MELISSA BLOCK, HOST:
From NPR News, this is ALL THINGS CONSIDERED. I'm Melissa Block.
ROBERT SIEGEL, HOST:
And I'm Robert Siegel. We've heard stories of turnaround artists in big business, even in public education, an outsider sent to transform a troubled company or a school district. Well, Los Angeles is hoping to do the same thing for its public health system.
BLOCK: In L.A., all eyes are on Dr. Mitch Katz, and he has quite the challenge ahead of him: Some two million L.A. residents are uninsured. They and millions more on Medicaid depend on a system of public hospitals and clinics not known for their efficiency or organization. Sarah Varney from member station KQED has the story of the man hired to turn it around.
SARAH VARNEY, BYLINE: It would be easy to confuse Dr. Mitch Katz with any other doctor at the Roybal Clinic in East Los Angeles. His desk in a closet-sized, windowless office is littered with patient records, X-rays and cans of Diet Coke.
DR. MITCH KATZ: Hello? Is this Juan? Oh, Juan, I've heard such great things about you. So I have a patient that I have spoken to...
VARNEY: His everyman demeanor belies his stature. As director of the county's Department of Health Services, Katz oversees L.A.'s public hospitals and clinics, the place of last resort for millions of low-income Angelenos. He has 22,000 employees and a $3.7 billion budget. When he arrived in Los Angeles last year after running San Francisco's Health Department, he insisted on seeing patients one afternoon a week, a demand that struck many here as odd, if not impossible. How would Katz have time to treat patients with a system in ruin?
KATZ: (Foreign language spoken)
VARNEY: Right now, though, Katz is focused on a man who has walked into the clinic with a large tumor in his lung.
KATZ: (Foreign language spoken)
VARNEY: Katz speaks Spanish in his native Brooklyn accent. He sits opposite the man, their knees almost touching, and carefully explains the possible causes of the tumor and what he hopes a visit to a lung specialist will reveal. After the exam, I remark how unhurried Katz seemed with his patient.
KATZ: What I wanted him to know was that there were other possibilities, and that I was going to stick with him no matter what until we knew what it was. My view is that this then lowers people's anxiety levels, and they don't wind up in the emergency room because, you know, now they're very frightened about what they have. They need a plan.
VARNEY: It's clear Katz finds these clinic hours deeply satisfying, but the effect is much more practical. His time in the clinic informs his priorities as an administrator. He sees the roadblocks and tries to clear them. Katz's primary aim, though, and what he came to Los Angeles to do is to steer low-income Angelenos away from the overburdened emergency rooms they've long relied on and into primary care clinics where costs are lower, chronic diseases can be managed and problems, like a tumor, can be detected earlier.
KATZ: They sent me the Los Angeles org chart. I said, where's primary care? They said, well, it's under the hospitals. Well, that may explain why you have a problem with primary care.
VARNEY: Katz has moved swiftly. In the last six months, his team has assigned nearly a quarter of a million people to a primary care doctor at county clinics.
KATZ: In fact, I didn't hire a single additional doctor. What I did is say, no, we're not running this anymore as a drop-in, you know, see who you see and no one is responsible. If no one is assigned to be your clinician, then who's responsible for whether or not you got a mammogram? No one.
VARNEY: Katz's predecessors promised many of the same reforms, but government observers here say they were stymied by a board of supervisors, which often governs Los Angeles like five competing fiefdoms. Indeed, many of the people I interviewed said they advised Katz not to take the job, that Los Angeles was beyond repair.
I met Michael Cousineau, a professor at the University of Southern California's Keck School of Medicine, at a buzzing L.A. cafe. Cousineau says that sense of resignation, of defeat, may have worked to Katz's advantage.
DR. MICHAEL COUSINEAU: I just think that people are just so tired of failure.
VARNEY: County leaders are not just fatigued; they're scared of losing money. Should the Supreme Court uphold the federal health law, the federal government will sharply reduce payments in 2014 to public hospitals that treat the uninsured. That's because nearly all those who are legally documented will have coverage. That's a worrisome prospect for the county of Los Angeles. Millions of newly insured people who have long had no choice but public clinics and hospitals will be able to switch to private providers.
One report commissioned by the county put it bluntly: If L.A. loses its paying customers and is left treating only the undocumented, the financial survival of its health system is at stake. USC Professor Cousineau agrees.
COUSINEAU: To move it rhetorically from a system of the last resort to a system of choice is not going to be an easy thing. But the price of failure is thousands of people losing their jobs, closing of hospitals and health centers. So that's what the supervisors have to grapple with.
VARNEY: For their part, the supervisors seem supremely and unusually confident in Katz and his initiatives. Supervisor Gloria Molina represents East Los Angeles.
GLORIA MOLINA: I was one that was worried that he was just going to be another guy that just took us so far and then, you know, would leave us. But instead, he's had the most daunting challenges, and he's meeting all of our expectations.
VARNEY: One test of Katz's vision for remaking L.A. into a desirable public health system is taking place at the heart of where it all went terribly wrong. The Martin Luther King Jr.-Harbor Hospital in South Los Angeles closed in 2007 after it reached near-Third World standards and one woman died of egregious errors. It's now reopened as a clinic where patients with chronic diseases are counseled by a team of nurses and medical assistants.
KIMBERLY THOMAS: The patients like the fact that they have someone that they can call, that they know who to call.
VARNEY: The clinic's nurse manager, Kimberly Thomas, says customer service is now a top priority, and the clinic staff offer incentives to patients to improve their health.
THOMAS: They'll bring patients who have diabetes, high cholesterol. They'll bring them back, look at their labs to see if they improved or gone down. And they give gifts to the people who are the most improved, and they really love that.
VARNEY: Assigning low-income patients to a medical home makes for better medicine, but whether it engenders good will and loyalty when these same patients gain insurance is an open question. And this may, in fact, be Director Katz's greatest challenge: giving Angelenos a reason to believe in what the county can offer.
UNIDENTIFIED MAN: (Unintelligible) Parking Lot will be closing at 6 o'clock.
KATZ: Oh, I have to move my vehicle.
VARNEY: OK. Mine's in there too.
KATZ: OK. Let's go.
VARNEY: Back in East Los Angeles, the Roybal Clinic has closed up for the day, and Dr. Katz and I are ushered out of the building by a security guard into the cool, spring night. I ask Katz if he's ever overwhelmed by the sheer magnitude of what he's trying to do in Los Angeles. No, he says quickly. Spreadsheets and politics don't keep him up at night.
KATZ: One thing that is always stressful is patient care. I woke up at 3:30 last night perseverating about a patient. Why? Because it's really, really hard. This is someone who may have a very serious disease. And whether I do the right thing or not and the speed at which I do that might actually affect his life. Most administrative decisions are not like that.
VARNEY: The very name safety net spells out what's long been expected of these public health systems across the country: Spare the most vulnerable from total ruin. But in Katz's mind, the safety net should have higher aspirations.
KATZ: Someone will talk to me about their medical problems, and I'll start asking them about, you know, what's going on in their marriage, with their kids, in their home, and people will begin to cry. People will begin to tell you amazing things about what are really the issues. And often, the physical symptom, both to you and to them, is just the opening salvo in a conversation that they want to have with someone who cares about them.
VARNEY: And that's when medicine, says Katz, becomes more about the art of healing than a science. For NPR News, I'm Sarah Varney.
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BLOCK: This story is part of a reporting partnership that includes KQED, NPR and Kaiser Health News.
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SIEGEL: This is ALL THINGS CONSIDERED from NPR News.