For more than two decades, Wanda Remo has battled one illness after another. Asthma, chronic lung disease, heart disease, high blood pressure, arthritis, depression, chronic pain, strokes. Specialists treat her lungs, her heart and her joints.

Her litany of ailments brought her to emergency rooms six times last year, between numerous additional visits to a federally subsidized health clinic in South Los Angeles.

"You are one of the million-dollar patients," her doctor, Derrick Butler, tells the 57-year-old as she leans on her walker during one appointment.


Remo and countless other chronically ill patients like her pose one of the biggest obstacles to medical professionals, hospitals and political leaders trying to rein in costs as they overhaul the healthcare system.

Starting next year, clinics in rural and urban areas will receive an influx of millions of newly insured patients — many with complex, chronic diseases — and face higher expectations to keep costs down. Many of those patients are so ill — or resistant to altering behaviors — that they repeatedly cycle through expensive emergency rooms and hospital beds.

Keeping them away from hospitals can be difficult because of patients' reliance on emergency rooms and because clinics typically lack sophisticated X-ray and laboratory equipment or the capability to perform advanced medical procedures.

Still, researchers have found that patients at community health centers are less likely to be hospitalized than those receiving treatment elsewhere, resulting in significant savings.

Despite the clinics' many successes, tracking Remo for six months demonstrates the limits of what clinic medical providers can do as they try to provide efficient, low-cost care for large numbers of seriously ill patients.

"A lot of people come here so they don't have to go to the ER," says Butler, associate medical director of To Help Everyone Clinic, known as T.H.E. "Sometimes it's beyond what we can do."

Clinics are trying to improve the odds of keeping patients healthy, including expanding weekend and evening hours and adding pharmacies so patients don't head for emergency rooms to refill prescriptions.

At T.H.E. Clinic, patient services representative Joanna Franco follows up with every client discharged from a hospital, whether the patient went in for a minor stomachache or a life-threatening asthma attack. She schedules appointments and encourages patients to come to the clinic and avoid the emergency room whenever possible.

Some patients hang up on her. Others don't keep appointments. "They aren't compliant," she says. "They wait until they are really sick and they go back to the emergency room.

"All we can do is call them and [try to] get them here."

Franco speaks regularly with Remo, who lives alone but has a visiting caregiver. She sleeps in a hospital bed, next to a nightstand covered with water bottles, medications and an ashtray full of butts. An oxygen tank and a breathing machine sit nearby.

Remo says she calls 911 only when she can't keep her medication down or control her breathing. She's been to hospitals across Los Angeles County, including Cedars-Sinai Medical Center, Hollywood Presbyterian Medical Center and Centinela Hospital Medical Center in Inglewood.

In September, she arrived at T.H.E. Clinic sweating, throwing up and hyperventilating. The clinic's driver took her to the emergency room.

Remo is covered by Medi-Cal, the public program for poor and disabled Californians. But a private insurer manages her care under a program intended to improve treatment and control costs. The company, Care1st, has assigned Remo a case manager.

In October, after her hospital stay, Remo is back at T.H.E. Clinic for a follow-up appointment. Disheveled and overweight, she moans as she pushes her walker and portable oxygen talk into the exam room. Her heart is racing, and she feels nauseated. It's a struggle to breathe.

"Please don't send me to the hospital," she tells Butler.