Calls for action after regulators criticize delays in LA County's public health system

In mid-December, a woman in her early 40s with severe abdominal pain and unexplained weight loss was referred to a gastroenterologist at Los Angeles County-USC Medical Center.

The specialist said she would have to wait two and a half months for an appointment. Then she learned she'd have to wait another two and a half months for an MRI scan of her intestines. And four months for a colonoscopy. The news was frustrating but not a shock— the county hospital system had recently kept her waiting two years for a mammogram, she said.

Her experience mirrors those of thousands of other patients who for years have faced delays to see specialists at Los Angeles' county-run hospitals—waits that have cost some patients their lives.

After a scathing report earlier this month accused the county's publicly run health insurance plan, L.A. Care, of failing to adequately monitor waits for appointments at the county's hospitals, local lawmakers are demanding action, including an independent review.

"The safety, health and protection of the residents who rely on L.A. Care shouldn't be jeopardized," said Holly Mitchell, chairwoman of the county Board of Supervisors, which is ultimately responsible for the care patients receive at the safety-net hospitals.

Mitchell, who is also on the Board of Governors for L.A. Care, said the panel agreed with her suggestion to "immediately hire" outside consultants to determine why the problems occur and how they can be prevented.

An L.A. Care spokesman could not immediately confirm details.

Supervisor Hilda Solis, whose district includes County-USC in Boyle Heights, said she would ask county health officials, and the county counsel, to address the issue. And she said she's working with the hospitals to "enhance their abilities to recruit and retain more providers, to help address workforce shortages" that can create delays.

"My heart breaks when I hear stories of county residents not being able to access essential health services when they need it," Solis wrote in an email. She acknowledged obstacles faced by county hospitals, including the pandemic, but said, "it ultimately does not matter. Our residents need to be able to access quality care whenever and wherever they need it."

Advocates for the poor, though, accused leaders of the L.A. County Department of Health Services, which runs the county's hospitals, of acting too slowly on a crisis that has plagued patients for years.

"These kind of delays are unacceptable, and the fact that they continue to go on says that LA County DHS has not taken seriously the need to address (them)," said Beth Capell, a policy advocate with Health Access California who helped push for a state regulation that requires health insurers to provide specialist appointments for their enrollees within 15 business days.

The time limit, which went into effect more than a decade ago, appears to have been openly ignored by county health officials for years.

While those officials place much of the recent blame for long waits on the pandemic and staff shortages, patients at county-run hospitals, including County-USC in Boyle Heights, Harbor-UCLA Medical Center in Torrance and Olive View-UCLA Medical Center in Sylmar, have long endured agonizing, sometimes deadly delays.

In 2020, a Times investigation found the average wait for patients to see specialists after a request from a primary care provider was nearly three months.

Even patients waiting to see specialists whose prompt care can mean the difference between life and death—neurologists, kidney specialists, cardiologists—routinely fell victim to delays that stretched for months, according to a Times data analysis of more than 860,000 requests for specialty care from 2016 through 2019.

Spurred by The Times' investigation, state regulators began looking at failures in the county's health safety-net system. Among other things, their report accused L.A. Care of failing to track how long it takes to get appointments with specialists at the county hospitals, which treat more than 2 million of the region's poorest and most vulnerable residents.

That failure, and allegations of the hospital system's poor communication with patients about the reasons for delays and denials for specialty care, contributed to regulators levying historic fines totaling $55 million against L.A. Care this month.

Regulators found that L.A. Care does not take into account the date on which a primary care provider first requests a specialist for their patient. More than 300,000 L.A. Care enrollees get care at county hospitals, according to the health plan.

"Without proper tracking," the regulators wrote, it's impossible to monitor whether patients are getting "timely access."

Coral Itzcalli, a spokeswoman for the county hospital system, said the health plan did not ask for data on wait times.

Regulators also said documents they reviewed during the course of their investigation suggest the health services department's internal messaging system, eConsult, doesn't provide patients timely decisions on access to care, doesn't provide them notification of the reasons for denying care and doesn't give them the opportunity to file grievances and request hearings—all required by state law.

Itzcalli pointed to the regulators' use of the word "suggests" and argued the "judicious phrasing only proves that they are unsure what the documents actually say and, more importantly, are unsure how eConsult actually works."

Instead of filling out a paper referral, the county's primary care doctors use eConsult, a system much like email, to confer with specialists about their patient's condition and to set up a face-to-face appointment.

County health officials credit the system with helping primary care doctors get quick advice and reducing the number of face-to-face appointments with specialists—who are in short supply across the U.S., but particularly in health systems that cater to the poor.

But in interviews with The Times, some county primary care doctors and nurses complained that eConsult seems designed to prevent and delay specialist appointments and circumvent the state-mandated time limits.

In their formal accusation this month, state investigators echoed that concern. They said documents they reviewed suggest, "there are no built-in timeframes for the various stages of the eConsult process" and no notification for the patients of the status of an appointment request.

The regulators also noted that the health services department instructs doctors using eConsult, "Do NOT tell your patient they are getting a 'referral,'" an instruction some county doctors interviewed by the Times believe is designed to prevent the clock from starting on the time limit.

"That is not the reason for the instruction," Itzcalli wrote in an email to The Times. "It is because eConsult is not a referral system." It's a "communication and collaboration platform," she said.

For The Times' 2020 story on the long delays, county heath officials made a similar argument, that they simply don't do referrals. Instead, they allow doctors to determine the best timing for an appointment based on the patient's medical needs—not "some bureaucratic regulation," as one high-ranking county medical officer put it.

Because the 15-day limit applies to insurers and not doctors and hospitals directly, they said they viewed it as "guidance" as opposed to a hard-and-fast rule.

"We don't see the state regulation as our goal or our target," Dr. Christina Ghaly, the county Department of Health Services director, told reporters at the time.

In emails following the imposition of the fines earlier this month, Itzcalli said county officials are working with the health plan to improve tracking requests for specialty care and notifying patients.

A spokesman for L.A. Care said the plan intends to contest the $55 million in fines, which are the biggest such penalties in state history. The previous record was $10 million.

Since much of L.A. Care's funding comes from the state, the fines would amount to returning a chunk of the money. A spokeswoman for the California Department of Managed Health Care, one of the two regulatory agencies that fined L.A. Care, said the first $1 million in fines her department collects each year goes to repay student loans for doctors who agree to work in rural areas. The rest goes to support Medi-Cal, the state program that provides health insurance for the poor.

While state regulators and county officials debate the definition of "referral" and argue over potentially enormous sums of taxpayer dollars, many patients depending on the county system are left waiting.

The woman who recently waited two years for a mammogram and is still waiting for an MRI asked that her name not be used because she's revealing sensitive health information.

In February she wrote to county supervisors—who are ultimately in charge of the safety-net hospital system—reminding them that "care delayed is care denied" and begging them to do something to relieve the suffering of millions of "vulnerable patients."

"The county isn't taking any action to improve these things," she told a reporter. "It doesn't seem like anyone on the Board of Supervisors is offering a meaningful response."

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