California Watch - Health and Welfare

Nurses accused of deception over Orange County school

Christina Jewett — Fri, 18 May 2012 07:05:04 +0000

Christina Jewett

The state nursing board is accusing five nurses of fraud and seeking to revoke their licenses for operating a school in Orange County and the Philippines that purported to prepare students to be registered nurses in California.

While students of Nightingale International California were led to believe their training would prepare them for nursing jobs, records say, the school was not approved by the nursing board or accredited. That means students who took classes from Nightingale were not allowed to take a state licensing exam and must repeat their coursework before seeking licensure, records show.

In at least one recent case, the nursing board worked with the state attorney general to shut down a sham school and get restitution for victims. But in this case, by the time board investigators went to the Garden Grove school in October 2010, they found an empty office, said Russ Heimerich, a spokesman for the nursing board.

He said the school operated from at least 2007 to 2010, and investigators do not know how many students went through the courses.

“The individuals involved have not been cooperating with the investigation,” he said.

One student who complained to the Better Business Bureau about the school in 2009 apparently got a $16,000 refund from the school for himself and his wife.

According to accusations filed against the nurses in December and February, Nightingale entered into agreements with two schools in the Philippines to offer a bachelor’s degree in nursing.

Nightingale advertised pre-licensure nursing courses with instruction in Garden Grove and hands-on experience in the Philippines. But students who took the courses discovered that they were not eligible to take the state licensure exam.

The Board of Registered Nursing filed accusations against the licenses of Nightingale board members Lorelie Malate [PDF], vice president of operations and a contact for students; Maria Teresa Avila Ibarra [PDF], vice president of clinical compliance; Hector Cascalla [PDF], vice president of operations, business and finance and a school instructor; Bella Gorospe [PDF], vice president of operations, sales and marketing; and Avery Malate [PDF], president and chief executive.

An accusation against Ibarra says she “distributed caps and pins at (Nightingale) ‘graduation’ ceremonies” and signed certificates of excellence given to students.

Another against Gorospe says she was an investor in Nightingale and expected an 8 percent share in profits. An accusation against Avery Malate says he promised students they would be eligible to take the licensing exam in California.

Avery Malate said he had not been involved in the school for two and a half years and referred California Watch to attorney Frederick Ray, who declined to comment. The other nurses could not be reached.

Nightingale has not been the only school accused of offering students an education that did not lead to a nursing license. In August 2010, the California attorney general’s office reached a settlement with the operator of a nursing school that also was unaccredited. About 300 students paid $20,000 to take classes at the RN Learning Center in Los Angeles, only to learn they were not eligible to take the nurse licensing exam, records show.

In that case, the school owner, Junelou Chalico Enterina, agreed to pay students $500,000 in restitution and never open a nursing school in California.

A pending bill carried by state Sen. Curren Price, D-Los Angeles, would give the nursing board authority to issue a cease-and-desist order to a nursing school that’s not approved by the board. The bill would require the board to notify the attorney general’s office of any such schools.

Advocates fear patient care will suffer under state budget cuts

Christina Jewett — Tue, 15 May 2012 07:05:03 +0000

Christina Jewett

ideabug/istockphoto.com

Gov. Jerry Brown announced a state budget yesterday that relies on hospitals and nursing homes to achieve nearly $400 million in savings – a week after a far smaller proposal prompted concerns about patient care.

The governor's revised budget is the starting point to closing a $15.7 billion deficit. He proposed making further cuts to human services, paring down hours of care provided to In-Home Supportive Services recipients, and limiting child care support provided by the CalWORKs program.

The revised budget poses a new set of challenges to care providers and patient advocates. Last week, groups representing doctors, nurses and nursing home residents decried a comparatively minor budget change that would have cut the mandate for hospital and nursing home inspectors to perform unannounced inspections to monitor compliance with state laws.

The budget proposal by the state Health and Human Services Agency would have eliminated 25 nurse-inspector positions and slashed fees paid by hospitals and nursing homes that go toward enforcing patient safety laws.

Health and Human Services Agency Director Diana Dooley said that the proposal to change facility inspections was unrelated to yesterday's budget cuts. Rather, it was meant to streamline state operations “where we believed we could assure quality and safety in care,” Dooley said.

While both Senate and Assembly budget subcommittees voted down the proposal last week, advocates say they are wary that it may arise again. Ken August, a spokesman for the Department of Public Health, which inspects care facilities, said no decision had been made as to whether the proposed change might resurface.

Under the proposal, inspections for compliance with federal patient safety safeguards would still take place. But advocates opposing the proposal point to a raft of California-only provisions that are meant to protect patients young and old.

The California Medical Association, which represents about 30,000 doctors, wrote a letter in opposition, listing some protections that might be curtailed if inspectors stop checking.

The protections include requirements that emergency medications in neonatal intensive care units are appropriate for babies. They encompass informed-consent rights for patients undergoing a sterilization or hysterectomy. And they require that inspectors verify that reports are made to the state Medical Board about potentially errant or negligent doctors.

The budget proposal would have also removed the requirement that hospitals be inspected by a licensed doctor, nurse and "persons experienced in hospital administration and sanitary inspections.”

The medical board also opposed that proposal, saying in an era of major changes due to budget cuts and health reform, “the need to continue to ensure facilities’ compliance with vital state laws has never been greater.”

State hospital and nursing home inspectors fine facilities for some violations. For others, they cite deficiencies and follow-up with administrators on corrective actions.

The California Hospital Association has not taken a position on the proposal, said spokeswoman Jan Emerson Shea.

Representatives of the United Nurses Association of California and Disability Rights California opposed the agency's budget change. Also, advocates for nursing home patients spoke out during last week's hearing.

Sylvia Taylor-Stein, executive director of Long Term Care Services of Ventura County, said the end of inspections to check compliance with state law would “set us back 30 years of reform.”

“To be doing this, we would be going so far back, we would be abandoning the residents who depend on us,” Taylor-Stein said.

A Senate committee analysis of the proposal said the changes would end checks on laws that require a doctor to approve the use of physical restraints on patients.

It would also lift requirements that the state examine nursing homes’ use of antipsychotic medications, which can hasten death in patients who have dementia.

The California Advocates for Nursing Home Reform reviewed a series [PDF] of 2010 state inspections on the matter and found that facilities repeatedly failed to obtain informed consent or dispensed potent and risky drugs to patients who had a tendency to wander.

The proposal would have had no effect on federal inspection requirements. Medicare authorities can put nursing homes under aggressive quality-improvement monitoring or cut their funding after major and recurring problems. A recent investigation by the U.S. Health and Human Services inspector general concluded that California health inspectors were falling short in documenting and ensuring compliance with federal standards.

During last week's hearing, Sen. Elaine Alquist, D-San Jose, spoke against the proposal, which would have also pushed out deadlines on complaint investigations that were set in a bill she carried in 2006.

“I think it’s really important to find out in a timely fashion what occurred, so hopefully it doesn’t happen again,” she said.

Lawmakers: Health care districts must unleash bank accounts

Katharine Mieszkowski — Mon, 14 May 2012 07:05:03 +0000

Katharine Mieszkowski

U.S. Census Bureau

California lawmakers are moving to crack down on taxpayer-funded health care districts that have banked tens of millions of dollars at the expense of funding community-health projects.

A bill moving through the Legislature targets the spending habits of these little-known governmental agencies that were created to run hospitals, which many of them no longer do. These districts are run by publicly elected boards that have power over multimillion-dollar budgets.

New legislation in Sacramento would require the districts to spend at least 95 percent of their annual tax revenue on community programs and services. Districts would have to report their spending annually to local officials, including their county boards of supervisors.

Some of these districts have banked tens of millions of dollars and diverted resources to administrative and overhead costs.

“We really felt that there were three things that we wanted to see from these districts: transparency, accountability and responsibility,” said Assemblyman Rich Gordon, D-Menlo Park who co-authored the legislation, AB 2418, with Assemblyman Roger Dickinson, D-Sacramento.

In March, a Bay Citizen investigation revealed that about 30 of the state’s more than 70 publicly funded health care districts no longer run hospitals, a departure from their original mission. Some now give grants to fund community-health programs, such as physical education in schools.

Four grand juries over the last decade have called for the dissolution of the Concord-based Mt. Diablo Health Care District. The district has not run a hospital since 1996, yet it spent just 17 percent of its $3.2 million in property-tax and other revenue on community grants from 2000 to 2011, according to public records. The district is currently being taken over by the city of Concord.

Dickinson, chairman of the Assembly Committee on Accountability and Administrative Review, held a hearing last month at which district officials were grilled on their spending practices. “We found districts that had large real estate holdings, providing noncompetitive grants and have very large reserves,” Dickinson told the Assembly’s Committee on Local Government last Wednesday.

Health care district officials do not relish the increased oversight and regulation. None of them is supporting the bill, and a lobbyist from the Association of California Healthcare Districts spoke against the bill before two Assembly committees last week, arguing that it would hinder the ability of smaller districts to operate.

“AB 2418 will have a dire unintended consequence for many districts that serve underserved communities and the communities that created them,” said Amber Wiley, senior legislative advocate for the association. “Restricting the use of these tax dollars will have a detrimental effect on small, rural districts.”

Lawmakers want all the districts to refocus on providing health services.

“These are property-tax dollars, and in a time when you have literally millions of people across the state uninsured with no access to any kind, let alone quality health care, I think you have to prioritize,” Dickinson said in an interview.

The Assembly Committee on Local Government approved the legislation last Wednesday, one day after it was approved by the Assembly Committee on Health. If it becomes a law, it would take effect on Jan. 1, 2013.

Supporters of the bill include health advocates from Health Access, a consumer advocacy group, and SEIU California, a union representing health care workers who may benefit if more money is injected into providing health services.

Assemblyman Luis Alejo, a Democrat from Salinas, where a financial scandal engulfed a local health care district last year, is attempting to restrict lavish payouts to hospital executives by health care districts. His bill, which the Assembly will consider this week, would prohibit districts from giving financial perks to hospital administrators that are not available to other employees.

"This is ongoing in many places for far too long," he said. "Some of their expenditures have been questionable."

Rural towns devise unique plan to solve water problems

Bernice Yeung — Mon, 14 May 2012 07:05:02 +0000

Bernice Yeung

woodleywonderworks/Flickr

For a good part of its rich history, residents of unincorporated Allensworth, the first African American colony west of the Mississippi, have gone without a reliable supply of safe drinking water.

This is still the case today, where the Tulare County community’s wells – which provide water to the neighboring Colonel Allensworth State Historical Park that commemorates the area’s legacy – exceed federal levels for arsenic.

Arsenic is naturally occurring in the area, and consumption of the semi-metal can cause nausea and skin discoloration. It has also been associated with various cancers.

Residents of Allensworth and neighboring Alpaugh – both rural, unincorporated communities in Tulare County whose water has elevated arsenic levels – have advanced a novel proposal to resolve the water issues in their communities. Under the plan, the Allensworth and Alpaugh Community Services Districts would combine with the Angiola Water District, which sells water for irrigation, to deliver drinking water to residents. Late last week, Allensworth and Alpaugh’s proposal received nearly $420,000 in state grants [PDF] to research its feasibility.

Safe drinking water is a "necessity for healthy living and economic growth and opportunity for the community,” Denise Kadara, president of the Allensworth Progressive Association, said at a recent meeting of the Strategic Growth Council, a cabinet-level committee that coordinates activities related to issues such as water quality and public health among five state agencies. “Rural communities like Allensworth face huge barriers to clean drinking water and we need innovative solutions to overcome these barriers.”

Consolidation of water districts – there are more than 8,000 public systems in California – has become increasingly appealing to rural communities. “It’s become harder and harder for a very small water system to provide safe water and to keep the rates affordable,” said Laurel Firestone, the co-executive director of the Community Water Center in Visalia. “There’s an overall trend of water systems looking for collaborative solutions to help cut costs.”

The Allensworth-Alpaugh proposal is unique because it involves a consolidation between remote rural community water districts and an irrigation water district. The arrangement could serve as a model for other rural communities, water policy experts say.

“A lot of dispersed communities face similar challenges, and what is learned here could be pretty influential in the rural West,” said Tony Rossmann, an attorney who has handled some of the state’s most significant water cases.

The proposal had the support of the Tulare County Board of Supervisors, which submitted the application to the state Strategic Growth Council. “We know that in Tulare County, we have clean water issues in our unincorporated communities,” said Allen Ishida, a county supervisor. “We are not going to be able to solve these issues without consolidation because it’s too expensive.”

Ishida said the funding for the feasibility study is a step toward “finally, after all these years, getting acceptable and potable clean water” to unincorporated communities “so that residents can enjoy the health benefits and lessen the financial burden of having to buy bottled water.”

According to surveys conducted by advocacy organizations like California Rural Legal Assistance, residents of low-income, unincorporated communities spend up to 10 percent of their income on water.

California law states that residents have a “right to pure and safe drinking water,” but while the state Department of Public Health is charged with monitoring public water systems, there are few enforcement mechanisms, said Camille Pannu of the Center on Race, Poverty & the Environment, who helped draft the Allensworth-Alpaugh proposal.

“The gap between rights on the books and rights on the ground is particularly stark in the (Central) Valley,” Pannu wrote in a recent issue of the California Law Review.

The Allensworth-Alpaugh proposal also included an additional $450,000 funds to study the extension of sewer service from the city of Tulare to the unincorporated community of Matheny Tract.

As California Watch has previously reported, Matheny Tract, on the outskirts of Tulare, is located just a few miles – and downwind – from the municipal wastewater treatment plant, but residents currently can’t connect to it. Residents rely instead on aging septic tanks.

A memorandum of understanding is already in place between the city and county to explore a wastewater connection to Matheny Tract, but feasibility studies are a crucial step toward infrastructure improvements for low-income unincorporated communities, advocates said.

A common obstacle to construction is "not getting through the planning phase,” often because there's a lack of funding, said Phoebe Seaton of California Rural Legal Assistance.

Tulare County Supervisor Pete Vander Poel added that the studies for the Allensworth-Alpaugh and Matheny Tract projects "can be used to leverage additional funds for construction." He said that state and federal funding sources typically require feasibility studies and preliminary engineering work to be completed before projects will be considered for future funding.

A separate $383,853 proposal to draft a planning document for unincorporated and disadvantaged communities in Tulare County along the Highway 99 corridor was also approved by the Strategic Growth Council.

Numerous Central Valley communities face similar conditions with water quality, access and delivery. A report by the environmental research organization Pacific Institute found that between 2005 and 2008, about 1.3 million San Joaquin Valley residents drank water with unhealthy levels of nitrates, which can lead to severe illness and even death among infants.

According to Oakland think tank PolicyLink, an estimated 1.8 million Californians live in low-income, unincorporated communities like Allensworth and Alpaugh, and many lack potable drinking water or other basic infrastructure. In the Tulare Lake Basin area, there are at least 370 of these communities.

Community clinics try to fill dental care gap

Callie Shanafelt — Fri, 04 May 2012 20:23:12 +0000

Anonymous

YouraPechkin/istockphoto.com

Roughly three million poor and disabled Californians had their coverage for dental services cut three years ago, and community dental clinics have struggled to cover preventative services ever since.

“It was not something we wanted to do,” says Robert Isman, a consultant with the Dental Program for California Department of Health Services. “We knew that there would be repercussions and there have been.

Dental services aren’t mandated under the federal Medicaid program and California, with a program called Denti-Cal, was once one of the few states to cover non-emergency services for adults. But with the state budget crisis, legislators cut the non-mandatory services.

Community clinics are quick to offer painful examples of clients who need help with their teeth since their benefits were slashed.

For instance, an elderly patient at Asian Health Services in Oakland’s Chinatown had all his teeth pulled so he could get dentures. Then the Denti-Cal cuts went into effect, and dentures were no longer covered. He was left with no replacement teeth.

His daughter called Huong Le, AHS’s Dental Director to ask for help. “He was losing weight. He couldn’t eat because he didn’t have his teeth – the physicians were really concerned about his health condition,” Le said.

Le applied to Asian Health Service’s Community Care Fund and was able to get the money for his dentures. But the fund, made up mostly of donations from AHS staff, covers medical procedures as well oral health. There isn’t enough to pay for dental care for everyone. “We still have to be able to keep the doors open,” Le said.

To cope with the Denti-Cal cuts, AHS started charging for their services using a sliding scale. Most of their patients qualify for 75 percent of their fees to be subsidized from AHS general funds.

But Le says many patients still can’t afford the $80 it costs for a filling in a small cavity.

“We watch the small cavity become bigger and bigger and bigger, and then the patient comes in with the tooth 2 to 3 years later, and the tooth has to come out,” Le said.

Medi-Cal benefits still cover the cost of pulling a tooth.

“Replacing a tooth is much harder, much more expensive – not to mention all the pain and suffering,” Le said. “So if the state would pay for the filling at the beginning when it is a much smaller region, then it would be much cheaper.”

Community clinics also struggle to find specialists to perform more advanced procedures at a non-profit rate. Asian Health Services opened a dental clinic in 2003, and for the first three years they didn’t have any specialists.

“So our general dentists, including myself, had to do everything,” Le said. “When we encountered difficult cases, we had to refer the patients out to the private specialists in town, and nobody went because they couldn’t afford it. So then they all came back to us without having dealt with the problems. So that was very frustrating.”

Le used her network through the Alameda County Dental Society to connect with specialists in the area. In the last six years, she hired five specialists who come in on a part-time basis. “They have their own private practice where they see the other type of patients – the ones that pay,” said Le.

But Le still struggles to book procedures for patients because the specialists are only at the clinic part time. Recently an HIV-positive patient was very upset because he needed a root canal but couldn’t get an appointment for the procedure for six months. Le is trying to work with the clinic’s endodontist (a root canal specialist) to add a day to their schedule to fit the patient in.

La Clinica De La Raza also struggles to provide all services at their six dental clinics and four mobile units. “In our clinics it is very hard to attract specialists because it’s not a lot of pay and it’s a lot of work,” said Teresita Churchill, Operations Administrator in the Office of the Dental Director.

La Clinica is also compensating for the Medi-Cal cuts by using a sliding scale, where patients pay 25 percent of the cost of services. “But if they cannot afford it, we cannot do it,” said Churchill. They also apply for the few grants available for providing dental care.

“We have some programs for the homeless and Alameda County has good programs,” Churchill said. “But the need is bigger than the actual help that we receive.”

That need is popping up throughout the medical safety net. Arlene Glube coordinates oral health programs for children in Los Angeles County for the Center for Oral Health but still gets a lot of calls from people looking for adult care.

“People are looking desperately for anything with oral health,” Glube said. “They beg for adult care and there is none.”

A study from the California Healthcare Foundation looked at the impacts of the cuts in the year following their implementation. The study found a $6 million increase in the use of hospitals and emergency rooms for dental issues that could have been dealt with on an outpatient basis.

Huong Le says when ER doctors treat patients’ dental issues, the problem continues. “What they usually get would be maybe prescriptions for pain medication, for antibiotics, and then they go away,” Le said. “That’s not treating it. That’s not even managing it.”

The increase in emergency visits following the Denti-Cal cuts was primarily among blind and disabled adults. The Medi-Cal dental services branch is now partnering with The Department of Developmental Services to restore funding to what it was for those patients. As of Jan. 13, 2012, they restored coverage to 200,000 adults.

The California Healthcare Foundation study also found that expenditures for federally required procedures dropped along with spending on the procedures that are no longer covered. The study suggests that providers may not have known what procedures were no longer covered. Robert Isman thinks it’s likely that providers were aware of what was still covered, but patients may not have been.

Isman says a silver lining in the cuts was an increase in children’s visits to the dentist. “Clinics and private dentists rely on revenue from the dental program, they compensated by seeing more kids,” said Isman.

Huong Le points out that it is important to make a connection between dental care and medical care. “Oral health is an integral part of primary health care,” Le said. “The mouth is the portal of entry – you know everything goes through the mouth before it gets to other parts of the body.”

For example, Le points out that diabetic patients with gum disease have a difficult time managing their diabetes because of the bacteria in their mouth. So part of managing their diabetes is treating their gum disease. Le also says people with gum disease are prone to heart attacks.

Yet, even as California leads the way in implementing the Affordable Care Act, there are no indications that healthcare reform will increase dental coverage. The health benefit exchange is legally required to include health plans that provide dental coverage for children. Beyond that there is no guarantee that the exchange will include dental plans.

State Senator Alex Padilla is sponsoring SB 694, which would establish an office of oral health – something a majority of states in the US already have. The bill would create a state dental director to study dental coverage throughout the state. It would not provide funding to improve dental coverage. The bill passed the state Senate and has now gone to the Assembly.

“Everything is still kind of up in the air,” Le said. “If its not spelled out than we can’t count on it.”

Though much of the clinic’s focus is on treating acute problems, prevention continues to be the biggest challenge in oral health.

“Unfortunately the patients come in with so many problems that we feel like we are too busy putting out a fire that we don’t have time to be proactive in educating our patients,” Le said.

Le says home care is key to good oral health. She recommends avoiding soda and sugary snacks. As many people already know, brushing and flossing every day is an important way to maintain oral health. “So that’s what we’d like people to do,” Le said. “Just take some of these simple steps to prevent dental problems.”

This story is courtesy of HealthyCal.org, a nonprofit journalism group based in Sacramento.

Prime hospital cited for patient confidentiality violation

Lance Williams — Fri, 04 May 2012 07:05:03 +0000

Lance Williams

Monica Lam/California Watch Shasta Regional Medical Center in Redding

A Prime Healthcare Services hospital in Redding broke state law when it publicized a patient’s confidential medical files in an effort to discredit a California Watch news report, state regulators say.

The state Department of Public Health on Tuesday issued five "deficiencies" against Shasta Regional Medical Center for what were described as repeated breaches of patient confidentiality last year.

At one point, the hospital CEO sent an e-mail to 785 people – virtually everyone who worked at the hospital – disclosing details from a 64-year-old diabetes patient’s confidential files, state investigators found.

Federal and state law forbids hospitals from disclosing a patient’s medical files without permission.

By state law, hospitals can be fined as much as $250,000 for breaching a patient's confidentiality.

The health department considers the issue of financial penalties after deficiencies are corrected, a spokesman said. Deficiencies are violations of laws or regulations applying to state hospitals.

The hospital did nothing wrong and has filed an appeal, said Prime spokesman Edward Barrera. The company "continues to believe that the disclosures, if any, were permitted under both federal and state law," he said in an e-mail.

The disclosures occurred as Prime was attempting to rebut a California Watch story on a supposed outbreak of a Third World nutritional disorder called kwashiorkor at the Redding hospital. The hospital had billed Medicare for treating more than 1,000 senior citizens for kwashiorkor over a two-year period, records show.

One of those patients, retired teacher's aide Darlene Courtois, told California Watch that she had been hospitalized for complications of diabetes, not malnutrition. She denied she was malnourished and said she had never before heard the word kwashiorkor, which means “weaning sickness” in a Ghanaian language in West Africa.

According to the health department, Prime officials zeroed in on Courtois in an effort to discredit the California Watch report.

At one point, top hospital officials took her confidential medical files to the editor of the Redding Record Searchlight newspaper and successfully lobbied him not to print the story.

Later, the hospital CEO sent an e-mail to 785 of the hospital’s medical staff and employees disclosing confidential information about Courtois’ hospitalization, according to the investigator's report.

Prime officials have claimed that her medical files proved she had been given a nutritional consultation as a treatment for malnutrition. That substantiated the kwashiorkor billing, they claimed.

Courtois denied receiving a nutritional consultation. She said the documents she received when she requested her medical files from the hospital didn’t include any information about a nutritional consultation.

Courtois’ daughter, Julie Schmitz, said she and her mother were especially troubled to learn of the reported mass e-mail of the medical records. She called the hospital’s actions “reckless and vindictive.” She said her mother isn't interested in suing, but would like the hospital to say it's sorry.

“My mom just wants a written apology, saying what they did was wrong and they wouldn’t do it to anybody else,” she said. They haven’t received an apology, she said.

The disclosures of Courtois' records were first reported in January by the Los Angeles Times. Since then, Prime has insisted it was blameless, arguing that it was permitted to publicize Courtois’ files to the public because she had showed the medical records she obtained to California Watch.

The health department report said that the hospital’s general counsel, communications director, CEO and medical officer were involved in the illegal disclosures.

The report doesn’t identify them by name. Silas Lyons, editor of the Record-Searchlight, has identified the hospital officials who brought Courtois’ records to the newspaper as Randall Hempling, the hospital CEO, and Dr. Marcia McCampbell, its chief medical officer.

In January, FBI agents interviewed Courtois in what she described as a federal inquiry into the Redding hospital's Medicare billings and the unauthorized disclosures of Courtois' files.

Prime hospital bills for malnutrition, but patient says she wasn’t treated

Decoding Prime

Prime hospital’s stent placements violated state regulations

Christina Jewett — Wed, 02 May 2012 07:05:03 +0000

Christina Jewett

This story was edited by Denise Zapata. It was copy edited by Nikki Frick.

Monica Lam/California Watch Charleen Kerkes said she thought about suing after her husband died at Desert Valley Hospital. She decided against it after an attorney asked to exhume her husband’s body to perform an autopsy.

Dale Kerkes was lean and tanned at 71. In retirement, he turned a backyard hillside into a terraced garden and built a two-story garage.

On the morning of April 28, 2008, he and his wife, Charleen, saw his doctor to check into his occasional heart palpitations. Neither expected problems.

But during a stent placement to prop open a blocked artery, Dale Kerkes died on the operating table at Desert Valley Hospital.

Desert Valley had a limited cardiac license, which means it was allowed to place stents only in emergencies, such as after heart attacks. State hospital regulators determined several months later that the San Bernardino County hospital placed Kerkes "at great health risk” by performing the procedure without the trained staff or specialized equipment required.

Since then, in response to inspections, the hospital repeatedly pledged to follow state regulations and enforce its own policies.

Yet regulators found repeat violations when they examined the cases of another patient who died and two who were injured during cardiac care at Desert Valley.

A fourth patient, whose case was not examined by the state, was injured after a stent treatment that a lawsuit alleges should not have been performed at Desert Valley.

The state Department of Public Health – the agency that documented recurring problems and unmet promises – in March granted Desert Valley a full cardiac license for its new heart center. Public Health officials declined to be interviewed for this story but said in a written statement they conducted two thorough inspections and found no deficiencies.

Charleen Kerkes, who had hoped her husband’s death would lead to changes, feels defeated. “I do think my husband died in vain,” she said. “It’s disappointing.”

Charleen Kerkes, as well as other patients and family members, said they were not told that until March 20, Desert Valley Hospital had a limited license for cardiac surgeries. Nearby St. Mary Medical Center was in fact the only local hospital with a full license at that time.

The move to expand Desert Valley’s cardiac license came as the hospital’s interventional cardiologist, Dr. Siva Arunasalam, faces a trial over accusations that he performed heart surgeries for financial gain while working at St. Mary almost a decade ago. Arunasalam is not an employee of Desert Valley; its medical executive committee granted him admitting privileges that allow him to treat patients.

Families of Desert Valley patients also said they didn’t know Arunasalam had been banned in 2005 from operating at St. Mary. The hospital’s medical executive committee revoked his privileges, citing “hostile and disruptive conduct” that included “dishonesty” and disregard for patients’ welfare, according to court records.

Medicare records from Dale Kerkes’ procedure at Desert Valley, which Charleen Kerkes shared with California Watch, show that 40 minutes after Arunasalam deployed a stent, someone shouted, “code blue.”

Charleen Kerkes said she feared the worst when she saw another physician in street clothes sprint toward the operating room. In an instant, she lost the man who brought her coffee in bed each morning for 40 years.

“It was a nightmare,” she said.

After her husband’s death, Charleen Kerkes considered filing a lawsuit. She said she decided against it when an attorney who reviewed photos of the procedure asked to dig up her husband’s body to commission an autopsy.

Arunasalam, who has been treating patients at Desert Valley since 1995, declined to be interviewed and said through an attorney that he could not discuss individual cases due to patient confidentiality.

Desert Valley is owned by Prime Healthcare Services, which has been the subject of a yearlong California Watch investigation that uncovered a pattern of billing Medicare for rare ailments that generate lucrative bonus payments for the hospital chain. In recent months, FBI agents have questioned former Prime employees and a former patient about the firm’s billing practices.

Desert Valley implanted 118 stents in 2010, according to information supplied by Prime. That was four times the statewide average for hospitals with a limited heart care license, a California Watch analysis of hospital billing datashows.

Hospitals earn from $5,500 to $16,300 for stent procedures, depending on whether the case is done on an inpatient basis. For many patients, stents are not the only tool to manage clogged arteries. Leading medical research shows that medications and lifestyle changes can be just as effective as stents.

Prime Healthcare spokesman Edward Barrera said Desert Valley, which Prime bought in 2001, “has followed and continues to follow all applicable laws and regulations.” He said it is important “to remember that there are unexpected complications with coronary interventions at all hospitals that no one can predict or prevent.”

Barrera said two patients died during stent procedures in 2011 at Desert Valley. Statewide, the California Watch analysis shows that about 2 percent of patients undergoing a stent procedure die, about the same percentage for Desert Valley last year.

Kathleen Billingsley, chief deputy director of policy and programs at the state Department of Public Health, wrote hospital executives in November saying the new heart center would not be approved until the department is “assured of the absence of systemic health and safety issues in the hospital.”

Since then, state authorities said they performed extensive examinations of the hospital and its cardiac services, on Feb. 14 and March 20. Because the hospital was in compliance with regulations on both of those days, the full cardiac care license was granted, according to the public health department.

Inspections find repeated deficiencies

Of the 57 hospitals in the state with a limited heart care license, five facilities implanted more stents than the number Desert Valley says it placed recent years.

But only Desert Valley has been cited repeatedly for its heart care, state inspection records show. Since 2007, the state has found deficiencies in cases involving 40 patients seen in Desert Valley’s cardiac lab.

The California Department of Public Health has inspected Desert Valley Hospital dozens of times since 2007. During five reviews of cardiac care, it cited lax enforcement of hospital policies or failures to warn patients of surgical risks.

In response to Kerkes’ death, regulators inspected Desert Valley in July 2008 and determined that the hospital violated state regulations by implanting a stent “they were not licensed to provide.” An inspection in 2011 found that Arunasalam had performed a stent procedure that, for the second time, violated state regulations and resulted in a patient’s death.

Monica Lam/California Watch Desert Valley Hospital in Victorville was the first in the Prime Healthcare chain. State health inspectors have found repeat violations at its cardiac lab.

Hospitals that don’t correct violations face penalties ranging from loss of their state operating licenses to severance of Medicare funding. After each violation at Desert Valley, state public health officials have required the hospital to submit a “corrective action plan,” but they have not sanctioned the facility.

The key difference between hospitals with a limited cardiac license and a full open-heart surgery license is staffing and equipment. Limited-license hospitals are expected to diagnose heart conditions through imaging procedures and intervene only in emergencies.

Hospitals with a full license operate with a heart-lung machine and staff trained to crack open a patient’s chest and perform an emergency operation in case of complications.

The state is studying whether to allow coronary stent placements at limited-license hospitals. Legislators are expected to vote on any proposed changes.

But for now, “you’re not allowed to do it,” said George Smith, past president of the California chapter of the American College of Cardiology and an adviser for the state study overseen by the Department of Public Health.

Regulations defied

Although Desert Valley was allowed to implant stents only in emergencies, state inspectors found several cases over the last four years that did not meet that criterion.

As part of the July 2008 inspection in the Kerkes case, public health authorities found that the hospital performed stent procedures on 18 other patients in defiance of regulations. Some stent cases were scheduled ahead of time, records show, and some took place amid no evidence of an emergency.

Inspectors returned to the hospital in October 2008 and discovered that Arunasalam had injured a patient by delaying care, records show. On July 31, 2008, a 43-year-old uninsured patient suffered a heart attack, an emergency condition that would have allowed Desert Valley to implant a stent.

But instead of rapidly treating the man or transferring him to another hospital, Arunasalam waited too long, and the patient’s heart muscle became severely damaged, the inspection report says. The patient may need a heart transplant, Arunasalam wrote in the medical record and noted, “Overall prognosis was poor.”

In response to inspectors’ questions, Arunasalam said that after the July inspection, a Department of Public Health doctor told him to “let patients die before performing cardiac interventions,” according to an inspection report. Arunasalam – who has been licensed in California since 1989 – had scrawled on the medical records of several other patients that their care was “suboptimal” due to the state health department “protocol,” according to the inspection report.

Desert Valley administrators say they told Arunasalam to stop citing protocols that “did not exist.”

Again, the hospital pledged to change. An outside reviewer would look at all coronary stent cases, a new cardiac lab director would be appointed, and an attorney would train the hospital governing board on its oversight duties, according to a February 2009 report Desert Valley Hospital submitted to Medicare.

Former patient sues

Three months later, in May 2009, Steve Wong, a 54-year-old machine operator at a Rancho Cucamonga textile warehouse, received two stents in a procedure that left him in need of a heart transplant, according to a lawsuit Wong filed against Desert Valley and Arunasalam.

Courtesy Steve Wong Steve Wong went to Desert Valley Hospital with chest pain. His attorneys allege that the hospital and Dr. Siva Arunasalam made mistakes that badly damaged his heart.

Ilan Heimanson, Wong’s attorney, said a cardiologist paid to review the case found that Arunasalam should have implanted one stent and transferred Wong to a better-equipped hospital to implant the second one. Instead, Arunasalam placed stents in both vessels and did not prescribe medication strong enough to prevent major bloodclots, court records contend.

Both Desert Valley Hospital and Arunasalam said in court filings that their conduct in the case did not cause damage to Wong’s heart. “(Wong’s case) is replete with speculation and wrongfully attempts through smoke and mirrors to place responsibility on DVH personnel,” attorneys for the hospital wrote.

Arunasalam testified in a deposition that he placed Wong's stents because the case was a true emergency. Wong’s team did not prove that Arunasalam caused any injuries, according to the cardiologist’s attorneys.

Wong has said he wasn’t aware that Desert Valley was limited in the cardiac care it could provide. He testified in a deposition that he’s expected to live two to six more years unless he gets a heart transplant.

“I am scared of this operation because I had a narrow escape on my last operation,” he testified, noting that he hadn’t gotten on a transplant wait list or discussed it with his wife. “I’m not prepared myself emotionally.”

In November, San Bernardino County Superior Court Judge Steven Malone denied Arunasalam’s motion to be dismissed from Wong’s lawsuit. Malone cited Wong’s medical expert, who said Arunasalam should have returned Wong to the operating table as soon as it became apparent that he had a postoperative heart attack.

Public health inspectors made no note of Wong’s case or other catheterization lab deficiencies in a 90-page report documenting a wide-ranging inspection in August 2009. Department of Public Health spokeswoman Anita Gore said authorities did not receive a complaint about the case.

Prime spokesman Barrera said Prime could not comment on details of the case, but stated, “We are completely confident that we will prevail based on the facts.” Barrera said the hospital “cannot interfere with the clinical judgment of a highly trained cardiologist” as to which case is an emergency.

Doctor faces civil trial

Arunasalam attracts hundreds of patients with cardiac troubles to his medical office, the High Desert Heart Institute in San Bernardino County. Records show that he is board certified in internal medicine and cardiology and obtained his medical degree at Emory University in Atlanta.

During a 2005 employment trial that covered a wide range of practices at Desert Valley, Arunasalam testified on behalf of Prime chain owner and fellow cardiologist Dr. Prem Reddy. On the witness stand, Arunasalam dismissed doctors’ accusations against Reddy, saying the hospital owner is the only area cardiologist he trusts.

That same year, the state Medical Board filed an accusation to revoke Arunasalam’s license, alleging gross negligence and failure to keep adequate medical records. Thomas Douvan, an attorney for Arunasalam, said the case was dismissed.

Arunasalam faces a civil trial in coming weeks over St. Mary’s accusations that from 2002 to 2004, he implanted 59 medically unnecessary defibrillators in patients. A cardiac defibrillator is implanted to regulate the heartbeat. The hospital says it discovered the cases during an internal audit and refunded Medicare the $1.4 million it was paid for the procedures.

Arunasalam has denied all accusations in court records, saying Medicare never deemed the procedures improper. Also, his attorneys said St. Mary administrators attempted to ruin Arunasalam’s reputation because he planned to build a competing heart hospital.

Despite Wong’s case and others cited by inspectors, Desert Valley continued to implant stents in cases that did not meet emergency criteria.

Courtesy the Smith family William "Ned" Smith, 72, died during a stent procedure at Desert Valley Hospital. State inspectors say he did not sign a consent agreeing to the procedure.

William "Ned" Smith, 72, died during a stent procedure at Desert Valley Hospital.On Dec. 30, 2010, William “Ned” Smith, 72, of Hesperia died during a stent placement at Desert Valley, just weeks before the Air Force veteran was planning a vacation to a vintage air show with his wife.

Patricia Smith, who was married to Ned Smith for 48 years, said Arunasalam did not explain the hospital’s limited license status to the couple. She also said he told her that he was only going to examine her husband’s heart. Smith said she didn’t know a stent was placed until after her husband had died.

A Medicare report shows that when Arunasalam began the procedure, Ned Smith was pain-free and had stable vital signs.

A report approved by Arunasalam that Patricia Smith shared with California Watch says one of her husband’s arteries was perforated, which set off uncontrolled bleeding. According to the report, Arunasalam said he tried to plunge a needle into Ned Smith’s chest to draw out the excess blood, but the effort failed.

Patricia Smith said she remembers seeing Arunasalam emerge from the cardiac lab, somberly shaking his head. “I started crying, ‘No, no, no, this can’t be right,’” Smith said.

Smith said Arunasalam told her family that Ned Smith’s vessels may have been fragile because of his diabetes. Patricia Smith said she is upset that no one at Desert Valley told her that nearby St. Mary Medical Center had the staff and equipment to attempt to rescue her husband if something went wrong.

“He’s not God,” she said of Arunasalam. Smith and her son have shared her husband’s medical records with an attorney who has not yet filed suit.

Inspectors discovered Ned Smith’s case while investigating another Desert Valley complaint late last year. Inspectors determined that the hospital put patients in “immediate jeopardy” of injury or death when Arunasalam performed interventions in cases that didn’t meet the hospital’s definition of a cardiac emergency. In addition to Smith, another patient was rushed to a local hospital after a vessel ruptured during an October stent placement.

In November, the Department of Public Health said in yet another report that the hospital had once again failed to hold doctors accountable for violating hospital policies. And Desert Valley, the report said, had failed to send all of its stent cases for review by outside parties, breaking a promise to regulators.

Patricia Smith, who reviewed state inspection reports, said she is concerned patients at Desert Valley’s new heart center might not get clear explanations of surgical risks.

“I feel like they will take more advantage of the system by opening up the heart center,” she said. “They will have free reign.”

This story was edited by Denise Zapata. It was copy edited by Nikki Frick.

When and why should patients get a coronary stent?

Christina Jewett — Wed, 02 May 2012 07:05:03 +0000

Christina Jewett

Medical studies spanning years and examining thousands of patients have upturned conventional thinking about heart attack prevention and treatment. The studies found that for many patients, coronary stents are not more likely to save lives or prevent a heart attack than medication and lifestyle changes. Yet some patients are not given the opportunity to weigh the risks and benefits of various treatment options.

Regulators for the California Department of Public Health discovered that “there was no consent for placing stents” in William “Ned” Smith, 72, who died after the procedure. Nor was there an emergency need for the procedure, regulators concluded.

His case is one of several highlighted in an investigation of heart care at Desert Valley Hospital, a facility owned by Prime Healthcare.

Physicians typically place stents after performing an angiography, or an imaging procedure to inject dye into the coronary arteries to see whether vessels are blocked. In some cases, physicians thread a tiny tube through an artery in the groin or wrist and then inflate a tiny balloon. That balloon expands a small wire-mesh tube that’s meant to facilitate the flow of blood through the blocked artery.

Physicians agree that placing a stent within 90 minutes of a heart attack is beneficial to patients. They differ when it comes to patients who suffer from milder discomfort that comes with physical activity.

Here are some considerations to mull, based on a conversation with Dr. John Wong, the medical editor for coronary artery disease at the Informed Medical Decision Foundation. Wong is also chief of the Division of Clinical Decision Making, Informatics, and Telemedicine at Tufts Medical Center in Boston.

When is a stent elective?

Wong said a stent is considered elective, or a matter of patient preference, when a patient suffers from stable angina. That condition is characterized by pressure or pain in the chest during physical exertion or emotional strain. Stable angina symptoms tend to go away when the physical or emotional stress has passed.

What are the risks of getting a stent for stable angina?

According to Wong, elective stent placements carry a risk of death for 6 to 7 people out of 1,000. Complications include heart attack and artery perforation. Risk of death may be higher if you’re older, have diabetes, heart failure, kidney disease, or have more than a few vessels blocked.

A data analysis by the California Office of Statewide Health and Planning and Development showed that for 2009 inpatient cases, about 2 out of 100 patients died during hospital stays when a stent was placed. That data does not account for whether the patient had stable angina or a more dire condition.

What are the benefits?

Wong said that one study showed that coronary stents relieve the pain and pressure of angina more quickly than an approach of taking medications, exercising and improving one’s diet. However, that study found that in the long run, there was little difference in heart attack or mortality rates between those who had elective stents and those who pursued medical therapy and lifestyle changes.

What is the bottom line?

Wong said patients with stable angina should weigh the benefits and risks of both approaches and make a decision that fits best with their lifestyle.

“Some important questions are how much does the angina bother you, and does it bother you enough that you’d consider the potential harms,” he said.

What about getting a stent in a hospital with a catheterization lab versus one with open-heart surgery?

In California, nearly 60 hospitals have a cardiac catheterization lab that allows them to place stents in emergencies, such as after a heart attack, when a patient has pain that doesn’t subside with treatment or amid major swings in blood pressure. Those labs are meant for diagnostics, not treatments. A group of California cardiologists is currently studying whether the state should allow stents in those hospitals, as many other states currently do. That team is expected to send a report to lawmakers.

Hospitals licensed to perform open-heart surgeries have teams and equipment to crack open the chest and operate. If a stent procedure leads to a complication, such as major bleeding from a tear in an artery, those hospitals are best equipped to save patients.

Where else can I obtain information?

Emily Bazar with the Center for Health Reporting wrote guides about when elective angiography is appropriate and described a variety of heart procedures.

Health Dialog publishes a decision-making guide for patients who are diagnosed with coronary heart disease.

Unincorporated South Dos Palos struggles with economic development

Bernice Yeung — Fri, 27 Apr 2012 07:05:03 +0000

Bernice Yeung

Bernice Yeung/California Watch A former pool hall stands abandoned in South Dos Palos.

Once a thriving rural community with a nearly equal number of bars and churches, South Dos Palos, an unincorporated area in Merced County, has been in decline for decades.

But it’s still possible to make out the contours of the community from a time when it was a growing place. On the edge of town, which borders the city of Dos Palos, there’s an abandoned reddish-trimmed building that used to be a popular pool hall.

The railroad station a few blocks away is now dark and defunct, and it's not far from the skeleton of the produce packing shed where workers used to give melons to local kids. The textile mill is now an empty edifice, a disintegrating monument to a more prosperous past.

Technological advances in farming and manufacturing, coupled with the economic downturn, have created fewer jobs in the area, said Jerry O’Banion, the county supervisor who represents South Dos Palos. “Basically, it’s gone the way of rural America,” he said. “Having the community out in a farming area is not a viable structure as far as being able to survive.”

Despite ongoing efforts to revitalize South Dos Palos, as a poor and unincorporated community, development has been hampered by a dearth of precise information about the place and people who live there.

“It is extremely difficult to gather discrete data for disadvantaged unincorporated communities,” Veronica Garibay of California Rural Legal Assistance’s Community Equity Initiative wrote in an e-mail. “For example, in many cases, these communities are placed in large census tracts or block groups that encompass a broad geography that includes wealthier areas. When data is aggregated, the results are not representative.”

According to a community survey released this week, an estimated 48 percent of South Dos Palos residents live below the poverty level, and the annual median household income ranges between $15,000 and $18,999. The U.S. Census Bureau, however, reports the annual median income in South Dos Palos at $28,931.

Surveys of other low-income unincorporated communities reflect a similar phenomenon. In Parklawn near Modesto, the U.S. Census Bureau says the median household income is $32,902, while a local survey puts that number at $18,999. In Lanare, outside of Fresno, the official federal tally for median income is $42,813, though a local survey reports a range of $22,000 to $25,999.

The community surveys have been conducted by the advocacy organizations California Rural Legal Assistance and PolicyLink with assistance from University of California researchers and students. These groups say they are trying to fill in data gaps for low-income and unincorporated communities because state and federal agencies rely on these numbers to dispense grants that could help pay for infrastructure improvements.

“Many communities like South Dos Palos suffer from severe underinvestment in infrastructure,” Garibay said. “Because they are low-income communities, many qualify for state and federal grants for improved services,” especially for drinking water and wastewater.

“If the data is not representative of the community, the community can potentially be negatively impacted with high water and sewer rates,” Garibay added.

According to the recent South Dos Palos survey, residents cited crime and safety, access to markets and services, and poor infrastructure as their top three concerns.

Howard Redding, president of the board of the community center in South Dos Palos, said infrastructure improvements are needed.

“The main thing is to get the sidewalks in, beautify the place,” he said. “Things to make it look like a town again. Because frankly, people, when they talk about South Dos Palos, it’s not in a good light, but it could be. It could be beautiful.”

Robin Maria DeLugan, a UC Merced anthropologist who oversaw the South Dos Palos survey, said in an e-mail that the data demonstrates the tension between “low-income household expenses and the costs of basic services.”

For example, despite the high poverty rates in the neighborhood, 56 percent of the residents purchase bottled water each month because they are worried about the way the tap water smells and tastes. Additionally, half of the residents spend $200 or more each month on gas and don’t use lower-cost public transportation because the routes are infrequent and don’t stop near their jobs. Residents also reported feeling unsafe walking at night in the community because there are no sidewalks, few streetlights and dogs that run loose on streets.

O’Banion, the county supervisor, said he is concerned about the poor infrastructure in South Dos Palos and plans to try to find federal funds to install sidewalks and upgrade aging water and sewer lines.

“For safety’s sake, that’s the most important reason to put in sidewalks,” he said. “It also will improve the appearance of the community. There is old infrastructure that needs to be addressed in the future, the water and sewer lines. They are going on over 50 years old, and they are going to start breaking down.”

The community’s infrastructure is tied to its potential for growth, said Ismael Diaz Herrera, director of the San Joaquin Valley Rural Development Center, which is working in South Dos Palos.

“Infrastructure is needed for housing and economic development; you can’t have one without the other,” he said. “If you don’t have infrastructure and transportation, then it’s hard to recruit and retain businesses and encourage people to open businesses.”

Despite the challenges, incremental improvements can be seen in the community, which started out as an Italian enclave in the late 1800s, became an increasingly African American neighborhood in the 1930s and is now home to a primarily Latino population. Although abandoned buildings litter the landscape, it also has its share of new houses interspersed between historic homes and tidy clusters of public housing and apartments.

The jewel of South Dos Palos is the recently refurbished George Washington Carver Community Center, the site of baby showers, quinceañeras and a monthly food bank. The county is also planning to open a kiosk at the center so that residents can sign up for social services without traveling 30 miles to Merced.

Built in the early 1960s by residents, local growers and a church pastor, the building began to show some wear and tear in recent years. The roof leaked, and the heat and cooling system that had been suspended from the ceiling generated a loud roar. A small group – including Denard Davis, a retired assistant superintendent of Merced County schools and longtime South Dos Palos advocate – pushed for a new building. It was refurbished for about $300,000 with federal grants and county funds and reopened in late 2010.

The public presentation of the South Dos Palos community survey was made this week at the Carver Center. Angelica Rivera was one of only a handful of residents who attended the presentation.

She has lived in the community for 18 years, and she said she became interested in improving South Dos Palos because she has two daughters in college. “I’m thinking that when they graduate, they will not want to come back to the community because they will not find work here,” she said. “I want to make things better so they will come back.”

California Lost is an occasional series examining challenges facing neglected communities around the state.

Lawmakers move to curb hospitals from 'capturing' patients

Christina Jewett — Mon, 23 Apr 2012 07:05:04 +0000

Christina Jewett

Monica Lam/California Watch

The emergency room practices of a major California hospital chain have prompted new legislation to reduce what critics describe as a pattern of "capturing" insured patients in order to boost bills.

Sen. Ed Hernandez, D-West Covina, chairman of the state Senate Health Committee, is carrying the bill limiting how much hospitals are paid after they admit a certain rate of out-of-network, privately insured patients. Because current state law is so vague, hospitals can charge insurers top dollar for treating patients from outside their medical networks.

Hernandez, who was co-chairman of a Feb. 24 legislative hearing in Los Angeles, said the proposed bill comes after his office heard “about a growing business practice in the hospital world where unscrupulous hospitals avoid contracts with health plans, filter patients with commercial insurance through their ER, and bill higher ‘out-of-network’ charges to maximize profits.”

“This practice goes against the very idea of managed care, which is not only bad for our health care system, it harms patients,” Hernandez said in a statement.

He said he introduced the bill to "remove the economic incentive for a hospital to operate in this manner.”

Hernandez introduced his bill after a yearlong California Watch investigation into aggressive billing by Prime Healthcare Services, a 16-hospital chain based in Ontario.

Prime spokesman Edward Barrera said the bill is part of Hernandez's "increasing bizarre and illegal attempts to target one hospital system."

"This poorly written bill unduly gives more power to HMOs and insurance companies, makes no sense to anyone who understands the economics of healthcare and the already fragile healthcare safety net, and makes it even more difficult for hospitals across the state to stay solvent," Barrera said in an e-mail.

The bill would only affect hospitals where, during the course of a year, half or more of the privately insured patients admitted through the emergency room are outside of their care network. Once a hospital reaches that point, it would be paid Medicare rates or a "good faith and reasonable" estimate of costs.

The move comes as two health care providers, Kaiser Health Plan and Heritage Provider Network, are suing Prime in Los Angeles County Superior Court. Kaiser accuses the chain of attempting to increase profits by "capturing" their patients who come into Prime emergency rooms. Heritage says the chain misdiagnoses patients to justify keeping them in Prime hospitals.

Prime has denied those claims and filed the first lawsuits in the disputes with the insurers, saying both wrongfully withheld payments for patient care. The lawsuits are ongoing.

During the February hearing, Assemblyman Bill Monning, D-Monterey, and Hernandez heard testimony from a Kaiser emergency room doctor who said hospitals bought by Prime stopped communicating with Kaiser about patients.

Sandra Taylor-Davey, granddaughter of a Medicare patient, testified about the difficulties her family faced getting her grandmother moved out of West Anaheim Medical Center, which is owned by Prime.

Hernandez’s bill is up for a hearing and vote Wednesday.

Update: This bill passed out of the committee during the hearing.

The California Hospital Association opposes the bill. In an April 9 letter to Hernandez, the hospital association said the bill conflicts with current law, which lays out what emergency room doctors and managed care plans are required to do when dealing with out-of-network patients.

Kaiser and Heritage have accused Prime of subverting the law by routinely failing to notify them when a covered patient lands in a chain hospital. However, Prime General Counsel and Vice President Michael Sarrao has said its doctors make autonomous decisions about how to handle emergency care.

The hospital association said in its letter that when disagreements over the process can't be resolved, “the appropriate forum to resolve disputes remains the courts.”

Kaiser and the California Association of Health Plans, which represents major insurers, have not taken a position on the bill, spokeswomen for the organizations said.