Code Red for JPS
The former limousine driver ended up in Fort Worth’s John Peter Smith hospital emergency room and then in a coma that lasted seven weeks. He awoke from the coma on July 10, 2006, disoriented, panicky, and distrustful of the doctors and nurses around him. Over the next several days, however, he regained strength and the ability to do basic things like walk and talk again. Cattlett is grateful that JPS doctors and nurses saved his life and kept him alive. But his stay at JPS took on a nightmare quality that had to do only partly with his own physical and emotional problems. He was shuttled from room to room on almost a daily basis and on some days ended up with a bed in the hallway. He became addicted to Ativan, a drug used to treat severe anxiety and seizures.
And then JPS made it worse. He was still ill when doctors informed him that he would be moved to a hospice – not because he was dying or because that was the place where he could best receive the care he needed, but because he had no health insurance, Cattlett said he was told. Just before they put him in the ambulance for the transfer, a nurse gave him a last shot of Ativan. “You’re going to need this,” she said. The days that followed were a hellish blur for Cattlett. He almost immediately went into withdrawal from the heavily addictive drug, but could get no medication to alleviate the symptoms. As the withdrawal pain became unbearable, he begged to be taken to the emergency room but was ignored. He lay for days, tethered to his bed by a catheter and a feeding tube, imprisoned by a non-responsive bureaucracy that he is sure had forgotten about him. During his stay in the hospice, he never saw a doctor.
Cattlett’s experiences at JPS are a familiar story to Delbert Cantrell. On Sept. 1, 2007, after flipping over in a forklift at his millwright company and breaking his neck in three places, he was taken by air ambulance to the JPS emergency room – despite the fact that he and his son had asked that he be taken to Harris Hospital. When he arrived, he was bleeding badly from two deep lacerations on his forehead. It was 21 hours before anyone attended to his broken neck or sutured his wounds. The rest of Cantrell’s six-day stint at JPS didn’t go much better, his wife Dee said. She recalled that her husband lay soaked in his own blood for days, on sheets that were never changed, sharing a room with a noisy mental patient who had to be strapped to his bed. A halo brace was mounted on his head to stabilize his neck – needlessly, as it turned out, and installed dangerously crooked, Dee said. A non-JPS doctor told the Cantrell family that Delbert was lucky to have survived the treatment he received at the hospital.
Every hospital, and particularly every public hospital, produces its share of botched care and neglected patients. But the horror stories coming out of JPS these days are drawing the attention of doctors, nurses, administrators, county officials, and activists. Observers say that the hospital is critically understaffed and important jobs often don’t get done – but, curiously, it still manages to support a huge and growing budget surplus. Critics – including veteran JPS staffers – say that the administration seems more focused on expanding physical facilities than in providing the additional staffing and support systems needed for quality care. JPS administrators, confronted with stories like that of Cantrell and Cattlett, talk about how many lives the hospital saves every day and suggest that the overall picture is much better. But statistics, studies, and the experiences of long-term healthcare workers paint a big picture that is just as troubled – in terms of bad care, care denied and delayed, and major questions about how the hospital spends (and doesn’t spend) its money. In many cities, such problems at a public hospital could be chalked up to lack of money. But not at JPS, which has a whopping $97 million surplus – built up, in part, by the hospital’s failure to spend taxpayer dollars allocated specifically for charity healthcare.
Wait times at JPS’ system of clinics – designed to bring routine healthcare to neighborhoods and divert non-critical patients from the main hospital’s emergency room – are so long that the result in many cases is a de facto denial of care. The hospital’s own records show that clinic patients must wait five weeks for a routine appointment and, for some specialty clinics, a staggering six months. “There is horrible, horrible access” to care, said one member of clinic management with more than 20 years’ experience, who resigned over frustrations with JPS. “We are booked up until June. These people who are calling are very sick, and they can’t even get through on the phone sometimes.” If they do get through, patients find that JPS, which is the healthcare provider of last resort for many of the county’s poorest residents, has raised rates so high that it now collects almost triple what it actually costs to provide the care. Rules for qualifying for JPS’ indigent care program are so stringent and application processes are so cumbersome that activists and other observers think the hospital’s statutory responsibility for serving the poor is being abrogated.
Patient satisfaction with JPS’ care ranks well below regional and state standards – and they’re not the only ones complaining. JPS physicians, in the past several years, have taken their concerns to the county commissioners who appoint the members of JPS’ governing board. In some cases, top physicians and veteran administrators are jumping ship. A survey commissioned by the board last year found that JPS doctors felt worse about their hospital than their peers at 150 other U.S. hospitals and that understaffing and leadership problems are major contributors. Leadership, specifically that of hospital system CEO David Cecero, is a particularly sore point among longtime JPS staffers and critics. Many of them charge that Cecero – now one of the highest-paid public hospital administrators in Texas, and the highest-paid administrator in Tarrant County – is on a single-minded quest to make JPS function like a for-profit hospital, de-emphasizing poor patients and turning away undocumented patients from charity care.
Despite staffers’ insistence that Cecero was willing to talk to Fort Worth Weekly for this story, he never replied to repeated requests for an interview. But in a statement on the JPS website, Cecero listed JPS’ goals: improve access to care, expand service capabilities, better communicate with the community, promote a positive work environment, continue responsible fiscal management, and “demonstrate unwavering commitment to being a valuable asset to the community.”
Many of his critics say that JPS is failing to meet any of those goals, that Tarrant County’s largest health network is actually regressing in almost every respect, and that it may be operating in conflict with its charter, which says the hospital district “shall assume full responsibility for providing medical and hospital care to the needy inhabitants of the county.”
Dr. Wayne Williams was appointed to the JPS board of governors in part to give physicians a greater voice there, and he has been one of Cecero’s most outspoken critics. “It all started when David Cecero came, and [a previous JPS board] decided that they needed to get paying patients to pay for the indigent patients,” said Williams, a general practitioner and former manager of all JPS’ clinics. But now, a different set of board members – different, in large part, due to county commissioners’ concerns over JPS – is asking why the hospital hasn’t added more poor patients to its client list in the last five years, Williams said. The board is looking at “how many more … indigent patients we have had. And the answer is, we don’t have one more. So I think they got away from the basic mission of this hospital. We need to get back to just good, solid patient care.”
Cattlett is one of those who feels he was discriminated against at JPS because he was uninsured and poor. When JPS transferred him to the Marine Creek hospice, the hospital system failed to make sure that the proper authorizations to treat went with him. When he went into full drug withdrawal, his cries were ignored by staff, Cattlett said, because no one was authorized to administer drugs. Eventually, his sister, who lives in Chicago, signed off on his transfer, and Cattlett finally existed in the eyes of his would-be caretakers. Even then, however, he never saw a doctor and had to fight to have the catheter and feeding tube removed. When his first roommate died, his place was taken by an especially loud patient with mental problems, who was only moved after Cattlett threatened to call the emergency number posted on the wall.
The former clinic manager who rated poor people’s access to JPS as “horrible” has seen the effects daily of JPS not providing the resources to give adequate medical care to poor people . “When someone tells me ‘I am sick and I need to come in,’ I just can’t do it,” the former manager said. Appointment slots designed to provide more immediate care, ironically called “same-day” appointments, are booked up a minimum of two weeks in advance.
The clinic manager has even had to call the police to deal with irate patients who were becoming potentially dangerous. In one such case a patient had waited months for his appointment, only to be rescheduled. When he finally got his day at the clinic, several weeks after the first appointment, the doctor he was supposed to see didn’t show up. The manager said one doctor or another fails to show up for scheduled work at the clinic about once a week. Robert Early, senior vice president of public affairs and advocacy for JPS, said he couldn’t confirm whether such long waits for clinic appointments are common. But, he said, “If that is the case, and people can’t get appointments, that’s obviously something that we should take a look at.” Overwork could be one of the reasons for the doctor no-shows. Last year, admissions to JPS increased by 11 percent and outpatient activity increased by 7 percent, while the staff increased by only 3 percent. The lack of staff leads to increased wait times and, potentially, mistakes by tired workers.
Leo Luebbehusen, a 61-year-old lawyer, is an oncology patient at JPS. He was a patient of Dr. Deborah Prow, former head of the oncology department. “She would be there at midnight and back at 6 a.m. and work 20 hours a day,” Luebbehusen said. “The nurses said she did that all of the time.” He lost one kidney to cancer and now has an inoperable tumor on his spine. He believes the doctor who gave him such good care was chased away by the administration’s unresponsiveness. “The main reason she left is that she wanted JPS to give her help, more people to handle the workload,” he said. “And they let her go instead … . I thought it was a terrible loss for Tarrant County and Fort Worth. I just felt like I was in good hands with her.”
Apparently, JPS also thought highly of Prow, who now works in another state and could not be reached for comment. In addition to being a department head, she was literally a public face for JPS – her name and image appeared on numerous JPS pamphlets and marketing materials. Tarrant County Commissioner Roy Brooks said he does not believe that JPS has a staffing problem. One of the reasons for the two-term commissioner’s confidence, he said, is the contract with the University of North Texas Health Science Center that has been using the county hospital as a teaching hospital for the past three years. Osteopathic faculty physicians as well as UNT residents and interns are working throughout JPS, he said. However, while the contract runs to the end of the summer of 2008, renegotiation talks have run into a snag that, if not worked out to everyone’s satisfaction, could affect the future staffing of the hospital.
A medical school and a public hospital should be a marriage made in heaven, said Brooks. “UNT needs a source to train its doctors, and JPS needs a source of doctors to better serve the community and relieve the pressure on the staff physicians,” he said. “But because we [the commissioners court] put the two tax-supported institutions, both headed by strong-willed managers, together without first getting them to agree on a shared vision of where [JPS] should be heading,” the talks that started a few weeks ago have bogged down. There are control issues, he said, such as the lack of an osteopath on the JPS board. Brooks didn’t go into details of other disagreements, but it’s no secret that Cecero wants to take the county hospital in the direction of a for-profit institution, while the osteopathic college has long followed a policy of serving poor and low-income communities by providing free or reduced-cost care in a number of neighborhood clinics.
“We have to work through these issues, get to a point where we are able to share resources, share knowledge, and agree on what it will take to have a comprehensive healthcare system for this community with not just a shared vision, but a shared long-range plan,” the commissioner said. Last week, a county-hired facilitator began the tough job of getting all the parties to the table. Brooks said a public hearing on the contract will be scheduled in about two months.
Even if most JPS officials aren’t willing to admit that poor people’s care in the JPS system is a problem, Tarrant County commissioners have gotten the message. County Judge B. Glenn Whitley was concerned enough to create a blue-ribbon committee to look into the question. The nine-member panel, consisting of four members appointed by the JPS board of managers and five chosen by the commissioners court, is supposed to investigate “barriers” that keep poor people from knowing about the JPS network and getting care from it in a reasonable manner. Steve Montgomery, chairman of the JPS board of managers and a member of the blue-ribbon committee, said he doesn’t believe that there is any specific problem with access to healthcare at JPS.
Early, the JPS senior vice president, didn’t take a stand on whether months-long waits for appointments, understaffing, and cases like Cattlett’s and Cantrell’s are proof of problems in delivering care. “I don’t know whether I agree or disagree with the fact that there are or not [problems with access],” he said. Both men, however, said they welcome the committee’s work on the matter. “If there are problems, JPS should take full responsibility for them,” Early said. “And if there aren’t, we need to continue doing everything that’s right.” Montgomery said the hospital board is open to any suggestions on improving JPS’ work. “That’s what we’re all here to do.”
Ann Sutherland is a dissatisfied voice on the committee. She strongly believes that JPS is not doing enough to take care of the poor. “They are not actively seeking indigent patients,” she said. Early disagreed. JPS is trying harder than ever to reach out to the poor, he said. He pointed out that eligibility for the hospital’s charity care program has been expanded and said the hospital system is doing more to educate the public on JPS services and how people can qualify for help. Despite Montgomery and Early’s enthusiasm for the access committee, one clinic employee said Tuesday that a JPS vice president had called and told them not to answer Sutherland’s questions about access problems.
JPS provides care for qualifying low-income families and individuals through the system called JPS Connection. The program generally is open to those who make too much money to qualify for Medicaid but not enough to pay for private health insurance. Last year, the maximum income allowed to qualify for the program was expanded from twice the federal poverty level to three times – or about $63,000 for a family of four here. To qualify, patients must be legal residents of Tarrant County and not covered by private insurance, Medicaid, or other government programs. About 27 percent of JPS’ patient load is in the Connection program. Members pay $10 for primary care visits, $20 for specialists, and up to $250 for procedures like delivering a baby.
Theoretically, public hospitals use the income from paying patients – that is, non-indigent people with private health insurance – to reduce their losses on charity care. JPS has certainly done a lot on the front end of that equation. Hospital system documents show that the markup on care to non-Connection patients has increased significantly every year since 2001, Cecero’s first year on the job. That year, on an average bill of $100, the markup – the charge above actual costs of care – was about $8. In 2007, it was $58. This year, it’s $62. The problem, to many, is that the income from those steep fee increases isn’t being spent on charity care. Instead, much of that money is going into JPS’ ever-growing surplus.
On top of that, since 2001, the hospital has consistently received more tax revenue than it has spent on uncompensated care. Between 2001 and 2005, JPS made a total of $69,732 in profit on charity care from local, state, and federal tax dollars. By comparison, in the last fiscal year, the hospital received $5 million more in tax dollars intended for low-income healthcare than it spent. In addition, JPS received $82 million last year from the federal government in what is called “dispro” funding – shared out to hospitals that carry a disproportionate load of charity patients (hence the “dispro” nickname) – and a little over $10 million in proceeds from the huge tobacco lawsuit settlement.
The tobacco settlement and the dispro money are large elements in the $97 million surplus. By comparison, Dallas’ Parkland system, much bigger than JPS, in 2006 had a $133 million surplus, but, according to news accounts, that number includes several one-time windfalls. When those amounts are removed, the actual surplus was closer to $38 million – and unlike JPS, Parkland accepts undocumented workers as patients. To Sutherland and others, the existence of a surplus of that magnitude, in the face of so many unmet needs, is a major problem. She also noted that the administration has no particular plans for the money. Montgomery said he understands there is a perception that JPS is hoarding money and gunning for profits, but he strongly disagrees. The hospital needs to be conservative in its spending, he said, because JPS can’t be sure it will get as much “dispro” funding in the future and also because President George Bush is proposing substantial cuts in the Medicaid program.
While he wasn’t willing to talk specifically about cases of substandard care at JPS or unacceptable delays in poor people receiving care, he did say that balancing the budget is an art. “Sometimes when we seek efficiency, the perception is that we are seeking profits,” he said. “I’ve heard that there is too much money in the bank, and I am very sensitive to those perceptions,” he said. “It’s an artful balance, and I say it’s an art because no one has the right balance between how much you keep in reserves to maintain a strong financial foundation and balancing that with maximizing your resources and maximizing patient care. We struggle with that every day.” Sutherland and others think JPS has adopted a “Chicken Little” business strategy, always planning for the sky to fall down on them. “They feel they have to budget for the worst-case scenario and not the most likely scenario,” said Sutherland. “And I don’t know that that’s the right thing to do.”
If JPS administrators really want to attract paying patients to their hospital system, they won’t be putting Delbert Cantrell’s story in any of their brochures. It reads like a classic charity-hospital horror story. When he landed at JPS, he already had a neck brace on. But for 21 hours after that, the only person who did anything to help him was his wife. The Cantrells said other doctors have since told them that his two deep wounds should have been sutured within an hour to prevent contact with the dangerous staph infections that lurk in hospitals. If he needed a halo brace to insure that his broken neck would heal properly, one would suspect that it, too, should have been put in place soon after his accident. But it was six days before a doctor arrived to install the brace, which involves placing screws in the patient’s skull. At that point, Cantrell still had not been given a bed bath since his accident, and the couple feared that the unsanitary conditions could lead to major problems.
Of course, as his own doctors later explained, the halo brace, first, hadn’t been needed at all, and second, was put on crooked. The private doctors told Cantrell he should have had immediate surgery, not a brace. In Cantrell’s room, the shower didn’t work properly, and the bathroom was so dirty that Dee felt obliged to clean it herself. Although Cantrell is a diabetic, staffers could not manage to get him appropriate food. To make matters worse, the patient in the next bed masturbated in front of them, with the curtain around his bed wide open. When Cantrell was moved to another room, his new roommate was a mental patient from Rusk State Hospital. And they could never find a doctor to answer any of their many questions. “The [non-JPS] doctor said [to Delbert] ‘You are a walking miracle,’” said Dee Cantrell, who believes the hospital intentionally prolonged her husband’s stay, in order to “milk workman’s comp. We never saw a scheduled doctor, always neophytes or less qualified [people].”
The doctor they never saw – the supervisor of the doctor responsible for putting the halo on Cantrell – is no stranger to controversy. While working at a hospital in El Paso, he was involved in a malpractice suit and later admitted he was addicted to a narcotic cough syrup and had written fraudulent preDELETEions. His license to prescribe drugs was temporarily suspended. The whole ordeal has been a financial strain on the couple, especially since Delbert still has not been able to return to work. The workers’ compensation program is footing the bulk of the hospital bill, but not all of it – not, for instance, the whole day’s worth of services he was billed for that he allegedly received the day after his discharge. Early said he has talked to Dee Cantrell and appreciates her concerns. But in a hospital the size of JPS, there are always going to be things that could be done better, he said. “You can get caught up in only the negative. I’ve met with people who are very appreciative,” he said. “There are so many people’s whose lives get saved every day.”
The patient survey at JPS two years ago suggests that Cantrell’s and Cattlett’s stories are not that unusual. Whereas the national average “satisfaction” rating for public hospitals was 83 percent, JPS scored between 73 and 78 percent. The emergency department ranked even lower in patients’ eyes, getting a 65 to 67 percent approval rating, while the average score for trauma hospitals of similar size was over 80 percent. There were similar gaps in the health center and day surgery grades. Many doctors and other workers at JPS, apparently, agree with those ratings – and feel that the hospital administration won’t give them the support they need to do a better job. “I will not work for JPS under the current administration,” said the veteran clinic manager who quit in frustration. “It’s rotten at the top. They won’t let us hire more, and then they tell us that we are responsible for the [low] patient satisfaction surveys.”
Williams, the physician and JPS board member, believes that the administration hasn’t properly supported the medical staff and is out of touch with what is happening on the ground. “Is there a morale problem? Yes, I think there is,” Williams said. “These doctors are world-class doctors … . In their hearts, they want to take care of all people, poor people [included]. There just hasn’t been an administrative effort to see what needs to happen to allow these doctors to just do their jobs.” The survey done last July by an independent marketing research firm, which confirmed the low morale among JPS doctors, also reported “an environment of mistrust and acrimony” toward leadership as one of the most common complaints – along with a lack of commitment to quality patient care.
In the wake of the survey’s release, JPS’ chief of the medical staff asked county commissioners to appoint two physicians to the board. Commissioner J.D. Johnson appointed Williams. Williams said persistent lack of staffing is just another way for the administration to save money so that Cecero can show the commissioners that the hospital is running in the black. According to Allied Communities of Tarrant County, which has advocated for JPS to start extending charity care to undocumented workers, Cecero’s compensation package totals $648, 480. That includes $250,000 in bonuses – which, like bonuses for other administrators, is tied in part to the size of the hospital’s surplus. “The way you make money at a county hospital is to not see patients” – and not hire staff – “because the tax rate stays the same,” Williams said. “I think they are going to have to go back to old staffing levels. They’ve cut down staff in the clinics, in the correctional health section [where prisoners are housed], and in the hospital itself.”
Montgomery said that the new patient tower due to be completed in May will be a huge step in alleviating patient wait times and providing better overall care. The $93.6 million project will add a new intensive care unit and emergency room and more than 100 new beds. He agreed that JPS is understaffed but said that’s a chronic problem for all hospitals. “We’re always recruiting. There is a national nursing shortage; we’re in the hunt with everyone else,” he said. “And our [staffing] numbers aren’t that bad; they’re pretty consistent with the numbers all over. Getting good doctors and nurses on our staff is not something that can happen overnight.”
But, according to Williams and others, if the administration, specifically Cecero, doesn’t do anything to retain the staff the hospital has now, no amount of money will be able to turn JPS around. Building new buildings isn’t tough, he said. “What’s really hard to do is to turn around attitudes, turn around your staff, and he [Cecero] hasn’t done any of that. “I think he’s forgotten the mission of this hospital,” Williams said. “I think our processes for taking care of patients are the worst they’ve ever been.” “Cecero is a very talented man,” Sutherland said, “and the changes he has made are, in many ways, unprecedented. We have more clinics than we’ve ever had.” But she, like Williams, thinks many of the other changes have taken JPS in completely the wrong direction.
When JPS doctors over the past few years failed to get any help from the hospital board in fixing their hospital’s problems, they went up the food chain to the county commissioners. The county officials, after seeing a report on discussions of access problems at JPS, set up the blue-ribbon committee, put some new faces on the hospital board, and are trying to get things like the UNT Health Science Center contract crisis resolved. But thus far, Cecero’s job seems safe. “No, I don’t think Cecero is in any danger,” Commissioner Brooks said, though he acknowledges there are problems at JPS. “I see [Cecero] as a very brilliant guy, but he comes out of the private hospital environment,” Brooks said. “This is his first public hospital experience. … He has put JPS on a strong financial footing, but my request to him from the beginning was, ‘We’ve got to serve more of the indigent.’”
Brooks said the hospital board’s recent decision approving the looser income eligibility requirements for the JPS Connection program was a step in the right direction. He also wants the board to rescind its policy of not providing non-emergency charity care for undocumented residents, but, “We still don’t have the votes for that one.” The blue-ribbon committee is a bit of progress, he said. He appointed Sutherland to that panel. She’s “no shrinking violet” when it comes to advocating on behalf of the poor, he said. “I expect her voice will be heard loud and clear.” One thing is certain, the commissioner said: “JPS is never going to become a ‘for profit’ hospital. … There is a balance that any public hospital has to have between paying and nonpaying [patients]. But for a hospital whose first mission is to serve the poor, that balance should always be weighted in favor of the indigent.”
Brooks said he understands that making profits and building up surpluses were important in the privately owned hospitals Cecero worked at in the past. “But the fact is, Peter Smith is a different animal; it was established for the poor. Its mission has been from the beginning to provide for the needy of this county, no matter who they are or where they come from.” In spite of the low morale, Brooks said the hospital provides “top-shelf care.” Most staffers, he said, “could make more money elsewhere, but they are there because they feel an obligation to give back to their community.” And while it’s not the commissioners’ job or the hospital’s board’s job to manage the day-to-day operation of JPS, it is their job to see that the mission of the hospital is carried out,” he said. “We are bringing [Cecero] around.”
Critics say Cecero’s been at JPS too long to just now be learning what his role as the CEO of a public hospital should be. Several present and former employees, who asked for anonymity for fear of retaliation, said that serving the poor seems to be the last item on his agenda. Cecero’s policies are increasing the cost of medical care to the poor and reducing services, they said. “He is running it now like it is a private hospital,” one said. Others expressed fear that, if other public hospital boards see JPS’ huge surplus, healthy bottom line, and shiny new buildings, Cecero’s policies will begin to take root at other public charity hospitals in the state. That, they fear, would damage public healthcare across the state.
Former intern Pablo Lastra contributed to this story.
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