One year ago today, Stanislaus County closed its public hospital and Doctors Medical Center of Modesto stepped in to provide emergency and hospitalization services to county residents.

The public-private partnership between the county and the for-profit hospital was met with uncertainty and anger by some, optimism by others. No one really knew what to expect.

In one year, a lot has happened:

• The county and Doctors blended their philosophically different working environments. Some patients noticed a change in care -- for the good.
• County patients mistakenly assumed that when Stanislaus Medical Center closed, the outpatient clinics shut down, too.
• Staff shortages at Doctors paralyzed its emergency department last winter, just as one of the worst flu seasons in recent years hit.
• A change in the way Medi-Cal patients receive health care has made it more difficult for poor people to see certain doctors, especially specialists.

Merging philosophies

One worry was how county and Doctors employees -- and their different working philosophies -- would meld.

County staff, most of whose patients were poor, wondered how Doctors' staff would fare with the new charges.

"We had two very disparate cultures," said Bev Finley, director of the county's Health Services Agency. "The for-profit's goal is to make money. That's not bad. It's just different from the county's (goal). The county's responsibilities are to ensure access and care to everyone. But all of us need to make money to stay in business."

"I think it's (gone) pretty well," said David Soper, a former SMC employee who worked for the county 21 years.

"There may have been some initial resentment from a few people at Doctors who thought we were taking their jobs," Soper said. "The fact is, they welcomed us with open arms. It went really well in that respect."

The question of how emergency staff would deal with trauma patients once treated at SMC isn't an issue, said Doctors' Bob Beehler, the chief financial officer: "We got most of the trauma cases, anyway. Overall, it hasn't been all that dissimilar."

And county patients now going to Doctors are seeing the familiar faces of staff who once worked at SMC.

"I had to go the SMC for an operation once -- before it closed -- because my HMO insisted on it," said 60-year-old Carol Richard of Modesto. She said she thought the staff was pleasant and the care was good.

"I also went to Doctors once -- before the county hospital closed -- for a serious condition because the services I needed weren't available at SMC," Richard said. "Their attitude then was very cavalier.

"I've since gone back to Doctors and have noticed how their attitude and care have improved. Now that they're the only choice, they're a lot more helpful."

Outpatient clinics

With SMC's departure, county health officials knew they would have to adapt the outpatient clinics to the community's needs.

Family planning and sexually transmitted disease services, once offered only in Modesto, were moved into clinics as well, said Kathy Kohrman, associate director of ambulatory services.

Physicians, nurses and other health workers stressed preventive care.

"Educating the patients has been a major component," said registered nurse Jim Austin. "We have to help them understand that they can go to their primary care doctor instead of the emergency room."

The Health Services Agency doubled the size of its Hughson clinic and opened two others: an urgent care center in SMC's old emergency room and a clinic in Empire.

Before the Empire clinic opened in September, residents had to go to the Hughson clinic or wait until the county's Mobile Medical unit came to town.

Clinic workers at all sites were well-prepared for an influx of patients. The deluge never came. Many county patients thought that when SMC closed, the clinics closed as well.

"We worked hard to get the word out that the clinics were still here for them," Finley said. "There are people who still think everything closed."

When Medi-Cal patients come into either Doctors' or Memorial's emergency departments, workers get their ZIP codes. That lets the county see if the patients live in areas served by a clinic. They then redirect those patients to their neighborhood clinic.

Staff stretched thin

The timing of SMC's closure coincided with a horrendous flu season, a crisis that paralyzed hospitals and emergency rooms in Modesto and throughout California.

Patients flooded emergency rooms in December and January. Reports of waits of four to six hours were common. At Doctors, staff was stretched uncomfortably thin. Hospital administrators realized that even with 54 extra bodies from SMC, the hospital still didn't have enough staff.

Partly because of last winter's aberrant conditions, Doctors' emergency department continues to adapt. Since last year, Doctors increased its staff 40 percent.

"Wait times are down, but there are still opportunities for us to do better," said Tim Maurice, Doctors' chief operating officer.

Medi-Cal managed care

While not caused by the transition, Medi-Cal managed care has raised concerns about access to care and caused headaches for patients and physicians, Doctors and the county.

Last year, Stanislaus was one of a dozen counties in California to enroll part of its Medi-Cal recipients in managed-care programs.

Managed care replaces the old fee-for-service system, where patients went directly to doctors and specialists and Medi-Cal simply picked up the tab. Now, Medi-Cal patients have primary care doctors who oversee their treatment and control access to specialists.

Providers who treat Medi-Cal recipients are paid a set amount for each patient, each month. The dilemma: Medi-Cal reimbursement rates are significantly lower than what private insurance and federal Medicare pay. As a result, many doctors refuse to take Medi-Cal patients.

The result: The county's two Medi-Cal managed care providers, Omni and Blue Cross, are having problems recruiting doctors, said Finley.

That doesn't bode well for the county, which is trying to teach patients to rely on primary care doctors for routine care instead of expensive hospital emergency rooms.

Medi-Cal patients, meanwhile, face the challenge of finding one of the few primary care doctors willing to treat them.

And patients unlucky enough to have an ailment that warrants a specialist are worse off. Some primary care doctors with Medi-Cal patients have reported having to send them to Sacramento for specialty care.

The impact on Doctors, said chief financial officer Beehler: "We became responsible for the specialty care delivery system."

That means specialists, such as a cardiologist or orthopedic surgeon, who provided care to patients in the hospital had to take on those patients.

That responsibility wasn't addressed in the agreement between the county and Doctors, and the outcome angered physicians.

County health officials are working to remedy the problem. The Health Services Agency is looking to contract with a temporary doctor, called a locum tenet.

"It's like a substitute teacher," Finley explained. "You contract with them to provide services. We are in the process of recruiting one. We would hope to have one in early January. He or she would work in partnership with some of the orthopedists."

There's also talk of converting the Health Services Agency building's empty third floor into a Medi-Cal specialty clinic, offering surgery, oncology and gastroenterology services. The clinic could be up and running by spring.

Different times

The decision for county and Doctors to become partners was brought on in great part because of changes in how health care is paid for and distributed to patients.

Fewer patients were being hospitalized at the more than 100-year-old Stanislaus Medical Center, and those who were admitted stayed fewer days. Medi-Cal limited how much the hospital was paid.

County and health officials knew that eventually, the hospital would lose money. It could no longer afford to keep open the inpatient unit and emergency room. Yet the county still had a legal obligation to provide care to a portion of its population.

Doctors' proposal called for closing SMC and transferring emergency and inpatient services to Doctors. The county would keep its outpatient clinics. In January, the Board of Supervisors voted 3-2 in favor of Tenet-Doctors. The partnership was formed.

Measuring success

When it comes to evaluating the partnership, Doctors and the county say they will look at patient feedback.

In July, the county hired a consultant to review outpatient and clinic operations.

"Are there long waits in our clinics for services? Do we need to increase the number of inpatient days in the agreement? Those are some of the questions we'll be asking," Finley said.

Her assessment so far: "My gut tells me the medical care (former county patients receive) is good."

Reprinted by permission of Modesto Bee