Big issues include affordability and quality of care, long ER waits, and sweetheart contract with Sharp Health Care
By Mark Gabrish Conlan
October 30, 2012 (San Diego’s East County)--How healthy is our healthcare district--and what remedies to candidates for the Grossmont Health Care District Board have to offer?
ECM contacted all candidates and obtained responses from eight of the nine (all but Emad Bakeer). Virtually all saw the same principal issues facing the district, though they differ on solutions--and their approaches differ as much as their backgrounds.
Key issues include terms of the $1-a year lease contract with Sharp for Grossmont Hospital, quality control in the wake of malpractice scandals, heavy use of the emergency room (ER) by people who don’t have emergencies but don’t have health insurance either, and how to deal with lower-income and under-served communities in the face of federal and state budget cuts. Concerns over affordability of care and how federal healthcare reforms may impact the distract were also among the issues discussed.
Candidates include three incumbents: president Deborah McElravy, treasurer/secretary Robert “Bob” Ayres, and member at-large Michael Emerson. All were initially appointed to fill a vacancy — McElravy in 2006, Ayres in 2010 and Emerson in 2008 — though both McElravy and Emerson were elected by voters to subsequent terms in 2008. A fourth candidate, LeRoy “Lee” Knutson, is a former Hospital Corporations board member. Another challenger, Betty Stieringer, is the wife of former board member Jim Stieringer. John Whalen, retired chief financial officer at Alvarado Hospital, also served on the Hospital Corporations board for one year as an appointee. Other candidates are Sandra McMillan, John L. Hammerstrand, and Emad Bakeer.
Most have experience in health care. McElravy has been a pharmacist for 38 years and is currently managing the pharmacy at La Mesa Costco. McMillin has worked for 15 years as a registered nurse (R.N.) at Sharp Mary Birch Hospital for Women in Clairemont Mesa. Stieringer, also an R.N., has worked 13 years as head nurse and staff nurse for San Diego County Sheriff’s Department at juvenile detention facility. Emerson has been involved in health care for 36 years, owns Hart Optical Company, and is an American Board and California Medical Board certified optician (or as he terms in, “ophthalmic dispenser.”) Hammerstrand worked for over a quarter-century as an environmental health specialist, and Whalen is a retired hospital CFO. Bakeer also claims medical experience — his e-mail address is email@example.com — though his main business is running a center for immigrants to help them get green cards and avoid deportation.
Other candidates have worked in business. Ayres pointed to “my 47 years of both public and private sector banking and construction financing experience” and said that “my financial credentials and long history of community involvement in East County were primary factors in my selection” over 25 other applicants for appointment to the board. He and Emerson both noted their involvement in the oversight committee for spending money under Proposition G, the voter-approved bond issue to modernize Grossmont Hospital. Knutson is the former city attorney of La Mesa and past president of several organizations: La Mesa Chamber of Commerce, La Mesa Rotary, Foothills Bar Association, and California City Attorneys’ Association.
Though Betty Stieringer is endorsed by the San Diego Republican Party, the East County Chapter of the California Republican Assembly and local GOP legislators Brian Jones and Joel Anderson, she’s the candidate who voiced the most concern about what she calls the Grossmont district’s sweetheart deal with Sharp.
“We should not be leasing Grossmont Hospital for $1 per year,” she said. “We should not be donating money to Sharp Health Care. Since the district is donating our residents’ property taxes to Sharp, we should inquire as to why Sharp pays its Grossmont Hospital CEO more than $600,000 a year when so many East County residents are experiencing difficulties with medical bills.” Stieringer questioned why Sharp charges for parking in garages built with taxpayers’ money, and said, “We should begin ‘testing the market’ to see if other hospital chains would be interested in leasing Grossmont when the current lease expires in 2021.”
McElravy, by contrast, ruled out shopping the lease to other operators. “Renewing the district’s lease with Sharp Hospital as the day-to-day operators of the hospital is a key objective,” she said.
Malpractice Scandals and Quality of Care
The district’s relationship with Sharp was cited by many of the candidates in response to a question about how to improve the quality of patient care.
Sharp Grossmont Hospital has twice been cited by the California Department of Public Health for severe medical malpractice in recent years, once in 2008 and once in 2010. The 2008 incident was about Larry Napolis, a 45-year-old male heart patient whose automatic ventilator was mistakenly turned off, leading to his death. The 2010 incident was about a 93-year-old man who went in for brain surgery, and the doctors duly operated … on the wrong side of his brain. Napolis’ death resulted in a $25,000 fine against the hospital, the maximum allowed by law.
A 2008 investigation by East County Magazine, “Tough Medicine,” revealed concerns about Grossmont’s ER wait times, nursing staff ratios and of secrecy by which Sharp’s administrators allegedly kept board members in the dark about problems with the quality of care. The hospital has since implemented some new procedures aimed at addressing the concerns. The building itself has undergone a major remodel in 2009, adding new beds to free up spaces in the emergency room.
McElravy and Whalen were both quoted in the “Tough Medicine” articles, and McElravy was angry that as a Grossmont board member she wasn’t notified about the problems by Sharp’s staffers. But her response to the ECM board questionnaire four years later was more conciliatory towards Sharp.
“Under the terms of our lease with Sharp Hospital, they are the day-to-day health care providers; these incidents are reported to the District Board members after the fact, followed by specific causes or rationales for their occurrence,” McElravy wrote. “As Board members, we continually monitor the level of health care our hospital patients receive, and are seriously concerned that such incidents occur. We also remind the hospital that these incidents must be learning experiences and [they must] avoid them in the future.”
The other two incumbents responded similarly. Emerson said that the lease of Grossmont Hospital to Sharp “has exceeded expectations” in improving the quality of patient care, and added, “We take lapse in care incidents very seriously. What I can do is make sure the proper procedures are followed. The District has an agreement with the hospital to notify us immediately when incidents occur. We are notified of what happened and the root cause, what their team is doing to protect our patients and prevent similar incidents from happening in the future as well. Hospital leadership, medical staff and all clinical members swing into action to investigate adverse occurrences with an end result of education and training for staff and new policies and procedures implementation.”
“It’s unfortunate when errors occur, but the reality is that they occasionally do at every hospital,” said Ayres. “The Health Care District leases the facilities to Sharp Health Care and is not directly involved in the day-to-day operations and management of the hospital. The requirements for Sharp Health Care to comply with all rules and regulations as overseen by the California Department of Public Health are taken seriously by Grossmont Hospital and the Grossmont Health Care District Board. Reports consistently show that Sharp Health Care is exceeding the standards as set forth by the California Department of Public Health. They are committed to maintaining high standards and to be[ing] fully compliant.”
John Whalen, retired chief financial officer of Alvarado Hospital, marveled at the price discrepancy between his privately owned institution and Grossmont Hospital in the 1960s-1980s, which was then publicly owned and operated. “Grossmont Hospital had the lowest prices in the county,” Whalen told East County Magazine (ECM). “I was aware of this because Alvarado had the highest prices. The reason was that as a private company, we had to make a 15 percent profit. Grossmont’s profit was equal to the annual property tax revenues the district received, and their focus was how to take care of people as cheaply as possible.” That changed in 1991, Whalen said, when the Grossmont board decided to lease their hospital to the privately owned Sharp company for $1 per year.
Whalen, who in 2008 called on board members who didn’t attend meetings to “resign, because you are being negligent in the performance of your duties,” is just as feisty today. “The district is being run like a boys’ club, with too little spending on poor people,” he told ECM. “In the 1950’s the people running the hospital knew most East County residents were blue-collar people without insurance.” He said that when the malpractice scandal broke in 2008 one board member decided he was “too busy” to attend the meetings, so he sent his son instead — breaking the confidentiality of the briefings, which were supposed to be for board members and Sharp staffers only.
Hammerstrand says the district “already has a watchdog” but it “needs to look at avenues that are potentially dangerous to the life and health of the public.” He said if the watchdog isn’t doing their job, “the board members need to be watchdogs and make sure we do not endanger patients, staff and the public in general.” Hammerstrand also said that via the Internet, “any citizen, inside or outside the district, can contact any board member at any time. It’s situational awareness. We need to be proactive so these events don’t happen again. We need to communicate these issues with our board members and bring them up and discuss them.”
“The Board must be more active in reviewing unsatisfactory reports and [must] demand that the hospital administration take quick action to correct them,” McMillan said. She also said that one way the hospital could boost the quality of patient care is “additional support for the training of all hospital personnel. This includes support [to] local colleges, a family practice residence program” — which, she said, Grossmont Hospital once had, but got rid of — “and scholarships for current employees to improve their medical skills.” She also wants the board to cut back the salary it pays its own nine-member staff — particularly CEO Barry Jantz, a former aide to Republican legislator Jay LaSuer — and use the savings “for medical care for our residents.”
Stieringer said that under the current 30-year lease of Grossmont Hospital to Sharp, “they are solely responsible for maintaining the physical plant and for maintaining the quality of care given to the public. Sharp takes this responsibility seriously, although there have been several documented instances where they fell short and patient care was less than perfect. The District Board currently receives a closed-session quarterly review on the patient care and patient feedback statistics. It may be good if that briefing were held in a public setting, with patients’ names kept confidential.”
Knutson called the sanctions against Grossmont Hospital “strictly a state matter. Neither I nor any of the Grossmont Health Care District board members have any expertise in that matter.
Emergency Care and “Obamacare”
Asked about the allegations that wait times for care in Grossmont’s emergency room (ER) are especially long, a number of the candidates said that the real problem is there are so many East County residents without health insurance that whenever they need any care at all, they come to the ER.
“Grossmont Hospital’s Emergency Department operates the busiest emergency room in the San Diego region,” said Stieringer. “With more than 70,000 visits per year (nearly 200 per day), the hospital serves the needs of individuals both within and without the District’s political boundaries. … The emergency room is the portal to the hospital by providing a large percentage of its admissions. The down side from an economic viewpoint is that vast numbers of uninsured and underinsured use the ER as their primary care physician. The District Board can, and should, assist Sharp in identifying how additional personnel and additional facilities can be employed. The Board deserves credit for this year having mailed to all addresses within the District a complete listing of the many urgent care providers available to them.”
Both Emerson and Ayres cited the creation of 90 more ER beds under the bond issue they’re administering and say that will alleviate but not eliminate the crunch. Emerson and Knutson both said one way to ease the demand on Grossmont’s ER would be to create a network of community clinics in East County that could better handle people who come to the ER now but don’t have a real emergency. Hammerstrand suggested that the hospital require patients who are coming to the ER for primary care to make an appointment in advance, so the ER’s facilities will be open for people who are really having emergencies. McElravy said that the ER’s problems, like the quality of patient care, are Sharp’s responsibility — not the district board’s.
For Whalen, Sharp Grossmont’s ER policies — particularly their turning over unpaid ER bills to collection agencies — are yet another example of how the privatized hospital has given up on the ethos of public service it had when it was publicly run. Uninsured ER patients “should not be charged full price,” Whalen said. “Ninety percent of the charges are from Medicare or Medi-Cal. If you don’t have insurance, the hospital will charge you full price. By state law they can only charge what they would charge HMO’s [health maintenance organizations], but a lot of patients don’t know that and think they have to pay the full price.”
McMillan combined her answer to the emergency room question with her response to another on ECM’s list: what the effect of the $716 billion cutback in Medicare reimbursements to care providers and insurance companies under the Affordable Care Act — so-called “Obamacare” — may be on Grossmont Hospital and what the candidates propose to do about it. “Insuring that all residents have access to effective medical care,” McMillan responded. “The Board must place more emphasis on a more efficient method of handling emergencies and those wanting to enter the emergency room. By this, I support a triage method of quickly ascertaining the needs of the patient, then sending them to the correct area for help.” She joined Emerson and Knutson in suggesting the district needs outpatient “facilities” as an alternative to ER care for uninsured or underinsured patients.
Stieringer said the answer to the Obamacare cutback question “will not be known until the fate of Obamacare is determined by the courts or a new President takes office on January 20. However, I’m willing to venture a guess. The $716 billion taken from Medicare would purportedly be used to supplement Medicaid (known in California as ‘Medi-Cal’) and to subsidize the ‘Health Exchanges’ which most states are creating and help pay for the ‘Individual Mandate’ under which everyone is required to carry health insurance. Theoretically it would be a zero-sum game whereby hospitals and other providers would lose on the reduced Medicare reimbursement but gain it back on fewer charity cases. The real problem occurs in 2018 when the government subsidy for the ‘Health Exchanges’ expires. At that time the states will assume full responsibility for the cost of the exchanges. Of course, every state will then be bankrupted and the Congress will again have to step in.”
McElravy had this to say. “The Affordable Care Act will hold hospitals more accountable for the quality of services. While the Act is still in the evolution state, it would be premature and inappropriate to speculate [on] the specific costs to Grossmont Hospital and what their strategy would be to make up, or recover, any loss of revenue. Be assured that the Health Care District Board will be monitoring those activities to ensure that East County residents are treated fairly.”
The other incumbents said that any cutbacks would be Sharp’s problem, not theirs. “The due diligence of any cutback in reimbursements would be handled by the hospital’s financial threat assessment team, and therefore I would not be able to discuss any financial plans the system has regarding the Affordable Care act at this time,” said Emerson.
“The District, under the terms and conditions of its lease with Sharp Health Care, does not have any control over how the Affordable Care Act revenues will be allocated,” Ayres said. “This is to be managed by Sharp Health Care and will become a focal point as the act is implemented.”
Like Stieringer, Hammerstrand said, “It’s conjecture whether there’s going to be a cut because we don’t know who will win the election. We have a $50 million emergency fund and our CEO, Barry Jantz, and the board will debate what direction we would take so we have a met health care need.”
“Some doctors are already not taking Medicare patients because of the reductions in reimbursements,” Knutson said. “The district receives $6 million in revenue, and only $1 million goes to Grossmont Hospital. They’re paying $300,000 to a part-time attorney who only meets with them twice a month.”
Unlike the other candidates, Whalen supports the $716 billion cutback in Medicare reimbursements under the Affordable Care Act. He thinks that money has been wasted all along. “Right now,” he explained, “you have people on Medicare who sign up with insurance companies or HMO’s for supplemental insurance. The government pays extra money to these companies to manage the patients and get them preventative care. Through Obamacare, the government wants to eliminate the middlemen who are paid more per person than Medicare would pay directly to the hospital. If there’s a slight effect at the hospital, it’s going to be made up by 45 million more people having insurance and going to hospitals.”
Whalen added that individual doctors, unlike hospitals, may directly feel the effects from the Obamacare reductions in Medicare reimbursements — but according to him, they should. “They all make a lot of money,” he said. “Kaiser doesn’t pay their family practitioners $200,000 per year. I would pay them $60,000 in the 1990’s. If doctors get cut back a little, it’s long overdue. Hospitals and doctors are crying wolf.”
Endorsers and Visions
A number of the candidates have secured high-powered endorsements from East County political leaders. Stieringer and Ayres are both endorsed by State Senator Joel Anderson. County Supervisor Dianne Jacob has endorsed both Ayres and Knutson. La Mesa City Councilmember Ernie Erwin has endorsed Ayres, and Lemon Grove City Councilmember and Assembly candidate Mary England has endorsed Knutson. Also on Knutson’s endorser list are Edwin Meese III, former County Supervisor George Bailey, and at least one Democrat, East County activist Jo Anne Boyle.
Other candidates reject the whole idea of endorsements. “To ensure objectiveness in all my decisions, I have not gone after special-interest endorsers,” McMillan said.
“I haven’t asked for anybody to endorse me,” said Whalen. “I’m doing it the old-fashioned way, going door to door.” In fact, Whalen is doing it in such an old-fashioned way he doesn’t have an e-mail address. “I have people who would give me all the money I would ask for, but I’m too proud to ask,” he added. “Dianne Jacob isn’t going to endorse me.”
Hammerstrand said his endorsers are “myself, relatives and friends. I’m a low-keyed candidate putting out business cards and walking precincts to let people know I’m out here as a long shot.”
The candidates’ overall philosophies are as varied as their attitudes towards endorsements. The incumbents, and the more “establishment” challengers like McMillan and Stieringer, see service on the Grossmont Health Care District board as mainly a bureaucratic exercise, watching but doing little to interfere with the private company that leases Grossmont Hospital and will continue to run it for at least the next nine years.
Others in the race have a broader vision. Hammerstrand says the most important public health issue in East County — along with fluoridation of drinking water, which he strongly opposes — is “the unmet health care needs in our community,” particularly providing good, affordable health care for traditionally underserved populations. “There’s always unmet needs for ethnic groups in San Diego — poor Blacks, Hispanics and whites — and others that barely survive and make a living.”
Whalen sees the big issue as the decline in public service and simple compassion at Grossmont Hospital since it got turned over to Sharp 21 years ago. “When I was at Alvarado, I would never take someone’s home or car to pay an unpaid medical bill,” he said. “Those days are gone forever. I saw a woman with a growth on her neck who got a $4,000 bill from Alvarado, and they took it out of her little paycheck for years. I don’t see [Grossmont Hospital and the Grossmont Health Care Board] doing much for the poor, and that’s where they should focus. With the recession, construction in East County is down 50 percent and a lot of people are uninsured.”