Bay Clini Blues
How bad is it?

Patients turned away because the doctors are already booked up at 8 a.m. Employees fired without warning, then escorted out the back door. Community programs suddenly defunded.
What's happening with the Bay Clinics?
The Bay Clinic, Inc., which runs Hilo, Puna and Ka'u's only federally funded community clinics, will get its third CEO in two years September 1, when Paul Strauss takes over the reigns of the non-profit and its facilities in Hilo, Kea'au, Pahoa and Na'alehu.
Strauss is inheriting a troubled organization. The clinics are the only ones in the area required to serve patients regardless of insurance status or income; clients pay on a sliding scale. The clinic's current interim CEO, Robert Cooper, notes that the Bay Clinic facilities have also become the first line of care for many newcomers, regardless of whether they have insurance, because there are very few doctors here who are taking new patients.
Yet patients are turned away because the clinics are booked solid before they can get in the doors. The overcrowding has been exacerbated by inadequate facilities and by a high turnover rate among staff, who complain of mass firings and low morale.
One recently fired employee gave the Journal a list of over 25 employees who quit or were fired in the past two years, out of a staff of a little over a hundred. Most were at Pahoa Family Health Center. Other ex-employees from the Kea'au facility report similar attrition problems. Fired staffers included doctors, nurses, administrators, outreach workers, secretaries, filing clerks, an asthma/tobacco specialist-even a reading specialist.
Some said they couldn't talk to us because of impending lawsuits, or because they had reached settlements that included gag orders. Those who did talk painted a picture of a new administration with a top-down orientation and a growing atmosphere of isolation and insecurity, exacerbated by sudden firings and program cuts.
Not Liking Mike
In the spring of 2006, Hilo Bay Clinic hired Mike Mihora as CEO, despite his checkered track record. While head of the United Memorial Hospital in Greenville, Michigan, he hired anesthesiologist Jeffrey Askanazi. Mihora later resigned to join Askanazi's lucrative private practice.
But Askanazi lost his license after a Memorial Hospital patient died in 1996 from a botched anesthetic injection. Askanazi, two other doctors and the hospital were convicted of billing fraud.
"United Memorial's board of directors, its executives and various of its physicians utterly failed in their responsibilities to Dr. Askanazi's patients, and this case demonstrates how serious the consequences can be when a hospital puts its financial priorities ahead of patient safety and quality medical care," wrote health law columnist Francis J. Serbaroli in the New York Law Journal.
Mihora was charged with perjury over his testimony in the various cases; charges were dropped after witnesses against him changed their testimony. By that time, he was president of Cheboygan [Michigan] Memorial Hospital.
Mihora came to Bay Clinic and immediately began centralizing administration-and firing people. Most of the clinics' outreach workers (including case manager Lynn Ka'awaloa, who had worked at the Pahoa facility for over a decade) were let go.
"We dealt with a lot of homeless people that came to the area and had no place to go and were sick," Ka'awaloa says. "We found them shelter, got them hooked up with Care-A-Van, bought them some food."
She also helped elderly patients who "fell through the cracks"-who didn't qualify for Medicaid or Medicare and couldn't get insurance. She'd often call drug manufacturers to get her clients their medicines through various subsidy programs.
She and the other Pahoa case managers had no warning of their impending firings. They were called to a meeting, she says, at which Mihora "just got up and said our positions had been eliminated." The fired employees were given their paperwork and told to clean out their desks immediately.
"After 10 and a half years, they just walked out," she said. "No thank you for your services, nothing. Just walked out, like we were nothing."
The scene was repeated frequently over the next few months.
One size fits all?
"It used to be that we would come together for a meeting and they would talk about centralizing, says former Bay Clinic Special Programs Manager Belinda Cole. "But we couldn't do it. You couldn't keep it central for everything."
The clientele for the different clinics, she said, were just too different. The Ka'u clinic, for instance, served many Marshall Islanders. "You need a lot of interpreters. The amount of time that you spend with a patient-it just can't be the same."
Cole oversaw a variety of programs, including a diabetes prevention program; family violence intervention classes; a Reach Out and Read program, a $98,000 OHA grant to provide health care for elderly Hawaiians; and a breast cancer program for the Marshallese. She also served as coordinator for a large volunteer program in which community members did everything from nursing patients to reading to them.
"When Mike [Mihora] came on, my programs were eliminated," she says. Both she and her assistant, Linda Lucero, were laid off.
"Everything was so departmentalized, nobody really knew what was going on in the other departments-not in detail," Cole complains.
"When new people came in, they didn't know about the grants, they were just interested in eliminating it....
"We tried to raise a big ruckus through the funders, but it seemed like nobody cared," she says. "What can they do about it? Nobody cared that Marshallese were going unserved, that there was money out there that just evaporated."
Some of the federally-funded programs continued. Cole says the family violence intervention program kept going because the instructor worked without pay for months, until it was taken over by another agency.
Keaukaha confusion
Terri L. Napeahi was president of Ho'ololi Ola (Life Changing), which taught aerobics classes to Native Hawaiians as part of the diabetes prevention program in Keaukaha. Funding for the instructors and equipment came from a grant from the Hawai'i Community Foundation, administered through Bay Clinics. But payments for the 2004-2005 fiscal year suddenly dried up before she was paid for all expenses, even though about $2,500 had not been spent. She then taught the classes voluntarily, and used her own computer to maintain the data on the project.
Her organization was awarded another $10,000 grant for the next year's programs, but never received the money from Bay Clinic.
For months, she says, she got no response. Finally a letter arrived, saying the Bay Clinic had returned the remaining money for 2005-05 and all of the funds for 2006-7 to HCF, because Napeahi hadn't submitted certain documents and her program was redundant with another Bay Clinic program. Napeahi said she submitted all requested paperwork and noted Bay Clinic offered no other exercise classes in Keaukaha.
Frustrated docs
"I chose family practice so I could work in underserved communities," says Stefan Carl Harmeling, MD. Harmeling worked for a year and a half at the Hilo, Kea'au and Bay Clinics. He left in October 2006 because "it was just so frustrating and disappointing that I just didn't want to be involved with them anymore."
He saw the same problems in all three clinics.
"You hire physicians or professionals who have years of experience working in clinics, yet they are given no sort of leeway in running the clinics. Everything has to go back to the central authority-and the central authority was essentially disorganized, a poor communicator, and felt intimidated by any new ideas that weren't already there," he says.
Like many others we interviewed, he says getting a doctor's appointment was a major problem.
Beyond that, scheduling policies bollixed long-term care. If a patient at the Pahoa clinic in October, for instance, needed a follow-up appointment in December, s/he had to wait until December to even schedule the appointment.
"It really affected our ability to manage chronic medical problems effectively, and I think our community suffered because of it," he says.
Life after Mike
The Bay Clinic fired Mihora last March, but the bloodletting wasn't over.
Interim CEO Bobby Cooper stopped by Dan Domizio's office in Pahoa. Domizio was the former Clinical Programs Director at the Pahoa Bay Clinic. Under the Mihora regime, he'd been demoted to physician's assistant.
Cooper asked Domizio what he thought needed to be done. Domizio says he suggested that some of Mihora's appointees needed to go, too.
"He told me, 'Can you be specific about who it is that needs to be out of here?' I told him, 'Okay,'" Domizio recalls. One of the names he named was that of Medical Director Toni Brown.
On March 30, Domizio was handed a letter signed by Cooper and Brown, notifying him that his employment was terminated "immediately" for "insubordination" and "conduct that negatively affects the employee's relationship to his/her job, his/her fellow workers his or/her supervisor(s) or clinic services." The letter specifically cited that Domizio favored Brown's dismissal.
"I had patients in rooms" at that moment, Domizio says. He wasn't allowed to finish with them. "They walked me out the back door with my box of personal effects."
Domizio believes long-time staff were especially targeted, and that their loss has hurt the organization's ability to serve the public-a charge repeated by other former employees.
"You can't afford to lose 11 providers in a year," he maintains. "Recruiting new providers only partially solves the problem because they're new and they don't have those relationships with the community... If you're taking care of a guy's diabetes for ten years, your interaction can be brief, efficient. You've already taken care of the basics."
As a result of the firings, he claims, the clinic has "a diminished capacity to meet walk-in/urgent care demands: "I saw, generally speaking, 30-35 patients a day. All but a few of those were walk in. Where I saw 30-35, [now] they're seeing ten."
No room
While the clinics may have lost scores of years of experience, they haven't lost that many warm bodies. Cole estimates that the clinics had employed about 112 staffers when she was there. Today, according to Cooper, there are 105.
"So far we've been pretty able to compete," he says. "There are some medical professionals who really like what we do. Money isn't the most important thing in their lives."
The difficulties that patients have in seeing doctors, he says, are a product not just of personnel shortages, but of too many patients and not enough waiting rooms. The four clinics, he says, are "all overcrowded." At all four sites, he says, "Maybe we need 50 or 100 percent more square footage."
The clinics generally serve patients with appointments first, but if a walk-in is having serious trouble that can't wait, s/he is either taken to the Hilo Hospital ER by ambulance or triaged and taken ahead of other patients.
The Hilo Bay Clinic has lost its lease, but already has found new locations: the medical facilities are moving to the current Social Security Building on Kino'ole, while administration is headed to a building on Haili St. In the long term, he hopes to find funding to build a whole new Hilo clinic, perhaps on state land. The same goes for Pahoa, which rents its current facilities. The Ka'u clinic, which one board member said is "falling down," sits on land that the clinic owns; Cooper says a new facility can be built there. The problem, of course, is cash.
"The best solution for me is to have Alan and a batch of his friends come up with $25 million so we can improve all our facilities," he joked to this reporter.
The Journal later learned that while we were investigating this story, Cooper had sent out an e-mail notifying the staff that a reporter was asking questions, and requesting that anyone contacted "refer the reporter to me."
New competitor?
The former employees have their own suggestions for improvement. Two suggested that the organization should have four new directors: one for each clinic. Carmeling suggested that the next permanent CEO of Bay Clinics should have community clinic experience and should be from Hawai'i.
In that, he gets his wish. Strauss is currently CEO of Waikiki Health Center, another community clinic, and graduated from Kolani High School on O'ahu.
Meanwhile, the veterans of the Bay Clinic firings have moved on. Harmeling divides his time between the Hilo Hospital and his new clinic for AIDS and HIV patients. Napeahi is finishing her MBA and developing an online gallery for Native Hawaiian artists. Ka'awaloa is retired, though she misses community service and would like to return to it in a part-time position.
Domizio and colleagues are planning their own urgent care center in Pahoa. He says they need about $200,000 to open their doors. "We're looking for grants, donations, a fundraising committee. A fundraising letter is being sent out. We'll be having pot lucks and car washes."
But he says the new center will not be competing with Bay Clinics. Like most of those we talked to, he hopes that organization will recover because they're serving a vital need in their communities.
"We would partner up with 'Bay Clinic," he says, "if Bay Clinic is ready for that."

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