In Poor Health : Family Practice Program Ends; What Next for Those It Served?

When San Pedro Peninsula Hospital decided earlier this month to close down two medical services and sell another, it called the action the first step in restructuring the financially ailing community hospital to put it back on its feet.

But the inclusion of the family practice residency program on the closure list has angered its director, Dr. Robert Avina, who called the move a devastating blow to the physicians in training and a disservice to more than 2,000 medically indigent patients who receive care in the program. Family practice physicians offer comprehensive care akin to that of traditional family doctors.

The current active patient load of the San Pedro program is 3,200, but Avina and the hospital believe that expectant mothers and children--about 900 patients in all--will be cared for by the hospital or by other physicians.

Trouble for Patients Predicted

Avina said the other patients will have trouble finding regular medical care elsewhere in the community because physicians are reluctant to accept new Medi-Cal patients. Physicians say that Medi-Cal repayment rates are well below costs and that reimbursement is slow.

Avina termed the scheduled June 30 closure “callous, shortsighted and unfeeling.”

He said it is unprecedented to close down a family practice training program, in which the physicians have invested from one to three years, with just 60 days’ notice. He said the hospital rejected a one-year phase-out that he and second-year residents proposed.

Hospital President John Wilson defended the closure, saying physician training “is a program for a medical center, not a community hospital.”

He said the program was started a decade ago when hospitals were expanding, starting new programs and passing costs on to private insurers and to the federal Medicare and state Medi-Cal programs. In 1983, he said, the government and insurers began reducing coverage and holding the line on costs, causing hospitals to trade expansion for retrenchment.

Wilson said the hospital, which expects to save $400,000 a year by eliminating the family practice residency, has assigned a vice president and a manager to the family practice department, which will continue without the training program. They will help the 10 physicians still in training to find new programs and secure other medical care for the patients.

Dr. David Campisi, a San Pedro internal medicine and pulmonary specialist and chief of staff-elect at the hospital, said each hospital department is meeting this month to explore ways to continue caring for family practice patients.

He said some staff members strongly favor retention of some of the residents, who would be trained by staff physicians. Wilson said a proposal is being considered that would place four residents in the offices of San Pedro physicians.

But Avina called this “too little, too late” and not educationally sound. “They need to be available at the family practice center to give ongoing care to their patients, not in someone’s office,” he said.

Despite the drawbacks of slow and limited Medi-Cal reimbursements, Campisi said he believes “the medical staff in general will be willing to do its fair share” in taking on the Medi-Cal patients, “but no one wants to be the guy in town who takes all of them.”

He said he is not optimistic that the majority of patients will find regular care without going to other hospitals that have family practice residency programs. The nearest are at Memorial Medical Center of Long Beach and St. Francis Medical Center in Lynwood, he said.

The hospital board of directors voted unanimously May 3 to end the family practice residency and psychiatric hospitalization. It also voted to sell the outpatient dialysis unit, which is located in a separate building across 7th Street from the hospital.

Wilson said the action will save the hospital $700,000 to $800,000 a year, primarily through staff reductions. The hospital has already eliminated 23 jobs in psychiatry, and will cut 23 in family practice. The dialysis unit has 10 employees.

At the same time, the board voted to spend $2.5 million to renovate and remodel its maternity and child health center so it will be what Wilson called “the finest of its kind in the South Bay.”

‘Critical Service’

“We feel this is a critical service to our community,” said Wilson, adding that the center has fallen behind those of other hospitals and must be made into a “center of excellence.”

The board also gave conceptual approval for a cardiovascular surgery program, which has a $1.5-million price tag. “Cardiology has been excellent here over the years and (the program) would add to this,” Wilson said. He said the program would produce an annual profit of $1 million in the first five years.

Wilson, who had been acting chief executive officer since the forced resignation on Jan. 25 of President Rodney Aymond, was given the job of president on a permanent basis in another May 3 board action.

Psychiatric hospitalization services ceased May 5. Dr. Thomas Dale, chairman of the psychiatric department, said the department will continue to offer consultation and emergency care.

He called closure “a real loss to the community” because psychiatric patients will have to be transferred to Long Beach and Torrance for hospitalization. “I was there for 16 years . . . the one who opened the place,” he said. “I’m very saddened by the closure.”

Dale said similar closures are occurring at hospitals across the country because of sharply declining patient loads due to cutbacks in insurance coverage. He said that on an average day, his department had 15 hospitalized patients.

Wilson said the board action was based on recommendations from the national accounting firm of Ernst & Whinney, which was retained by the hospital in the wake of an estimated $8 million in losses during 1987 and 1988. The firm, in a plan designed to put the hospital back in the black, identified areas in which money could be saved and recommended elimination, sale or lease of some services and enhancement of others.

Wilson said a “lot of soul searching” went into the board decision about cuts. “The need for change is compelling,” he said. “It’s tough for the people involved in these programs, but it’s best for the hospital to become a viable institution in the future.”

For his part, Avina praised San Pedro hospital’s medical staff and acknowledged that the hospital has financial problems to solve. He said his criticism stems more from the abrupt way the hospital is shutting down the residency training program than from the shutdown itself.

“(Residents) have signed contracts with the hospital . . . and in May, 1989, they have the hospital say, ‘We feel we won’t honor this contract,’ ” he said. “It’s quite a shock.”

Of the 14 resident physicians in the three-year program, four will graduate in June. Avina said the future of the others who still have training to complete is up in the air. “They don’t know where they can go,” he said.

Avina said some of them may have to wait a year before resuming their training.

Four physicians who were due to start their first year of residency in July have been placed in other family practice programs. Three will be in Southern California--at Los Angeles County-Martin Luther King Jr.-Drew Medical Center in Willowbrook, White Memorial Medical Center in Los Angeles and the San Bernardino County Medical Center. The fourth will go to a program in Columbus, Ohio.

Although there is an escape clause in the contracts for the hospital in the event the training program is canceled, Avina said the resident doctors have retained an attorney.

Of the residency program’s 3,200 active patients, he said, 95% are on Medi-Cal. Wilson said hospital obstetric physicians have agreed to care for 200 who are expectant mothers. Avina said 600 to 700 of the patients are children and will receive care because they are covered by Crippled Children’s Health and Disability Prevention, a state-subsidized insurance program.

But he is pessimistic about the future care of the others, saying many will wind up in emergency wards because they “will not have had continuous health care provided for them, and their chronic illnesses will become acutely worse.”

Wilson was more optimistic, saying that physicians in San Pedro will accept Medi-Cal patients. But he conceded that “some may have to leave town.”