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Poitier isn't the only one to raise the specter of record-keeping irregularities. Says John Aldrich: "I've seen people sit with stacks of records falsifying visits," inserting information that wasn't true, sometimes even to the point of asserting that clients had come to the center for appointments when no such documentation existed.
During the HOPWA crisis, when dozens of desperate Family Health Center clients sought help from the People with AIDS Coalition (PWAC), that group complained to the City of Miami and the U.S. Department of Housing and Urban Development (HUD), which funds the HOPWA program. PWAC administrators also took affidavits from several clients who asserted they'd been required by Family Health Center caseworkers to sign undated forms indicating they'd received services they had not yet received but ostensibly expected to in the future. (The complaints lodged by PWAC, which also accused the city of mismanagement and lack of oversight of the HOPWA program, have so far gone unanswered, according to Luke Balboa, PWAC's executive director.)
Similar allegations arose again in July, in a report authored by the Metro-Dade Audit and Management Services Department, which allocates federal Ryan White Title I AIDS funding -- a source distinct from HOPWA -- to local organizations. Family Health Center received almost $1.9 million in Title I money this past fiscal year.
The audit revealed a pattern of record-keeping errors and omissions, including instance after instance in which the center was reimbursed for services that hadn't been documented. In one case the agency billed the county for three days of day care for a child who was absent from the day-care facility on those days. Some files showed the converse -- that services had been provided but not billed for. Among other irregularities: Professional licenses and certifications were missing from some staff files; several client files contained signed blank forms; several clients apparently received more assistance than they were legally entitled to; and most client files lacked at least some paperwork required for Title I funding, including patients' proof of eligibility.
"There are systemic problems, and they have begun to address them," says Audit and Management's Dan Wall. "There are still some other specific issues we're going through with them." Wall says he expects to work with the center for another few weeks to correct the problems and make adjustments. "If things aren't able to be sufficiently documented," he adds, "then we would disallow payments [to make up the difference next year]." In any event, the center's Title I funding will be reduced for the coming year, by at least fifteen percent. Among the factors that prompted the reduction, according to Wall: "Past performance."
Family Health Center responded in writing to each of the problems raised in the 1995 financial audit: "Management concurs with this finding and will implement the necessary procedures in accordance with the recommendation." As to the allegations made by clients and former staffers regarding record keeping, Trice contends, "If people are saying we falsified records, that would go against the grain of what this agency is all about. We're all human and subject to making mistakes, and there may have been some mistakes made, but to intentionally falsify records -- if that was brought to our attention, whoever the culprit was would not be here."
Frankie Swain says one case manager was responsible for most of the mistakes found in the patient files reviewed by Audit and Management and has been fired, and that much of the missing documentation cited in the audit report was actually recorded but not placed in the files that were inspected by the audit team.
About 80 percent of Family Health Center's $20 million annual budget is supplied through federal grants; the rest consists mostly of revenue from patient fees and Medicaid payments -- reimbursements from the government for each Medicaid patient seen by a health-care provider.
Along with federal support come the inevitable rules and requirements, chief among them the mandate to serve people who can't pay.
This is a growing problem for every one of the 850 federally funded clinics nationwide. All of Dade's five community health centers are grappling with unprecedented external challenges to their own well-being. While the amount of funding the agencies receive for primary health care -- basic medical and dental services -- has remained stable over the past several years, other factors have made operating more expensive.
Public-health experts say the proliferation of private health maintenance organizations (HMOs) may pose the biggest threat. HMOs are in direct competition for Medicaid patients, who now represent attractive revenue, thanks to recent changes in federal law that allow higher reimbursement rates. Coincidentally, the number of uninsured (and therefore unprofitable) patients is growing. "There's a lot of pressure at health centers to come up with the money to expand services so the uninsured can be taken care of," explains Yvonne Bice, spokeswoman for the National Association of Community Health Centers. "But the grants they get from the federal government have been flat for a number of years. So that's a struggle -- when you're looking at most of your patients with either Medicaid or no insurance at all. And you have to have a funding source."