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From his law office on the 28th floor of a downtown high-rise, Michael Kosnitzky, cigar clenched in one hand, is poring over last year's Annual Operating Agreement between the Public Health Trust (PHT) and University of Miami. The county-run PHT gave UM's School of Medicine approximately $70 million in taxpayer money last year to, among other things, pay their doctors to treat the county's poor and uninsured. Kosnitzky thumbs through the pages.
"Look, here it is," he says, pointing to a line item in the contract titled: Dean's Indirect Clinical Support -- $4 million. "That's all there is. What does that mean? I even asked [UM] what it was and they told me no details existed. They just have these lump sums. You can't audit a line item like that!"
Kosnitzky, the PHT's recently ousted chairman (he remains on the board), will eagerly point to dozens of similarly vague items in the contract. And he will eagerly share his thesis: That the PHT, which spends $1.3 billion annually to run Jackson Memorial Hospital and its associated facilities, has an uncomfortably cozy relationship with its biggest vendor, the University of Miami's medical school. More than that, he says, "The vendee [PHT] is controlled by the vendor [UM]." That topsy-turvy situation exists, he asserts, because several UM sympathizers sit on the PHT's 21-member board of trustees; two members, in fact, sat on both the PHT and UM's boards until recently.
Kosnitzky has been quite public in his criticisms, and that hasn't won him many friends. "He has completely embarrassed the board with his antics," says former PHT board member Joe Arriola, now Miami city manager. "What Michael Kosnitzky has done is not a service; it's a personal vendetta." Arriola claims that Kosnitzky has targeted UM's contract with the PHT because university forces would not support him when he was fighting to save his chairmanship. "He said, 'If UM doesn't support me to stay on as chairman I'll come after UM,'" Arriola asserts, quickly adding that he's all for more public scrutiny of the budget process, he just objects to "the way [Kosnitzky] went about it."
As happens with distressing regularity in this town, public policy is being forged amid clashing personalities. In this case, however, the public will benefit. I don't even care that this episode has devolved into name-calling and other puerile antics (Arriola branded Kosnitzky a "cancer" at a public meeting). Kosnitzky's kvetching has prompted significant changes in a powerful public agency. "I'm not a gadfly or a malcontent," he insists. "I just wanted to see the information."
His timing could not have been better. The PHT is beginning to negotiate next year's contract with UM, and may approve it as early as next month. The university is seeking an increase of roughly six million dollars. Also on the horizon, the PHT is launching a search for a new president after the messy termination of fifteen-year veteran Ira Clark. The search could be completed by summer. With nearly half a million uninsured people in Miami-Dade County, vast numbers of whom rely on Jackson for their primary healthcare, a lot is at stake.
It's not as though the hospital is functioning without problems: Last year Jackson ran a deficit of about seven million dollars; acquisition of supplies is hampered by bureaucratic bottlenecks, and complaints continue that the PHT concentrates on Jackson to the detriment of poor people in other parts of the county who don't have adequate healthcare.
One can understand why UM and the PHT are so secretive. They sit on a lot of money -- roughly $220 million annually from a half-penny sales tax and a portion of property taxes, more than $400 million from insured patients, and $600 million from Medicaid patients. The PHT board sees itself as the guardian of that cash, but the wolves are at the door. In 2000 the state legislature came close to taking control of the PHT's tax money and diverting it to other needs. Private hospitals in Miami-Dade have argued they deserve some of it because they too must treat indigent patients. No surprise, then, that the PHT is distrustful of outsiders butting into its business.
"I recognized the need for reform a year after I joined," Kosnitzky says, "but I realized they don't allow people to rise there unless they are team players." The 44-year-old lawyer and CPA says he spent a quiet five years noting what needed to change. In his view, the problems started at the top. PHT president Clark's notorious arrogance alienated people in the healthcare industry. "He has not spent a lot of time and energy working with his colleagues," notes Linda Quick, a frequent Clark critic and president of the South Florida Hospital and Healthcare Association, a coalition of private hospitals.
Similar complaints were heard from the county commission, which oversees the PHT, and even from UM and PHT board members. So when Kosnitzky became board chairman a year ago he engineered Clark's departure with the support of UM medical school dean Dr. John Clarkson and UM president Donna Shalala. But Arriola says Kosnitzky botched the episode. It was supposed to be a smooth transition and instead it became heated and racially divisive when Clark, who is black, fought to keep his job.
With Clark out of the picture, Kosnitzky's next struggle was to keep UM interests from muscling in on the selection of a new president. "I want someone who can be independent and stand up to the university," he says. The battle over the makeup of the selection committee cost him his chairmanship, he maintains, not some fictional personal vendetta.
It hardly matters. Turning Kosnitzky into a lame-duck chairman was the best thing that could have happened. He found himself with little time left to address important issues, so he went gunning for change. Rat-a-tat-tat he called for an independent audit of the PHT-UM contract. He demanded greater transparency. He wanted trust meetings televised. He pushed for Jackson to provide space for the county's Office of the Inspector General, which, among other things, reviews contracts and looks for waste and mismanagement. PHT trustees initially voted down all these initiatives.
But despite rejection and loss of his chairmanship, Kosnitzky's blitzkrieg has paid off. Change is coming.
The Office of the Inspector General was eventually approved to set up shop at Jackson. (It could be operating there in a few months.) Miami-Dade Manager Steve Shiver ordered a county audit of the PHT. Two weeks ago county Commissioner Dorrin Rolle introduced for consideration an ordinance directing the trust to create an internal auditor. Last week the first PHT meeting ever was taped for broadcast on public access television. The cantankerous Arriola has resigned from both the UM and PHT boards of trustees. But most emblematic of the new atmosphere is this year's proposed Annual Operating Agreement with UM. "It's the most detail we've received from them -- ever," notes Linda Quick.
After Kosnitzky has reviewed the contract with me in his office, I get up to leave. "This just came in -- you want this?" he asks, holding a draft of the new contract with UM. "I haven't even had time to look at it."
He may not be happy with the entire document, but at least on page twelve there's an analysis of the Dean's Indirect Clinical Support, the four-million-dollar mystery item that had him stumped. Kosnitzky is beginning to get his answers.