DIRECTOR—Boarding Disaster

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Next County Health Director to Face Daunting Tasks

It’s the job from hell.

The director of the county’s $2.6 billion Department of Health Services heads a bureaucratic mess of an agency about to lose a massive amount of funding. Giant cuts need to be made, but at the same time, patient access to care must be dramatically increased. If that’s not enough pressure, the director has a meddlesome board of supervisors second-guessing and criticizing him every step of the way.


Any takers?

The position will become vacant June 30, when Mark Finucane leaves the post that he has held for the past five years. But filling it may be a very difficult task, despite the fat paycheck it garners. “It’s an impossible job working for a thankless group of five politicians with inadequate funds operating a system that is bureaucratized and unionized,” said Dr. Brian Johnston, who sits on both a department advisory panel and the board of the California Medical Association. “It’s not a job I am going to apply for.” Finucane, who earns $241,062 annually, is leaving at a critical time as the department attempts to carry out a plan aimed at weaning itself off a federal waiver that allows it to be paid $900 million over five years for outpatient care. The Medicaid funds, which would normally reimburse only hospital stays, slowly diminish and then dry up in the 2004-2005 fiscal year, hence the projected deficit. The waiver, secured Jan. 16, is the second the county has received since 1995, but federal officials have vowed it will be the last. The department is facing a future projected annual deficit of $500 million or more as it is called upon to make its services more accessible to the county’s 2.7 million or so uninsured residents. Meanwhile, energy purchases are eating up potential health dollars in Sacramento, while a Republican who has so far not shown himself sensitive to California’s needs occupies the White House. And that’s not to mention rising health care costs, and a Board of Supervisors who, according to critics, are more interested in protecting their political turf than making the hard decisions necessary to right the system. “We can’t revenue our way out of it. We can’t cut our way out of it. We can’t hide our way out of it. It’s a very, very daunting task, but it’s possible,” said Finucane. “I think there will be a lot of applicants, but I think the board will end up with only a small group of qualified people.”


Tough to fill

So who would want a job like this one that seems predestined to failure and possibly public humiliation and ridicule?

Norman Roberts, vice president of the executive search practice for DMG-Maximus, has led many county executive searches, including the one for Finucane. He acknowledges that search was a tough one, and this one won’t be easier. “It was not a great cast of characters that lined up for the job when Mark (Finucane) took it. I know the board was glad to get him,” said Roberts, who sold his firm Norman Roberts & Associates to his current employer. “You need a risk-taker who has tremendous self confidence. You need somebody who has worked on a large scale, yet this would be a step up. There are probably a dozen people in the country equal to the task, if you limit (the search) to the public sector.” The search is also bound to be complicated by the fact that the Board of Supervisors has had a history of upbraiding Finucane in public, though even critics have felt he did about the best he could under the circumstances. It was even worse for his predecessor Robert C. Gates, who passed out after one particularly grueling session with the board. “The department has just become more and more difficult (to manage), not only because of the expectations but (also because of the) lack of resources,” Roberts said. But while there is general agreement that the job presents far-reaching challenges, not everyone agrees that there will be few qualified takers, especially county supervisors. Third District Supervisor Zev Yaroslavsky said critics like Johnston who believe the job will be a tough fill don’t give credit to the progress the county has made over the past five years. Finucane took the job just after the county secured its first five-year federal waiver, all while teetering on the edge of bankruptcy and facing the total collapse of the health care system. “We stabilized the system. There are going to be a lot of (qualified) people interested in this job,” Yaroslavsky said. “It’s a challenge, there is no question about it. But if you are in the public health field, this is one of the top if not the top job in the United States.” The supervisor added that intermediaries for “very credible” people interested in the job have already called him, but he would not be more specific. Yaroslavsky was joined in his optimism by Second District Supervisor Yvonne Brathwaite Burke. “Today, most hospitals are in (a fiscal) crisis, so there are an awful lot of people looking for moves and places to go,” she said. “If they do (this job) successfully, they will come out with quite a reputation.”

Finucane, former director of Contra Costa County’s health department, said he is not leaving the job because he concluded it is a hopeless task. Rather, the county had recently secured its second Medicaid waiver and it is time to move on and leave the next set of challenges to a fresh face, he said. The county’s strategic plan calls for reducing the department’s projected shortfall by seeking other funding, and closing any remaining gap by eliminating positions, outsourcing various services and increasing efficiency the latter potentially by radically restructuring the department. “It’s a very demanding job. In the beginning, it was upwards of 70 hours per week, but then it toned down to 50,” Finucane said. “Intellectually, it’s very satisfying; you grapple with virtually every health care issue. But you are constantly on duty. It got to the point where I had done it long enough.”


Impossible task?

Finucane has agreed to stay on past June 30 in a consulting role, if necessary to assist his successor. But the differences among stakeholders are so vast that some don’t believe the county should even make a permanent appointment. Dr. William J. French, director of a cardiac lab at Harbor-UCLA Medical Center, sat on a blue ribbon task force that last fall recommended supervisors consider restructuring the department, possibly replacing it with a health authority or public benefit corporation. He believes an interim director is in order while the supervisors further study the possibility of instituting a new governing structure. “The only solution is to change the governance. That is the only way the health system is going to work better,” said French. Such a governing structure would both free the health system from the larger county bureaucracy something Finucane said was a constant irritant for him and would insulate the department’s decision making from political forces. Others assert that while “re-engineering” the department (as the current lingo goes) could certainly eke out greater efficiencies any effort that relies on cost-cutting is doomed to failure. Dr. Angela Nossett is president of the Joint Council of Interns and Residents, which represents 1,600 interns and resident physicians. She said there already has been too much of a “slash and burn” mentality. She recalled an incident last year in which she ordered an ultrasound of a patient’s carotid artery, standard protocol for someone exhibiting signs of a stroke. It took days for overworked technicians to perform the procedure. “She shouldn’t have had to stay more than 72 hours, but in recent years we have cut so many positions it ended up being a costly week-and-a-half hospital stay,” she said. “The ultrasound was negative. If we had additional money up front and had an additional tech, we would have saved it in the long run.” Barbara Pulley also wonders where any new director would cut services. She is senior vice president at QueensCare, which operates six outpatient clinics as part of a public-private partnership established last decade to treat more indigent patients outside of costly county hospitals. She agrees there is simply not enough funding in the system, and that Finucane’s successor may find additional cuts an impossible job. “Cutting costs? That’s the $64,000 question, but in the case of Los Angeles County, it’s probably the multimillion-dollar question,” she said. “It’s what everybody is grappling with, and I don’t think there is a single answer to it.”

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