MARK FINUCANE — Curing Health

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Mark Finucane, head of the county health department, was the point man in securing a federal waiver to keep the system going. Does he have a long-range remedy?

Mark Finucane’s nearly five-year tenure as director of Los Angeles County’s Health Services Department has been a roller-coaster ride of emotional highs and lows.

His most recent high was successfully negotiating a waiver of federal Medicaid rules for outpatient treatment that will pump an additional $1.2 billion in state and federal funds into the county health department’s budget. The money will help the county provide more outpatient clinical services and keep its health care system afloat for the next five years. Now his job is to figure out how to survive when the funds dry up.

The lows have come during the long periods of negotiating with state and federal officials, and the stress that comes with not knowing whether the money will be there to keep the county system afloat.

Finucane came to Los Angeles in early 1996 from Contra Costa County, where he was the health services chief. He now heads up the second largest public health system in the nation, with an annual operating budget of $2.6 billion, nearly 23,000 employees, six county hospitals, six comprehensive health centers, and 39 clinics.

He lives in South Pasadena with his wife Laurie and their two daughters.


Question: How difficult was it to negotiate the waiver with the federal government?

Answer: I was not present at the first negotiations (five years ago). But I heard a lot about it and came to work in L.A. shortly after the first one was done. They were both very difficult, and not because people were trying to deny services to poor people. But you have a complicated problem to begin with and three branches of government involved in the negotiations. Everyone wants to be comfortable when they walk away from the negotiating table that they did their job. Add to this the complexity of today’s health care industry and the fact that when you negotiate something for a five-year period, you are trying to predict the future. It was very intense.


Q: Was there any time you thought the county would not get the waiver?

A: No, I always thought the county would be granted a waiver. What I feared was, the county would be granted a brief one and one that was not helpful from a restructuring and reform standpoint.


Q: If you had gotten a waiver for one year, how would that have affected the county’s health services?

A: What would have happened is that the Board of Supervisors and the Chief Administrative Officer would have used the year to petition a new (federal) administration for the remaining four years (of the waiver). But that would have been a tough assignment. With a new administration you have to wait for new appointees, so it would have taken a year to establish relationships to make our case with the new officials.


Q: How is the county health department going to become financially independent from the Medicaid waiver funds?

A: At the end of the five-year period, the department will no longer get these Medicaid waiver funds. That does not mean we will not get other federal revenues during the next five-year periods. We will get paid our outpatient (clinic) costs. That is one of the conditions of the waiver. The policy objective in the waiver was to get better payment (from the federal government) for outpatient care and change the way we got paid for inpatient care.


Q: How is the county going to fund health care services for the working poor who do not have Medi-Cal, can’t afford insurance and turn to county hospitals and clinics for medical visits?

A: We have to use this period to work on it and point out to the federal government that the indigent population continues to grow, and there is no comprehensive solution to it. This period has to be used to attack that problem on the state and federal level.


Q: What do you think of county Supervisor Mike Antonovich’s recent motion that the entire county health department be audited?

A: I welcome it. We are audited regularly by the state and federal governments. I know Mike is interested in making sure we stay on track with the waiver.


Q: If you are already audited by the state and federal government, wouldn’t it be redundant to have another audit by the county?

A: Under the county, we are audited for different things. What Mike is interested in is that we maintain a policy that keeps faith with the tenets of the waiver.


Q: Antonovich has also called for a reduction in the county health department’s staff. What do you think of that?

A: The gist of it is that the Board of Supervisors wants us to get ready for the end of this waiver. We negotiated this second waiver and now our job is to prepare for its disappearance. Sometimes that will mean making some reductions. It is the nature of the health care industry in general. We are committed to reducing by $91 million our expenditures over the next five years. Over the last five years, our staff has been reduced by 15.2 percent and we’ve reduced hospital costs at three times the national average. We reduced our emergency room activity by 27 percent over five years. We have been managing with fewer resources for a very long time.


Q: You came on board as head of the county health department in early 1996, during a difficult time. Do you ever regret it?

A: There is no question it is a hard job, but I don’t regret making the decision. The reason I deal with all this scrutiny and pressure is that it is a job that holds a lot of potential for doing a lot of good for a lot of people. We’ve started an office of women’s health care that gave free pap smears for 2,000 women who had never received a pap smear. If you happen to be sitting on top of a department that can do that kind of work, the satisfaction offsets the frustration. But the frustration is very great. It is a very big bureaucracy.

When I first came to work in L.A., there was a great degree of skepticism about whether the changes were really going to occur. That is one of the reasons I pushed for seeking a five-year waiver, not a two- or three-year waiver to show that the changes are permanent and we will not return to the system we had before.


Q: You spent a long time working in Northern California. Did you grow up there?

A: No, I grew up in New Jersey. I went to school at Wichita State University and Trinity College in Dublin, Ireland. I had a longtime interest in Irish literature. I’m half Irish and half Italian. I was there for a year and I had a great time over there. I returned and finished my studies in Kansas.

I was on my way to being an attorney when health care presented itself as a career in 1977. There was a health director from Wichita, Dr. Merv Silverman, who became the health director in San Francisco. He asked if I wanted to go to San Francisco with him as his executive assistant. Three months later, I called the dean of admissions at Washburn University in Topeka, Kan. and said I’m sticking with health care. I’ve never regretted it. I’ve been in California for 23 years.


Q: What’s a typical day like at work?

A: I like to say my office is where my mail goes, not where my job is. I get into my office at 8:30 to 9:15 in the morning. The first three and a half years down here I was without my family. That allowed me to work 60 hours a week and steep myself in the health department and do it without feeling guilty. I flew home every weekend. I was able to orient myself toward the whole department. As a result, I am more economical in the use of my time. My daughter kids me on how many meetings I have. There is a lot of paperwork associated with it, but my primary job is not just management but leadership responsibility to the department.


Q: What do you do to wind down from your intensive job?

A: I cook. You name it, I cook it. I’m a good cook. I do all the food shopping. I have a lot of cookbooks, at least 30. You know how some people have hobbies or a workshop? Well, the kitchen is my workshop. When we were looking for a house in South Pasadena, I looked immediately at the kitchen. I also read a lot, from fiction to fact. And I listen to music.

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