LA County’s health plan has been fined for delays in treatment

A cancer patient enrolled in a health insurance plan for Los Angeles County’s poorest and most vulnerable residents was left untreated because his health was rapidly deteriorating, according to state regulators.

Another participant suffered from “extreme pain” for weeks while awaiting treatment.

Treatment of a third patient, diagnosed with lymphoma and expected to live less than a year, has been delayed by more than two months. This patient left the plan, LA Care, for another insurance company in a desperate attempt to save his life.

All three cases stem from “ingrained” errors that state health officials said continue to threaten the health of the patients entrusted to LA Care. On Friday, the state announced $55 million in fines against the publicly operated health insurance plan that insures more than 2 million Medi-Cal patients and other low-income beneficiaries. It is by far the largest such fine in state history, surpassing the previous record fine of $10 million.

The historic fines follow a state investigation sparked by a September 2020 Times article that found that LA County patients who operate hospitals and clinics — many of which are covered by LA Care — are suffering with distressing, sometimes faced deadly delays to see specialists.

While health plans are required to offer their patients specialist appointments within 15 days, The Times found that the average wait time at LA County Department of Health facilities was 89 days after a primary care physician referral.

Even patients awaiting a doctor’s visit whose immediate care can make the difference between life and death — neurologists, kidney specialists, cardiologists — have endured delays that stretched for months, according to the Times analysis of 860,000 requests for specialty care at the county’s health department facilities from 2016 to 2019.

State regulators have found that not only does LA Care fail to ensure patients have timely access to medical care, but they also fail to approve required treatment and address patient complaints. According to documents released Thursday, the health plan had a backlog of 67,000 formal complaints that had not been resolved.

“The scope and breadth of [L.A. Care’s] Violations indicate deep-rooted, systemic flaws that threaten the health and safety of their members,” said Michelle Baass, director of the state Department of Health Care Services, one of two agencies announcing sanctions.

“I hope this sends a strong message across the industry that the state takes protecting all consumers very seriously, but especially our most vulnerable participants,” said Mary Watanabe, director of the Department of Managed Health Care, which is the highest Fined $35 million.

In an emailed statement, LA Care officials acknowledged some of the shortcomings found by state regulators but said they had objections to the unprecedented fines, which they called “unreasonable and not based on facts.”

The backlog of complaints will be cleared this month, and LA Care is working with the LA County Department of Health Services to bring them into “full compliance,” the statement said.

The statement described the fines as “arbitrary and unnecessarily punitive” and said LA Care will appeal them.

While patients covered by LA Care have access to some private practice physicians, many receive care through the county’s safety net hospital system, which includes Los Angeles County-USC Medical Center in Boyle Heights and Harbor-UCLA Medical Center in Torrance belong and Olive View-UCLA Medical Center in Sylmar.

State regulators highlighted several complaints of long wait times at county health department facilities.

In one case, a patient suspected of having skin cancer had to wait seven weeks for a dermatologist appointment and another seven weeks for a biopsy. According to the indictment, the dermatologist stated that appointments were usually waited for two months.

“It’s been like this in this clinic for 35 years,” says the dermatologist.

In another case, a patient’s eye surgery was repeatedly postponed over four months. By the time the patient lodged a complaint, the permit for the surgery had expired.

“The scale of LA Care’s violations that have harmed members requires immediate action,” regulators said in a press release.

In an emailed statement, Dr. LA County Health Services Director Christina Ghaly said the majority of regulators’ findings relate to issues unrelated to the care provided by her agency.

“To be clear, neither LA Care nor the state have requested systemic changes to our delivery of timely access to specialty care,” she said.

For The Times 2020 story, reporters could not determine how many patients died while waiting to see specialists; County health officials said they had not followed up on such findings. But the reporters obtained medical records of six patients who faced delays of at least three months to see specialists and died from the diseases they had been waiting for treatment.

They included 61-year-old Isabel Lainez, whose bladder and kidney problems were so bad she became incontinent – wet on the bus, in the car or in the elevator – while waiting 10 months to see a specialist. She died of chronic kidney disease before she could get an appointment.

Majid Vatandoust was denied a colonoscopy despite classic symptoms of colon cancer because he was 49 years old and his district gastroenterologist said the cancer screening “is not valid for patients under the age of 50.” By the time Vatandoust turned 50 and was accepted for the test, the cancer in his colon had spread to other organs. It killed him two years later, according to the Times investigation.

Members of the LA County Board of Supervisors, who oversee the health department, did not immediately respond to requests for comment.

A decade ago, a public outcry over long medical delays and patient deaths spurred California to set specific limits on how long insurers could make sick people wait before seeing a doctor.

Beth Capell, a political advocate at Health Access California, a consumer group that helped push for the 15-day limit on seeing specialists, called the $55 million fine “significant.”

“We are very pleased to hear that they are taking aggressive action to ensure every patient in the LA County hospital system has timely access to medical care,” Capell said.