Who's Minding the Clinics?
City/County Divided on Public Health
There's no room anywhere. Every time you turn around you bump into something," complains Delores Peralez, maneuvering out of the cubbyhole where she checks in patients at Travis County's South Rural Health Clinic in Del Valle. Her supervisor, Jesse Colunga, steps around piles of boxes as he wends his way through the clinic, housed in a modular building scarcely larger than a boxcar, and through the center's main building, itself compressed into tight hallways and closet-sized rooms. One area of the center, the Women with Infants and Children (WIC) exam area, is merely a widened passageway with a short strip of colorful Disney characters tacked up on one green wall. But, as Colunga proudly points out, a wealth of social services for indigent county residents are crammed into these humble buildings. "You talk about seamless delivery of care and assistance, this is it," Colunga says, opening pantries stocked with nonperishables such as powdered milk - useful to clients living without electricity.
Colunga fears, however, that his center's role as a human services umbrella for rural and outlying city residents will be diminished if Travis County contracts with a private HMO to manage its public health care.
South Rural is a "one-stop" delivery point for emergency food and rent assistance, medical prescriptions, free lunches, family planning, HIV testing, and counseling. Colunga has been the center's supervisor since 1975, and was reared on the Del Valle soil which the building now occupies. Two of the center's caseworkers, Hazel Wilson and Elaine Moreno, have been at their posts nearly 20 years. The names and faces of clinic patients are familiar to staff members, who say the care they give reaches beyond the examination room. "We spend hours just calling pharmacies to check and see if patients are getting their prescriptions re-filled," explains head nurse Beverly Millwee.
But rural clinic patients might soon have to get used to new faces. Two weeks ago, the Travis County Commissioners Court approved moving ahead on a request for proposals (RFP) that officially puts the county's health care system up for sale. Commissioners say the county is in no way abdicating its role as a committed safety net provider, only searching for cheaper delivery in an era of spiraling medical costs. Still, if an HMO provider submits an acceptable bid to the county, the five county-owned clinics might be closed and their employees dismissed.
County Judge Bill Aleshire, wedging the heels of his hands together at an angle to illustrate his point, says it's time to "put the Y in the road" - to at least consider the free market route. "We're not answering a question with this proposal," Aleshire says, "we're asking a question that needed to be asked a long time ago: Is there a better way to guarantee health care services out there? I think it would be a mistake to continue without even checking whether or not we can purchase health care in a way that would be far better for our clients and taxpayers."
The latest county action illustrates yet another clash between the city and county over the management of Austin/Travis County's 13 Federally Qualified Health Centers, all of which are managed by the city, even though five of them are in Travis County, outside city limits. Only a few days before the Commissioners Court sent out its RFP, the Austin City Council had already taken a decisive turn down an old, familiar path - continued city management of the clinics - by hiring a management consultant team to pare down clinic operating costs so the clinics won't have to be farmed out to an HMO. The city could spend as much as $1.3 million for the consultant team, San Francisco-based Goggio and Associates, whose job will be to manage the primary care division for one to three years, overhauling the clinics' record-keeping and billing methods and updating personnel training.
City Councilmember Jackie Goodman made it clear that the present council intends to preserve the clinics as a publicly run resource. Without management expertise from the private sector, she says, "It's almost inevitable that we'll continue to make the same mistakes until the only reasonable answer would be to privatize. I want to avoid that."
The council's action was applauded by members of the Indigent Care Work Team (ICWT), the task force whose presentation last January recommended streamlining the clinics' administration as a precursor to placing long-term solutions, such as a taxing hospital district, before the public. As ICWT member and Texas Nurses Association administrator Stephanie Tabone explains it, the management team is a needed tonic to cure the clinics of unsound accounting practices and convince taxpayers that the public health system is not a lost cause. "If we haven't placed those clinics in the best position to be competitive, with the most efficiency that they can get, we can't come forward again with open hands," Tabone says.
Clinic employees also welcomed the private management team. Dr. Brendan McDaid, a pediatrician, says he was impressed that Goggio was not espousing slash-and-burn downsizing policies, but seemed genuinely interested in cooperating with frontline staff as it tackles operational weaknesses. "If this firm fulfills its assurances, then it will have the wholehearted support of our clinic workforce," McDaid says.
But Judge Aleshire, confronted with the $1.3 million consulting bill, the latest in a series of outlays to solicit expert advice on running the clinics, banged down his gavel and said, "Enough."
"That represents a belief that it is proper only to try to fix the system and keep it under the same basic structure... I have not been convinced [of that], after hundreds of thousands of dollars on consulting fees already," Aleshire says. Technically, this latest contract will not be a county expense, but Aleshire says he has lost faith in the city's management of the clinic system. By seeking an HMO provider, the county is looking to withdraw its funding commitment from that system and instead use the money to purchase insurance coverage for non-city residents.
"It came out of the blue to us that the city staff had written and advertised an RFP to put our clinics under a private management firm... and to add $1.3 million in overhead to the costs of the clinics, which are pronounced by every consultant that's looked at them as being too darned expensive already," Aleshire says. When the county commissioners inspected the city's RFP, he adds, they thought it was downright "dumb" because it failed to set a fee based on a percentage of savings the contractor actually produced. Aleshire says he found it "shocking" that the city would risk paying a consultant up front with money that could otherwise be spent on health care.
Austin City Manager Jesus Garza, however, defends the hiring arrangement, saying it would not be feasible to pay Goggio on a contingency basis because the consultant has been hired to perform a management task as well as identify cost-saving refinements. "What we're doing is appropriate, and I thought the county understood how we were proceeding," Garza says, adding that Goggio's contract can be terminated if an appointed oversight committee determines that the company's work is unsatisfactory.
Dissension in the Ranks
Aleshire and clinic workers such as Colunga (who is also president of the local chapter of AFSCME, the union representing city, county, and state employees), agree that city administrators and frontline county staff are out of touch with one another and dissension is growing - from employee lounges all the way to the Commissioners Court. Colunga and his Del Valle staff, for example, already feel they are operating with a skeleton crew, yet Austin/Travis County Health and Human Services director David Lurie insists that clinic staffing ratios are "out of line."
A full-time clerk's position at the Del Valle clinic was recently transferred to a city clinic, and the resident social worker recently quit rather than comply with an order that she circulate among urban clinics. Moreover, under a new staffing lineup suggested by the Osborne Report, the latest in a series of consultant audits compiled on the clinics, Del Valle would not even have the services of a full-time physician, and its nursing staff would be cut from three to one. Doctors would perform diagnoses and prescribe medications over the phone. Dr. Gail Havorka, Del Valle's current physician, says it just doesn't make sense trying to treat patients without even seeing them, particularly elderly ones with complicated symptoms. That arrangement, however, has only been suggested, not put on paper, according to HHS officials.
From the perspective of Colunga and other county clinic employees, the staffing reductions represent a "circling of the wagons," a gradual shifting of resources and funding away from the county clinics into the city. Aleshire says he believes the delivery of human services at the county level has definitely been weakened by city management, and argues that contracting for health care would not likely do any more damage. "I would take exception with anyone who thinks the way we've got it set up is all that good for the clients, that there's this seamless connection between neighborhood center-based social services and the clinic operations," says Aleshire. "You're talking about an exceptional case if someone even sees a physician right now.... We can't even spend the money we've budgeted [for doctors], because we can't get the physicians to join in these clinics. The city's not hiring them."
The assistant city manager who oversees health services delivery, Marcia Conner, responds that staffing realignments have been made to match ratios recommended by the Osborne report, and are calculated on a system-wide basis according to the populations clinics routinely serve. And Garza adds that rotating physician schedules are often the result of an arrangement, agreed to by both city and county officials, to use interns from hospital residency programs.
Finally, Aleshire says that the "strange, unfocused, and convoluted," organization of the Health and Human Services Department leaves the county out of the management loop. He dislikes the arrangement whereby the county's chief liaison between the department and the Commissioners Court, currently executive manager Stephen L. Williams, also serves as an assistant division director for the city. Williams admits his position is awkward, but questions why Aleshire feels isolated from department business, since Williams briefs the court weekly.
Aleshire insists that it's clinic staff members who are most neglected. "The city of Austin's management is not connected to our line employees out in the field, many [of whom] understand the human service industry real well. It is upsetting to me and we've got to deal with it. We had strong social service functions before we risked integrating with the city," says Aleshire, referring to the merger three years ago of the county and city health and human services departments.
Tossing Bedpan Out With...
But social workers and county clinic staff are afraid that Aleshire and the Commissioners Court may sicken the county health system through their efforts to save it. They say that rural and outlying city residents, like those in Northeast Austin who depend on the Pflugerville county clinic, may be forced to commute long distances if the five rural clinics are closed. That would also remove health care delivery from the community centers, taking away the "one-stop" human services net currently offered. Critics also question if some clinic customers - the working poor whose incomes are too high to be enrolled in the Medical Assistance Program but who receive sliding-scale discounts at the clinics - would qualify for coverage under an HMO plan.
County Commissioner Margaret Gomez says she is sensitive to these worries, and that the county will not allow an HMO contractor to slough off duties the county has performed in the past. "What I think we're gonna have to do is say, `Don't reinvent the wheel; here is what we have in place and we do not want to abdicate our responsibility for the indigent.' In the contract is where I imagine we can talk about this," Gomez says.
Aleshire asserts that the county will maintain complete control over determining eligibility for an HMO plan, and says that higher-income clinic customers - the working poor - will not be left out. In fact, says Aleshire, an HMO plan represents an even better deal for these clients because it would cover hospital care for which they currently receive no aid.
"We're not proposing a radically different method for acquiring comprehensive health care for these clients than we have for our own employees and their families," says Aleshire, referring to county employees' HMO coverage.
Advocates for indigent care maintain, however, that the county will invariably lose control of its residents' quality of care if it removes itself from day-to-day clinic operations. City/county medical social worker Betty Learned testified before the Commissioners Court that many clinic patients, often elderly and illiterate, are ill-prepared to participate in managed care plans. Learned pointed out that many clients eligible for the MAP and STAR insurance programs aren't enrolled because "people still just don't get that system." Clients who did enroll in an HMO plan, Learned said, would not readily complain if their needs were not being met, so the county could quickly lose track of them.
"Managed care has not been sensitive to the population we serve, and if that's the road you end up taking, I'm not sure what kind of fail-safes you can build into it for the patients, because they're reluctant to come forward and talk," said Learned.
Rose Lancaster, of the Citizens Health Care Network, agrees. "Once you turn patients over to somebody else, it's hard to keep up with what happens to them.... The county could do that better if they're in there running it than if we spin it off to somebody else," says Lancaster.
Colunga also foresees potential problems under an HMO-managed system. "I can tell you that in the HMO managed care program that the county has [for employees], my wife and I have personally had problems trying to access certain speciality services," he says. "You just can't do it without having somebody who is assertive in saying, `Hey, this is what I need.'"
Aleshire, however, believes county caseworkers can handle the task of advocating forcefully for their clients. And Gomez says that both county employees and the HMO provider will be required to "explain the whole process to customers, to avoid them being shuffled around, or getting so frustrated that they don't go for help."
Life After HMO
If an HMO provider does agree to contract for the county's health services, which is by no means certain in light of the expensive population the company would be asked to serve and the depth of services commissioners say they'll demand, it is uncertain whether the company would choose to use the existing county clinics. If the clinics were not shut down, city residents might still be able to visit them if the city contracts with the HMO provider to serve its MAP enrollees; conversely, city clinics (assuming they do one day operate competitively) could be included in the county's HMO service plan. HHS director Lurie and assistant city manger Conner agree that a mix of health plans for the county's indigent is not necessarily problematic, nor even unprecedented, considering the overlapping programs that exist currently.
ICWT member Tabone, whose experience in the local health systems runs deep, says she believes the county has jumped out in front on privatizing health care in an attempt to influence the entire system. "What I think they'll probably do is... privatize the whole thing and make it look good for the county in the short run, so that they can pitch it to the city, because that's the way they've always wanted it," says Tabone.
Aleshire argues that contracting with an HMO is compatible with one vital premise of the ICWT's recommendations, which is that the indigent need an "umbrella" system that supplies every medical need, including hospital coverage. He says he expects to receive an acceptable offer in response to the county's RFP, but if not, at least taxpayers will know what the cost of public health has to be. "If nobody meets those specifications, then I'm satisfied that we have tried, and then we're gonna have to invest everything we can into improving the operations of those clinics," he says.
And he also warns that, if officials look on passively as the costs of medical care escalates and federal, cost-based Medicaid reimbursements peter out, politicians down the line are going to be confronted with a painful choice between cutting back care for the indigent or inflicting heavier taxes on the public. "I can no longer stand to be held accountable for what I think is going to happen - even after I'm long gone - to the clients and taxpayers if we don't begin this now.... I'm not easily stampeded into things, but I am thoroughly convinced that we're headed for a train wreck on the track we're on."