A City Where Hospitals Are as Ill as the Patients
By JENNIFER STEINHAUER
http://www.nytimes.com
There are 22-year-olds, holding neat piles of pills on their laps, small children whose mothers try to distract them with plastic rattles, elderly immigrants who sit silently, staring at nothing in particular, until their names are called.
And there are nearly 70 percent more of them walking into the clinic, the St. John’s Well Child and Family Center in Compton, since nearby Martin Luther King Jr.-Harbor Hospital closed last summer.
For thousands of residents of South Los Angeles who had depended on the large county-run King-Harbor hospital, the past 10 months have been a grueling exercise in cobbling together medical care. When King-Harbor was shut by federal officials, it became the 15th general acute care hospital to close in Los Angeles County since 2000, about half of which served residents in South Los Angeles.
The loss of King-Harbor was less a seminal moment than another episode in the continuing health care ordeal among this city’s sickest and poorest residents.
South Los Angeles is one of the most difficult places in the nation to both receive and give medical care. Family doctors are few and far between, and the area is one of the hardest to draw new doctors to, physician recruiters say.
Chronically ill residents say they never quite know what a call to 911 will yield.
“You call an ambulance and you think you’re going to St. Francis and they say it’s full,� said Denise Provost, whose largely untreated asthma routinely sends her to the emergency room. “So they take you to Kaiser. If that’s full, then it’s Long Beach. You go way out of your way.�
Julia Villalobos, among those waiting at St. John’s one recent morning, heads to a different clinic in Long Beach when she is sick. She takes her mother, who suffers seizures, to St. Francis Medical Center in neighboring Lynwood. And when her two young sons need checkups, she parks herself at St. John’s.
“They are good here,� Ms. Villalobos said. “They explain everything really good.�
The vast majority of residents in central Los Angeles are uninsured or are on the state’s Medicaid program — known as Medical — which offers the lowest reimbursement rates in the nation, and a growing population of illegal immigrants who are not eligible for government insurance have flooded the ranks of the uninsured.
Gov. Arnold Schwarzenegger, a Republican, has proposed another 10 percent cut in the state’s Medicaid program to balance the state’s budget while Congress contemplates a host of reductions to the program that, if approved, would mean $240 million less for Los Angeles.
Los Angeles County’s health department, the provider of last resort, is sagging under its own budget woes, and it adopted complex patient-transfer policies that have shifted an increasing number of its indigent patients to private hospitals, which are in barely better financial shape.
“We have an all-out crisis here,� said Carol Meyer, the director of governmental relations for the Los Angeles County Health Services Department. “In terms of lack of access to care, emergency room overcrowding and total underfunding of the health care system.�
In many ways, the woes of South Los Angeles mirror other poor urban health care systems. Medical centers in Philadelphia, Washington, Cleveland and elsewhere have closed or fallen into bankruptcy in recent years, leaving patients scrambling.
Also, Medicaid reductions in recent years have helped contribute to the rising tide of the uninsured — roughly 2.2 million more in 2006 than in the previous year — largely because of a decrease in employer-sponsored insurance and Medicaid reductions.
“Over the course of the last 10 to 15 years, there are entire populations that have been wiped off Medicaid,� said Larry S. Gage, president of the National Association of Public Hospitals.
But even against that backdrop, the situation in South Los Angeles is particularly grave. Most strikingly, the state Medicaid program offers the lowest reimbursement rate per capita in the nation, nearly 12 percent less than the second lowest-paying state, Arizona, according to 2005 figures.
Roughly 14 percent of the nation’s uninsured live in California, and one in three visits to a Los Angeles emergency room are made by someone without insurance. Many of those patients have conditions that have gone untreated for months and need to be admitted, further straining hospital resources.
From 2000 to 2006, the number of Medicaid-covered patients using the South Los Angeles hospitals on Medicaid increased 18 percent and the uninsured ranks rose more than 20 percent, while patients with commercial coverage fell 20 percent, according to the hospital association’s figures.
As a result, many hospitals in the South Los Angeles area are unable to stay afloat, and centers that once served 100,000 patients here have closed.
“I don’t think we have seen that many closures occur in any part of the U.S. in the last 25 years,� said Jim Lott, vice president of the Hospital Association of Southern California. “We have less than one hospital bed per 1,000 residents here compared to 4.3 per 1,000 in the U.S. When you add up all the forces, the price of indigent care is putting people over the edge.�
King-Harbor hospital, as it has been known in recent years, opened after the Watts riots in 1965, and quickly became a jewel of the largely minority community, serving as a medical home for many and a steady source of employment for black doctors and local residents. But in recent years the hospital had been found to have myriad management and quality problems, including patient deaths that health officials said were related to poor care.
The hospital shut down last August after federal regulators found the center was out of compliance in 8 of 23 conditions. (The state has been looking for a private operator to reopen the hospital, but has found no takers.) Only an outpatient clinic remained, leaving Watts and other neighboring communities without an emergency room for several miles.
While nine hospitals in the area are officially considered “impacted� by the closing of King-Harbor, the closest, St. Francis Medical Center, has clearly taken on much of the burden. Its emergency room has added 14 beds, for a total of 46, as the number of patients has increased to almost 180 a day, from about 155, since King-Harbor closed.
St. Francis’s intensive care unit once had about 26 patients on any given day; it now houses about 33, which has greatly strained the staff, said Gerald Kozai, the hospital’s president.
“All of us would say it has probably been our most challenging year,� Mr. Kozai said.
And it has gotten harder to find help. South Los Angeles is rated 9 on a scale of 10 of undesirable places for doctors to work, said Phil Miller, a spokesman for Merritt Hawkins & Associates, a large physician recruiting firm. “It has become fairly well known in the physician community that the Medical reimbursement rate is not good, and you add the negative publicity from the closures there,� and few doctors are willing to step in, Mr. Miller said.
After it closed, King-Harbor maintained a clinic that set a target of 190,000 visits a year, but it is falling well below that goal. On a recent visit, the waiting room was nearly empty, while the St. John’s clinic was filled.
Health care providers and patients said King-Harbor’s reputation for poor care had sent patients to other emergency rooms or area clinics. “It has a bad reputation,� Ms. Villalobos said. “I wouldn’t want to go there.�
Indeed, area clinics have been absorbing needy patients. Among the nine clinics run by St. John’s, there has been a 157 percent increase in visits since King-Harbor closed, said Jim Mangia, who runs the consortium.
The clinics provide free or low-cost health care to its patients — 65 percent of whom are uninsured — via subsidies from grants and money distributed by the county beginning in July. Those funds usually get the clinics through most of the year, but the St. John’s clinic in Compton ran out in February.
“Community clinics are picking up the slack and not getting reimbursed from those services,� Mr. Mangia said, “and many community clinics are teetering on the brink of insolvency.�
If patients are not using King-Harbor’s clinic, its emergency room is missed. “I know they called it Killer King, but they always took good care of me,� said Lionel Waller, a lifelong resident of Watts.
Mr. Waller, like others in the neighborhood, said that since the hospital closed, seriously injured people had to be taken to centers 10 to 15 miles away, including a friend of his who recently died of a gunshot wound.
“I keep wondering if they would have taken him some place closer if he would have made it,� Mr. Waller said. “We need that hospital here.�
