LOS ANGELES-Los Angeles County's Department of Health Services director said he is disappointed by the lack of progress in the restructuring of the deficit-ridden six-hospital county system. The county was required to revamp its health services to focus on outpatient care as part of a five-year HCFA bailout that began in 1995.
"The re-engineering is not going as well as I wanted," Director Mark Finucane said. He said he is considering asking for an extension of the bailout, which, according to county documents, may provide a total of $926 million in federal funding over five years.
Finucane's office released data in December that showed more outpatient care being provided through the county system and fewer dollars flowing to the hospitals, but the number of outpatient visits was still far below goals set for 2000. Moreover, the county projected it would save $294 million by 2000 but is expected to miss that target by a whopping $212 million.
The county restructuring plan focuses on joint ventures with 110 private providers, most of whom are accepting county patients at their own clinics or have used their own resources to take over facilities previously operated by the county.
"The complexity of doing the re-engineering of a multihospital system was underestimated by all of us involved in the project," Finucane said. Consultants hired to construct a formal plan also underestimated the time frame, he said. "You divert your energies if you're attacking so many (problems) simultaneously. I should have changed the expectations we had."
Some observers have suggested that county officials knew about potential implementation problems before the project began. E. Richard Brown, director of the University of California at Los Angeles Center for Health Policy Research, said he believes that savings estimates, for example, were inflated to secure federal funding-something Finucane strongly denies.
But Brown and Finucane agree that transforming the county's healthcare system is a 10-year, not a five-year, project.
"Right now, the county should just be satisfied (with) the increase of outpatient primary care," Brown said.
The county handled 2.4 million outpatient visits in the fiscal year ended June 30, 1998, up from 2.2 million in the previous year and the first increase after three years of steady decline.
However, that was still more than 1 million visits short of the county's goal of 3.9 million outpatient visits by 2000, despite a 50% increase in the number of outpatient sites between January 1997 and July 1998. The sites were created mostly through the private-provider partnerships-a successful aspect of the project, Finucane said. To reduce emergency visits for basic care, the county also established outpatient-referral centers at its hospitals, which resulted in nearly 50,000 referrals last year.
Rene Santiago, county director of the restructuring project, said the decrease in outpatient visits before last year's increase was deceiving because simple tasks like refilling prescriptions had been shifted to telephone consultations from in-person visits. Santiago believes the county will remain on target for outpatient visits by 2000.
Finucane was less optimistic about reaching the target but noted that his department is hiring 420 employees to work at county clinics, which will spur more outpatient visits and fewer inpatient visits.
A plan to increase ambulatory care-in part by extending clinic hours and providing transportation-will be presented to the Los Angeles County Board of Supervisors later this month, Santiago said.
Santiago and Finucane pegged the failure to meet savings estimates to a 1997 pay boost for employees-the first in six years.
Finucane said fractious relations with labor unions have eased as the county has cut the work force by 16%, or 4,300 jobs, since 1995. Hospital expenditures have been cut by 11% since 1995, and budgeted inpatient beds have declined by 28%.
"That is all seen by HCFA as part of the overall picture," Finucane said.