Tailfeather v. Board of Supervisors

• Decision Date: 22 August 1996
• Docket Number: No. B093679,B093679
• Citation: 48 Cal.App.4th 1223,56 Cal.Rptr.2d 255
• Court: California Court of Appeals Court of Appeals
• Parties: , 96 Cal. Daily Op. Serv. 6314, 96 Daily Journal D.A.R. 10,308 Daisy TAILFEATHER et al., Plaintiffs and Appellants, v. BOARD OF SUPERVISORS OF LOS ANGELES COUNTY et al., Defendants and Respondents.

Page 255

56 Cal.Rptr.2d 255

48 Cal.App.4th 1223, 96 Cal. Daily Op. Serv. 6314,

96 Daily Journal D.A.R. 10,308

Daisy TAILFEATHER et al., Plaintiffs and Appellants, v. BOARD OF SUPERVISORS OF LOS ANGELES COUNTY et al., Defendants and Respondents.

No. B093679.

Court of Appeal, Second District, Division 4, California.

Aug. 22, 1996.

As Modified on Denial of Rehearing Sept. 18, 1996.

Western Center on Law and Poverty, Inc., Robert D. Newman, Clare Pastore, Los Angeles, San Fernando Valley Neighborhood Legal Services, Beth A. Osthimer, Pacoima, National Health Law Program, Yolanda C. Vera, Los Angeles, Legal Aid Foundation of Los Angeles, Kirk McInnis, Oakland, Yolanda Arias, Los Angeles, American Civil Liberties Union, Mark Rosenbaum, Silvia Argueta, Los Angeles, Legal Services Program for Pasadena and San Gabriel-Pomona Valley, John E. Rittmayer, Santa Monica, for Plaintiffs and Appellants.

De Witt W. Clinton, County Counsel, Roberta M. Fesler, Assistant County Counsel, Steven J. Carnevale, Principal Deputy County Counsel, Patrick A. Wu and Ada Treiger, Senior Deputy County Counsel, for Defendants and Respondents.

BARON, Associate Justice.

Plaintiffs, a group of indigent residents of the County of Los Angeles who rely on County medical facilities, brought a complaint for injunctive and declaratory relief and a petition for writ of mandate against the Board of Supervisors of the County of Los Angeles and Robert C. Gates, the Director of the Los Angeles County Department of Health Services (collectively referred to as "the County"). Plaintiffs sought a ruling that the County violated its duties under various provisions of the Welfare and Institutions Code by failing to adopt formal written standards governing waiting times for receipt of medical care. The trial court granted the County's motion for summary judgment, and plaintiffs appealed. Limiting our review to the narrow issue raised by the complaint, we conclude that the statute does not mandate the adoption of formal standards concerning waiting times for medical care and affirm the grant of summary judgment, although we disagree with some of the grounds set forth in the trial court's order.

FACTUAL AND PROCEDURAL BACKGROUND

The Complaint

According to the complaint filed by plaintiffs herein, "[i]t is a common experience for the needy poor to wait many weeks, even months, to obtain a scheduled appointment at a County outpatient clinic." Plaintiffs allege that the County is responsible for these backlogs because it "has failed to establish written standards concerning access for the poor to necessary medical care at County facilities, including, in particular, reasonable waiting times for a scheduled appointment at a County outpatient clinic and for examination and treatment in a County emergency room." In addition, "the County has failed to adopt some system or plan for monitoring the poor's access to necessary medical care at County facilities and for addressing problems, such as the current backlog of scheduled appointment at the outpatient clinics." In a somewhat different vein, the complaint also contends that the County has violated Health and Safety Code section 450 and "failed to protect and preserve the public health" by "allowing harmful and contagious medical conditions to increase and spread in the absence of any standards concerning the prompt delivery of care to the dependent poor at the County's hospitals and health centers."

The plaintiffs ¹ sought to represent a class "consisting of all indigent residents of the The complaint sought a writ of mandate, an injunction, or a declaratory relief judgment "compelling defendants to perform acts required by State law as set forth in the above causes of action, namely: to promulgate and adopt standards on indigents' access to essential medical care at County facilities, especially as to reasonable and adequate waiting times to be seen for emergency care and outpatient specialty care; and to operate these County facilities in accordance with such standards."

                County who are or will be in need of the medical services [48 Cal.App.4th 1228] provided by the Los Angeles County Department of Health Services."   By order dated July 7, 1994, the class was certified
                

The Cross Motions for Summary Judgment

Both sides moved for summary judgment, agreeing that the sole issue presented--whether the County was required to adopt formal written standards concerning reasonable waiting times for indigent medical care--was one of law. Few "facts" were set forth in statements of undisputed facts. The County's statement consisted of: (1) a description of the class which had been certified by the court, (2) the dates of various legislative actions, and (3) statements of legal principles most of which were to be determined by the ruling on the motion. Plaintiffs established in their statement of undisputed facts certain background matters, including: (1) the number of medical facilities in the County, (2) the fact that the County had not adopted any ordinances or resolutions to address waiting times or to monitor whether outpatient care appointments were scheduled pursuant to the treating physicians' instructions or whether emergency care patients were seen in accordance with triage guidelines, ² (3) that the County denied that it had a legal obligation to adopt any such ordinances, and (4) that as of July of 1994, 99 outpatient clinics in the County health care system reported backlogs of appointments of 10 weeks or more.

In addition, both sides submitted lengthy declarations containing additional factual assertions. Robert C. Gates, Director of the Department of Health Services for the County of Los Angeles ("DHS"), stated in his declaration on behalf of the County that the board of supervisors had created a Task Force for Health Care Access. According to the declaration, the Task Force was charged with "providing the Board ... a description of the critical unmet health needs of the medically uninsured/underinsured and the current capacity of public and private resources to meet these needs, ways to improve the health status of underserved residents by adjusting the existing splintered patterns of access and care through optimal utilization of existing resources." Gates' declaration established that DHS operates six hospitals, three with trauma centers, six Comprehensive Health Centers, and forty public health centers. DHS submitted a Strategic Plan for the future to the board of supervisors in June 1992. "The Plan provided a framework for the overall future direction of the County's health services and for addressing specific issues and problems with County health care. The Plan provided the foundation for the integration of personal health services within geographic 'Clusters' and the transition to managed care." DHS established the Community Health Plan ("CHP") in order to test the managed care approach within a large, publicly operated health care system. The CHP is licensed by the California State Department of Corporations The declaration of William F. Loos, M.D., attending physician at County's Olive View Medical Center, submitted in support of the County's motion, described the order of treatment in County emergency rooms, stating that it was based on a "triage" system of sorting patients according to need. According to Dr. Loos, each county hospital adopts its own triage guidelines. He described the triage guidelines at Olive View, Martin Luther King, and Harbor-UCLA Medical Center. He further stated: "Patients having non-emergency conditions who seek care in County emergency rooms will be seen by emergency room physicians. Typically, such patients will be referred for appointments for outpatient care in the appropriate County outpatient facility, within the time specified by the physicians. [p] ... Appointments for out-patient care are scheduled according to referring physician specifications, even if this means scheduling some patients ahead of previously scheduled patients with less urgent need. Typically, the longest scheduled appointments are for patients with the least critical conditions (those who are chronic or stable). Non-referred individuals who indicate an urgent need for care are referred to emergency rooms or urgent care clinics."

                as a health care service plan under the Knox-Keene Act (Health & Saf.Code, § 1367 et seq.) and has been granted federal Health Maintenance Organization qualification.  CHP standards for appointment times are:  "urgent--according to medical necessity;  new member, non-urgent--30 working days;  follow up, established patient--15 working days;  specialty referral, non-referred patient--30 working days."   The declaration went on to state that as of August of 1994, backlogs averaged 2.2 weeks in health center clinics and 3.5 weeks in hospital clinics.  The wait for initial prenatal service backlogs averaged 1.2 weeks and for initial pediatric clinic services averaged 2.5 weeks.  Three percent of the health center clinics and 11 percent of the hospital clinics had backlogs of 10 weeks or longer
                

Plaintiffs also submitted declarations in support of their motion for summary judgment. More than two dozen physicians and other County health care workers described the waits experienced by non-urgent indigent patients suffering from chronic and undiagnosed medical conditions. The consensus of the declarants was that facilities and budgets should not be cut. There was no reference to a need for formal standards for wait times.

After the hearing on the motion, the trial court made numerous factual and legal determinations in a lengthy written order. The following are the most significant:

(1) Assembly Bill No. 1012, 1991-1992 Regular Session, (passed in 1992) abolished the requirement of access standards for indigent health care and the only standards counties are required to meet for indigent health care and general relief are the fiscal standards in the...