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California regulators launch review of long, deadly delays in L.A. County specialty care

Los Angeles, CA, August 24, 2019 - Majid Vatandoust, a 49-year old heating and air conditioning technician from Canoga Park, who went to LAC clinic Mid-Valley for a check-up in early 2014. He had unintentionally lost about 20 pounds and routine tests found he was anemic and had blood in his stool, all early indicators of potentially deadly colon cancer. His doctor put in a request via eConsult for a colonoscopy but was denied, his medical records show. The gastroenterologist who turned down the request without ever seeing Vatandoust said the test used to detect blood in Vatandoust's stool was "not valid for patients under 50 years old." Thousands of patients in L.A. County's public hospital system who endure long, sometimes deadly delays to see medical specialists, a Times investigation has found. Doctors, nurses and patients describe chronic waits that leave the sick with intolerable pain, worsening illnesses and a growing sense of hopelessness. According to a Times data analysis of more than 860,000 requests for specialty care at the L.A. County Department of Health Services, a sprawling safety-net system that serves more than 2 million, primarily the region's poorest and most vulnerable residents. (Robert Gauthier / Los Angeles Times)
Majid Vatandoust died of colon cancer at age 52, three years after a request for a colonoscopy was denied by a specialist working for L.A. County despite tests that showed clear indicators of the disease. (Robert Gauthier / Los Angeles Times)

As current and former doctors in Los Angeles County’s public hospital system condemn delays in providing specialist care, California regulators have launched a review of the long, sometimes deadly waits faced by patients who need treatment from one of the nation’s largest public health systems.

The actions come in the wake of a Times investigation that found patients of the Los Angeles County Department of Health Services face agonizing delays to see specialists after referrals from primary care providers, leaving many with intolerable pain, worsening illnesses and a growing sense of hopelessness. The Times report included several patients who died of the conditions they waited to have treated.

The California Department of Health Care Services will review whether any managed care plan that offers Medi-Cal — the government-subsidized program that covers low-income Californians and most county patients — violated its contract with the state to provide adequate access to care, an agency spokeswoman said.

“Any untimely death is a tragedy, and our hearts go out to the families suffering the loss of a loved one. The wait times outlined by The Times are unacceptable,” Michelle Baass, undersecretary of the California Health and Human Services Agency, said in a statement. “Timely access to care is a fundamental patient right.”

The review is the second underway by the state. The California Department of Managed Health Care began an investigation of the county’s wait times this year in response to questions from The Times about delays in specialist appointments.

Baass is overseeing both inquiries after her boss, state Health Secretary Dr. Mark Ghaly, recused himself. Ghaly is married to the director of the Los Angeles County safety-net hospital system, Dr. Christina Ghaly.

The average wait to see a specialist in the L.A. County system was 89 days, according to a Times data analysis of more than 860,000 requests for specialty care at the county’s Department of Health Services, which serves more than 2 million people, primarily the region’s poorest and most vulnerable residents.

Even patients waiting to see doctors whose prompt care can mean the difference between life and death — neurologists, kidney specialists, cardiologists — endured delays that stretched on for months, according to the data, which consisted of nonemergency requests from primary care providers to specialists from 2016 through 2019.

Several doctors who now work for the county or recently left called for reform, including better communication between primary care providers and specialists as well as a dramatic increase in hiring of specialists.

Dr. Michael Hochman, a primary care physician and associate professor of clinical medicine at USC’s Keck School of Medicine, who has practiced at safety-net health systems on both coasts, said Los Angeles County’s is “the least effective system that I’ve worked at in my 14

Pandemic Delays Treatment, Threatening Patients and Research

Editor’s note: Find the latest COVID-19 news and guidance in Medscape’s Coronavirus Resource Center.

The COVID-19 pandemic has taken a severe toll on patients with retina diseases, according to leading European specialists who took stock and exchanged tips on innovative responses to the crisis at the virtual European Society of Retina Specialists 2020 Congress.

The number of new patients with neovascular age-related macular degeneration decreased by an average of 72% after the onset of the pandemic, said Adnan Tufail, MBBS, MD, from Moorfields Eye Hospital in London, citing findings from a survey he and his colleagues conducted at three treatment centers in the United Kingdom.

A delay in treatment initiation of 3 months could cause an increase of more than 50% in the number of eyes with age-related macular degeneration with 6/60 vision or worse, the survey team estimates, and a 25% decrease in the number of eyes with driving vision over a year.

Significant declines in the number of patients presenting to the hospital for retina treatments were also reported in France and Spain.

“The problem was that patients were afraid to go to the hospital for the injections in their eyes,” said Cesare Mariotti, MD, PhD, from the University of Ancona in Italy.

The overall drop in patients going to the hospital for treatment — roughly 80% across Asia, Europe, and the United States — posed challenges for research, as well as for patients, said Susanne Diehl, PhD, from Novartis in Bavaria, Germany. “Trials will be delayed, approvals will be delayed, and innovation will come to the market delayed.”

Mobile Injection Units

One inventive response to the crisis was to form a mobile intravitreal injection clinic so patients, particularly seniors, could receive treatments in their homes, said Anat Loewenstein, MD, MHA, from Tel Aviv University in Israel.

That service required a lot of infrastructure to set up, and a physician was delegated to review all patient charts to identify those who did not need to be examined before an injection was administered.

It would not be feasible to continue over the long term, but patients loved it, she told Medscape Medical News. “You can’t imagine how people were grateful and happy and were begging us to do that.”

Crews on the mobile units wore masks, face shields, gowns, and gloves, and were tested periodically for COVID-19, Loewenstein reported.

And an entire floor of an office building that wasn’t being used during the pandemic was donated by WeWork, the coworking company, so that Loewenstein and her colleagues could set up a satellite injection clinic, complete with an optical coherence tomography (OCT) machine, for patients not comfortable visiting the hospital.

The strategy in France was to issue a press release and information sheets to reassure patients that they could safely come to the hospital for treatment, said Laurent Kodjikian, MD, PhD, president of the French Society of Ophthalmology.

“Despite that, about 20% to 30% of the patients didn’t come,” said Jean-Francois Korobelnik, MD, from the University Hospital of Bordeaux

Deadly delays in L.A. County’s public hospital system

A tip from a doctor led Times reporters to investigate specialty appointment waits in Los Angeles County's public hospital system. <span class="copyright">(Robert Gauthier / Los Angeles Times)</span>
A tip from a doctor led Times reporters to investigate specialty appointment waits in Los Angeles County’s public hospital system. (Robert Gauthier / Los Angeles Times)

It started with a phone call in the fall of 2018 from a doctor working for the Los Angeles County Department of Health Services.

Patients by the thousands were suffering unnecessarily because of extremely long waits to see specialists, the doctor said. Some were dying before they could get an appointment.

The tip launched an investigation that spanned nearly two years and focused on the county’s sprawling safety-net healthcare system that serves more than 2 million, primarily the region’s poorest and most vulnerable residents.

We interviewed dozens of current and former county healthcare providers, patients and outside medical experts. We also analyzed L.A. County data from hundreds of thousands of specialist referrals and obtained thousands of pages of medical records.

How we verified long waits

The stories we heard were always the same: Wait times were dangerously long.

But the patients and their families were most often relying on memory. Doctors and nurses can’t talk about cases for fear of retaliation from their bosses and concerns about violating strict medical privacy laws. We needed medical records to verify the accounts.

By law, medical records are private. So requests have to be signed by patients or, if the patient has died, by the person who signed the death certificate. We spent months driving across Southern California knocking on doors and collecting signatures.

More months passed as families waited to receive the records. When the documents finally arrived, county health officials had almost always withheld important parts of the medical files.

Conspicuously absent were records from eConsult, an internal email-like system that primary care doctors and nurses use to discuss cases and arrange face-to-face appointments with specialists. We helped the family members push back and demand everything they were entitled to.

It was only after county officials learned The Times was working with the families that they turned over records from the referral system — with an apology for the delay.

After asking for permission from the families, we shared the documents the county finally produced with medical experts inside and outside the county system. Long waits were obvious in every case.

Half a dozen of the patients died after waiting at least three months to see a doctor in a critical specialty — cardiology, oncology, gastroenterology and nephrology. It wasn’t always clear how much the long waits contributed to the patient’s death, but in every case, the experts said, the patient should have been treated much sooner.

Though the individual stories were heartbreaking, they were also anecdotal. We needed to find out whether they were unusual or represented a common experience for L.A. County patients.

How we calculated overall wait times

We knew that it was possible to measure wait times for routine specialist appointments provided by the Department of Health Services. In 2017, two county health services executives published a study with