Jim Cooper's Orange County; Health Care for the Needy: OC Time Bomb

Jim Cooper's Orange County is made possible by grants from Disneyland Park, announcing its new attraction, Star Tours, now boarding passengers for a space flight adventure. By Signal Landmark, Incorporated, developer of Southern California real estate and builder of landmark homes, and by Robert Hath and Account Temps, providing permanent and temporary accounting, financial and EDP personnel, with offices in Newport Beach and throughout Southern California. Orange County now has 3,400 practicing medical doctors. It has 41 hospitals with 6,900 beds. It has 8,500 skilled nursing and intermediate care beds, and it offers outpatient care through some 23 community clinics. For most people with health insurance, there's excellent medical care available.

But despite all these resources, there are many thousands of others in the county who include the handicap, the poor, minorities, unemployed, refugees, hourly workers and many seniors who fall through the crack and don't qualify under any private or public medical health program. Health care for them is getting more difficult to obtain every day. The problem has been described as Orange County's time bomb. I'm Jim Cooper, and I look into the problem today with my four special guests. The problem of providing adequate health care for thousands of Orange County is becoming more critical each month.

There are thousands in Orange County who aren't covered by private health insurance and don't qualify for Medi-Cal or Medicare. For them, the hopes for medical care is out of reach or it must come under the impacted indigent medical services program or community clinics. Today we'll talk with people of the new United Way Health Task Force examining a problem. But first, let's look at some places where medical crunch is experienced every day. This is Orange County Health Care Agency's clinical services building in Santa Ana. Most of the people who come here have no private medical insurance, no Medi-Cal, no Medicare, and don't qualify for IMS (indigent medical services). For most of the 150,000 patients served here last year, this is their only medical care. The patient load here jumped from 20,000 over the previous year. This young girl is receiving free immunization shots and polio vaccine, part of 200,000 immunizations given to 100,000 clients last year. The load is getting bigger every day and yet federal, state, and county funds are shrinking and new cuts are now being proposed.

Another free facility is the Women, Infant, and Children, or WIC Clinic. It began in 1975 serving 10,000 poverty level infants, children, and women each year. Today it numbers 60,000 patients and the program continues to climb. For these mothers, infants, and children, there would be no other source of care. Many have hourly jobs and don't have resources or insurance to get services they need at local hospitals or from private physicians. 35% are Hispanic, 51% are Indochinese, all are poor. This is the family planning clinic, which provides free pregnancy testing, maternal health services, and prenatal care. The story is the same, a critical need for limited services. Many women still have no prenatal care before they deliver their babies, despite the fact that 25% of such mothers will give birth to premature babies. First year, 1,000 pregnant mothers were turned away from prenatal services here because the clinic couldn't handle them.

Dr. Gerald Wagner, pediatrician, is in charge of child health services, and he's been a public health physician in Orange County for the past 23 years. How serious is this problem of growing need for good health care in Orange County? Well, I think we continually see children in our clinics who have undetected abnormalities with a serious problem in access to medical care, where they're not able to get in to someone who can make diagnoses at an early stage treat abnormalities when they're easy to treat so that they don't form long-term disability. If you are poor, you also may go to the Community Clinic of Orange County in South Santa Ana. This clinic is operated by the University of California College of Medicine. It provides all general family medical care with a staff of 34 family practice residents from the UCI hospital, plus five full-time doctors. This is the Women, Infants, and Children's Clinic. In 1986, there were 30,000 patient visits for the entire clinic compared to 14,000 the

previous year. Five languages are spoken here. 50% of the patients are Hispanic, 28% are Southeast Asian. Many are among the county's 20,000 seniors whose income is at the poverty level. Here Dr. Jose Sandoval, a family practice physician, examines a patient. Patients pay if they are able, even if it's only $1 to $3 a visit. Otherwise they pay nothing. Dr. Mary Roth, family physician, is a professor at UC Irvine Medical School and is medical director of the Community Clinic of Orange County. How real is this medical crunch based on your experience here for the past seven years? Over the seven years we've seen a decline in the number of places and the number of physicians who are able to see the indigent. The indigent is well defined in that it is all those persons who do not have the adequate cash or defined insurance to seek medical care when they need it. This includes undocumented aliens.

This includes the working poor, those individuals who do not have health insurance. This includes the refugees who have limited coverage in their first months in this country. They have found that the average physician is not able to incorporate them in their practice, and therefore they seek a multitude of alternative sites for medical care. Community Clinic of Orange County, which has been here for 15 years, serving the underserved of Orange County, has found that slowly but surely the numbers of those who need to come to us is in large, including larger numbers from all over Orange County and not just from the Barrio. This is not just a Barrio practice, but includes individuals from Placentia, Anaheim and South County because there is a shortage. What happens if more facilities are not brought to address this problem? What do you see in the future if nothing more is done? The first thing that will be lost is preventive medical care. Those things that could have been prevented, those illnesses that seem casually not to be important. Massive trauma will always be taken care of. But what my concern is is the preventive care such as prenatal care, well child care, care of hypertension, diabetes, and those chronic diseases that are not so

obvious will not be cared for, and we'll have sicker people who have more morbidity, who will die in our hospitals. This is the Huntington Beach Community Clinic, one of 23 community clinics operating in Orange County. It is supported by United Way, the City of Huntington Beach, and state funds, as well as patient donations. There are 14 different Orange County organizations which support these 23 clinics. They provide services free or for a minimal cost, for a total of 12,000 patients seen every month. In 1986, the Huntington Beach Clinic served 15,000 people with medical care, and another 1,000 with psychological counseling. Marty [Arlabau?], executive director, has been with the Huntington Beach Clinic since 1975. How would you express to somebody how serious the health care problem is, the people you see? I think Jim that the health care problem in Orange County is becoming increasingly magnified. I think that one example is that we have seen a 22% increase in the number of patients

that we have seen this year from the number we saw last year. Last year we saw about 17,000 patient visits. This year we're expecting to see over 20,000. So that's quite a healthy increase. We've had to increase our staff, and we've had to increase the length of time that we can see patients to be able to meet those needs. What's a typical profile of people who don't fit the Medi-Cal or Medicare framework or don't fit any program? What's a typical profile of your people? Well we like to call them the working poor. That means in general that they do have jobs, that they do have residences. Most of them do, some of them don't. They are unable to have any kind of health care coverage and that they aren't eligible for medical. They aren't eligible for any of the other health care packages that are available. And for them their dollars are very, very scarce and they really don't have the financial resources for health care. And so that's one of the reasons that they come to us. Jim [Nett Eber?], registered nurse at the clinic, sees one of the scores of people who appear each day. The patient is Lee Engelbert, one of many homeless people who are patients.

From infants to seniors, Orange County has a clouded population of many thousands, sharing an unhappy, common fight. Inadequate health care in the midst of abundance. And now let's meet our guests. John Gilway is executive director of the Hospital Council of Southern California Orange County area. He's a member of the United Way Task Force examining health care for the county. He was formerly assistant director of the Orange County Medical Association. He helped set up the Indigent Medical Service program for Orange County. Dr. Michael Kennedy is president of the Orange County Medical Association representing 2200 out of the county's 3400 practicing physicians. He's a general surgeon and specialist in vascular surgery. He's a fellow in American College of Surgeons. He's on the Commissions of the California Medical Association for both state and federal legislation. Joanne Andre is executive director of the Visiting Nurses Association of the County including 60 nurses, 50 therapists and 20 home health aids. Previously she was nurse consultant for the Regional Center of Orange County, a case management organization for developmentally disabled

children. She's on the United Way Task Force and serves as the vice president of the California Association of Health Services at Home. Tom Eurem is director of the Health Care Agency of Orange County. The agency directs the county's programs for mental health and drug abuse, public health and alcohol, indigent medical services and emergency medical services. His budget's about $140 million with revenues of about 120 million involving 1500 employees. Well you represent both the private and the public sector of the health care delivery mosaic for Orange County, and I think you're all aware of this crunch and the bind that seems to be getting worse of shrinking resources and growing demands for medical health care. You want to start, John, and give us your perspective and I know you're speaking for the hospital as well as [inaudible]. I think the main reason or the main example is that we, Orange County hospitals are trying to fill two specific goals. We're trying to make quality health care available to everyone who needs it in the county and we're

also trying to economically survive into the future, and that second goal of economic survival is one that is coming under intense jeopardy because of both state and federal cutbacks and the funding that's been set up to support both the Medicare and the Medicaid program, and I just don't see how we can continue to keep cutting and cutting at those programs. We've suffered major cuts in past years. We're getting ready to face new proposals for major cuts coming and the reimbursement from those programs has now gotten to a point that the actual reimbursements do not meet even the cost of delivering the services that are required by the beneficiaries of the program. That is what is putting us in a bind is that difference between our costs of delivering the services and the funds that are coming in to support them and we have less and less and less places to go to try and make up that difference. So that is putting us on a collision course.

There's an ominous term that I think our public should know about. That ominous term is "uncompensated care," and it means that when a resource or when a medical service is given it's not compensated because it doesn't come under any program. I understand only 25% for example of IMS services rendered actually wind up in reimbursement to the provider. $100 million to these hospitals, particularly $100 million, uncompensated care in 1986 alone. What does that mean? That means a tremendous stress on the hospital system. It means it's tremendous stress on the physicians in the county. It's something that our resources can only sustain so much load and our resources are now at a point of nearing exhaustion and we now are looking at how can we continue to cover that load? And even with half of your beds empty? True. 50% of the occupancy. I think the occupancy thing needs to be examined a little bit too and that yes we do have

a lower occupancy at around 50% in the county but with the government reimbursement situation being the way it is if you say you need to take beds away those beds that would be taken away and closed first are those beds that we can afford to lose the least, and those are the beds that are taking care of the poor and indigent in the county. Do all the hospitals take Medi-Cal and Medicare? Yes. All of them accept that. Dr. you have certainly an input. A lot of people say we have 3400 doctors practicing positions in Orange County. We should have no problems at all, and yet that's not the case. Why don't you give us your perspective on it? Well, physicians have always taken care of the poor for thousands of years. We have our expenses too. We have to maintain our staff and keep our offices open. But most physicians do see patients who they know are not going to be able to pay. The problem, two big problems that really bedevil us in this situation. One is the liability issue. There are a lot

of physicians who maybe wrongly are frightened of some of these patients. There's a, there's a... Now you're talking about indigent patients or all patients? Yeah, the Medi-Cal patients, and notoriously among physicians is likely to sue. And doctors are afraid of that. And I'm not sure that the statistics bear that out, but they worry about that. And that affects access on the part of some Medi-Cal patients to physicians. The high technology type of medicine we have now, things may not be available. And that medications are very drugs are expensive. Hospitalization is expensive. Operations are expensive. The days when the patient could go to the doctor's office and see the doctor and be examined and maybe be given a few pills that would solve the problem are really kind of gone. Most physicians are used to practicing high technology medicine and they worry if they have to render something other than what they consider to be frontline care because they're afraid they're going to be sued if

something goes wrong or the results are not satisfactory and that's a concern. That's one concern. You said there were two. Well, the cost of running their own offices, the cost of maintaining their practice. And this burden really falls on the physician and the poor neighborhood in the Barrio and the ghetto. One of the great ironies of this problem is that we hear from the government and we hear from social scientists that it's a shame that physicians won't practice in poor neighborhoods. They all want to practice in Beverly Hills or South Orange County. Or Newport Beach? Or Newport Beach. And then when you get a 10% cut in Medi-Cal reimbursement, who is hit the hardest? Not the doctor in Newport Beach who probably sees one Medi-Cal patient a month. It's the poor guy that's in the poor neighborhood who's trying to make a go of it and whose overhead is running 55 or 60% and who may be making less money than the fellow that has a hamburger stand on the corner. So the concept that all the doctors are affluent or all driving Mercedes-Benz

is not true and it's particularly not true for the physician who's trying to render care to the poor. We hear now as we're doing this program that the federal government is talking about a $20 billion cut for example in programs that will be in Medicaid which translates out to Medi-Cal in California. We hear that the governor is talking about a 10% cut in reimbursements on Medi-Cal. What is that going to do to the doctors in Orange County who are already taking Medi-Cal patients, who are taking Medicare, who are trying to balance their practice with both those kinds of patients as well as their private patients? It's going to reduce the incentive to see those patients. I know general practitioners for example who are trying to edge away from the Medicare program because they're worried about this. They're trying to cultivate a practice of insured affluent patients and this works to the detriment of the poor and frankly it's contrary to what we all thought we were going to do when we decided to be physicians. So what's the answer then? What do you

see ahead? Fewer and fewer doctors who will see these kinds of patients? We're already seeing that. In addition, I think where everybody is casting about for a solution to this problem. We've got 17% of the population in 1985 who were not covered by any kind of insurance or public payment program. Doctors are still seeing those patients but as the physician on your tape said there are problems like diabetes, hypertension that are not being treated enough. The access is limited. When they have a crisis they can go in and I think most doctors will see a patient in an emergency. You said in your statement that you gave about this problem but these physicians treating the indigent refugee and the alien population are rapidly dwindling. Would you say that's the same problem? The patience or willing to see the indigent population or the refugees? Why are they dwindling? Well I think they're having trouble making a go of it. They've got, they have malpractice insurance to pay. They have salaries for their employees. They

have office rent and they go into neighborhoods where they have a heavy Medi-Cal and indigent and uninsured patient load and they're giving up and they're going to work for walk-in clinics or they're going to work for HMOs and they're closing their offices in poor neighborhoods or not opening them in the first place. And that even magnifies the problem. That's right. A lot of people feel with skilled nursing homes. I notice that your occupancy rate unlike hospital which is about 50% the skilled nursing home and intermediate care homes have a 92% occupancy rate. So apparently a lot of people are going that way because it's an easier way to solve it. What about the nurses part of this? Well I think what's happening as John alluded to is that as reimbursement becomes tighter and tighter upon the hospital system, the patients are being discharged from the hospital much earlier than they were in the past and much sicker than they were in the past. And much of the burden is falling upon community agencies such as home health care agencies or as you point to perhaps a skilled nursing facility to pick up the slack, to pick up the

care for the patient at that point in time. Which would be all well and good if pressure was being put on this part of the system and this part of the system was being able to expand a little bit in order to compensate for it. Unfortunately what we're seeing with federal policy is that the same time that pressure is being put on the hospital part of the system there's also a ratcheting down of reimbursement to the other parts of the system. And what that is leading to is to as Dr. Kennedy spoke to a disproportionate share of uncompensated care coming to certain types of community agencies who face the same type of situation as the physicians face. They either need to make up the difference in fundraising in the community in United Way funding or by taking on another line of business that perhaps generates a profit to feed into compensating for the uncompensated care. But it's all kind of a stop gap measure. The basic problem as pointed to before is that there's a much greater need than there is reimbursement to cover the need at this point.

Chaucy Alexander of the United Way, of the United Way Task Force has a colorful expression, he said we're playing a shell game, in which we shift the costs the name of the game is to shift the costs and the federal government, as you remember, said they're going to shift the cost to the state, and the state programs put in, now they're going to shift it to the county and the county was going to have a Medi-Cal here and then they put in IMS with a $35 million cap. So it looks like we're playing we are playing some kind of a shell game of shifting the cost but still it doesn't make the pot any bigger. I'm talking about the pot of money available to address the needs for all the people who seem to need them, to want them. Let me ask you one more question. If there was one thing you'd like to see happen as far as public involvement and concern on this problem, and I applaud the efforts of the United Way Health Task Force and the Medical Association and other groups to try and deal with this problem, to recognize and say it is a problem and it isn't going to go away. What would you like to say see done about this that everyone can get involved in? Well if I can say two things, I would say one I would like to see everyone be aware

of what's happening on a state and federal level become involved and support those issues that are important to this. Secondly that they contribute to United Way or to community agencies that are bearing the brunt of this problem and participate with them either financially or by volunteering but in some way attempt to broaden the base of the people that are working with the problem and become directly involved in it. Well here's a good microcosm of what could happen on the community. I see on your United Way Health Task Force people who are not directly connected with medicine yet who are willing to get involved and say this is a problem that concerns all of us. That's true. Because it concerns the economy, what kind of a society we're going to have, and the larger question of what kind of people are we going to be? Exactly. On our task force, we have senior citizens, we have employers, we have insurers, we have all the people who need to be involved in the solution to the problem and I think it's really important that the people in the community become involved because it can't come just from the health care providers. What about the public sector

coming back to you Tom? You're the man sort of in the hot seat. You have all these people wanting the health services and you can't pay for all the services that seem to be required. What do you have to say about the problem? First I'd like to say that we're, you know, you used the word microcosm, and we are a microcosm of the state and federal scene and I think things are better in Orange County than they are in other counties in the state. Well that's a blessing for the people in Orange County, but it's still, we're still symptomatic of the bigger problem. Yes, when the state passes down money and we're an administrative arm in the state and we have to administrate program, and we pass out the dollars as best we can and the dollars start to dwindle, we're in real trouble. The good example is the indigent medical program that you talked about. 35 million dollar cap. Well, that money is about 50 cents on a dollar that we get, and we try to pass it out, and Orange County is very fortunate that they have hospitals aand a medical society that will talk to the county and deal with us and we can get together and sit down, and iron out the best contract

we can and handle the program that way. Orange County is better than most counties. Most counties have county hospitals and they're filtering all through that system and that's a very expensive system, and it does take away from the private sector, so I think the crisis or the time bomb that you talk about will hit other than Orange County, and that's, I think that's fortunate for us because we're not in the limelight right now. Everybody's talking about education. Well, you should be in the limelight. I mean, this problem should be in the limelight. We'll get back there. I've been through this a couple, a few cycles and we'll be back. Let me get one of our figure, and this is it to me astonishing, and that is uncompensated care costs. You've provided this to your group. Uncompensated costs on the statewide level are $1.5 billion for 1986 and translated into Orange County, we have a hundred million uncompensated costs. These means services rendered that will never be paid for. Right. So how long can the system go on with that kind of an explosive burden? There's another force. Excuse me, John. There's another force here and that is those services

have been paid for. Maybe not retail, as some people say, they're not paid a hundred percent but they're paid in some fashion by cost shifting. And cost shifting is a dirty word among businessmen and others because the private patient is paying for services that they really aren't getting because those are how the hospitals and the doctors to some degree... have to make up for the patients... That's right, have been shifting the cost of uncompensated care. We are now in a vice by the insurance companies, the Blue Cross Blue Shield plans, and the businessmen. They are stopping us from cost shifting. And so some of the crisis that you're seeing is a crisis of this new cost control type of legislation which is preventing us from doing things that we've done for a hundred years. And so it's accelerating a process. We are having more. It's got to come to a head, though doesn't it? I think we've got to take a look at too is the trend and how that number has grown to that $1.5 billion number. bBack

in 1982 when the legislature enacted major Medi-Cal reforms, and those reforms were designed to save the state government approximately half a billion dollars a year. You have to see that the health system is really one big system and if you've constricted on one end it's still going to come out as an expense on the other and the business community saw that coming, which is why they put in the contracting program. If there was one quick wish you'd have about addressing this problem as far as the public is concerned, what would you say as to have people do? I think that people have to look at their own health care, determine what they want to have and let their representatives know what that is, and thata they want the government to pay for the services that they have promised society that they would deliver. It's a very complicated problem. Our time is almost up now and I want to thank our special guests for insights into a health care problem which concerns all of us. Please join me next week at the same time when my program looks into the Marine Corps air station at El Toro

and the general who runs it. I'm Jim Cooper. Thanks for being with us. Jim Cooper's Orange County is made possible by grants from Disneyland Park announcing its new attraction Star Tours, now boarding passengers for a space flight adventure. By Signal Landmark Incorporated, developer of Southern California real estate and builder of landmark homes and by Robert Hath and account temps providing permanent and temporary

accounting, financial, and EDP personnel with offices in Newport Beach and throughout Southern California.