CONVERSATION / MARY RAINWATER : If County Hospital Closes, Can Volunteer Clinics Fill the Void?

Outright closure of the huge County-USC Medical Center is under serious consideration, mostly because Los Angeles County can’t afford the $1 billion cost of replacing the aging, earthquake-damaged physical facility. Some county officials have suggested that nonprofit neighborhood clinics could do more of what the county does, at far less cost. JAMES BLAIR talked with MARY RAINWATER, director of the nonprofit L.A. Free Clinic, which is the nation’s oldest no-cost health clinic, founded in 1967. She discussed how the clinic operates, areas where it could expand and the effect of closing county facilities.

We provide urgent, primary medical care--the basic “you feel sick and need to see a doctor� kind. We don’t provide continuity care for things such as diabetes or heart conditions. We also have dental care, legal services, counseling and a number of programs that work with adolescents and runaway youth and HIV services, so we’re very broad.

Almost 90% of the people we see here are the truly indigent. They don’t have insurance. They don’t have MediCal. They are the working poor, or they’re homeless or they’re in transition. We had 45,000 patient visits last year, but had to turn away 60,000.

The model we use to deliver care is volunteer-intensive. We have a full-time medical director on staff who is paid, but the rest of our physicians are volunteers--residents in training from medical schools, practicing or retired doctors who come here by choice. It’s a wonderful training opportunity for the students as well as an enriching opportunity for the practitioners. They see some very challenging medical problems.

If the county truly wants to start from scratch and redesign the public health system here, I think we can be a very important piece of that and help reduce some of the burden. Some of the money that they’re spending now--$200 or $300 per patient visit--they need to shake loose and give to us. Some of those same patients could be seen for a lot less.

The county should look at the things we can do and help us expand. For example, we don’t run Saturday clinics. I know there are a lot of practitioners who would like to volunteer but we don’t have enough resources to open our clinic on Saturdays right now. They can use us for our strengths. We can do a lot of the preventive stuff--screening, urgent care.

But there’s a whole level, a depth of service, especially trauma, emergency and surgery--especially elective surgeries--the county provides for indigents that there’s no way community clinics can completely pick up.

If an indigent person who comes here needs more extensive treatment than we can provide, or has diabetes, for example, we send them to the county. If County-USC Medical Center closes, and concurrently the county closes outpatient facilities that provide specialty treatment in an extensive and ongoing way that we don’t provide here, it would be devastating to the patients and the community that we serve.

An inherent problem in the county system is that it’s a large bureaucracy that ends up being very complicated. We have support staff who do a lot of what I call “connective tissue work� so that our doctors can see patients. [The doctors] don’t want to volunteer and fill out 25,000 different forms, though obviously they have to do the charting and things they’re medically [and legally] required to do. But we really try to focus on having a very smooth patient flow that allows them to practice good old-fashioned medicine.

County facilities provide some services similar to ours--several of the clinics do a lot of urgent care, family planning and treatment of sexually transmitted diseases--which we could do cheaper here.

At the Free Clinic, a family planning visit or treatment of a sexually transmitted disease runs between $35 and $60 per patient. That is one-half to one-third what it costs the county--that’s something the county might want to think about as they approach this crisis. We’re a much better bang for the buck.

One of the reasons we can do what we do so cheaply is because we have a very aggressive board, staff and group of volunteers that leverage donations of all sorts--printing, medication, supplies, resources [like lab and X-ray work] that we would otherwise have to pay for. All of that helps us keep our costs per patient way down.

The whole question of the work force and [unions] is very complex. We don’t have that. So part of our ability to be lean and efficient in how we operate is that we don’t have a lot of the governance and labor force issues the county has.

Of our $4-million annual operating budget, about half is government funding from all levels and different government entities. The other $2 million is raised through private foundations, corporations, individuals, special events. If we had to add in all the gifts-in-kind, the dollar amount contributed to the clinic would be much higher. And if we had to add all the volunteer time, our budget would probably be close to about $10 million.

There’s a trend these days to think that the private sector can take care of everything [with] government stepping back--[but] it’s that marriage of the two, if you will, that allows us to be efficient. We need public support and private support to address the overwhelming health needs in this community. I hope that this time the county does take this as an opportunity to look at what they might be able to do differently. But it’s important for people to recognize that there’s no way this can all be taken care of by either closing everything overnight or by looking to the private community to take over. The issue remains: Who’s going to see these patients and who’s going to pay?