Los Angeles County investigators and health department officials now say that unapproved moonlighting by doctors employed at public hospitals is a serious problem throughout the system, though they cannot accurately assess either its magnitude or its impact on patients because their system for monitoring physicians' work habits has broken down.
"What we have are physicians forgetting their obligation to county patients and working exclusively with their private patients," said county Supervisor Mike Antonovich, who has summoned top health officials to appear before the board today to answer mounting questions about the problem.
Health department sources say that the 2,946 doctors, residents and interns at the county's six public hospitals seldom face discipline unless malpractice allegations against them expose the county to legal liability. Even then, loose regulations loosely enforced--often by supervising physicians who are themselves moonlighters--make it difficult to obtain sanctions against the doctors, who are protected by Civil Service.
Over the last 18 months, the district attorney's office has been probing the outside activities of at least six doctors suspected of moonlighting so excessively that county auditors believe they have committed criminal fraud. But sources familiar with the district attorney's investigation say there may be no prosecutions because no one ever officially, and sufficiently, told the physicians that what they were doing was wrong.
Dr. Donald C. Thomas III, the health department's newly hired second in command, said Monday that he plans to open additional investigations into the conduct of about a dozen doctors who have been the subject of continuing complaints.
"As to the magnitude" of the moonlighting problem, Thomas said, "I don't know today [Monday], but I do plan to know tomorrow," when he appears before the Board of Supervisors.
County regulations permit doctors to accept 24 hours of outside employment per week, if their supervisors approve. By permitting some outside employment, the county allows its doctors to close some of the gap between their incomes and those usually earned by colleagues in the private sector.
But Antonovich criticized Health Services Director Mark Finucane for ignoring what he said was "evidence of poor enforcement" of county anti-moonlighting policies uncovered by the district attorney's office during its investigation. At today's meeting, Antonovich said, he also will ask Dist. Atty. Gil Garcetti to give the board a report on "irregularities and possible criminal negligence by county physicians," including the six now under investigation.
Many of the conclusions reached by county investigators and auditors who have probed the moonlighting problem were confirmed Monday by high-ranking officials in the Health Department, who asked not to be named because Finucane and Thomas were preparing to address the issue before the supervisors. Those officials agree with the findings of the auditors and investigators, who have concluded that the problem begins at the hospital level, where supervisors fail to monitor the activities of problem doctors. Among the conclusions confirmed by the high-ranking officials:
* Loosely worded hiring agreements allow many doctors to enter the county work force expecting to moonlight far more than the 24 hours weekly and work far less than 40 hours per week for the county, the Health Department officials say. Such agreements sometimes are required to obtain the services of surgical specialists. But, county auditors and department officials say, they have become so common that patient care is being jeopardized because so many surgeons spend so much of their time away from county hospitals.
* Lax controls over time cards and sign-in sheets allow doctors to fudge their hours, saying they worked when they didn't, officials and investigators say. The problem, they add, is compounded by supervisors who don't monitor doctors to ensure that they are pulling their weight and who don't evaluate them annually to put them on notice of deficiencies.
* Many doctors do not fill out the required outside employment forms designed to allow their bosses to decide whether their moonlighting interferes with their county duties. The forms on file, county investigators say, are often incomplete, outdated, unsigned by supervisors or so vague that it is nearly impossible to determine what the doctors are doing. Documents obtained by The Times indicate that some doctors have as many as three outside practices, but that their supervisors often do not even know about them.
* Investigators and auditors have found, and high-ranking department officials confirm, that there is virtually no "progressive discipline" in which problem doctors are given written warnings and, then, more severe discipline if their problems continue. And when warnings are given, the officials say, they are rarely followed up with disciplinary action.