The crisis of the Los Angeles County public hospital system: a harbinger for the nation.

The public hospital system in Los Angeles County, California, is in the midst of a major fiscal crisis that has already led to a serious reduction of capacity and could continue to worsen. Given the importance of the public system in a county where 30 percent of the population is uninsured and private hospitals provide very little uncompensated care, what happens in L.A. County is a harbinger for other cities and counties in the United States. This article highlights the issue of the extent to which local taxpayers, as opposed to state or federal taxpayers, are responsible for the continued operation of public hospitals and safety-net facilities in their communities.     

CA hospital brands image with a vibrant, colorful campaign. Effort promotes hospital's service lines with "always first" campaign

Hoag Memorial Hospital Presbyterian in Newport Beach, CA, faces tough competition each year. Located in a densely populated county in Southern California, the 511-bed hospital is up against stiff competition for patients in Orange County, where hospitals not only compete with others in that county, but also with hospitals in its more famous neighboring county: Los Angeles.     

Urban health care in transition: challenges facing Los Angeles County.

The authors examine the Medicaid Section 1115 Demonstration Project currently underway in Los Angeles County. The waiver was designed as part of a response to a financial crisis the Los Angeles County Department of Health Services (LACDHS) faced in 1995. It provides financial relief to give the county time to restructure its system for serving the medically indigent population. Los Angeles County's goal is to reduce its traditional emphasis on emergency room and hospital care by building an integrated system of community-based primary, specialty, and public health care. This case study describes activities completed through the spring of 1997, approximately 1 year after the waiver was approved.     

The 1966 enactment of Medicare: its effect on discharges from Los Angeles County-operated hospitals.

The effect of Medicare on two public hospitals in Los Angeles County was analyzed by examining the percentage of patients 65 years of age and older among all discharges from 1958 through 1971. At Harbor General Hospital, discharges of elderly patients had dropped from 21.7% to 7.9% by late 1966; at Los Angeles County General Hospital, discharges decreased from 15.3% to 10.7% between 1966 and 1967. Monitoring public hospitals' demographic changes after enacting a national health plan may provide information on patients' and providers' acceptance of insurance and on resources needed by public hospitals to care for those left without coverage.     

Changing the paradigm: planning for ambulatory care expansion in Los Angeles County using a community-based and evidence-based model

In 1998, Los Angeles County's Department of Health Services (DHS) embarked on a planning process to expand ambulatory care services for the county's 2.7 million uninsured and otherwise medically indigent residents. This planning process was novel in two ways. First, it used a quantitative, needs-based approach for resource allocation to ensure an equitable distribution of safety-net ambulatory care services across the county. Second, it used a new community-based planning paradigm that took into consideration the specific needs of each of the county's eight geographic service planning areas. Together, the evidence-based approach to planning and the community-based decision-making will ensure that DHS can more equitably provide for the needs of Los Angeles County's medically indigent residents.     

Loss of Medicaid and access to health services

In this article, the authors assessed the effects of the loss of Medicaid eligibility on access to health services by the medically indigent population in two California counties. An historically derived baseline of health services received by each county's medically indigent adults under Medicaid was compared with the volume of services provided by the county to the same population after they lost Medicaid eligibility. The baseline figures were used as an "expected" volume of services which can be compared with the actual, or "observed," volume of services. The analysis found fewer hospital discharges than expected in Los Angeles and much fewer outpatient visits than expected in Orange County, suggesting that these groups experienced substantial reductions in access related to loss of Medicaid eligibility.     

Impacts of the medical malpractice slowdown in Los Angeles County: January 1976.

The Los Angeles County (California) physician strike of January 1976 resulted in a partial withdrawal of physician services. Among recorded impacts were a $17.5 million loss in hospital revenues and an $8.5 million pay loss for hospital employees. Several surveys revealed no evidence of a significant impact on the general public in finding medical care. Analysis of emergency room visits and paramedical ambulance calls showed no significant increases during the strike. County mortality statistics for the strike were not affected. Eighty-eight fatalities among 2,171 patients transferred during the strike were analyzed; a Case Attributable Mortality Probability generated on 21 cases selected for final review by a five-physician multispecialist panel indicated that 29 per cent of the Attributable Mortality could be ascribed to the strike itself and 71 per cent to ongoing "patient dumping" from private sector to County hospitals. Even if sample attributable mortality rates were generalized to overall county deaths, the resultant figures are below the estimated range of 55 to 153 deaths that did not occur because of the number of elective operations not performed secondary to the strike.     

Selling Community General

As Community General Hospital approaches its thirty-second year of operation, its once bright future appears dim. Public support, medicare cost reimbursement, and private insurance have always been sufficient to keep the facility in reasonable working order. With medicare now using DRGs for determining payments, however, the hospital is being forced to reduce its costs. Complicating matters is the deteriorating physical plant, the growing public concern over hospital operations, the declining census, and competition from a larger, newer, better equipped city hospital. County officials are now faced with a dilemma: issuing bonds to either build a new facility or to renovate the existing structure. If such bonds were issued, the problem then becomes how to repay them. As an alternative, county officials have decided to investigate selling the hospital. The above scenario faces many public hospitals. Sooner or later, public officials will have to consider selling the hospital. This article's purpose is to explore those topics that relate to this decision.     

Development and utilization of incentive systems for mental health operations: Successful and unsuccessful knowledge utilization in California and Los Angeles

Based on the effort to develop a comprehensive and effective management system for mental health services in Los Angeles, an incentives model is proposed as a general managerial approach for any mental health organization. The successes and failures of strategies to improve a large state (California) and county (Los Angeles) mental health delivery system are reviewed and evaluated. During a six-year period ending in 1984, using an incentives approach, Los Angeles County services to the seriously mentally ill increased, staff morale improved, hospital utilization decreased, residential treatment facilities increased by six times, and high costs per unit of service fell to competitive levels. Care shifted from the hospital to the community, and regional resources were partially redistributed to become more in line with patient needs. However, severe budget cuts consumed operational economies and political resistance hampered efforts to redistribute regional resources. A radical state-level reorgenization is proposed to focus responsibility and to avoid county governance.     

Public health week: marketing the concept of public health.

The Public Health Programs and Services (PHP&S) Branch of the Los Angeles County Department of Health Services began a strategic planning effort in January 1986 to meet new disease trends, curb rising health care costs, consolidate limited resources, and handle shifting demographics. A strategic plan was designed to assess the opportunities and challenges facing the agency over a 5-year horizon. Priority areas were recognized, and seven strategic directives were formulated to guide PHP&S in expanding public health services to a changing community. Health promotion was acknowledged as a critical target of the strategic planning process. Among the most significant results of the health promotion directive was the establishment of an annual Public Health Week in Los Angeles County. Beginning in 1988, 1 week per year was selected to enhance the community's awareness of public health programs and the leadership role PHP&S plays in providing these programs to nearly 9 million residents of Los Angeles County. Events in Public Health Week include a professional lecture series and the honoring of an outstanding public health activist and a media personality who has fostered health promotion. Other free community activities such as mobile clinics, screenings, and health fairs are held throughout the county. With intensive media coverage of Public Health Week, PHP&S has been aggressive in promoting its own services and accomplishments while also educating the community on vital wellness issues. The strategic methodology employed by PHP&S, with its emphasis on long-range proactive planning, is receiving national recognition and could be adopted by similar agencies wishing to enhance their image and develop unique health promotion projects in their communities.     

L.A. County settles suit by Healthcare Foundation

The Los Angeles County Board of Supervisors agreed to pay a $1.2 million settlement to the AIDS Healthcare Foundation, which charged that the county eliminated much of its funding in retribution for a series of protests criticizing county officials for cutting AIDS services funding. The foundation produced an audio recording of a meeting in which members of the HIV Commission discussed controlling the Foundation via its funding. The Foundation currently serves 5,000 HIV-positive patients in the Los Angeles area.     

Re-engineering the Los Angeles County public health care safety net: recommendations from a Blue Ribbon Health Task Force

Public hospitals throughout the United States are under increasing fiscal and political pressure to survive because of dynamic changes in healthcare delivery, an increasing uninsured population of patients and rapidly declining reimbursement. These safety net health care programs are also saddled with outdated and bureaucratic governmental policies and procedures which make it even more difficult to improve the quality of care and efficiency of the organization. As these pressures mount, some public hospital systems have attempted to be reinvented through the re-engineering process. Los Angeles County, the second largest health system in the United States, has done relatively little to adjust to changing times. Los Angeles County Department of Health Services has been attempting to re-engineer for the past three years, but this has not averted the need for a second billion-dollar waiver in 2000 from the state and federal governments. A Blue Ribbon Health Task Force was appointed to examine the failure of re-engineering to restructure the Los Angeles public health delivery system. In this article, the group's findings and recommendations are reported. They cover three general areas: eliminating bureaucratic hurdles, improving healthcare planning and management of operations and setting priorities on critical investments in health services.     

县医院综合改革的理论基础、困境与突破——以陕西子长医改为例

从目标定位、基本理论出发,探讨了县医院改革思路,并对陕西子长县医改方案进行了分析。作为农村医疗体系的龙头,县医院的定位是以适宜的水平提供常见大病的诊断治疗,但面临如何转变利润驱动运营机制带来的挑战。公立医院治理结构的理论思路是在完成社会公共目标和提高医院自主激励机制之间的平衡,先决条件是医疗市场环境的监管水平。价格扭曲、药品流通市场垄断和医疗保险的粗放管理水平是我国公立医院的特殊运营环境,县医院改革必须充分考虑这些因素。陕西子长县通过政府承担医务人员的工资和医院的发展资金,同时进行工资和绩效管理等人事制度改革来解决社会目标和效率之间的矛盾。子长改革的挑战是克服政府集中控制带来的效率损失。     

Building a respite for children and families.

The Los Angeles County-University of Southern California (LAC-USC) Medical Center is noted among the country's major metropolitan hospitals. Operated by the county of Los Angeles, this medical center ranks as the largest academic medical institution in the country with 2,045 licensed beds and an average daily census of 1,500. The sheer number of patients strain all available resources. Each year, more than 80,000 persons are admitted to the medical center and nearly 800,000 patients are seen in emergency and outpatient areas alone. While the medical center serves a county-wide and ethnically diverse population, it's also a crucial resource for the local community in East Los Angeles and downtown areas. Thousands of people from this community enter the hospital each day, either to receive treatment or to visit ill family members.     

Predicting demand for publicly dispatched ambulances in a metropolitan area.

A model to predict demand for publicly dispatched emergency ambulance service in Los Angeles County is constructed using 1970 census tract and land usage data and 1973 population and utilization data. Although data were not available for many communities within the county, results indicate that the mode, which uses four socioeconomic variables, can accurately explain actual variations in ambulance demand for individual communities in Los Angeles County and for larger regions within the county.     

我国县级公立医院改革关键问题与路径选择

自县级公立医院改革试点以来,在各领域都有所探索并形成初步的改革思路。但是,在改革中仍有不少关键问题未得到解决,诸如：改革的多元顶层设计思路、补偿机制的持续性与稳定性、地方政府财政压力加重、医院管理体制机制改革未能协同进行、调动和保障医务人员积极性的机制亟待完善、医疗服务定价无法体现医疗服务价值、人才队伍建设滞后、医保基金的使用等。建议下一步县级公立医院改革应在多元化、多层次的顶层设计指导下。坚持公益性与医院经营效益相结合,建立县级公立医院的现代医院管理制度。改革要从创新人力资本管理机制、完善破除“以药补医”后的补偿机制和配套措施、推进法人治理和政事分开、加强医保基金对居民医疗需求的引导、加快医院信息化建设等方向上寻求突破。     

Hospital Utilization for Injection Drug Use-Related Soft Tissue Infections in Urban versus Rural Counties in California

Drug related-soft tissue infections (DR-STIs) are a significant source of hospital utilization in inner-city urban areas where injection drug use is common but the magnitude of hospital utilization for DR-STIs outside of inner-city urban areas is not known. We described the magnitude and characteristics of hospital utilization for DR-STIs in urban versus rural counties in California. All discharges from all nonfederal hospitals in California in 2000 with ICD-9 codes for a soft tissue infection and for drug dependence/abuse were abstracted from the California Office of Statewide Health Planning and Development discharge database. There were 4,152 DR-STI discharges in 2000 from hospitals in 49 of California's 58 counties. Residents of 12 large metropolitan counties accounted for 3,598 discharges (87% of total). The majority of DR-STI discharges were from urban safety net hospitals with county indigent programs and Medicaid as the expected payment source and opiate related discharge diagnoses. Hospital utilization for DR-STIs in California is highest in large urban metropolitan counties, although DR-STI discharges are widespread. Increased access to harm reduction services and drug treatment may reduce government health care expenditures by preventing unnecessary hospital utilization for DR-STIs. Heinzerling is with the Department of Family Medicine, David Geffen, School of Medicine at UCLA Los Angeles, California, USA; Heinzerling and Asch are with the VA Greater Los Angeles Health Care System, USA; Etzioni is with the Department of Surgery, David Geffen, School of Medicine at UCLA, USA; Hurley and Holtom are with the Keck School of Medicine, University of Southern California, USA; Bluthenthal and Asch are with the Health Program and Drug Policy Research Center, RAND, USA.     

Salmonella arizona infections in Latinos associated with rattlesnake folk medicine.

In 1987 two Los Angeles County (California) hospitals reported four Latino patients with serious Salmonella arizona (Salmonella subgroup 3) infections who gave a medical history of taking rattlesnake capsules prior to illness. Capsules supplied by the patients or household members grew Salmonella arizona. We reviewed surveillance data for this Salmonella species and conducted a case-control study to determine the magnitude of this public health problem. Eighteen (82 percent) of the 22 Latino cases in 1986 and 1987 who were questioned reported ingesting snake capsules compared to two (8 percent) of 24 matched Latino controls with non-subgroup 3 salmonellosis or shigellosis (matched pair odds ratio = 18.0, CI = 4.2, 76.3). An average of 18 cases per year of Salmonella arizona were reported in the county between 1980 and 1987. In this investigation the majority of S. arizona cases reporting snake capsule ingestion had underlying illnesses such as acquired immunodeficiency syndrome (AIDS), diabetes, arthritis, cancer. The capsules were obtained primarily from Tijuana, Mexico and from Los Angeles, California pharmacies in Latino neighborhoods. Despite publicity and attempts to remove the capsules from sale in California, Salmonella arizona cases associated with snake-capsule ingestion continue to occur.     

The health care workforce in Los Angeles County and New York City: a comparison and analysis.

New York City and Los Angeles County have the largest health systems in the United States, but they differ significantly in structure. This study compares and analyzes the structural and workforce differences between the two. The health system in New York City is centered around its large hospitals, and as a result New York employs many more health workers than Los Angeles County, where the health system is centered around physician groups. Health care is a significant contributor to the economy of both areas, but a larger contributor to the economy in New York City.     

California settles lawsuit by AIDS Healthcare Foundation

The California Department of Health Services agreed to settle a lawsuit alleging it withheld funding from the AIDS Healthcare Foundation (AHF) in retaliation for AHF's advocacy on behalf of its clients. The public protest arose when the department attempted to cite one of the AHF hospices for not having a licensed nursing home administrator, which would have blocked Medi-Cal payments for patient care. For the type of facility being cited, having a nursing home administrator is not a requirement under State regulations. AHF charged the state with engaging in a pattern of discrimination, in violation of the Americans with Disabilities Act, the Federal Rehabilitation Act, and California's Unruh Civil Rights Act. A U.S. District judge granted summary judgment to the state on all claims except one transferring AHF's oversight responsibility to a county without AHF facilities. The transfer was viewed as having been aimed at AHF lobbying efforts and as an attempt to silence the foundation. The settlement returned AHF monitoring to Los Angeles County and dropped its claim that the two hospices had to hire a licensed nursing home administrator.