Political Infighting, Egomania, And A Grab For State And Federal Healthcare Bucks Is Ruining A Perfectly Good Wefare Program.
By Emil Franzi
"A bath is a bath is a bath."
--Dr. Richard Carmona, Pima County Integrated Health Care System
THIRTY YEARS AGO, Pima County began a program known as
Home Health. Back then, before the bean counters took over, healthcare--private
and public--was more humane and more closely tailored to the needs
of the patient, rather than the needs of the dysfunctional system
itself.
The Home Health was designed to provide in-home care for the
elderly and others who might otherwise be forced into a nursing
home or other institution. A successful and popular program, it
eventually came to provide good-paying jobs for more than 150
locals, ranging from nurses to clerks.
Today Home Health is caught in a political crossfire fueled by
power and ego. It's being gutted and destroyed. The losers are
not only its employees, but the patients--many of whom are the
among the neediest in the county--the program has served so well.
THE GOAL OF the current county administration is to merge
Home Health with Pima Health Systems (PHS)--the county's in-house
HMO--allowing bureaucrats to grab more state and federal money,
thereby making the program "profitable."
Currently, Home Health has 48 regular employees and about 100
more who are paid on a per-visit basis. PHS officials claim they
"can't afford" the current Home Health setup, which,
they say, is running a deficit of roughly $65,000 a month.
The origins of Home Health's current dilemma are found in the
larger battle over control of healthcare and the massive budget
that comes with it. That battle is currently being waged by the
present Board of Supervisors.
One side, led by Democratic Supervisor Raul Grijalva, has managed
to consolidate all health-related services into an "Integrated
Health Care System" under a self-perpetuating board of directors
called The Pima Health Care System Commission. The Commission,
currently headed by Grijalva political ally Sylvia Campoy, is
employing Dr. Richard Carmona as its "health czar."
Carmona's appointment was supported by the two GOP county supervisors,
Mike Boyd and Ray Carroll.
Opposing this approach are the other Democratic supervisors,
Sharon Bronson and Dan Eckstrom, and County's Administrator Chuck
Huckelberry, who's being reduced to the manager of a bifurcated
county government--and budget--with Carmona as his higher-paid
co-equal. Huckelberry reports to the elected Board of Supervisors
while Carmona doesn't, which may well make Carmona the most powerful
individual in county government.
And it's Carmona who's led the attempt to diminish the role of
Home Health and merge the program into others to "reduce
costs." The mantra chanted throughout this exercise has been
that "Home Health loses money." Not exactly shocking
news, considering Home Health is, and always has been, a straightforward
welfare program.
OF COURSE, CARMONA and like-minded bureaucrats never publicly
discuss the possibility that Home Health's deficit may be caused
by a number of factors within their control, including:
- $10,000 a month the program pays to the county-controlled
Kino Community Hospital for overhead;
- An additional $10,000 a month for administration;
- $17,000 more each month for county overhead;
- $5,000 a month in rent; and,
- $9,000 in monthly debt service for the six years Carmona's
staff maintains the program has run a "deficit."
Home Health workers see the situation differently. (Many of them
have asked for anonymity because Carmona has declared his intention
to retaliate against dissidents.) They complain that Carmona and
others at Kino Hospital have loaded up their programs with administrative
costs already borne by other health programs. Why? To make Kino
and Pima Health Systems look less expensive; and to gut Home Health
and move its clients and Arizona Health Care Cost Containment
System (AHCCCS) money into other pots.
Of course, some Home Health costs could be reduced by contracting
services to a lower level of provider--hence Carmona's statement
about a bath is a bath. Those getting the bath, however, often
find there's a difference between state-certified nursing assistants
and attendant care workers. One difference is state licensing;
the other is 75 hours of training as opposed to 12. The biggest
difference to Carmona, however, is the difference in pay, as much
as $4 an hour.
There are other differences in services as well. The 2,000-plus
Home Health clients generate more than 10,000 monthly calls, sometimes
necessitating weekend attention. That portion of service current
staff now handles will undoubtedly be cut. The minimal training
and lack of licensed personnel will preclude certain client options
or reduce their effectiveness. And worst of all, lower-paid temps
will mean a higher turnover in caregivers, which can only increase
the anxiety level of aged patients who've built up long-term trust
and confidence with their current care providers. It's a factor
that mere dollar value can't measure; but it's a factor that Carmona,
a physician, ignores.
FOR YEARS, DR. Richard Carmona has been a colorful figure
in Pima County. A living definition of the term "high-profile,"
he works the media like a pro--which, in this town, doesn't require
much finesse.
At one time he ran Tucson Medical Center's trauma center, a position
from which he was dismissed. His subsequent lawsuit against TMC
was settled out of court; Carmona received several million dollars,
and the judge sealed the court records.
Carmona's high opinion of himself is evidenced by the multiple
titles and positions he's accumulated. While he serves by contract
as head of the county's health program, he's also health advisor/consultant/director
to Rural Metro Fire Department; medical officer to the Sheriff's
S.W.A.T. team (although he's not a commissioned deputy, he loves
to use the title); chief physician to the recent Senior Olympics;
head of UA Student Health Services; and, thanks to a successful
public-relations coup, medical advisor to spring-training baseball.
He's also attending the University of Arizona in pursuit of a
master's degree in public administration. If space aliens ever
crash around here, Carmona would no doubt expect to supervise
the autopsy.
His wide spectrum of duties and titles leads critics to wonder
how much time he really has to run the county health system. Carmona
is paid $180,000 a year on contract for that job, a sum he's declared
to be "inadequate" for someone with his great talents--apparently
administrative as well as surgical. He's said publicly that he's
making a great sacrifice by taking the job, and he claims to have
turned down much better ones.
Meanwhile, his critics complain Carmona seldom seems to show
up at Kino Hospital. He responds that he's a policy maker, adding
his excellent hand-picked staff will take care of the day-to-day
problems in running a program with an annual budget pushing a
quarter-billion dollars. He clearly prefers talk shows to staff
meetings.
Carmona worked his way into the job of the county's top doc as
the chairman of a blue-ribbon committee appointed by the supervisors
to study Kino Hospital. That committee was formed after it finally
dawned upon the supervisors that Kino was in trouble after former
supervisors Ed Moore and Paul Marsh, joined by Boyd, basically
gutted the operation by firing much of the top staff, as well
as the management company overseeing the county's medical programs.
In other words, Carmona didn't exactly have a hard act to follow.
The good doctor is also a veteran of the Vietnam War. He was
an army paramedic before receiving his medical degree, with honors,
from the University of California, San Francisco. Carmona's 'Nam
tour may have instilled in him a principal he seems to be using
regarding Home Health: Sometimes you gotta destroy the village
to save it.
But Carmona is not acting alone, although that clearly wouldn't
bother him. There's the Pima Health System Commission, to whom
he reports, and the Board of Supervisors, who are ultimately responsible
for Pima County government, regardless of how hard some of the
supervisors try to duck it.
Home Health employees took the issue to the Commission, whose
members promptly put the matter on hold, claiming they needed
to gather more information. The Commission also placed a gag order
on the employees. Meantime, no one gagged Carmona.
HOME HEALTH employees believe part of the problem stems
from service costs that often aren't really theirs. As an example,
they point out the current "acting administrator" of
Home Health is also the director of medical records at Kino Hospital.
They complain she has no nursing background, and is headquartered
at Kino, where paperwork must be brought to her to sign.
The role of Campoy and the Commission seems conciliatory, but
many Home Health workers see this as a stall tactic while the
program is starved out, workers are run off, and their jobs are
converted to low-paying grunt status, while the county HMO sucks
up as much AHCCCS money as possible.
While the Commission has made a show of instructing Carmona to
quit grabbing Home Health patients for PHS until the issue is
resolved, Home Health workers say he's already pulled about 300
Home Health clients into the HMO. Whether he'll comply with the
Commission's wishes is yet to be seen--Carmona has a habit of
doing what he pleases, and critics complain he's got the Commission
in his pocket. They also say Supervisor Raul Grijalva hasn't done
much to rein in Carmona in the past.
Grijalva's is perhaps the most interesting role in this Byzantine
political drama. The two GOP supervisors, Boyd and Carroll, are
easier to understand here: They're Republicans who like tidy bottom
lines. Grijalva, however, seems to be discarding his long-time
image as a caring liberal by sharing that bottom-line mentality.
His message to Home Health employees was simple: If you want to
keep the program, go get three votes on the Board of Supervisors
and budget some more money. Don't plan on taking it from Kino,
or overhead, or anywhere else.
And Grijalva has never even said whether he'd be one of those
three votes. Both he and his chief aide, Glenn Miller, used a
recent meeting with Home Health personnel to blame the whole problem
on the fiscal conservatism of Supervisor Bronson and County Administrator
Huckelberry.
Bronson and Huckelberry, and other county staffers, have pointed
out what they believe to be waste in the county's overall healthcare
budget and the long term debt--roughly $18 million--accumulated
over the years by Kino Hospital. Grijalva and Miller take this
almost personally, and their dislike for Bronson and Huckelberry
is well known. Some, including Bronson, see the Carmona plan for
Home Health and Grijalva's support of it as retaliation for Bronson's
position on Kino and Grijalva's desire to cut Huckelberry's authority.
Grijalva knows the option he presented the Home Health workers
with won't fly--the rest of the Board isn't going to vote additional
funding from new sources. Boyd and Carroll see no need to do so,
while Eckstrom and Bronson are unhappy with what's being spent
now.
One example: Carmona has been more than generous to his most
loyal administrators, handing out a batch of hefty pay raises
to top-end bureaucrats ranging from $6,000 to more than $20,000
for seven individuals, according to press reports earlier this
year. Naturally, that move hasn't gone over well with bottom-end
employees facing layoffs and pay cuts of as much as $4 an hour.
Carmona's only response to their concerns, however, sounds like
the one given by the old GOP majority on the Board of Supervisors
when they implemented their now infamous 1993 re-organization
plan: "It'll ultimately save money."
Carmona reportedly went ballistic when one county bureaucrat
suggested that perhaps he should consider cutting his own $180,000
annual contract ($40,000 a year more than Huckelberry) to set
an example. Many find the size of Carmona's salary obscene for
what is, in reality, a part-time job. Apparently Carmona isn't
willing to make a bigger sacrifice for the good of the program.
And he's re-applied for the job as director. Most observers expect
the current Commission to re-hire him.
SO HOW HARD would it be--really--to fix the Home Health
program while keeping its current employment and wage levels?
Not very, according to several high-ranking sources in Pima County
government. Unlike most fights over the cost of healthcare that
pit providers against insurers, here they're the same entity--Pima
County is both. The amount of money--less than $750,000 a year--is
comparatively negligible considering the negative impact the program's
reduction would have on many people, both employees and clients.
Most of the deficit problem could be solved through internal bookkeeping
changes with no real increase in cost to taxpayers.
Unfortunately, too many egos and power trips seem to be involved.
Grijalva simply blames Bronson and Huckelberry. Bronson blames
Carmona and the Commission. Boyd and Carroll see no big problem.
Eckstrom is opposed to the whole new system and tends to side
with Bronson. Meanwhile, the Commission waits for more guidance
from its employee, Carmona, whose agenda--for himself, at least--is
very clear.
Quotable Carmona
"If certain Home Health workers continue to maliciously and
falsely spread rumors and call clients and the press in hopes
of discrediting us and/or destabilizing our organization, I will
be forced to transfer patient services to other providers in the
private sector in order to protect our patient's interests."
--Memo to Bonnie Osukup, Administrator, Home Health, 2/23/98
"...a great deal of the information you request is not germane
to your mission, which is to provide me with your recommendations
as to how Home Health may be structured in a manner suitable to
you that is also cost effective. Once again, I want to be quite
specific. I am not looking for further criticisms of our plan,
nor an I looking to comparisons with other components of the System,
which are unique and distinct from Home Health."
--Memo to PHH Employee Committee, 3/5/98
"Providing Home Health services at competitive rates would
create the opportunity to market these services to private health
care providers in the community and positively position PHS for
the competitive ALTCS bidding process in 2000."
--Memo to Pima Health Care Commission, 1/30/98
"I have some concern that we seem to receive a disproportionate
amount of requests for information from Supervisor Bronson's office.
These requests from Supervisor Bronson's office either directly
to me or Department Directors, frequently require a significant
amount of staff time to complete. In several instances, I have
asked that Supervisor Bronson and/or her staff let us know what
questions they are trying to answer since we may be able to provide
the answers in a more time and cost effective manner."
--Memo to Supervisor Bronson's office, 3/13/98
"I would like to take this opportunity to thank you for your
time and extraordinary effort in making our baseball clients transition
a smooth one...As we begin to appreciate our 'vision' it is clear
to me that our future success is guaranteed with continued 'home
run' performances like you demonstrated on Sunday"
--Memo to all Kino Staff, RE: White Sox Physical Exams, 2/22/98
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