MDs Unite with Community to Reinstate Medical Leadership of District Hospital

February 12, 2017

Corporate attempts to silence physicians fails

Physicians at Tulare Regional Medical Center rally to demand the administration reinstate the lawfully elected Medical Executive Committee. From left to right: Drs. Lonnie Smith, Prem Kamboj, Assit Shah, Isvan Potorke, Susan Haack, and Robert Orth

Physicians Organizing Committee (POC) members and other physician leaders from the Tulare Regional Medical Center (TRMC) organized with community residents this summer to win the first round in the battle to reinstate the illegally deposed Medical Executive Committee (MEC) and save their hospital. Defying a gag order imposed earlier this year by the hospital management corporation, Health Care Conglomerate Associates (HCCA), which threatened to revoke the admitting privileges of any physician who publicly criticized the hospital, the physicians organized a white coat rally on July 25 directly across the street from the hospital.

The rally attracted a crowd of over 70 physicians, nurses, health district residents and community activists.  Speaking from the platform of a flatbed truck with a sound system, POC TRMC member physicians took the lead and issued a call for reinstatement of the lawfully elected Medical Executive Committee. At a community forum the following week, physicians spoke passionately with over 100 residents in attendance about the patient care consequences of a hospital operating without an independent medical staff.

At the August 3 community forum, the doctors circulated a petition inspired by the Coalition to Save Tulare Hospital demanding the California Department of Public Health (CDPH) suspend the license of the hospital if they do not reinstate the lawfully elected Medical Executive Committee. The CDPH is responsible under state law to ensure hospitals, as a condition of licensure,  have an independent, self-governing medical staff that selects and removes medical staff officers and adopts medical staff bylaws. The petition from the Coalition to Save Tulare Hospital — an organization of doctors, nurses, business owners, community activists and other health district residents — claims the hospital board violated this requirement when they chose to terminate the medical staff and its officers, and impose their own MEC and bylaws.

“They claimed the new bylaws gave them the right to censure us and revoke our admitting privileges if we criticized the hospital,” noted past Chief of Staff and POC member Lonnie Smith, M.D. “If we can’t vote for our medical leadership, we have no voice in how the hospital addresses quality of care issues.”

Rash of patient deaths add urgency

A rash of four tragic patient deaths in September added urgency to the doctors’ demand that the administration restore medical oversight of quality of care at the hospital by the lawful MEC without administrative interference.

These deaths occurred after HCCA had terminated 29 employees at the hospital that same week, including nurses, medical assistants and others with patient care responsibilities, along with key people in the hospital’s lab and pharmacy, including some of the most experienced staff who had been at the Tulare hospital for as long as 20, 30 and 40 years. These reductions resulted in staffing shortages in all affected departments, which statistically increases the incidence of negative patient outcomes.

Former Chief of Staff prevails over illegal attempt to silence him

On February 16, Abraham Betre, D.O., M.D., Chief of Staff at the time of the HCCA-led ouster of the lawfully elected MEC, applied for a temporary restraining order (TRO) to stop the administration from installing their own MEC. He warned that cases of improper care that the elected MEC was reviewing against three physicians on staff at the hospital would probably be dropped by the administration’s MEC, leaving patients vulnerable to substandard care.  The three doctors named in Betre’s TRO as being under review, sued him for supposed invasion of privacy, intentional interference with prospective economic relations and unfair business practices. Although Tulare County Superior Judge David Mathis denied Dr. Betre’s request for a TRO, he stated in his decision that the suit against Betre was based on “speculative and unsupported allegations” and that it was an attempt to silence Betre, which is known as a SLAPP (Strategic Lawsuit Against Public Participation) suit, i.e. it was strictly retaliatory, not based in fact.

Ten Health District residents filed a lawsuit against the Tulare Local Health Care District Board, HCCA, Benny Benzeevi, M.D. and Rebecca Zulim, M.D., and the Hospital Board, which had allocated over $98,000 of health district funds to pursue a private civil case against Dr. Betre on behalf of Drs. Zulim, Kumar and Benzeevi. The residents served the lawsuit in a surprise appearance during the public comment section of the monthly September 28 meeting of the TRHC District Board. At the meeting, Alberto Aguilar also served Parmod Kumar, M.D., with a notice of intent to circulate a petition to recall him from the board.

Community petitions Department of Public Health to intervene

The recent patient deaths underscore the urgency of the doctors’ demands for reinstatement of medical supervision of the hospital led by doctors elected by their peers, instead of doctors appointed by the administration for financial and political gain. The past five chiefs of staff of TRMC are participating in a petition campaign launched by the Coalition to Save TRMC demanding that the California Department of Public Health (DPH) take action, as the hospital continues to operate without an independent self-governing medical staff. In a call with Jean Chiang, District Manager of the California DPH in Bakersfield in September, POC Benefit staff member Nick Teslovich informed her that “Our physician members in Tulare have asked to know what her agency intended to do about the illegal insertion of an illicit administration-appointed MEC at the hospital and its detrimental effect on patient care.” She said her office was aware of what was happening at the hospital, but this issue was not one of urgency.

Despite two site inspections by the federal Centers for Medicare and Medicaid Services (CMS) at the beginning of 2016 detailing problems at the hospital so serious as to cause the agency to threaten to revoke the hospital’s Medicare Provider Agreement, no action has been taken by CMS to correct the hospitals’ failing evaluation results and patients continue to suffer.

In addition to questions of poor quality patient care, several presenters at the August community forum including former hospital board members, a retired city manager, a nurse, physicians and those who had roles overseeing the hospital’s finances, objected to how HCCA had secured a contract which included exor­bitant costs to the community. According to attorney Joseph Soares, speaking at the community forum, the hospital board is represented by Bruce Greene who is also HCCA CEO Benny Benzeevi’s personal attorney and the same attorney who drafted the contract for HCCA to manage the hospital.  Soares showed how the Management Service Agreement (MSA) signed between the hospital board and HCCA on May 29, 2014, nets Benzeevi $3,000,000 per year with an automatic 6% increase and how wording in the contract indicates that HCCA had planned to terminate the MEC before HCCA even got the contract.

At the time of the contract negotiations, the firm of Dooley Pedersen represented TRMC. According to the Visalia Times-Delta, the firm claimed in a November 2015 settlement agreement that severed their relationship representing the hospital, that Benzeevi and HCCA had interfered with their ability to fulfill their contract with TRMC.  After terminating Dooley Pedersen as their legal counsel, the hospital board retained Bruce Greene of the firm Baker and Hostetler, LLP, who was also Benzeevi’s personal attorney.

How did HCCA get the hospital contract?

TRMC is a District Hospital, built and financed through taxes levied upon homeowners in the local health care district and governed by a Health Care Board elected from among residents in the district. However, the May 29, 2014 contract states that the Board shall not interfere, directly or indirectly, with HCCA’s decisions; the Board Members cannot access the Hospital without HCCA’s approval and the Board can’t in any way criticize HCCA’s conduct. Soares concluded by asking, “Who is in control of TRMC?”

According to local dentist Dr. Patricia Drilling, HCCA submitted their bid to manage the hospital in July 2013, after the closure of the bidding window.  HCCA’s bid was accepted even though it was late. Drilling described how TRMC’s Request for Proposals to manage the hospital asked interested parties to submit records of facilities that they had owned or operated; proof of recent and long-term financial operating success; proof of financing to complete the hospital construction and their most recent audited financial statements. Dr. Drilling stated that HCCA was chosen despite having had no prior experience running hospitals, and with no financial background.  HCCA had no record of their experience or financial practice because HCCA did not incorporate to exist as a corporation until two days after the Board chose their bid to run TRMC.

Claims of financial achievements questioned

According to an August 2, 2016 story in the Visalia Times-Delta, although Benzeevi claims to have achieved a significant turnaround in the hospital’s finances, “An examination of the TRMC monthly financial reports and annual audits shows two major factors in Benzeevi’s ‘real-life Cinderella story’.” The financial gains of the hospital are a result of two factors.  First, the ACA increased supplemental payments to hospitals to augment the cost of caring for patients under Medi-Cal and Medicare; secondly, the HCCA that took over personnel functions from the health care district and canceled two hospital employee pension plans and a hospital retiree health plan valued over $1.3 million in 2014. The supplemental payments totaled more than $11.3 million in 2015 and for 2016 will total more than $15 million.

 Hospital requests additional $55 million bond – Voters say ‘NO’

Although the original bond measure to upgrade the hospital with an as yet-to-be completed, seismically fit hospital, passed with an 85% approval rating in 2007, subsequent financial mismanagement detailed in a civil grand jury report “Tower of Shame,” together with HCCA’s refusal to provide an audit as to an accounting of the original $85 million, soured the community’s interest in the hospital’s current request for an additional $55 million this summer. Despite HCCA spending the equivalent of nearly $120 per vote in publicity funds promoting the measure, residents of the district rejected the special mail-in “Bond Measure I” in August by a 66 to 33% margin.

Hospital’s board incumbents vulnerable

Two of the hospital board members, Sherrie Bell and Laura Gadke who were backing Measure I, are up for re-election this year. Criticism of the board for its failure to provide transparency in regard to the original $85 million bond as well as the problems with poor patient care in the wake of the administration terminating the physician leadership at the hospital has community groups, such as the Alliance for Justice and Citizens for Hospital Accountability, backing candidates they hope will be more responsive to the medical needs of the community.  According to Citizens for Hospital Accountability founder Deanne Martin-Soares, R.N., who used to work as a nurse at TRMC, “I had problems with the hospital for a while, but when they terminated the MEC they had gone too far and I had to get active.”

Lack of transparency still at issue

Alberto Aguilar, a member of the Bond Oversight Committee created to oversee the $85 million bond stated, “We want the financing for the new hospital, but we want a transparent board with accountability.” At the August 3 community forum, Aguilar presented copies of his multiple, but futile, requests to the Hospital Board for an audit of the $85 million bond.  He said at the last meeting of the Bond Oversight Committee that the hospital board presented the committee with a three-page report they claimed to suffice as an audit, that concluded however, with the statement, “We are not engaged to, and did not, conduct an audit.” The committee refused to accept this as an audit.

While the suit against the hospital to reinstate the lawfully elected MEC moves slowly forward, POC members in Tulare continue to reach out to the California Department of Public Health and Centers for Medicare and Medicaid Services for action on the quality of care issues, while coordinating with community activists who are working to take back control of the hospital by replacing two of the five board members who are running for reelection this fall and recalling a third in hopes of creating a hospital board that can eventually get a different operator for the hospital.

“We have demonstrated time and time again that we can defeat bad actors on the medical scene, but until we achieve long-term change in the root of the problem that enables the likes of a Sutter, HCCA, Columbia HCA, Prime Health and other profiteers to proliferate in the health-care sector, the problem won’t stop,” said POC President, Geoffrey Wilson. “This precedent cannot be allowed to stand and by organizing the doctors together with the community we can win.” Physicians facing similar problems should call POC at (415) 434-9335.


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