The patients’ needs are so great that many are referred to hospitals for expensive specialists — treatment the county can’t afford.

That high level of care has kept Windley, 52, alive. She has survived three heart attacks and five cases of congestive heart failure, the last occurring when her best friend was shot on Windley’s porch.

Unable to exercise because of her weakened heart, she suffers from obesity as well as arthritis, pre-diabetes, hypertension, sinus infections and a persistent depression she doesn’t like to talk about.

Her husband, Sam, also battles pre-diabetes, as well as high cholesterol, sleep apnea and a mysterious infection in his large intestine. Neither can work because of their health. They take 14 medications between them.

“As we emphasized more outpatient care, we picked up more disease that required specialty care or hospitalization,” said Dr. Gail Anderson, medical director of the county-run Harbor UCLA Medical Center, which gets many clinic referrals. “That’s the irony here.”

Rush of patients

The strain on the county’s public health clinics shows in the long lines at the Hubert H. Humphrey Comprehensive Health Center in South Central, a forbidding high-rise that is the most advanced and specialized of the county-run health centers.

When mounting costs forced county supervisors to close 11 public clinics last year, the nearby Imperial Heights clinic was among them. Twenty-thousand patients needed a new medical home, and all were sent to Humphrey.

Clinic officials insist that the quality of care has not changed, that it is merely more inconvenient. But the clinic is bursting at the seams, and experts say quality can’t help but suffer when harried doctors can spend only a few minutes with each patient.

In handling such a huge pool of patients, the clinic is one of the county’s guards against making problems worse at emergency rooms — but crowding is forcing cracks in that wall.

Some patients, who can’t or won’t brave the long waits and leave the clinic before being seen, later wind up in emergency rooms when their illnesses worsen. Some people whose regular clinic closed now have no idea where else to go, and also head for the hospital.

Inside the clinic, interim director Joe Keys sifts through a mountain of 5,000 letters telling such patients where they could now find help. All these letters came back — stamped “Return to sender” because of moves or the false addresses many undocumented patients give their doctors.

Clinic staffers have no time to track these patients down. Last year, doctors treated upward of 130 patients a day in the urgent care center, which stays open until midnight. “Now,” Keys said, “we’re hitting that number before noon.”

Outside, slumped in a plastic chair in a bleak concrete courtyard, Tyrone Jose Ayon had the resigned air of a man whose fate it is to wait.

When he arrived at the clinic’s urgent care center on a weekday morning, Ayon was told it would take 10 hours to see a doctor about the silver-dollar-size abscess on his arm.

Four hours later, he had yet to embark on the first stage of his visit: having a nurse take his vital signs.

“I’m not paying for it,” said Ayon, 43, who is studying to become a medical assistant before his welfare payments run out. “So I guess I can’t really complain. I just sit here. I bring my lunch — and my dinner.”

On the day Ayon visited, the urgent care center had 60 patients waiting when it opened at 7:30 a.m. It had processed 98 patients by 11 a.m.

“We’ll be up to 200 by 5 p.m.,” said Dr. Casper Glenn, who directs urgent care. “There’s just such a big rush of patients now. I just don’t know what’s going to happen.”

Temporary fix

Capri Maddox has health insurance and a good job as a paralegal. She has never set foot in any of Los Angeles County’s public clinics; she’s never needed to.

But she did need emergency-room care for a severe asthma attack in 1999. That experience, she says, gave her new respect for the region’s hospitals and hammered home the need to support them, even if it meant something close to unthinkable in Los Angeles — new taxes.

“We all watch the news and you see every day that someone ordinary all of a sudden has something tragic happen to them,” said Maddox, 31. “You know that everyone is pretty vulnerable.”

For Los Angeles residents who are middle class or richer, the county’s public health crisis isn’t generally a major concern despite intense media coverage. County-run clinics and hospitals typically are in neighborhoods they avoid.

But in November an overwhelming proportion of county voters — 73 percent — approved Measure B, a property tax increase to shore up the county’s public hospitals and trauma centers. They were spurred, many believe, by a last-minute barrage of television ads portraying paramedics desperate to find an open emergency room.

The passage of Measure B, showing public support for the health care system, also proved pivotal in the county’s negotiations with state and federal authorities for a recent $250 million bailout that will help ease some of Los Angeles’ problems. The tax — three cents on each square foot of a building (the annual tax on a 2,000-square-foot house would be $60) is expected to raise $168 million a year.

But even with the passage of Measure B and a temporary bailout, Dr. Jane Spiegel, a West Los Angeles internist, worries that her patients won’t be able to get the care they need, when they need it.

At St. John’s Hospital in Santa Monica, where Spiegel is affiliated, “a lot of the time our ER is completely filled and my patients can’t get a bed in the hospital itself.” Recently, one of her patients had to wait 36 hours for emergency abdominal surgery.

“No one cares if you have insurance if the doors are closed,” said Maddox, the paralegal. “It’s not about insurance; it’s about accessibility.”

L.A.’s critical condition

Posted on Wed, Feb. 26, 2003

L.A.’s critical condition
The needs of L.A.’s uninsured are overwhelming emergency rooms. Could this be the future for all of California?
By Barbara Feder Ostrov
Mercury News

It’s a routine day at Los Angeles County’s Harbor-UCLA Medical Center’s emergency room: By 3 p.m., every bed is filled. The waiting room is packed with an additional 60 patients. An elderly man on crutches says dejectedly that he’s been waiting 17 hours to see a doctor.

More than 100,000 patients will appear at Harbor-UCLA’s ER this year. Most won’t have health insurance, or doctors of their own. They turn to Los Angeles emergency rooms like this one for basic care — to such an extent that on any given day, 40 percent of the county’s 81 emergency rooms must divert incoming patients and ambulances to less crowded hospitals.

“We are a pitcher of water that can’t be filled any more,” the ER director, Dr. Robert Hockberger, said. “It’s just overflowing.”

Look hard at emergency rooms like this one. As patients around the state see their health care options shrink, the struggle in Los Angeles hospitals could be the future for health care throughout California.

In Los Angeles, the traditional emergency-room patient — the heart attack victim, the person with a broken arm — increasingly collides with California’s newer emergency: millions of people with no health insurance.

Both groups need help quickly, often from the same place. There aren’t enough doctors or beds in the public health system to care for them all. Here, the gap between the Beverly Hills executive pulled from a fender-bender and the flu-stricken laborer from East L.A. is erased: Neither can be sure of how quickly they will see an emergency-room doctor.

The shock of that convergence, combined with a severe budget deficit in Los Angeles County, has pushed the health care system here to the edge. The financial collapse has already forced the closing of two of the county’s six public hospitals and 16 of its 40 health clinics. A move to shut down two other hospitals — including Harbor-UCLA — galvanized Los Angeles voters in November to approve a rare property tax increase. For now, the two hospitals are saved.

But the breathing room gained by that tax does nothing to address the underlying problem: that about 20 percent of Los Angeles County’s population has no health insurance, compared with just 8 percent in the Bay Area, and that the needs of the uninsured are overwhelming the entire health system.

“Everybody’s all maxed out,” said Kazue Shibata, executive director of the Asian Pacific Health Care Venture clinic in West Los Angeles, where the wait for appointments has doubled and new patients are being turned away. “It’s a very stressful time.”

Is the rest of California headed the way of Los Angeles? Some experts think so, if other parts of the state begin to mirror Los Angeles’ large numbers of poor, uninsured patients.

Rising health care costs, an increasingly sick population, and more people without insurance certainly aren’t unique to Los Angeles. As the numbers of uninsured grow throughout the state, Los Angeles’ plight — however extreme — looks more and more like California’s fate.

“We’re all on the same highway,” said Bob Sillen, who oversees Santa Clara County’s public health system. “It’s merely a question of timing.”

The following dispatches explore the travails of a health care system shaken to the core, and its implications not only for Angelenos, but the rest of us.

`Lurking danger’

Crowded emergency rooms are the most visible symbol of Los Angeles County’s health care crisis — and the one that most concerns everyone, rich and poor alike.

“I think people know there’s a lurking danger that when they clutch their chests, they’re going to have a hard time getting into an ER and a hospital bed,” said Dr. Michael Karpf, who directs UCLA Medical Center and Santa Monica Community Hospitals, both private hospitals.

“This is not just a problem for the poor,” he said. “The health care crisis in California transcends class. It covers everybody.”

The critical factor is “diversion,” when an emergency room gets so crowded it starts turning away patients. Ambulance drivers must often radio hospital after hospital looking for an ER willing to accept a patient, and then sometimes drive long distances to deliver patients to an open bed. The county’s hospitals are on diversion status 40 percent of the time.

Just after 6 p.m. on a Friday night, the emergency room at UCLA-Harbor Medical Center is already chock-full, and so is its waiting room. In the entire hospital, only two beds are open.

By 8:15 p.m., as paramedics deliver a 20-something drunk driver with a four-inch gash on his scalp, only four of the county’s 81 emergency rooms are accepting new ambulance patients. The others are on diversion.

With a click of a mouse, Harbor-UCLA joins them. “It’s time,” said nurse Russ Wright. “We’re just too full.”

Jennifer Davis, who is 30 and lives in Paramount, was one of the ones who made it in. She had come to the ER to attend to a broken arm that fractured again after a fall. At Arby’s restaurant, where Davis and her husband make sandwiches for $7 an hour, only managers are offered health insurance.

Davis waited only three hours this time. Two days earlier, trying to get her arm cared for, she waited seven hours.

“I was irritated,” she said, “but there are a lot of people that are sicker than I was.”

As Davis leaves at 12:45 a.m., Conan O’Brien, on TV, is failing to entertain dozens of sleepy, frustrated patients. An announcement comes over the ER loudspeaker.

“Will patient number 97 please go to Window 5.”

Preventive care

Los Angeles’ public health system cares for 800,000 people a year, equivalent to nearly the entire population of San Jose.

Most are uninsured. Many are poor, sick and unable or unwilling to change their lives in ways that might make them healthier.

In the 1990s, county health officials tried to save money by paying community clinics to provide preventive care to thousands of uninsured or underinsured patients who previously went to county emergency rooms and clinics.

Doctors tried to do the right thing. At free clinics like the one in South Central operated by the University Muslim Medical Association, primary-care physicians identify problems they are not equipped to treat. They send those patients to specialists at the county’s King-Drew Medical Center.

“The treatment we get at the UMMA clinic is fantastic,” said Kathy Windley, a longtime patient there.

But that “fantastic” care is a key part of the reason the public health system is facing a crippling $710 million deficit over the next four years. The patients’ needs are so great that many are referred to hospitals for expensive specialists — treatment the county can’t afford.

That high level of care has kept Windley, 52, alive. She has survived three heart attacks and five cases of congestive heart failure, the last occurring when her best friend was shot on Windley’s porch.

Unable to exercise because of her weakened heart, she suffers from obesity as well as arthritis, pre-diabetes, hypertension, sinus infections and a persistent depression she doesn’t like to talk about.

Her husband, Sam, also battles pre-diabetes, as well as high cholesterol, sleep apnea and a mysterious infection in his large intestine. Neither can work because of their health. They take 14 medications between them.

“As we emphasized more outpatient care, we picked up more disease that required specialty care or hospitalization,” said Dr. Gail Anderson, medical director of the county-run Harbor UCLA Medical Center, which gets many clinic referrals. “That’s the irony here.”

Rush of patients

The strain on the county’s public health clinics shows in the long lines at the Hubert H. Humphrey Comprehensive Health Center in South Central, a forbidding high-rise that is the most advanced and specialized of the county-run health centers.

When mounting costs forced county supervisors to close 11 public clinics last year, the nearby Imperial Heights clinic was among them. Twenty-thousand patients needed a new medical home, and all were sent to Humphrey.

Clinic officials insist that the quality of care has not changed, that it is merely more inconvenient. But the clinic is bursting at the seams, and experts say quality can’t help but suffer when harried doctors can spend only a few minutes with each patient.

In handling such a huge pool of patients, the clinic is one of the county’s guards against making problems worse at emergency rooms — but crowding is forcing cracks in that wall.

Some patients, who can’t or won’t brave the long waits and leave the clinic before being seen, later wind up in emergency rooms when their illnesses worsen. Some people whose regular clinic closed now have no idea where else to go, and also head for the hospital.

Inside the clinic, interim director Joe Keys sifts through a mountain of 5,000 letters telling such patients where they could now find help. All these letters came back — stamped “Return to sender” because of moves or the false addresses many undocumented patients give their doctors.

Clinic staffers have no time to track these patients down. Last year, doctors treated upward of 130 patients a day in the urgent care center, which stays open until midnight. “Now,” Keys said, “we’re hitting that number before noon.”

Outside, slumped in a plastic chair in a bleak concrete courtyard, Tyrone Jose Ayon had the resigned air of a man whose fate it is to wait.

When he arrived at the clinic’s urgent care center on a weekday morning, Ayon was told it would take 10 hours to see a doctor about the silver-dollar-size abscess on his arm.

Four hours later, he had yet to embark on the first stage of his visit: having a nurse take his vital signs.

“I’m not paying for it,” said Ayon, 43, who is studying to become a medical assistant before his welfare payments run out. “So I guess I can’t really complain. I just sit here. I bring my lunch — and my dinner.”

On the day Ayon visited, the urgent care center had 60 patients waiting when it opened at 7:30 a.m. It had processed 98 patients by 11 a.m.

“We’ll be up to 200 by 5 p.m.,” said Dr. Casper Glenn, who directs urgent care. “There’s just such a big rush of patients now. I just don’t know what’s going to happen.”

Temporary fix

Capri Maddox has health insurance and a good job as a paralegal. She has never set foot in any of Los Angeles County’s public clinics; she’s never needed to.

But she did need emergency-room care for a severe asthma attack in 1999. That experience, she says, gave her new respect for the region’s hospitals and hammered home the need to support them, even if it meant something close to unthinkable in Los Angeles — new taxes.

“We all watch the news and you see every day that someone ordinary all of a sudden has something tragic happen to them,” said Maddox, 31. “You know that everyone is pretty vulnerable.”

For Los Angeles residents who are middle class or richer, the county’s public health crisis isn’t generally a major concern despite intense media coverage. County-run clinics and hospitals typically are in neighborhoods they avoid.

But in November an overwhelming proportion of county voters — 73 percent — approved Measure B, a property tax increase to shore up the county’s public hospitals and trauma centers. They were spurred, many believe, by a last-minute barrage of television ads portraying paramedics desperate to find an open emergency room.

The passage of Measure B, showing public support for the health care system, also proved pivotal in the county’s negotiations with state and federal authorities for a recent $250 million bailout that will help ease some of Los Angeles’ problems. The tax — three cents on each square foot of a building (the annual tax on a 2,000-square-foot house would be $60) is expected to raise $168 million a year.

But even with the passage of Measure B and a temporary bailout, Dr. Jane Spiegel, a West Los Angeles internist, worries that her patients won’t be able to get the care they need, when they need it.

At St. John’s Hospital in Santa Monica, where Spiegel is affiliated, “a lot of the time our ER is completely filled and my patients can’t get a bed in the hospital itself.” Recently, one of her patients had to wait 36 hours for emergency abdominal surgery.

“No one cares if you have insurance if the doors are closed,” said Maddox, the paralegal. “It’s not about insurance; it’s about accessibility.”