Thursday, March 20, 2003
Copyright © Las Vegas Mercury

Sickly system

The health care crisis in Southern Nevada leaves uninsured, indigent with limited options

By Larry Wills

Four years ago, indigent health care in Las Vegas was a mess. Clark County's University Medical Center was bleeding county money amid the soaring number of low-income patients at its doors. Only one other facility served the poor, the Community Health Centers, which had its U.S. Public Health Service contract yanked over reported mismanagement of funds.

Today, it's little better. UMC is in worse financial shape, and only four federally subsidized clinics in the valley are accepting the indigent.

The situation is especially frustrating for Thom Reilly, the county manager, who, when he was a UNLV sociology professor, spearheaded a communitywide effort to expand indigent care. Reilly cobbled together a consortium of local providers to find ways to make health care accessible to all citizens. He became a rallying point for better health care.

Today, Reilly finds himself on the other side of the equation. As county manager, he's facing a crisis at UMC, with staggering operating losses that required a $38 million bailout and forced an overhaul of public health care.

"Last year, UMC depleted our $40 million rainy day fund," he says. "They had $20 million in past due bills."

Although indigent care costs were not the only reason for the crisis, they raise the question of whether Clark County alone can afford to meet its mandate to care for the growing number of indigents. Clark County's social service workload, for example, has jumped from 8,000 to 11,000 in just one year, placing increasing pressure on health care.

Take, for example, the county's dozen remaining Quick Care clinics. The clinics were originally intended for paying and insured patients only, to offset losses at UMC. But they brought criticism from private providers, since the county is required to treat the poor.

Two years ago, the Quick Cares started accepting indigents. Everything would be all right, the reasoning went, since Quick Cares would make money referring patients to UMC. Except they didn't do that, with many patients going elsewhere.

Last year, the financial tent collapsed. The Quick Cares weren't making money, suffering a 15 percent reduction in patients in 2002. UMC's paying patient income dropped $10 million in one year. And the costs kept soaring. Physician salaries were $27,000 a year above the average.

Worse, patient bills were not being sent out. Reilly says the perception was that the Quick Cares were free. The patients, he says, "were treated first and then they attempted to get the payment later. They weren't even collecting co-pays."

Stopping the runaway train required drastic surgery. Reilly demoted staffers, closed clinics at Jean and the Community College of Southern Nevada, laid off workers and started a top-to-bottom overhaul of county health care.

"We cut $10 million from operations, closed two clinics and laid off 33 people.

"We estimate a $15 million loss this year," chump change compared to the $38 million lost last year.

Reilly retains a cautious optimism that UMC and its Quick Cares can be viable operations. "I'm confident we can get UMC under control," he says.

Reilly is expected to give his recommendations to the County Commission this month. They will include the conclusions of two outside studies and a local citizens task force. Those recommendations may seek fundamental changes in UMC's operations.

"It a daunting task," County Commissioner Rory Reid says. "It's the most difficult problem facing the county."

But Reid says the commission is letting Reilly come up with a rescue strategy before making a decision. "We've been careful not to suggest solutions until we understand the nature of problem," he says.

Most agree that major changes are in the offing that will affect health care for the poor. Reilly hopes to retain that service in key neighborhoods, but sees no reason for indigent care in affluent neighborhoods. The patients just aren't there in appreciable numbers. "There should be different criteria in different neighborhoods," he says.

He'll ask the County Commission to permit indigent care at Quick Cares at Nellis and Charleston, the Enterprise Center in West Las Vegas and in Spring Valley. Indigents also will be treated anywhere in emergencies, as well as those who hold county indigent cards and need non-urgent care.

Maintaining three Quick Cares for the indigent will help residents on the east and southwest sides of the community, where no comparable clinics exist. But Enterprise, on Martin Luther King Boulevard, shares a building with a Nevada Health Centers clinic. Staggered operating hours minimize competition.

But even that falls far short of the need. Steven Hansen, CEO of Nevada Health Centers, worries that the high percentage of indigents is skewing profitability.

"We see 65 to 70 percent [indigent]," he says. "If we can have 50 percent uninsured and 50 percent Medicaid, we could hire more doctors."

But more doctors would mean more money. "We have 2,600 patient visits a month," Hansen says. "There are so many people in need and so few dollars. With the money, we could double the number of visits."

The sparse mix of county and federal dollars, along with the few paying patients, may preclude substantial expansion of indigent services. "Even though there's a huge demand, I can't meet that demand or I would put myself out of business," Hansen says.

So Hansen's getting creative. He's working with school clinics, operated by the county health district, to open another facility in about 18 months, depending, of course, on whether the money is there.

And he's submitted a grant to expand natal services, with more OB care doctors and midwives. "This state has the fewest doctors to patients," Hansen says. "One of our doctors is carrying 200 patients."

Hansen operates clinics at Enterprise, Cambridge on Maryland Parkway, Civic Center Drive in North Las Vegas and the St. Vincent Shelter downtown, which serves the homeless.

He sympathizes with Reilly's predicament at UMC. "Thom is handling this the right way, maximizing revenue and evaluating where and how the clinics should be. They should put them in the right spot for the right purpose."

But he sees no major increase in indigent care from the county, at least for the time being. "Until they catch their wind, they're not looking at spending money," he says.

Reid agrees. "We can't turn our back on this problem," he notes. "Nevada law requires us to provide this care. But we may have to change the mission at UMC. We can't afford to continue to subsidize it at the rate we have been. We need to undertake a kind of triage look at all the responsibilities UMC has and determine which are priorities."

And where that leaves indigent care is frustrating for Reilly. "How do we deal with the 240,000 people without health insurance? How do we have healthy citizens?"

It seems we can't go there, at least for a while.