A cancer patient enrolled in a health insurance plan serving Los Angeles County’s poorest and most vulnerable residents was left untreated as their health rapidly deteriorated, according to state regulators.
Another enrollee was left “suffering extreme pain” for weeks while waiting for treatment.
Treatment for a third patient, diagnosed with lymphoma and given less than a year to live, was delayed for more than two months. That patient left the plan, LA Care, for other insurance in a desperate attempt to save their life.
All three cases stem from “deep-rooted” failures that continue to threaten the health of patients whom LA Care is entrusted to serve, according to state health regulators. On Friday, the state announced $55 million in fines against the publicly operated health plan that insures more than 2 million Medi-Cal patients and other low-income recipients. It is by far the largest such penalty in state history, outstripping the previous record fine of $10 million.
The fines follow a state investigation sparked by a September 2020 Times article that found patients at LA County run hospitals and clinics — many of whom are covered by LA Care — faced agonizing, sometimes deadly delays to see specialists.
While health plans are required to offer their patients specialist appointments within 15 days, The Times found the average wait at the LA County Department of Health Services facilities was 89 days following a referral from a primary care provider.
Even patients waiting to see doctors whose prompt care can mean the difference between life and death — neurologists, kidney specialists, cardiologists — endured delays that stretched on for months, according to The Times’ analysis of 860,000 requests for specialty care at LA DHS facilities from 2016 through 2019.
State regulators not only found that LA Care is failing to ensure that patients have timely access to care, but they are failing to authorize needed treatment and address patients’ complaints. The health plan had a backlog of 67,000 formal grievances that had not been resolved Thursday, according to documents made public.
“The scope and breadth of [L.A. Care’s] indicate deep-rooted, systemic failures that threaten the health and safety of its members,” said Michelle Baass, director of the state Department of Health Care Services, one of two agencies announcing sanctions.
“My hope is that this sends a strong message to the entire industry that the state takes very seriously protecting all consumers, but particularly our most vulnerable enrollees,” said Mary Watanabe, director of the Department of Managed Health Care, which imposed the largest fine , $35 million.
In an emailed statement, LA Care officials acknowledged some of the deficiencies found by state regulators but said it took an issue with the fines, which it described as “unreasonable and not based on facts.”
The backlog of grievances will be resolved this month and LA Care is working with LA DHS to bring them into “full compliance,” the statement read.
The statement described the fines, as “arbitrary and unnecessarily punitive,” and said that LA Care will contest them.
While patients covered by LA Care have access to some doctors in private practice, many get care through the county-owned, safety-net hospital system that includes the Los Angeles County-USC Medical Center in Boyle Heights, Harbor-UCLA Medical Center in Torrance and Olive View-UCLA Medical Center in Sylmar.
State regulators highlighted several grievances over long wait times in the LA DHS facilities.
In one case, a patient suspected with skin cancer had to wait seven weeks for a dermatology appointment and another seven weeks for a biopsy. According to the accusation, the dermatologist said that there was usually a two month wait for appointments.
“That is the way it has been in this clinic for the past 35 years,” the dermatologist said.
In another case, a patient’s eye surgery was repeatedly rescheduled over four months. By the time the patient filed a grievance, authorization for the surgery had expired.
“The magnitude of LA Care’s violations, which has resulted in harm to its members, requires immediate action,” regulators said in a press release.
For The Times 2020 story, reporters were unable to determine how many patients died waiting to see specialists; County health officials said they didn’t track such outcomes. But the patients obtained medical records of six who faced delays of at least three months to see specialists and died of the illnesses they were waiting to have treated.
They included 61-year-old Isabel Lainez, whose bladder and kidney problems were so bad she became incontinent — wetting herself on the bus, in the car, in an elevator — while waiting 10 months to see specialists. She died of chronic kidney disease before she got an appointment.
Majid Vatandoust was denied a colonoscopy, despite classic symptoms of colon cancer, because he was 49 and his county gastroenterologist said cancer screening is “not valid for patients under 50.” By the time Vatandoust turned 50 and was approved 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 DHS, did not immediately respond to requests for suspension.
A decade ago, a public outcry over lengthy medical delays and patient deaths spurred California to set specific limits on how long insurers can keep sick people waiting to see a doctor.
Beth Capell, a policy advocate with Health Access California, a consumer group that helped push for the 15-day limit to see specialists, called the $55-million fine “substantial.”
“We’re very glad to hear that they are taking aggressive action to ensure that every patient in the LA County hospital system has timely access to care,” Capell said.