by Martha K. Huggins, Ph.D.......
Be Compassionate and Giving; Welcome the Stranger. The sacred texts of major world religions—Buddhism, Christianity, Catholicism, Hinduism, Islam, and Judaism—talk of the inherent goodness of the poor and extol followers to welcome the stranger and assist the needy. Capitalism-- in most of the modern world--elevated to that of a religion, considers poor people risky, a nuisance, and fiscally dangerous: Mere ‘things’ requiring “risk management.” Contracts are written and legal opinions delivered, to protect corporate wealth and its very well-paid executives from the imagined exactions that the poor, poorer, and indigent allegedly pose to capital’s bottom line.
Case in point, the Lower Keys Hospital District Board, created by the State in 1967, is the government body responsible for the hospitals in the Lower Keys’ district. The Board paid Attorney Maria Currier, Esq., Partner at Holland & Knight’s Miami office, $25,000 dollars (for some workers an annual salary) to render a legal opinion about the Hospital District’s 1999 contract[i] with the for-profit corporation, Health Management Associates (HMA) to lease and operate the local hospitals.
Attorney Currier’s opinion focused only on the legality of leasing out the not-for-profit Memorial Hospital (5900 College Road) to HMA, a for-profit corporation, thus changing Memorial Hospital into a for-profit medical center – the Lower Keys Medical Center [LKMC]: Opinion: “The [Hospital] District was statutorily authorized to enter into the lease [with the for-profit HMA] and to delegate all of the Hospital Operating Decisions to HMA.” Opinion: “The Hospital District is preclude[d]…from retaining responsibility for Hospital Operations Decisions.” Opinion: “By HMA[’s] assuming the indigent care obligations of the District, without limitation, there is no need for the District to levy ad valorem taxes on the District’s residents over the entire 30 year term of the lease.”[ii]
But has HMA [now CHS, Community Health Systems], in fact, assumed the indigent care obligations of the District? This question is not strictly answerable since CHS is protected from responding to public information requests since the “Sunshine Law” does not apply to private entities like CHS. Florida Statute 155.40 is clear that, in “a sale or lease of a county, district, or municipal hospital,” there is an “enforceable commitment that programs and services and quality health care will… be provided to all residents of the affected community, particularly to the indigent, the uninsured, and the underinsured.”
The contract between the District and the for-profit company specifically demands that the company provide not only the statutory required indigent care at its hospitals, but also a Primary Care Clinic for all residents of the district including those that can’t pay.
“The clinic shall provide a broad range of primary care health services with an expanded operating schedule to all Residents regardless of the Resident’s ability to pay.”
The contract required HMA/CHS to furnish the space for the Clinic and all non-physician personnel; the District is obligated to fund the cost of physician services for the clinic’s indigent patients [up to a maximum of $500,000 per year].
"All administrative and non-physician allied health professional staff will be provided by Lessee. The physician coverage for the Clinic will be provided by participating physicians (at no cost to Lessee) practicing in the Lower Florida Keys Hospital District... Lessee will be obligated to maintain the space for the Clinic for the lease term and may only discontinue providing such space and administrative support prior to expiration of the lease term with approval of the Lessor..."
Indeed, The Lower Keys Hospital District indicates in its annual financial and budget statements, including the current 2016 budget statement, that it funds a “Primary Care Clinic” to the tune of $500,000 per year.
But Where is the Hospital District’s “Primary Care Clinic”? On December 1, 2016, I began surfing the Net, calling experts, talking with former employees of two Key West primary care clinics associated with the Lower Keys Medical Center, and walking and driving around Key West to locate “free” clinics listed on the Net. Looking first at the Stock Island Lower Keys Medical Center, my guess is that there is no “Primary Care Clinic” there, per se, that is operating with the help of the Hospital District funding for indigent care. Why not? The Lower Keys Medical Center’s website--in an article announcing the Florida Association of Community Health Centers’ “Outstanding Clinician Award” to Dr. Jerome Covington--stated that Dr. Covington, “serves at the Primary Care Clinic affiliated with Lower Keys Medical Center at the dePoo Medical Building at 1200 Kennedy Drive”[iii] (emphasis added).
Problem solved! It must be dePoo’s Primary Care Clinic that receives that half-million-dollar subsidy annually from the Lower Keys Hospital District for the care of indigent patients. To confirm, I called three people linked to the Hospital District: an administrator, the recently retired Chair of the District’s Board, and the Board’s lawyer: “Does the Hospital District help fund a primary care clinic at dePoo Hospital?” In no uncertain terms, each person told me in one way or another that, “we have nothing to do with that clinic.” In an email exchange with the Hospital District’s new Chair, a Blue Paper editor who asked where the clinic referred to in the contract is located was told: ‘You need to direct that question to CHS, as it is their responsibility.” What? Doesn’t the Hospital Boards’ Chair know where the contractually required Primary Care Clinic is and what the District's $500,000 per year payment is supporting? I don’t know about you, but I keep close tabs on all of my money; I especially track the use of my money by organizations receiving my donations.
In a daze: If the Hospital District is not providing a half-million to help fund the dePoo Hospital “Primary Care Clinic,” just where is the clinic that receives that District funding? Suspecting that a ‘Primary Care Clinic’ wasn’t even operating at dePoo, I drove to 1200 Kennedy Drive to find the clinic, if it was there. A very small silver sign mounted on the entry wall just behind an apparent information desk, listed the services available at dePoo Hospital. These included a “Primary Care Clinic.” Jerome Covington, MD was listed as practicing in that Clinic located on the hospital’s first floor in Room 1014. There was no indication in the dePoo hospital lobby of the Primary Care Clinic’s hours of operation, and I was there after the hospital’s closing time so I couldn't ask. The next day, I decided to call dePoo and ask about the Clinic’s hours. Some five telephone calls later, using each time an incorrect phone number found on-line, I finally got to a receptionist, who informed me that dePoo’s Primary Care Clinic was only open Tuesdays and Thursdays from 8am to 7pm and that the Clinic’s in-take worker helps establish a prospective client's eligibility for free treatment. Indigents -- people without financial resources or insurance to pay for their healthcare – can use the dePoo Clinic. But what about those who are underinsured and those with financial stability and insurance. My husband, with his two insurance policies – Medicare and AARP – had his ears cleaned at dePoo’s Primary Care Clinic - but that was two years ago.
Whew, all is explained. Just as I felt I knew where the Hospital District-subsidized Primary Care Clinic was operating, albeit only two days a week, my “Primary Care Clinic” odyssey got complicated. Interviewing former employees from dePoo’s Primary Care Clinic, I learned that until relatively recently, the dePoo Clinic had been operated by Monroe County’s Rural Health Network (RHN)—a not-for-profit organization with county and federal funding that provides primary healthcare for rural populations. When RHN was operating dePoo’s Primary Care Clinic, the clinic went by the name, “Lower Keys Community Health Center.”[iv] As for that clinic’s connection to HMA(CHS) and the District, my interviewee stated that HMA and the Rural Health Network had, for a time, been “partners” in providing indigent care at the dePoo clinic.
Too Many Balls in the Air: Sometime in late 2014 or early 2015, the RHN re-located its “Lower Keys Community Health Center” from dePoo Hospital to 3706 N. Roosevelt Blvd., in Key West. Open Monday through Friday from 8 am to 7 pm, when one calls its phone number the caller can choose to speak and hear prompts in English, Haitian (‘Creole’), or Spanish. Jerome Covington, MD is one of its practitioners and medical director. The North Roosevelt Boulevard “Lower Keys Community Health Center,” screams accessibility, unlike the Primary Care Clinic now operating at dePoo — which is only open two days a week and frustrating to connect with by phone. My research shows that Jerome Covington’s Roosevelt Boulevard clinic—managed by the Rural Health Network—is a Federally Qualified Health Clinic (FQHC) —meaning that it qualifies for:
“enhanced reimbursement from Medicare and Medicaid, as well as other benefits. FQHCs must serve an underserved area or population, offer a sliding fee scale, provide comprehensive services, have an ongoing quality assurance program, and have a governing board of directors.”
One very well placed interviewee recalls that, dePoo Hospital and Stock Island’s Lower Keys Medical Center—both operated by HMA/CHS —regularly referred patients to Dr. Covington’s “Lower Keys Community Health Clinic” on the Boulevard. According to my source, the Lower Keys Community Health Center receives no CHS or Hospital District support or funding.
Befuddled, I asked myself: Could it be that Stock Island’s Lower Key’s Medical Center’s Emergency Room, serves in practice as the Hospital District’s Primary Care Clinic? Not according to the definition of each kind of service: Emergency Care is short-term, usually performed in an Emergency Room, such as the one at the Lower Keys Medical Center. Emergent care, as it is called, is, “Medical or other health treatment, services, products or accommodations…to an injured or ill person for a sudden onset of a medical condition.”[v] In contrast, Primary medical care is long-term. It promotes good health through on-going illness prevention and health maintenance: “A patient's main source for regular medical care, [primary care] ideally provides… continuity and integration of health care services….[Such services] provide the patient with a broad spectrum of preventive and curative care over a period of time….” [vi]
A friend of mine had diabetes and was without either the cash or the insurance to cover his ongoing diabetes care and treatment. Without such resources, as time passed, his diabetes worsened and deep sores developed on his legs and feet. He alone could neither treat nor cure his infected wounds, so without medication, diet monitoring, and “regular foot care [to] help prevent development of severe foot sores,” [vii] my friend ended up having one of his legs amputated. This tragedy could have been avoided with on-going preventive primary care services.
Primary Care Clinic Required: The contract between the Lower Keys Hospital District and HMA, clearly includes Primary Care Clinic services for all residents in the district including the indigent, as a contractual requirement. And this stipulation was not removed by the most recent amendment: section 4 (i) of the 2003 Hospital District/HMA amendment to the 1999 contract retains language describing “primary care” as taking place in a clinic setting.
"Lessee shall maintain space for a primary care clinic ("Clinic") at the District Hospital or dePoo Hospital, or such other location as Lessee shall designate from time to time. The Clinic shall provide a broad range of primary care health services with an expanded operating schedule to all Residents regardless of the Resident's ability to pay."
The 2002 Amendment: In 2002 HMA and the District amended their agreement to allow the half-million-dollar Primary Care Clinic subsidy to be used not only to pay physicians who serve indigent patients who are clients of the Primary Care Clinic, but also any indigent patient who showed up at the Lower Keys Medical Center Emergency Room for care, but who didn’t need the services of an Emergency Room physician. Hospital physicians providing care for that indigent patient - at the hospital - would now be eligible for payment via the half-million-dollar district funding, based on a finding that the care required was not of an urgent nature. HMA/CHS is required to provide urgent Emergency Room care for indigent residents; the District is no longer (since 2009) required to subsidize HMA/CHS in any way for providing state mandated hospital emergency care for indigent residents.[i]
The 2003 Amendment: In 2003 HMA and the District again amended their agreement, this time allowing the half-million-dollar funding to be used to pay physicians who treat indigent patients who are brought to dePoo Hospital under the Baker Act.[i]
No Clinic, No Half-Million: Included in the agreement (and its amendments) is the stipulation that should HMA/CHS stop providing district residents with the Primary Care Clinic described in the contract, the District would no longer be required to provide any funding including funds to subsidize hospital non-emergency treatment of the indigent coming through the ER or care for indigent Baker Act patients brought to dePoo Hospital.
“In the event that the space for the Clinic and administrative support is terminated by the lessee, then, effective upon termination, all physician services provided after termination shall not be eligible for payment, whether for services provided as a result of referral from the Clinic or the Emergency Room.” [2003 amendment]
After tireless research, I cannot say with certainty where CHS’s contractually required Primary Care Clinic [“providing a broad range of primary care health services with an expanded schedule”] is located.
Power: Alpha Dogs and Omega pooches. In providing her legal opinion, Ms. Currier limited her research and opinion, as requested, to the de jure aspects of the Hospital District/HMA contract—Do its contractual stipulations adhere to the “law, [are they] authorized by law,… [or] by statute…” Another equally pertinent way of studying contractual relations is to look at the very real day-to-day playing out of a contractual relationship: Who benefits most and least from the contract? In ‘dog pack’ language, who is the Top, Alpha Dog and who is the bottom, Omega pooch?-- the lowest member of a dog pack. That question focuses on the de facto actions of the contracting parties: How does each contractual party, in fact, in reality, behave vis-à-vis the other one and toward a contract’s designated beneficiaries? Using CHS and the Hospital Disrict as the case in point, if the de Jure stipulations of a contractual relationship require that one or another party to the contract, or both, mount and operate an accessible, locatable, and affordable primary care clinic, then de facto—in fact—does such a clinic exist in the form required by its contractual description?
Perhaps the answer lies in a combination of the Hospital District’s contractual status, its psychological subservience to HMA/CHS and its willingness to let itself be uninformed about the end-uses of its $500,000 annual contribution to the Primary Care Clinic. In the words of John Padget, recently appointed Hospital District Chair, “We’ve learned that we don’t have any legal wiggle room, so let’s ask if they’re willing to amend anything.” Stating that he plans to write a “friendly letter” to Wayne Smith, Chairman of the Board of Community Health Systems and its Chief Executive Officer, Padget will cautiously ask CEO Smith: “Would CHS agree to negotiate and commit to additional operational criteria to be added to the lease as a show of good faith to the community?” And then, despite all that has gone wrong in HMA management of Stock Island’s Lower Keys Medical Center (LKMC), Mr. Padget sweetens his “friendly” deal by asking if HMA/CHS “is interested in extending the lease.” Well!
A corporate behemoth in the US healthcare industry--“CHS' Fourth Quarter 2014 Net Operating Revenues were $4.798 Billion.”[viii] In 2014 Community Health Systems' top executive, Wayne Smith raked in a higher compensation [$26.4 million] than all other CEOs in the healthcare provider sector.[ix] CEO Smith’s total compensation package for 2014 was almost 200%[x] more than his compensation for 2013.[xi] In contrast, in 2014, the Lower Keys Hospital District’s total net position was $10,288,694[xii] (declining almost $500K in 2015 to $9,860,378). [xiii] The Hospital District’s board members serve voluntarily—“without compensation for their services”[xiv] The largest chunk of the Hospital District’s humble revenue is derived from its investments,[xv] which can, as we know go up, or down.
‘Disappearing’ a Hospital. Using smoke and mirrors, the 1999 contractual ‘enabling act’ between the Lower Keys Hospital District and HMA effectively melded two Key West hospitals—dePoo and the Lower Keys Medical Center, located about two miles apart--into one for-profit capital asset. Only contemporary magician David Copperfield—who made the Statue of Liberty Disappear[xvi]—came close to accomplishing that feat! The hospital monopoly that has followed, greatly enhanced the value to HMA of its Hospital District asset. Having only one hospital, on paper, to serve the demographically “rural” Lower Keys, has transformed Stock Island’s Lower Keys Medical Center into a ‘cash cow.’ As last week’s Blue Paper “Editorial”[xvii] reported, the profit margins for LKMC have been as high as 32 percent of the hospital’s revenue; the US average hospital profit margin is only 7 percent. No wonder, HMA/CHS might not be interested in risking its bottom line by providing primary healthcare at low- to no-cost to the Lower Keys Hospital District’s poor and indigent. The minimalist dePoo Primary Care Clinic seems to be a functionally workable marriage: hospital profits for CHS are safeguarded, while the poor who use the dePoo clinic are minimally ‘helped’ in maintaining good health.
It’s Over When It’s Over. My research for the Blue Paper on indigent healthcare in the Lower Keys is far from finished, in fact, what I’ve written here raises more questions than answers. Most important: Is CHS using the Hospital District’s annual $500,000 dollar subsidy, ear-marked for a Primary Care Clinic, for LKMC Emergency Room and other related hospital expenses? Certainly my interviews with two former employees at dePoo’s primary care clinic, as well as a Hospital District administrator, have told me that ‘the Hospital Districts $500,000 goes to pay hospital physicians.” Well it is apparently contractually permissible for the Hospital District to allow its $500,000 in Primary Care Clinic annual funding to be used to pay for ER-sourced indigent "non-urgent" treatment and related hospital care as well as psychiatric services at de Poo hospital. However, it is not contractually permissible for CHS to short-shrift funding for a publicly accessible—open more than two days a week [!] well-advertised and locate-able, Primary Care Clinic that has an efficient plan for providing free and sliding-scale services to all Lower Keys’ residents: especially the poor, poorer, and indigent. This is precisely what is absent—and, by the looks of it -- contractually mandated.
We began with our duty to help the needy and end with William Shakespeare's reminder about law and power: King John 3:1—Constance to Cardinal Pandulph:
“When law can do no right, Let it be lawful that law bar no wrong: Law cannot give my child his kingdom here, For he that holds his kingdom holds the law.”
[ix] A healthcare provider is an institution (such as a hospital or clinic) or person (such as a physician, nurse, allied health professional or community health worker) that provides preventive, curative, promotional, rehabilitative or palliative care services in a systematic way to individuals, families or communities.
[xiv] Ibid, P. 3
[xv] PFM Management, LLC oversees The District’s rather humble stock and bond portfolio.