Who's Killing Home Health?

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.

Currents 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. TW

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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