Mum's the Word
BHOC Chair Norma Plascensia Almanza states her charge this way: "As a citizen, I'm supposed to make certain that Brackenridge is still accessible to the indigent community that most needs it. We're the eyes and ears" of the Austin City Council.
But Gentle complains that the BHOC is unable to be anyone's "eyes and ears" because it doesn't get enough information to do its job, and then can't pass along even the information it does get.Additionally, Gentle believes the standards established by the lease with Seton fail to provide the necessary safeguards. For example, he said, Seton is in compliance with the lease until it has "ceased to provide" one of the service areas it has agreed to perform. It takes only one of any given procedure in a 12-month reporting period -- such as one tubal ligation -- for Seton to maintain its compliance with the lease. This was just one of many weak links in the chain of accountability that drove Gentle to resign. "I felt like I was beating my head against a wall," Gentle said, "the wall being Jesus Garza and his staff."
Brack's Second Life
In fact, Garza has always taken heat for his position on Brackenridge. Back in 1994, when the city was looking for new management for Brack, he reportedly steered city efforts away from the front-runner choice, the Austin Hospital Authority, toward Seton. Garza argued -- and the City Council agreed -- that though the hospital authority could promise good management, it didn't have an adequate funding source and would have relied on increased city taxes, or the establishment of a new health care financing (read: taxing) district. Enter Seton, a godsend for a city government not eager to introduce a new vehicle for taxation.
At the time, there was substantial public concern about the implications of private management of Brackenridge, to the extent that Austin State Rep. Glen Maxey engaged in heated conflict with Garza over how explicitly the city-Seton lease agreement would guarantee access to care. The Chronicle reported Maxey's criticisms at the time: "At every turn, city staff has balked, demurred, refrained, adjured, spurned, dismissed, disproved, and refused to agree to plain language that would simply state your guarantee that the needy citizens of Travis County will have access to health and medical care."
Garza says he resisted Maxey's demands because the content of the lease with Seton was a matter to be decided by the city, not state government. Furthermore, Garza contends the lease requires Seton to provide hospital care to anybody who appears on its doorstep. "If anybody wants to come say, 'On these specific dates, these individuals were denied [access to medical care],' I would be all over it, because that would be a violation of the lease," Garza says. When asked to name exactly which provision of the lease requires this kind of universal access, Garza said he couldn't recall.
Seton's commitment to the poor is second nature, says Patricia Hayes, Seton's executive vice president. "Seton's own commitment, before Brackenridge, was to do everything possible regardless of income," she said. "That's why (the lease with the city) was such a good match." But she adds a caveat: "The lease doesn't say you have to go bankrupt if that's what it takes."
Some say that at the time the city was just happy to get the Brackenridge albatross from around its neck, and didn't want anybody asking questions that might derail the sweet new deal. Garza, then the brand-new city manager, was surely not the least of these, as he owed his ascent at that particular time to the untimely demise of his predecessor, Camille Barnett, over a $21 million accounting shortfall at Brackenridge. To Garza, protection from further financial liability seemed like a fair trade -- though Seton's management services, he told the Chronicle, would "create some separation from public accountability, away from the public eye."
Four years later, Garza's prediction seems to have come true. At least one City Council source agrees the city staff still holds a "don't look a gift horse in the mouth" attitude regarding the public hospital; if Seton is willing to take on the liability of treating the poor in Austin, let's not repay them with too many nitpicking questions about what they're up to. But nitpicking questions were what Mark Gentle's tenure on the Brackenridge oversight council was all about.
No Clear Picture
The information BHOC provided the council in its 1998 annual report in January contained a list of Brackenridge "Milestones," volumes of inpatient, outpatient, and emergency room patients treated, and the number of compliments and complaints made by both insured and uninsured patients. What the report did not contain, more than one councilmember agreed, was enough information to give the City Council or other interested parties a clear picture of what is going on at Brackenridge. And some of what was missing, says Gentle, is information the public really needs.
Chief among Gentle's concerns is the method, or formula, the BHOC uses to monitor access to hospital care for the indigent. There are several categories of hospital services for the poor in Austin: In addition to Medicare and Medicaid, there's the city Medical Assistance Program (MAP), which functions as a health insurance program for low-income Austin residents, and the Brackenridge Financial Assistance Program (BFAP), a sliding scale financial assistance program whereby Seton picks up some or all of a patient's hospital tab, depending on the patient's income. The city pays Seton $5.6 million annually for treatment of BFAP patients at Brackenridge, over $5 million annually for MAP patients, and about $5 million for physician services, in which private physicians are paid to provide care to the indigent. Any extra expense is borne by Seton.
Also, Seton must treat a minimum of 1,008 charity patients annually to remain compliant with the lease. But this figure is not based on the number of charity patients treated at Brackenridge prior to the city's lease with Seton. That's because there was no reliable data to determine how many charity patients were treated at Brackenridge before Seton took over. So Seton and city officials established a baseline minimum called the "Equivalent Admissions Formula," an estimate of charity patients treated derived by a complex series of calculations based on inpatient and outpatient revenue and actual and projected admissions numbers.
But since neither the BHOC, or the Austin City Council, or just about anybody else for that matter, really understands the Equivalent Admissions figures, the 1998 BHOC report complained that "the numbers ... do not represent actual numbers of patients" admitted. When the oversight council asked for the actual number of charity patients, Seton provided a number of 13,925 for FY 1998. In comparison to that number, the startlingly low 1,008 threshold -- established in 1996 -- is meaningless, said Gentle. Furthermore, he said, since the 1,008 threshold never increases over the 30-year span of the lease -- though demand for care is sure to increase -- it will become increasingly irrelevant as time goes by. "It's like setting the speed limit on MoPac at 500 mph and telling the oversight council to ticket anybody that goes over 500mph. What's the point?"
The report also expressed BHOC members' concern about the amount of information that is provided to them in closed session, which precludes them from releasing the information in their report to City Council. For example, no specific data on the quality of clinical services appears in the annual report (it was presented to the BHOC in executive session), except for the assurance that "Seton met or exceeded national quality standards in the vast majority of areas reported." Seton has stressed that there are several categories of information it must keep confidential. They include: patients' medical records, details on physicians' peer-review process, and market-sensitive information which could damage Seton's competitive advantage in the Austin health care market. While Gentle agrees that Seton has a right to keep some information under wraps, he questions how data concerning health care for the indigent could be market-sensitive. "There's no competition in this market for indigent care," he said.
One area where Seton has feared market recrimination for publicizing performance data is the time patients must wait to get an appointment at one of Brackenridge's specialty clinics. According to the BHOC annual report, the average wait for an appointment is 3.8 weeks. The report acknowledged that there is "heightened concern" about lengthy waits in a few specialty areas, but provides no specific information about which specialty clinics are cause for "heightened concern," and what the wait times are for those clinics, because that information falls under the confidentiality rule. "Under what theoretical legal premise is [that] confidential information?" asks Gentle. "Excessive wait times at any of the specialty clinics ... can pose an incredible risk in the uninsured, indigent population who have nowhere else to go."
City Manager Garza acknowledges that there is a problem with wait times at the clinics, and the problem is a holdover from the days of city management of Brackenridge. "That's a question you could ask: Were we funding (the clinics) at the right level? Did you have enough attending physicians ... to make sure the wait times weren't longer than necessary? I think that's being resolved." The BHOC report states that city and county officials are currently working with Seton to address the problem.
The confidentiality principle also prevails in a category which all parties agree is essential to maintaining accountability at Brackenridge: monitoring and responding to complaints. Toward that end, Seton instituted a compliments/complaints policy at Brackenridge in late 1996. Here's what the Austin City Council learned about complaints at Brackenridge in the BHOC annual report: The report cited 77 complaints from charity patients and 181 complaints from paying patients in 1998, adding, "Seton reports regularly to the BHOC on the number and type of complaints received at Brackenridge, along with information about their resolution." Since that information was received in executive session, however, it was not passed on to the council. Then there's "patient satisfaction." That information was also reported in executive session, and was thus unavailable to the City Council, but the report did offer the bland assurance that patient satisfaction data "show ratings to be within the expected range around the baseline of average satisfaction set during the first year of measurement." Jesus Garza last week said he agrees that some of the currently confidential information could be made public, and that he, along with city legal staff, "would look into it."
Gentle says the Austin City Council needs to be more aware of the kind of complaints Seton is receiving. He said while the names and medical
conditions of individuals and doctors should remain private, the "numbers and types [of complaints], whether they relate to access or not, should be public, and it should be in the annual report," he said. "If you follow the complaints, you follow the truth," Gentle said. "Complaints about what? Were they ever resolved? Did somebody die? Don't let it stop at Garza or one of the assistant city managers. It needs to go all the way to the top. The worst thing that can happen is not addressing problems as they come up, because they fester and get worse."
While Elaine Carroll of the Austin/Travis County Health and Human Services Department said city staff meets monthly with Seton officials to share information and work on resolving complaints, Gentle complained that his inquiries -- especially those surrounding the access to care formula -- were stifled by Garza. "That's why I resigned, because if the city manager of the city of Austin doesn't want the oversight council asking questions about the bottom-line, basic function of Seton under the lease, then we are faced with a hopeless dilemma. Because it's clear that the city is not going to back us up in our pursuit of what the truth is."
At this point, says Councilmember Bill Spelman, the only leverage the City Council has in its dealings with Seton is political leverage. "What we can do is suggest to them that [withholding information] is unacceptable. There's a lot of support on the council for asking Seton to cough up some better data." At the very least, adds Spelman, the city should be able to pressure Seton for more specific details on indigent care. "This is the biggest single contract the city has, and we don't have a good idea of what Seton is doing over there. All Seton is required to tell us is whether they're doing a lot of work with indigent patients. What we don't know is what they're treating indigent patients for, and what type of treatment are they getting."
On March 9, Spelman and Councilmember Beverly Griffith co-authored a memo to the BHOC regarding "questions left unanswered" by the annual report. The memo requests more information "so the [City] Council may better understand ...'quality of care' issues," including more specific wait time and complaint information, family planning referrals, and rates at which services are provided to BFAP patients as compared with the rates they are provided to all Brackenridge patients.
Asked to comment on their role in the city/Seton relationship, current BHOC members are circumspect. BHOC chair Almanza says city staff "did say, 'Hey, you can't revisit the BFAP [Brackenridge Financial Assistance Program] formula.' Seton was saying the same thing." BHOC member Carl Siegenthaler said that while he found the BFAP formula, or method, "problematic," he was confident that Seton is more than upholding the bargain it made with the city. "All the services that were there to begin with are still there, and then some," he said.
Perhaps BHOC and the taxpaying public would be better served had Gentle remained on the oversight council. He has a good reputation in public policy circles, though he is known to some as a squeaky wheel. Lawyer Claire Korioth, who served as chair of the State Board of Insurance when Gentle was a special counsel there, wrote a letter to Mayor Kirk Watson following Gentle's resignation citing him as "one of the nation's experts in health care delivery systems," and expressing her concern "about the attitude of the city manager" in regard to inquiries about the BFAP formula.
The ordinance creating the BHOC states that one of the five slots be held by a lawyer, presumably to add the kind of squeaky-wheel advocacy that Gentle attempted during his tenure, with some success. "Mark started us on a very good road to continue our charge, but to also say, 'Hey, why do we do so much in executive session?'" said Almanza. "He'll be missed."
So where does the buck stop for accountability at Brackenridge? It's characteristic of the situation that, even for those who work closely with
the hospital, it's very hard to determine just where the buck does stop. The Austin/Travis County HHS, the city manager's office, the City Council -- each of these has some responsibility for accountability at Brackenridge; none seems to have ultimate responsibility. City Manager Garza and Seton's Patricia Hayes concur that if the city and Seton agreed on a proposed change in the system, it could be done. But what if they didn't agree? What if the oversight council stood alone, a voice in the wilderness? And how would the need for change surface without adequate reporting of complaints?
In Seton We Trust
Hayes admits the BFAP formula is ineffectual; therefore, there will have to be some trusting of Seton on the part of the city and the public. "The
truth is, there is some reliance on good will, [because the BFAP formula] does not ensure the poor in Austin will be taken care of. It doesn't." Hayes cites Seton's recent lease of the publicly owned Edgar B. Davis Hospital in Luling as evidence that Seton is pressing forward in the field of public hospital management (see story, p.26).
In recent years, market pressures have forced the privatization of many public hospitals, and the outright closing of others. While several BHOC members have expressed confidence in Seton's commitment to indigent health care, BHOC chair Almanza warns that the time will surely come when market pressures threaten Seton's ability to care for the poor. For example, she cited the increasing numbers of employed but uninsured Austin residents who could place increased stress on hospitals, saying that there are going to be "more and more people out there without insurance." She added that Seton and the city have told the BHOC not to concern themselves, telling them "That's beyond your charge, [because it's] not indigent care." But if Brackenridge has enough bad debt, due to uninsured patients, "there won't be access to charity care. ... Overall, the poor are going to get treated if we've got a good operating hospital."
By most accounts, Brackenridge is still a "good operating hospital." Except in the area of specialty clinic wait times, no member of the Austin City Council or the BHOC has complained about the state of indigent care at Brackenridge (and according to Councilmember Gus Garcia, there are fewer complaints from the general public than ever). But times change, and if the city is unwilling to maintain the mechanisms that are holding the safety net in place, it could fail when tested. The Daughters of Charity and Seton have a mandate from Holy Scripture guiding their commitment to the poor; it is the city of Austin's task to see to indigent health care through earthly codes and ordinances.