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Dennis Hsieh JULIANE BACKMANN / for the Daily Journal
September 24, 2008
LEGAL AID CLINICS ARE JUST WHAT THE DOCTOR ORDERED Joint Medical-Legal Efforts Help Patients Deal With Inevitable Health-Related Issues By Evan George
Daily Journal Staff Writer
LOS ANGELES - Sitting at his new desk, attorney Eli Palomares hears every sniffle, laugh and muffled cry that permeates the North East Sun Valley Health Center as nurses usher children and parents into exam rooms. And when the doctors are through, they often lead patients down the hall to Palomares for a different kind of help.
Asthma blamed on nearby landfills, unfair medical bills, slum housing, trouble keeping the kids enrolled in government-funded health care programs - Palomares has seen the gamut of cases in his first month stationed at the health center.
Palomares runs one of three new legal clinics started by Pacoima-based Neighborhood Legal Services as part of its Health Consumer Center project. The roving legal aid office functions as a one-stop shop for working-poor and uninsured patients who normally would not seek legal advice or redress. Palomares also helps the doctors recoup state dollars for treating Medi-Cal beneficiaries who might otherwise fall through the cracks.
"A place like this is able to capture things even our own legal aid office couldn't capture," Palomares said. "This is definitely new to have an attorney stationed in a health clinic. You can imagine the medical field can be very distrusting of attorneys."
The idea behind these "medical-legal partnerships" is to drop lawyers inside clinics and hospitals where patients, and their doctors, struggle daily with the inevitable legal side effects of illness and health care. Though new to Los Angeles, the concept is already common practice by public interest lawyers in some parts of the country.
A Boston pediatrician kick-started the innovation in the early '90s, when he hired lawyers to help him battle inner-city health traps that kept landing the same kids in his waiting room. That hospital model caught on in San Diego and Marin counties, where private hospitals enlist legal aid lawyers to enroll patients in public benefit programs to guarantee they are paid.
Legal aid lawyers in Los Angeles pursued a different approach by working with overburdened community clinics in impoverished neighborhoods. Besides the Sun Valley clinic, Neighborhood Legal Services chose two health clinics in South Los Angeles run by the nonprofit St. John's Well Child and Family Center.
Funding for the Valley legal clinic comes from a $50,000 two-year grant from the Kaiser Permanente Grant Program. The two-year fellowship at the South Los Angeles centers was paid for by the Greenberg Traurig law firm and the John S. and James L. Knight Foundation.
Dennis Hsieh, a new law fellow at St. John's clinics, spends two days a week in South L.A. assisting doctors and caseworkers with the legal problems that afflict their patients. Hsieh said they chose those clinics, instead of big hospitals, for a reason.
"Being in the clinic setting, we are at the community level because they are the safety net," Hsieh said. "Here we can help out with a preventative treatment rather than catch people once they are in crisis."
Dr. Ellen Rothman said she no longer feels helpless asking her patients about health-related issues like housing and immigration problems.
"I honestly never really asked because when you ask and you find something, well what do you do then? Rothman said. "I didn't really have anything to offer."
She and other doctors praised the new legal clinics for already cutting down on unnecesary visits. Like the woman last week who asked Palomares how to make Medi-Cal pay for medical treatment and an asthma humidifier for her daughter.
"I said, 'By any chance is your apartment infested with cockroaches?'" Palomares said. "When she said, 'Yes,' I asked 'Did you know that cockroaches are a cause of asthma?"
Palomares asked her doctor to write a letter to the landlord about fixing the cockroach problem. He said that a doctor's note gets faster results than suing. "The whole goal," Palomares said, "is to try to help the doctors so they're not seeing the same problems over and over again if we can address them on a legal level."
This unlikely marriage of doctors and lawyers began as an experiment in 1993 at Boston Medical Center, a private nonprofit facility and one of the largest safety-net hospitals on the East Coast.
Dr. Barry Zuckerman, the head of pediatrics at Boston Medical, said he was exasperated with the number of children he would treat on a recurring basis for malnourishment when their families lost food stamps, or pneumonia and asthma caused by substandard housing conditions. Like many doctors, he knew his patients needed help beyond his reach.
Rather than ignore the problems, Zuckerman hired a lawyer for his office.
"He took the bold step to hire an attorney from the local legal aid organization to help him figure out how to provide legal assistance so that patients can get their basic needs met," said Ellen Lawton, the executive director of what is now called the Medical-Legal Partnership for Children at Boston Medical Center.
Zuckerman helped found two more programs and has been "evangelizing" lawyers and doctors across the country ever since. The Boston program recently won a grant from the Kellogg and Robert Wood Johnson foundations to form a national center for medical-legal partnerships. New York, Ohio and Conneticut also have productive medical-legal programs.
Last year, the American Bar Association passed a resolution encouraging law firms and legal aid groups to help form community programs committed to "preventative law," by catching debt and welfare-related cases in the medical settings where they are born.
The San Diego Advocacy Benefits Program is one of the California programs already receiving national attention for winning state dollars for cash-strapped hospitals. Reimbursements are especially vital because San Diego lacks a county-run hospital system.
Gregory Knoll, the program's executive director and chief counsel, said his three full-time lawyers focus on helping patients enroll in public benefits like Medi-Cal. The Scripps Hospital chain, which runs several for-profit facilities in San Diego County, pays the Legal Aid Society of San Diego for on-site attorneys.
Knoll said that about 40 percent of their cases receive reimbursements. "Last year there were over $8 million in billing that got we overturned," Knoll said.
One such case brought in more than $1 million alone for Scripps Mercy Hospital, which Knoll said has suffered financially from providing charity care to uninsured patients.
Knoll said he did not know the total amount his lawyers have saved the hospital.
"I keep asking and, of course, they don't want me to know, because they'd probably have to give me more money," Knoll said.
While saving money has been the driving incentive for some hospitals to fund legal-medical partnerships, others in academia are looking to expand the model in Southern California beyond the for-profit institutions.
Erwin Chemerinsky, founding dean of UC Irvine School of Law, said he hopes to form a partnership between his new law school when it opens next year and the medical school at Irvine.
Speaking Tuesday to legal aid lawyers at a conference on medical-legal partnerships, Chemerinsky said that he sees the collaborations as the best weapon for improving health care for low-income communities, like South Los Angeles. While constitutional law does not cast health care as an inalienable right, he said, state and county governments can be forced to provide care that is required by federal law.
"The reality is that because of how we structure medical services in the United States, a very significant percentage of those with medical needs will also have legal needs," Chemerinsky said. "Unless there is someone to go to court for that person, somebody to sue and challenge the government, the words on paper in the federal regulations are entirely meaningless."
In Compton, that somebody is Hsieh.
The St. John's Well Child and Family Center clinic in Compton is a one-story building that sits less than a mile from the mostly shuttered King-Drew Hospital, in between a rusty auto shop and an abandoned house electrified by years of neon gang graffiti. A slow-crawling line to see a doctor spews onto the sidewalk.
Hsieh spends every Monday in a makeshift office behind the clinic's romper room, where he helps caseworkers wade through the legal problems that crop up during exams.
On a recent morning, Hsieh walked Maria and Ruben Preciado through the pages of state forms they must fill out before Ruben can receive disability benefits. The former migrant worker is blind and can no longer hold a job.
Maria Preciado, who stays home to care for her husband, said they had no idea he was eligible for state benefits until they brought their young children to the clinic for shots and the nurse referred them to the lawyer.
"It has helped out extremely," she said in Spanish through a translator. "We wouldn't have known about these services otherwise."
Hsieh highlighted the sections they must fill out and showed them where they had made mistakes. He said that kind of trouble-shooting is the difference between people receiving the health benefits they need, and losing out.
Caseworkers at the Compton clinics said the legal hurdles that used to block them from helping a client were much easier to navigate with Hsieh sitting a few feet away. That was obvious when Miguel Chavez, one of the caseworkers, got a message from the father of an autistic child for whom he had helped obtain speech therapy.
Chavez leaned over and told Hsieh the family's situation - that a nurse at St. John's had caught symptoms of a developmental disorder and referred the boy to a mental health center. Even though the child had been diagnosed with autism, the school wanted a second opinion before enrolling him in special education classes.
"He can't go into general education classes, he needs specialized classes and the school district is still not providing that," Chavez told Hsieh.
Within five minutes, Hsieh had a learning rights attorney telling Chavez how to deal with the school. Chavez shook his head and smiled as he typed an e-mail to the boy's father. "That's one of the things I am really going to start relying on Dennis for."
evan_george@dailyjournal.com