This past March, Robert Blake, the University of Miami Medical School's general counsel, chastised Michael Kosnitzky, who sits on the board of the Public Health Trust. Kosnitzky was just asking too many damned questions about how UM was going to spend the roughly $65 million the PHT pays it to run Jackson Memorial Hospital.
In the past the relationship between the two has always been cozy and trusting. The PHT is an independent county agency with a $1.3 billion budget and a mandate to provide free medical care to the county's poor and uninsured through Jackson and its affiliates. It pays UM to staff Jackson with doctors who supervise an army of interns and residents. Kosnitzky was hell-bent on getting a breakdown of the money the PHT paid the UM doctors. He wanted to make sure taxpayers were getting "fair market value." Clearly UM was not used to this kind of grilling from Kosnitzky, and Blake said so.
"Actually, you're causing pain at the University of Miami through this public debate," Blake scolded the PHT board member, adding that this might bring unwanted attention from the state legislature. "At some point in time, we will come forward [with this information]. We ask that it be delayed until after this legislative session. The University of Miami is not attempting to hide things."
Blake should be choking on those words now. Even as he spoke them, the county's Office of the Inspector General had launched an investigation that indicated the hospital could sometimes be creative about disregarding its own rules, and wasn't exactly forthcoming when it did so. Back on July 21, 2000, JMH allowed a Cuban man living in Guatemala to be flown to the hospital and treated for serious burns suffered in a propane gas explosion, even though he was uninsured and had no money for a deposit, which hospital policy required for nonresidents. Selfish as it may sound, the free care that Jackson dispenses to the poor and uninsured is meant for county residents only. The names of Dr. Gerald Kaiser, senior vice president of medical affairs, and Ira Clark, president of JMH at the time, were on the document accepting the victim as a patient. Clark even sent a letter to the Guatemalan Consulate on behalf of the patient.
Just over eight months later, on April 4, 2001, the man died. Total cost to taxpayers -- $2.6 million. But the hospital never saw fit to inform the board, which goes a long way to explaining why the hospital shows a deficit of $7.4 million for last year.
After the patient's death, JMH administrators filed paperwork seeking Medicaid benefits and gave a Miami-Dade address for the patient. Although the address belonged to a relative, the dead man "had never been to the United States prior to his hospitalization," the OIG report states. "In an effort to obtain Medicaid benefits ... JMH misstated the facts concerning his residency." The hospital was eventually reimbursed $66,923. Given that this is potentially Medicaid fraud, the case has been referred to the State Attorney's Office.
Kosnitzky, it seems, was right to try and squeeze some accountability from the staff of JMH and UM.
Jackson spokeswoman Conchita Ruiz-Topinka has said that Clark waived the hospital's rules after getting a call from an aide to county Mayor Alex Penelas. Penelas spokeswoman Lynn Norman-Teck said Penelas had never heard of the patient and was not involved in placing him in the hospital. She said it was likely advocates for the victim called the mayor's office and someone handling constituent services in turn phoned the hospital.
"The Mayor's office, who had been contacted by a third party, called and asked us to review the case," Ruiz-Topinka wrote in a memo to board members. "This patient was accepted by JMH for humanitarian reasons. When the decision to admit ... was made, doctors felt a transfer could save the man's life. ... Because of the tertiary nature of the medical care we provide, we are sometimes asked to review cases either by family, elected officials or other members of the community."
It's not the first time Clark has bent to what was at least perceived as a politician's will. At the request of former county commissioner Bruce Kaplan, Clark admitted half a dozen Bolivian patients to JMH for treatment at taxpayer expense in 1996 and 1997. Kaplan, a lawyer, had clients in that country and was also exploring business ventures there. In 1997, Clark told New Times he felt the need to respond to the commissioner's requests: "I have to get along with the commission. They own me. They own this hospital."
JMH should be able to override its rules on who it can admit in order to save lives. But it should be up-front about it with its board and the public. The Cuban-Guatemalan burn victim's stay at JMH was never mentioned to the PHT board of directors, nor was the OIG investigation, even though Ira Clark received a draft copy of the OIG report on April 23.
Instead board members received a hurried memo from Ruiz-Topinka May 6 warning them that a newspaper article was imminent the day before the Herald published a story. Kosnitzky then got off his own memo asking why "this deviation from the Trust's policy was not disclosed to the board either before, during or after the event," and "why, after being advised by the Inspector General of an investigation into this matter, the board was still not advised."
All of this brings us back to Kosnitzky and his questions. Kosnitzky was reduced to filing a public records request to the PHT staff to find "any public record relating to the calculation of the stipend allocated to each University of Miami faculty member" for the last two years. He was told that "there are no such records."
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"The staff has refused to provide most of the information necessary to perform this analysis, and has also refused to provide other information in a format that Trustees can understand," he wrote in another searing May 6 memo. In light of the OIG investigation, Kosnitzky's next line speaks for itself. "One must also ask whether staff is properly representing the interests of the Trust, the County, and, ultimately, the taxpayers, given the refusal to provide this information."
Kosnitzky has his work cut out for him. At this point it's instinct for mammoth bureaucracies like the county government and Jackson, and a secretive entity like UM, to resist inquiry into how they operate. They're churlish by nature. And here we have three layers.
The only question is, how long can we afford to wait to change this?