Chapter 5. Conflict Under a Labor/Management Contract - 1982
January Dumping on Union Activist...................................................... 311
February Shared Time............................................................................ 318
March Negotiations, Grievances, Committees & Others...................... 324
April Administration & Board at Work............................................. 328
May Employees Regain Right to Vote............................................. 336
June Site Visit and HMO Report...................................................... 339
July Plot to Fire Union Activist........................................................ 345
August Reports of Deficit..................................................................... 350
September Suggested Cuts in Costs............................................................ 352
October Cost of Living Adjustment.......................................................... 358
November Board's Annual Election............................................................ 361
December El Rio's Annual Report.............................................................. 363 - 365
Chapter 5. Conflict Under a Labor/Management Contract - 1982
January 1982 - "Seems Like You Just Can't Bury a Problem"
January 1982
Management's Newsletter
"Dr. Kristin Olson, Internist in Suite 3, joined our medical staff on September 1 [1981]. Dr. Olson, a native of Boston, received her medical degree from Boston University School of Medicine. She completed her residency at Boston Veterans Hospital."
"Dr. Olson had practiced medicine in Guatemala and Oregon before joining our
staff."
January 4, 1982
Stringer's Letter
This days hearing dealt with Larsen's December 23, 1981 grievance based on Stringer's refusal to grant education leave. Larsen believed that Stringer and J. Garcia's planned to demote her, then upgrade the accounting clerk into her level. Improving Larsen's credentials made that plan more difficult.
After the hearing Stringer wrote a letter addressed "To Whom It May Concern."
"The conclusion reached [certainly not by the grievant] was that the call for the meeting was unwarranted and unnecessary."
Larsen won this grievance as she would win her numerous other grievances which took
place during the time she worked under Tony Stringer.
January 8, 1982
Letter from Showalter to Bogy
Showalter wrote to Bogy and requested the next level of the grievance hearing. He wrote:
"In accordance with Article XXIII, Section 3, this letter is the written formalization in response to Ms. Ethel Larsen's immediate supervisor's denial at the informal level.
The matter involves a violation of Article XVII Section 5 in that Ms. Larsen's request to attend courses that would ultimately lead to Masters and Public Administration degree at the Center has been denied. The written response from Mr. Stringer is insulting to this Union's commitment to an ongoing formalized process for solving problems. It is obvious that Mr. Stringer has no experience with unions who attempt to establish an ongoing cooperative relationship with management. Words like inane, unwarranted, unnecessary have no place in a problem solving process and this Union takes it very seriously.
Above and beyond the tonal qualities of Mr. Stringer's response, the Union takes issue with Mr. Stringer's contention that the request for leave is ambiguous. It is quite clear that her continued course work in this area will lead to promotional opportunities. We believe the denial is arbitrary and capricious if not punitive and we ask you to over turn your subordinate's decision.
I understand that Ms. Larsen has already corresponded with you concerning a
meeting. I will be her representative."
Larsen also wrote to Bogy, requesting a meeting with him to deal with her grievance.
"Since I am not satisfied with the response of my supervisor, Tony Stringer, in regards to my grievance governing education leave, I am requesting a meeting with you per Article XXIII, Section 3 of the Labor-Management Contract. I wish to have a union representative present at this meeting.
Since the walk thru registration at the University of Arizona will be held on January 12th and 13th and a definitive decision on my grievance might not be made before then, I would like to request your authorization to take time so that I may register.
I further want to point out that in response to my intention to take this grievance to
the next level and in the presence of several members of the accounting staff, Tony
Stringer made threatening statements about my position."
Larsen's letter to Bogy further enraged Stringer and he let loose a string of invectives at Larsen in front of the other members of the accounting staff.
As the results of Stringer's inappropriate action, management ordered him to apologize to
the accounting staff. Stringer did this through two memos: one went to Larsen and the other to
the five staff people in the accounting department.
Stringers Letter to Larsen
"In reference to your memo to Ben Bogy, Finance Director (not Business Manager) I didn't
threaten your position. I made a promise to do something about your persistent abuse of
'your contractual arrangement' with El Rio Santa Cruz Neighborhood Health Center, Inc.
and your consistent disruptive efforts in the accounting department."
Stringers Letter to Other Members of the Accounting Department
"I sincerely apologize for causing a disturbance this morning by losing my temper. Some of you can possibly empathize with me when considering the source."
Shortly after this incident, two of the five accounting staff members left the department.
Larsen's Letter
Because Stringer wrote that he promised to do something about "your persistent abuse of 'your contractual arrangement'" Larsen filed another grievance on February 4.
"...Mr. Stringer's promise to do something about 'constant disruptive efforts' is directed
toward my legitimate actions as a Union representative of Local 449. Further, this is part
and parcel of a continuing practice of discrimination and harassment in retaliation directed
toward me . . . [I have been] subjected to continual and unrelenting downgrading that is
part of an overall pattern to terminate my employment or force me to resign. This overall
plan of harassment is evidenced by the existence of an actual and witnessed 'shit list'
created by Mr. Stringer with my name at the top of the list and a memorandum indicating
that I would retain title and salary but be stripped of all responsibilities."
Both grievances were won by Larsen. Larsen registered for the graduate course, Administrative Leadership, and received the grade "A."
Sometime later, Larsen found a note, "Seems like you just can't bury a problem." signed by E. Bauman. How right he was!
January 29, 1982
Letter from Showalter, AFSCME Director to Mejia, El Rio Director
In preparation for the upcoming negotiations, AFSCME requested financial information in the form of monthly budgets for the months of April, August and December for the past five years, audit reports for the last three years and itemized budget by revenue sources and expenditures for the last three (3) years.
Five weeks later, on March 11 Bogy partially responded to these requests.
Sometime in January 1982
Board Minutes "Roll Call" Listing
They conducted very little business at this first board meeting. Most of the committees had not yet met. So this meeting served as a time for newly elected board members to become acquainted with each other.
Although many employees showed no interest in who served on the board, others who were interested believed many of this year's board members would be employee friendly. Among the board members expected to be employee friendly were Maria Borbon, Edmundo "Ed" Cardenas, Ed Espinoza, Isabel Garcia, Fernando Gaxiola, Lydia Grijalva, James Heermance, Andrew "Andy" Nichols, Patricia Nolan, and Kathy Tashiro.
Borbon, both a social activist and a law student, had several friends working at El Rio. Borbon also had a background of involvement in health care issues as an employee of the Free Clinic, a small nonprofit center that provided services to the indigent.
Many employees affectionately viewed Cardenas as an older man lacking sophistication. Although his recommendations, at times, were unorthodox, he remained a persistent and dependable supporter of patients and employees. Cardenas had been involved in the establishment of El Rio and through the years remained active in many community organizations. Cardenas truly wanted to be the representative of the people, all the people. Many of the employees expressed special fondness for him. Still, his vote continued to show independence.
Espinoza, a former El Rio employee, now worked for the county as a social worker. He had experienced some of the earlier conflict between the employees and board and he advocated for employee and patient's rights. Espinoza served on the board's HMO Committee.
Many employees considered Isabel Garcia, JD, a sharp lady who had strong interests in social issues. Garcia would serve as the Chair of the board's Grievance Committee and this led to ending administration abuse of union activists. Years later, Ed Celaya, the pharmacist, remembered Isabel Garcia as an outspoken board member.
Most employees also respected Fernando Gaxiola as another very astute attorney, who had strong social committments. Gaxiola received mix reviews from other board members, but most employees were very fond of him and felt safe with Gaxiola as the board president. Many board members disapproved of Gaxiola's suspicions about the viability of the HMO, whether the HMO brought in money or cost the clinic money. Gloria Gonzales believed that the board saw Gaxiola as too outspoken. She said that while she did not know much about Gaxiola, she saw him as ". . . a very intelligent man." Celaya remembered Gaxiola "as a very nice guy" while Warren saw Gaxiola as a bright defender of employees' rights and patient care issues.
Lydia Grijalva, RN, had a background in both health care and anthropology. She served on the board's HMO Committee.
James Heermance, a senior citizen who lived in the community, would only serve a few months before having to leave his position on the board.
Andy Nichols, MD, a long time appointee member of the board, represented the University of Arizona. Nichols would later represent his district in the Arizona State Legislature.
Although a few employees expressed fondness for Nichols, a few suspected his motives. Some people saw Nichols as the University's advocate on the board.
Pat Nolan, MD, received her education in Canada. After serving on El Rio's board, she later became prominent in public health first in Arizona and later in Colorado. Although Nolan had several friends among the El Rio employees, some viewed her suspiciously because of positions she took on volatile public health issues outside of El Rio.
Cathy Tashiro, FNP, formally worked with the Traditional Indian Alliance, a site where health care services were provided. After being elected to the board, Tashiro served
on the Quality Assurance Committee. This committee had the responsibility of reviewing expenditures for outside medical purchased services.
A few board members were believed to be hostile to the union. Among those perceived in that manner were Miguel Rojas, Alfonso Avitia and Lillian Lopez-Grant.
Miguel Rojas, a political activist in the Democratic Party, often sought support for candidates running for positions in the public elections. Rojas was more anti El Rio's union than just anti-union. This anti-union stand may have come about because of his close ties to Baldenegro.
Another anti-union board member and businessman, Alfonso Avitia, had strong ties to the community and knew many employees. Many union members respected and trusted this hard working and effective man even though took anti-union positions.
Many saw Lillian Lopez-Grant as a maverick, whose vote could not be predicted. She had been very active in the community and appeared to be a dedicated Republican. While the barrio population remained the center of her focus, Lopez-Grant acted as an independent patient advocate. Many employees found her abrasive and harsh. Still, her vote could not be predicted. Often employees did not trust her and some viewed her as anti-union.
A few other board members were largely unknown among the employees.
February 1982 - Polling the Membership
February 1, 1982
First Level in Larsen's Grievance
Larsen claimed that the contract had been violated when she had been harassed by
management employees. Because the first level involved her supervisor, Stringer, the problem
could not be resolved at this level.
February 2, 1982
Shared Time Sub-Committee
This joint Labor/Management Committee met. Sylvia Ortiz, an accountant, served on this
committee along with other union members, Linda Garcia, Ethel Larsen, Terry Martinez and Dr.
Kris Olson. This concept explained that two employees could share one job. All benefits
accrued according to time worked. From a union perspective, the successful working of such a
committee made it possible for working women to hold a permanent, part-time job that offered
some measure of benefits.
February 3, 1982
Union's Negotiation Committee Meeting
This committee began the work of looking at the contract for weaknesses that might be changed in the next negotiations. Much care had been taken to get a Negotiation Committee that was representative of the full membership and reflected the views of all the members. Physicians, nurses, office staff, family health worker, janitors all were contacted about the contents of the contract and many had representatives who served on the Negotiation Committee. So the views of the full membership were reflected, to a large degree, in the opinions of the members of the Negotiation Committee. The union staff also made recommendations.
For the physicians, the committee saw a need to look again at the Medical Executive Committee and to strengthen the by-laws governing that committee. Additionally, the health professionals hoped to define the role of the Chief of Staff through language in the contract, establish a physician's interview panel for the hiring of new physicians and define the degree of malpractice insurance in the contract. Other issues included the rotation of the administrative day, job sharing for physicians who wish to work part time and education leaves with pay.
The Negotiations Committee reviewed concepts involving "Leaves with pay" by looking at the contract language covering sick leave, more than 30 days of accrued vacation days, funeral leave, and disability. Also, some employees on the Negotiation Committee had a preference to celebrate the holiday "fiesta de los vasqueros" [festival of the cowboy's or Rodeo Day] instead of Washington's birthday.
In dealing with the issue of grievances, the committee did not see the need for the informal first step. They did, however, want only one set of personnel files. It had been rumored that the Personnel Department kept two separate sets of files. Employees, who performed in the role of Shop Steward, told committee members that they needed access to personnel files at times so they advocated contract language which allowed authorized union representatives to have that access when appropriate.
On the question of job classification, the committee wanted the union to be involved in the establishment of the criteria for new jobs. Because individual employees see their wages in terms of the employee working nearby, reclassifications proves to be one of the most difficult tasks for a union and frequently causes conflict within any bargaining unit.
A host of other issues were important to the committee and the membership. The union membership hoped for a real cost of living increase to match the real inflation rates and they wanted a review of the dress code.
The Negotiations Committee sought a review of the Labor/Management Committee and a strengthening of the Health & Safety Committee.
In general the union staff wanted financial information to come to them on a regular basis,
in addition to sporadic information on the progress of movement toward child care and the
concept of flex time. The union only occasionally received some financial information they
needed.
February 11, 1982
Workshop "Verbal Skills in Negotiations"
Larsen attended this workshop which had been set up by the American Nursing Association. The Registered Nurses on the eastside of Tucson at one particular hospital were hoping to unionize. In a close election to determine whether or not a union or professional organization could represent the registered nurses, the concept of collective bargaining lost.
But the workshop turned out to be a very useful tool for Larsen as she eventually became
the employees' chief negotiator.
February 22, 1982
Minutes of Shared Time Committee
This committee aimed toward allowing employees with heavy child rearing obligations or educational goals to work part-time.
For providers this meant that committee responsibilities, on call and all other basic job
responsibilities could be shared by two employees.
Larsen's Grievance
Larsen's grievance involving the January 8 incident went to the second level, to Mejia.
February 23, 1982
Special Union Meeting
The employees met to prepare for negotiations by reviewing responses from a questionnaire put out by the union. This questionnaire had been distributed to all employees in the bargaining unit, both union and non-union members, but the union members' responses were given greater weight.
The questionnaire tried to determine how the employees felt about current wages and
benefits.
The areas of the contract in which at least one third of the employees responses indicated either "Good" or "Poor" were:
Union Employees Non-Union Employees
Good Poor Good Poor
Disability X
Discipline X
Education Leave X X X
Evaluations X
Grievance & Arbitration X
Health Benefits X X
Health & Safety Committee X X
Non-Provider Staffing Patterns X
Promotions X X
Retirement Benefits X X
Sick Leave & Discipline X X
Vacation Leaves X X
Wages X X X
Lots of similarities existed between how the union members and non-union members saw
conditions at El Rio. The non-union members split on two issues: "education leave" and
"wages." Wages had become a major issue to many employees, both in and out of the union.
The non-union members did not comment on the issues of "disability," "discipline," "evaluations,"
"grievance & arbitration." They ranked "non-provider staffing patterns" as "average."
Some general comments made by the employees were:
--A cost efficiency expert should be brought in through the union.
--There should be more emphasis on nurse practitioner primary care rather
than expensive specialists.
--There was a need for more dollars for continuing education -
$250 per year was not sufficient.
--The concept of career ladders needed more attention.
Promotions were practically non-existent.
After you reach step 9 [the highest step] there was no where to go.
--Administration was top heavy. It was over staffed.
--There needed to be better access to information.
--There were discrepancies in wages--
some positions were overpaid while others were under paid.
--There were no controls over evaluations.
There needed to be objective criteria.
Some employees wanted evaluations of supervisors.
--The Medical Executive Committee (MEC) had no clout.
--Decisions involving provider staffing were made without input from providers
--Disability after 3rd day of sick leave was not necessary.
--The grievance procedure could be simplified.
--Sick Leave . . . Employees should not be penalized for sickness.
They should not be harassed for taking sick leave.
--The physicians received too low pay. This did not encourage physicians to stay.
March 1982 - Negotiations, Grievances, Committees & Others
March 10, 1982
Minutes of a Negotiation Committee Meeting
Issues were discussed in terms of what needed to be dealt with at the next negotiations.
The contract needed to specify entry level and step skills for family health workers.
A study group should be established through the contract for the development of a career ladder program for the purpose of studying potential options.
Those job classifications that had similar requirements needed to be determined and put into the contract.
Employees should be able to request a meeting with their supervisor to discuss their evaluation. At such times, a Shop Steward should be present. Many employees thought that they had the ability to fairly evaluate their supervisors.
Many employees thought that El Rio maintained more than one file for each employee. The employees wanted it contractually limited to only one personnel file for each employee. They also wanted their stewards to be able to have access to their files when they authorize such access.
Union physicians advocated that the Medical Executive Committee be expanded in
accordance with the MEC By-laws.
March 11, 1982
Letter from Benjamin Bogy, Director of Finance to Jon Showalter, Director of AFSCME
Showalter received only part of the information he requested on January 29. Bogy wrote that financial statements were not available as none "were proposed" for the months of December of 1977 and 1980, April 1981 and August of 1981.
Upon the completion of an audit in progress at the time of this letter, the December 1981
data and audit report became available.
March 17, 1982
Minutes of Union's Negotiation Committee
The Negotiation Committee met at 5:30 at a popular bar south of La Placita Center, in the center of Tucson, about half a mile from the clinic. Those who served on the committee were a pharmacist, licenced practical nurse, suite secretary, lab technician and accountant.
The pharmacists saw the issue of educational leave as very important. They wanted the same education leave benefits as the providers. The rationale for their position rested on the understanding that new regulations requiring pharmacist to have continuing education would be in place as of January 1982.
The American Society of Clinical Pathologists, the professional agency for the lab
technicians, had no continuing education requirements at that time. But, they were expected to
have requirements soon. Therefore, the lab technicians also sought education leave in accordance
with the requirements of their professional society. Additionally, the National Certification
Agency, the agency that certified lab technicians, did have a continuing education requirement of
40 hours per two years. The lab technicians thought that 30 hours might be acquired at El Rio.
How Employees Saw Showalter
Ed Celaya, who pressed for educational leave, saw Showalter as an excellent negotiator, as someone acting out a role when negotiating. Celaya astutely assessed Showalter theatrical perfomances at negotiations, but Showalter's antics were used judiciously and effectively. When negotiations began, Celaya astutely observed that union membership increased.
Elenez had a different view of Showalter. She believed that Showalter made things "sound real good" and that he made himself look like a big shot and then made everyone else do the work for him. She did not understand that the professional staff did the more difficult tasks like negotiations, handling complicated grievances and training stewards while the rank and file union members assumed much of the daily work. That the union staff had the knowledge, understanding and ability to carry out those tasks effectively remained the essential element.
Gallardo saw Showalter as a "starter upper," an organizer. While many might argue that this quality is also essential among professional union staffs, El Rio employees organized themselves. Showalter and his staff provided some aid but the employee carried out the central core of the work and this demonstrated a better that way.
Another employee, not eligible for the bargaining unit, saw Showalter positively as a very active and passionate man. She saw the union as an effective means for protecting the employees.
Most employees were appreciative of Showalter's talents.
Abalos, who sat in on her first negotiations, found the negotiation experience ". . . an eye
opener." Even though negotiations in 1982 were fast, efficient and relatively free of previous
hostilities, she commented on how bad the administration could be because ". . . the
administration wanted to be in total control."
March 23, 1982
Letter from Showalter to Mejia
The union became aware that El Rio had added or upgraded a number of classifications
without keeping them informed. This requested to get that information. Additionally, the union
expected that short-term disability, retirement and malpractice insurance for providers were all
topics to be at the table at the next negotiations. Therefore, the union also requested copies of
the clinic's policy papers covering those issues.
Mid to Late March 1982
Negotiation Committee Meetings
The committee met several times in March and then again in April. They had been
meeting on a weekly basis on Wednesday evenings after work. The Negotiation Committee had
prepared well by the time negotiations begun on May 12.
April 1982 - Administration & Board at Work
April 5, 1982
Memo from Chair of the Union Negotiation Committee Chair to Committee
Members of the committee were requested to get specific information in preparation for
the negotiations. Jim Cooley assumed the task of ascertaining how many employees received
personal leave days. Isabel Godoy, the-union's new Vice-Chair, needed to go to the new
employees and ask if they had received their job orientation and/or the union orientation. Ethel
Larsen needed to work with the nurse practitioners on some specific concerns of theirs. Mark
Nichols got information about physician salaries. Nichols had been an NHSC physician but when
he completed his obligation to the Corp., he decided to stay at El Rio and join the union. But,
shortly after seeing the disparity in physicians' pay at El Rio with those outside, Nichols left the
clinic for a more lucrative position. Alicia Tovar had the task of checking on some concerns of
employees in the Dental Department. In addition to the specific tasks of committee members, the
AFSCME staff requested an organizational chart, a listing of job descriptions, the 1981 financial
reports and the 1982 budget from administration.
April 7, 1982
Memo: From Board's Grievance Committee, To: Jorge Garcia, Deputy Director and Ethel Larsen, Accountant I.
Larsen filed her last grievance because she believed that there had been persistent and harrowing harassment coupled with being under paid. This grievance made it to the board's Grievance Committee and their findings resulted in Larsen's vindication. She would be able to perform her job with less harassment. The grievance also provided an upgrade in pay and a new title.
"Finding that the grievance by Ms. Larsen was timely filed, the Committee finds as follows:
1) Administration is to develop a system regarding outside purchased medical services which assures:
a) that Ms. Larsen received all information necessary to do job;
b) that Ms. Larsen be included in all pertinent meetings which concern accounts payable for purchased medical services;
c) that Ms. Larsen be permitted to exercise her judgment in regards to performance of duties directly related to making arrangements for bill determination;
d) that Ms. Larsen be allowed participation in technological
applications in her department; and
e) that Ms. Larsen continue as a lead person in her department, with authority to
make appropriate work assignments.
2) Administration is to revise Ms. Larsen's job description to accurately reflect those
duties and responsibilities to be performed by her within the Accounting
Department
3) Administration is to re-evaluate the present Accounting Manager in regards to his supervisory skills, with an emphasis on:
a) his ability to establish rapport with those employees under his supervision; and
b) his attitude toward union members and their contractual agreement with El
Rio.
Further, Administration should monitor Mr. Stringer's comportment in regards to #3 (a)
and (b) above for a period of 90 days with both the union and management providing
separate monthly progress reports to the Grievance Committee. If at the end of 90 days
the progress reports indicate no improvement, the Committee recommends Mr. Stringer's
discharge."
While this lessened the harassment and upgraded the pay, it did not end the harassment.
April 8, 1982
Management Meeting
Jim Lynch, a large man with a gentle bearing and a relatively new and reasonably capable administrator, described a grant proposal for servicing adolescent needs which would be submitted as a joint project with other community agencies. An earlier grant-funded project for services to adolescents ended in early 1980 with the termination of Bill Bemis, the project's director. Lynch's teen program had a different focus.
". . .education for self discipline, maximizing family guidance and support, promotion of
adoption and providing 'core' services to included pre and post natal care."
Lynch distributed a letter of consent from the Washington DHHS approving El Rio's request to again designate areas in the catchment/service area as medically under served areas. He also distributed a summary from DHHS concerning expected funding cuts that the Reagan Administration advocated. Finally, Lynch reported that the annual review and update of the clinic's fee schedule neared completion. Lynch also worked with the nutritionist on negotiations for a nutritional program with St. Joseph's Hospital.
The Home Health Director announced that the nutritionist and the Health Education Director had presented a health promotions program at New Pasqua, a Yaqui site.
The Dental Department Director indicated that the Indian Health Service would run out of money for dental services for the Yaquis by April 30. If no monies were found, services would stop. Because of the increasing problems with inadequate money, a regular pattern of needs not met kept growing.
Mejia announced the addition of Optical Services at El Rio. The Finance Director reported that optical services had become available at the El Rio and that Jorge Garcia prepared flyers for patients and staff.
J. Garcia gave the Personnel Committee report. He requested funds so that Julia Soto could provide a training session for employees in the registration and reception areas. The training would focus on patient rights and patient grievance procedures.
The Executive Committee set the following policies:
"--Any travel in excess of $100 would require advance approval of the Board Treasurer.
--Required a monthly summary of patient complaints and resolutions be submitted to the Board by the Director of Community Relations.
--Requested a check on the health hazard of use of phones.
--Requested a report on the waiting time for answering when calling for appointment.
--Required a review of registration update procedures and a flyer for patients to explain the procedures.
--Bids had been requested from lawyers based on fee for service. Applicants will be reviewed by Mr. Mejia.
--Directed that all contracts will be signed by the Board President.
--Set an informal meeting be scheduled between Mr. Mejia, Jon Showalter and Mr.
Gaxiola on procedures for contract negotiations."
April 12, 1982
Memo from Larsen to Bogy
The decisions of the Grievance Committee of the board were not being carried out. This contributed to a further decaying of payments for medical services outside the clinic. Larsen wrote this letter to inform Bogy of the problems.
"Because of the actions of Tony Stringer, Accounting Manager, the full implementation of the Grievance Committee Report has not been actualized. Although administration developed systems governing outside purchased medical services, that system has only had limited implementation, as follows:
1.a) Information necessary to the coordination of medical accounts payable is not received by the MAP [Medical Accounts Payable] coordinator.
1.b) There are almost daily meetings involving MAP with the accounting clerk and the HMO accountant but excluding the MAP Coordinator.
1.c) The Accounting Manager does not recognize the job description of the MAP Coordinator and subverts its implementation, i.e., an attempt has been made to move the MAP Coordinator away from the resources necessary to carry out the MAP Coordinator's job responsibilities.
1.d) The MAP Coordinator has not been able to act as lead person over the
clerk handling the hospital bills.
The Accounting Manager, Tony Stringer, persistently subverts the MAP Coordinator by giving directions involving medical accounts payable to staff other than the MAP Coordinator. Although the Accounting Manager will, at least tersely, respond to inquires by the MAP Coordinator, he does not initiate any discussion on any matter.
I understand how painful the situation is for all involved and would welcome a spirit of mutual cooperation. Unfortunately, in some areas, this has simply not happened."
Additionally, Larsen spent less time on union activities as she sought to deal with the
growing problems of unpaid bills.
April 22, 1982
Minutes of the Board of Directors
By this time, the board minutes were posted in the employee lounge so the actions of the board were considerable more open.
Gaxiola, the board president, chaired this meeting.
The By-laws Committee had not met in the past month because of a lack of a quorum. Still, Gaxiola reported that they were waiting to get San Francisco's approval on the by-law changes which reversed the infamous earlier changes.
Kathy Tashiro gave the Quality Assurance Committee report. Tashiro, another board member supported by the employees, informed the board that the committee continued to review the overall expenditures of the purchased outside medical expenses. Bogy indicated that he was in the process of trying to:
"...negotiate a flat rate from the outside purchased [medical] services; which he feels will
be a better system than paying on a per visit per service basis."
For several years many of the outside providers had given discounted rates to El Rio patients. Those agreements began to erode in the previous year or two. The erosion was probably due to two major factors: first the climate in the health care delivery community was changing dramatically with changes in national policy and secondly the internal problems of El Rio undermined relations with providers of health care outside of the clinic. As El Rio's deficits grew, management dealt with the problem by not mailing checks made payable for purchased medical services. Increasingly, Larsen sent reports to administration of unpaid bills for medical services but just as regularly they were ignored. Larsen expressed her concern that the good will with outside physicians which had developed over the years, was eroding. Still, the idea of flat rates, if successfully negotiated, would be an improvement.
The Personnel Committee gave their report resulting in a motion which passed supporting a training module for employees dealing with patient rights.
The HMO Committee motion's to endorse the University of Arizona - El Rio medical service agreement passed.
The Executive Committee put several issues on the table. Among the items Mejia introduced were a site visit and the introduction of Medicaid into Arizona. Mejia stated that the Project Officer, Jack Maready, planned to visit El Rio on the 29th and 30th of April. Mejia also reported on the development of AHCCCS (pronounced "Access"), Arizona's program for medically indigent and medically needy people. AHCCCS stood for Arizona Health Care Cost Containment System. This long awaited Arizona medicaid program was to be actualized in October. Mejia both introduced the program and stated that two physicians and four administrative staff people were studying the proposed program.
Under Executive Director's report, Mejia stated that about $100,000 worth of volunteer help had been received last year.
Bogy presented the financial report. Copies of additional financial information were attached and made a permanent part of the minutes. Bogy reported that El Rio, as had been standard procedure in the past, had received a verbal but not a written waiver or expenses from the NHSC.
The Personnel Committee notified the board that they had one grievance and that grievance had apparently been dealt with successfully.
Soto talked about some patient complaints. Under "Call to the Public" one patient and a
former employee, Pat Patton, presented her concerns regarding the late payment of bills. She
argued that bills should be paid within a reasonable amount of time. But in reality, as El Rio's
deficit grew, payments for the purchase of outside medical services were made later and later.
April 23, 1982
Letter from Showalter to Mejia.
Showalter again requested financial and personnel information, this time for the upcoming
negotiations.
April 30, 1982
Schedule of Medical Purchased Services for the Four Months Ended April 30, 1982
This financial report showed the amount budgeted for medical purchased service at this
time was $500,066 but the actual amount spent was probably close to double that amount.
May 1982 - Employees Regain Right to Vote
Early May 1982
1982 Contract Negotiations Began Again
The negotiations proceeded in a reasonably ordered and effective manner. A common event during negotiations was that one side or the other might call for a break. Then one team, management or labor, would leave the room. When the management team left, it was common for some of the members of the union negotiation team to go to the other side of the table so that they could face each other during these private discussions or "side bars."
One day, during one of those breaks, while sitting on the management's side of the table, a union member found open notes by the Medical Director. This Medical Director was commonly called by many of the union employees, "The General." On these notes were scribbled plans for ending, at El Rio, the use of all mid-level providers, primarily the family nurse practitioners.
While the use of nurse practitioners had been a source of pride for many at El Rio including most of the physicians, among the more traditional physicians outside of the clinic they were often looked upon as a threat to doctors. The Medical Director's casual notes reflected a view that was quite common, at the time, outside of El Rio. But to those union members sitting around the negotiation table, they were both a warning of a potentially ominous future and yet, because the notes were found, they were also viewed with humor.
The negotiations around nurse practitioner and physicians' assistants issues took on a more determined pitch. The "MidLevel" issues dealing with working conditions and with compensation had reappeared at several different rounds of negotiations and this round was not different. What follows is a sample of some notes made in preparation for negotiating mid-level issues:
"I. [Management is expected to argue] Nurse Practitioners/Physician's Assistants should work at least 9 sessions/week. This is based on the reasoning that there is no logical reason why they should work less.
Response [Union]: There is no logical reason why NP's/PA's should work more. They
already put in greater than 40 hours a week and see enough patients to satisfy
federal requirements. In fact it was only after combining patient-doctor visits with
patient-mid-level visits that El Rio was able to come up to Federal standards. No
other group of workers at El Rio is being asked to increase hours worked.
II. [Management's Issue] MidLevel Practitioners should work the extra session every two weeks for no extra compensation.
Response [Union]: Just as there seems to be little justification for increasing the number of hours worked, there seems to be even less justification for not providing some sort of compensation.
When the wage proposal was presented by management, it was promised that no
one would end up with less than a 3.8% increase in wages. The mid Levels are
being offered a 4.7% increase with the adjustment of the wage scale and a 3.8%
cost of living raise. This is an 8.5% increase but also coupled with this is a 5.9%
increase in work load. This leaves a net gain of 2.6%-less than the promised gain
in wages and not enough to offset inflations. The result is that Mid Level
Practitioners will work a longer week for an hourly wage that is less than what
was earned last year.
MANAGEMENT IS ASKING ON AN HOURLY BASIS THAT MID LEVEL PRACTITIONERS ACCEPT A REDUCTION IN WAGES. IF THIS IS ALLOWED TO HAPPEN TO ONE SEGMENT OF THE EMPLOYEE COMMUNITY, IT ENDANGERS THE POSITION OF
ALL EMPLOYEES."
May 16, 1982
Letter of Resignation to El Rio administrators and Board Members from Jay Silverman MD
At this time, Kris Olson served as the new Medical Chief of Staff and Vivian remained the Medical Director.
Dr. Silverman saw the clinic in deep financial trouble and predicted that AHCCCS would be a financial disaster. Silverman's dark view of El Rio's future held some truth.
Silverman's letter mentions his resignation but also mentions the large turnover of
physicians. Before Silverman left, even though he never joined the union, he received help from
the union in pressing a grievance.
May 21 to June 23, 1982
Negotiations Resumed
Except for working hours, the negotiations were left open to employees who wished to
observe the proceedings. Well over a dozen employees, mostly union supporters, observed
portions of the negotiations. They came during their breaks, lunches and after work hours and at
times, during the weekends.
May 26, 1982
Letter from Mejia to Showalter
The materials that Showalter had earlier requested arrived.
May 27, 1982
At a meeting of the Board, the EMPLOYEES REGAINED THE RIGHT TO VOTE!
June 1982 - Site Visit and HMO Report
June 1, 1982
AHCCCS Progress Report
As of May 24, the federal government received an Arizona state plan for a novel medicaid
type program known as AHCCCS. Because of this novel approach to the problem of supplying
medical care to the indigent, Arizona received a special waiver. Under Arizona's AHCCCS, the
eligibility requirements were far more stringent than other Medicaid programs but once inside the
program, the ability to receive quality care would be better than most other Medicaid programs.
After completing and submitting the Research and Waiver Request to DHHS for approval on May
24 El Rio expected to receive approval.
June 2 & 4, 1982
Calendar Notes
Labor/Management Negotiations continue.
June 8 & 9, 1982
Site Visit Report to Unit Chief in the Federal Department of Health and Human Services(DHHS)
The "Site Visit Report" noted that the consultant had contacted Mejia, Bogy, Snyder and Stringer. The site visit had been made at Mr. Mejia's request for the purpose of:
"...analyze staffing patterns, workload assignments, job descriptions and appropriateness
of salary ranges for positions in the accounting department."
The report went on to explain the purpose of the site visit:
"Due to the excess expenses over revenues reported on El Rio's FY'81 audited financial statements, El Rio's Project Officer, Mr. Jack Maready, requested that an evaluation be made of the Center's present financial condition and, if possible, determine the major problems or reasons for the excess deficits and identify any corrective actions necessary."
The report for the four month period ending April 30 indicated a deficit of $598,532. This reflected almost 70% of the total deficit for all of the preceding year. The available working capital had decreased from a negative $838,402 at the end of 1981 to a negative $1,025,287 as of April 30, 1982.
The total revenues for 1981 were $6,560,000 while the total expenses for 1981 were $7,417,394. The difference of expenses over revenues showed a deficit of $857,383. In 1981, $2.8 million of federal funding represented 41% of the total revenues. The HMO revenues were $2.6 million. This represented 39% of the total revenues. All other revenues came from local & state grants, collections from patients and third party, and miscellaneous donated.
The average monthly deficit from 1981 was $71,448.00, while for the first four months of 1982 they were averaging $149,633. So the deficit clearly grew.
The report pointed to "some corrective actions" that had been taken by the board and staff. New limits were put on purchased medical services. To attempt to deal with the expanding purchased medical services, internal controls in the form of pre-numbered referrals were instituted.
The sliding-fee-scale, the charges to El Rio patients were raised.
About 21 employees had been terminated reducing the payroll until the end of the year by only $100,000. This meant that the employees laid off were lower income earners, averaging less than $10,000.00 per year. The Medical Director resigned eliminating about $60,000 from the budget. However a new medical direction replaced Vivian so much of that $60,000 would not be eliminated.
Some of the recommendations in the Site Report were:
In conjunction with this site report, Robert Gomez later conferred with Gaxiola and explored the possibility of Gomez assuming the position of El Rio's CEO. Although impressed by Gomez, Gaxiola felt the salary Gomez requested was unaffordable for El Rio at that time.
Robert Gomez would one day become the Chief Executive Officer of El Rio.
June 14, 1982
Minutes of the Board's HMO Committee
Snyder discussed the question of whether El Rio should have an HMO. Because of the overwhelming criticism of the HMO, Snyder suggested that one solution might be to sell the HMO. Since Snyder headed the Marketing Department, whose sole mission involved selling the HMO, his suggestion went against his own personal interest. The University of Arizona and Pima Care were both interested in El Rio's HMO. Other board members argued that AHCCCS that they did not yet understand the ramifications of AHCCCS. Still, others simply felt uncomfortable with losing control of the HMO. But Gaxiola had worrisome reservations about whether the federal funds for the neighborhood people were subsidizing the HMO. The problem would be resolved in 1986.
Family members of El Rio employees had medical coverage as part of the employees' benefit package. Snyder recommended that this not be considered as part of the HMO. The committee voted approval of this recommendation. All the same this had no actual effect on the net balance on financial reports, as it shifted the costs from HMO to purchased medical services.
The committee voted in favor of authorizing the HMO to advertise in the university newspaper, the Wildcat, for State employee enrollments.
About Mid June 1982
Labor/Management Negotiations begin again.
June 17, 1982
Larsen gave Jorge Garcia a photocopy of her report card with a Grade "A" for the
completion of the graduate level course in Public Administration titled "Administrative
Leadership." The contract required that they insert this information into her personnel file.
June 24, 1982
Minutes of the Board of Directors
At the "Call to the Public," patients/members of the corporation brought up questions of transportation, payment of bills, etc.
Edmundo Cardenas, requested a list of all administrative positions with their salaries to be sent to all board members.
With the exception of a few typographical errors, Mejia recommended that the board approve the latest Labor/Management Contract and the board unanimously approved the contract.
As Vivian would cease to be the Medical Director as of July 16, the Quality Assurance Committee discussed the next Medical Director. A motion passed requiring Mejia to hire a Medical Director quickly. The most likely place to look for a new Medical Director was among the staff physicians at El Rio. Two compelling options for the position of Medical Director were Warren and Olson, both union members, one of whom would have to relinquish her union membership if she assumed the position of Medical Director. The Medical Director, as one of the top administrators, was outside the bargaining unit and therefore anyone chosen for that position could not remain in the union.
The Personnel Committee recommended acceptance of the educational leave policy. The committee moved that the BCRR found administrative costs to be appropriate and that after reviewing the existing management positions, no further reductions were necessary. But, board member, Pat Nolan, thought that this motion premature and needed to be tabled.
In the discussion of balancing the budget, Cardenas' motion to slash the salaries of the Administration Directors 30% was defeated.
Nolan expressed an interest in how staff prioritized the payment of bills for medical
services. Bogy stated that basically, the oldest bills were paid first. This answer provided a
somewhat distorted picture. The bills were batched by the firm that provided the purchased
medical services. Within the batch, some bills might be for services given much earlier but the
batch might also contain bills for recent services. In general, bills were paid by the "squeaky
wheel" method. That is, the firm complaining the most got the next payment.
June 30, 1982
With the deteriorating financial situation at El Rio, some of the new board members were
now considering another change in the top administrator. Perhaps in response, the
administration tried to paint a rosier picture.
July 1982 - Plot to Fire Union Activist
July 1, 1982
Letter from Department of Health and Human Services to Fernando Gaxiola, Pres. of the Board
This letter informs Gaxiola of the "increasing concern" of the Director of the San Francisco
government office of the DHHS. The DHHS requested a list of financial reports.
July 7, 1982
Executive Committee of the Board
Gaxiola considered selling the HMO to the University of Arizona Medical Center. But when the issue arose at this board meeting, Gaxiola was absent because of illness and so had to wait.
Apparently there had been a report about morale problems among the administrative staff. This too had to be dealt with later because the issue appropriately belonged in the Personnel Committee.
Garcia and Mejia recommended an executive session to be held so the "situation in the Accounting Department can be explained." The executive session would be held at the next board meeting.
The federal government planned to send another site review team to Tucson around the last part of July or the first part of August.
About July 12, 1982
Plot to terminate employment of E. Larsen
By the waste basket next to the photocopy machine, Larsen found a note with plans on how to get rid of Larsen.
"Perhaps you and Stringer should get together and speak to Ethel Re: The Move.
Explaining to her the term of insubordination and the consequences of an employee being
insubordinate - termination. Then again ask her to move, offer assistance in moving and
if [she] refuses we can proceed with a termination if Anibal is still around today. If not
suspend and then terminate."
July 12, 1982
Memo to: The clerk and Larsen, regarding "Change in Work Location"
The last paragraph read:
"By the end of the day on Tuesday, July 13, 1982, I would expect to have Mrs. Larsen in the office. . . [the claims clerk] now occupies and. . .[the claims clerk] in the main accounting department office."
While Stringer and Jorge Garcia had expected Larsen to reject this move, Larsen found
the change desirable. She no longer suffered by being in close proximity to Stringer so she no
longer had to endure his frequent rudeness and rancor. By this time, Larsen understood the
claims clerk's role as tool of the more spiteful men while the claims clerk did not understand her
role in this conflict.
July 14, 1982
Executive Committee Meeting of the Board of Directors
Present: Fernando Gaxiola President, Sr. Maria Teresa Apalatequi, Isabel Garcia, Ed Espinoza and Lillian Lopez-Grant. Guests present were Mejia, Bogy and Jorge Garcia.
Bogy, at this time, still held the title of Director of Finance while Jorge Garcia now served as "Deputy Director." Bogy produced a "proposed revision summary" to be sent to the federal office.
A motion passed to open up the dental clinic to adults on a 100% prepaid basis. Another motion passed to accept a new fee scale for optometry services.
In a letter to board president, Fernando Gaxiola, the Department of Health & Human Services expressed concern about El Rio's financial position.
"Based on the statement of revenues and expenses for the four months ending April 30, 1982, the deficit was $598,532. If this figure were annualized, the deficit by December 31, 1982 would total $1,494,696."
The committee agreed to meet again, on August 4 with DHHS officials.
July 16, 1982
From Personnel Dept. to Personnel Committee of the Board
For the period of June 1- 30th, El Rio hired one employee. Actually it involved just a transfer of one medical provider from the NHSC payroll to El Rio's payroll. During the same time thirteen employees left El Rio. Three were resignations and ten employees were laid off. By the end of June, there were 193 NHC employees and one employee through the NHSC.
Still, El Rio maintained more employees than had worked at the clinic in 1979 or 1980. Most believed that the swelling of administrative employees had caused much of the financial problems so when employees were laid off, it no longer seemed to be political firings. While many union members accepted the idea that the financial problems were real, they understood that the contract offered some protection by specifying how lay offs were to be done.
Beverly McSweeney served as the Chair of the union. She worked at an entry level job as
a family health worker.
About Mid July 1982
Change in Medical Director
About this time, Dr. Vivian ceased to be the Medical Director but he would maintain a
presence at El Rio doing minor surgical procedures. Dr. Olson, Chief of Staff, received a
promotion to the position of Medical Director. Unlike Vivian, Olson not only supported the
union, she had been a union member before her promotion.
July 19, 1982
El Rio Department Heads Meeting
In a desperate attempt to reverse the mushrooming deficit, Mejia and other administrators looked hopefully at the future new program called the Arizona Health Care Cost Containment System or AHCCCS. Copies of a summary of the program were later distributed.
AHCCCS would be a prepayment program open to Arizona citizens. The report optimistically estimated 71% of citizens would be eligible. The categories of potentially eligible citizens were:
The estimation that 71% of the state's population will be eligible proved to be totally unrealistic.
Initially, it was planned that instead of state administration, private administrators run the
program. The date for AHCCCS to begin state wide stood at October 1, 1982.
About End of July 1981
Larsen becomes ill and was hospitalized until September 22.
August 1982 - Reports of Deficit
August 19, 1982
A "Confidential" Memo from Mejia to Board Members, Medical Providers, Department Heads and All Employees Regarding "Financial Recovery Plan"
For the first time, Administration admitted suffering huge deficits. They then presented their concept of the causes for that deficit and finally laid out some plans to cut costs. After introducing the problem, department heads were directed to participate in developing budgetary plans that hopefully would result in a 20% reduction in non-personnel items. Only supervisors, and in their absence "Division Executives," would be permitted to sign supply and equipment requisitions. Supplies had been identified which seemed to be used excessively at El Rio.
The first paragraph reads:
"A financial recovery plan becomes necessary as a result of serious pre-existing conditions. In a nutshell, these conditions are underlined at El Rio by what all of us knew so far: During 1981, and until April of 1982, we have experienced a $1,100,000 budget deficit. The Federal Government has served notice that its funding may not continue in 1983, unless a dramatic deficit reduction occurs. Federal representatives initially reviewed our preliminary recovery plan and deemed it as being 'optimistic,' perhaps a little over optimistic."
After giving an explanation of some of the problems, the report laid out potential areas where a reduction in cost could take place:
The union, because of its mutual concern about the financial health of El Rio, went
through a process of discussion with El Rio employees that resulted in a September 2 letter to
Mejia delineating suggestions made by the employees for the purpose of reducing the deficit.
September 1982 - Suggested Cuts in Costs
September 2, 1982
Letter from Showalter to Mejia
This letter presented suggestions made by employees to cut costs.
"1. Discontinue distribution of over the counter drugs.
2. Reduce prescription amounts. Patients are given multi-day supplies for drugs that may have to be discontinued in a short period of time due to better diagnosis or drug reaction.
3. Charge patients for no shows.
4. A multitude of suggestions came from employees regarding what the employees believed was excessive photocopying.
5. The Union would provide to the Center the use of its offset press for large printing jobs.
6. Blood pressure cuffs should be locked up after the day.
7. Discontinue supplies that were currently given freely to patients, such as lotions and diapers.
8. Revamp the immunization clinic for increased productivity.
9. Patients should be instructed on the importance of clinic cards and lab orders and perhaps charged for the loss of same.
10. Data Base should be updated and not redone every year.
11. Providers should be more specific on lab order tests regarding what they are looking for in order to cut down on tests conducted.
12. Assistant Supervisors should be demoted to full-time workers.
13. Referral for charts for hospitalization should be channeled to Utilization Review Nurse.
14. It should be the Team Leader's responsibility to distribute and collect GC plates each
day.
15. El Rio should be more stringent and crack down on collections.
16. Repeat lab tests are being lost or discarded. This should stop.
17. Review phone refills for potential people who might qualify for Medicare reimbursement.
18. Cut all trips, subscriptions and cancel all credit cards.
19. Employee time sheets should be monitored more closely.
20. End switchboard's overtime.
21. Stop duplication of grounds maintenance.
22. Review specialty clinic productivity in contrast to referrals.
23. Review South Park Clinic productivity - South Park Clinic might do better with reduced hours or even closing.
24. Charge for Medicare co-payment on prescriptions.
25. Encourage voluntary leaves without pay.
26. Have the last lab run from South Park in by 4:45 p.m. to avoid overtime.
27. Review mileage slips for consistency
28. Charge $2.00 for HMO Prescriptions."
Additional union recommendations were later presented.
"1. Personnel Costs:
--Friday morning should be treated as work time so that employees should be either at an authorized meeting or at their work station.
--Friday afternoon "happy hours' should be discontinued. Management personnel should set the example by arriving on time and staying at least until 5:00 p.m.
--Certain administrative positions should be reviewed for overlapping
responsibilities, i.e. Are administrative personnel taking on traditional accounting functions? [This was true of the BCRR report. A
large portion of the report had, in the past been successfully done by
Larsen, but later it was being done by much higher paid administrators.]
2. To Maximize Current Resources
--Administration should review the misuse of personnel with the following
in mind. Maximize the talents of personnel. Do not abuse personnel by
putting them in situations beyond their current capabilities.
3. Lighten the Cash Flow Problems
--HMO Billings should be timely. The group plan billings should go out not later
than the 20th of the month preceding coverage. In the past, prepaid funds drew
interest and therefore were an added revenue.
4. Reduce Cost of Medical Purchased Service
--Detail reporting on the category of "Outside Medical" which is listed on the monthly financial reports.
--Medical A/P data should be made available so that it is feasible to shop around for less expensive but comprehensible service.
--Medical A/P data should be made available so that the Center would know when it is more economical to provide the service in-house.
--Medical A/P data should be made available so that the Center may negotiate prices with outside providers.
--A review should be made of the effectiveness of current contracts with outside providers and where appropriate, the contracts should be renegotiated.
--Where possible, discounts should be negotiated with outside providers."
After two days of discussions, the union and management agreed on a series of conditions by which the union allowed a temporary freeze on retirement contributions for six months. Should those conditions not be met, the retirement contributions would not be frozen.
Additionally, El Rio agreed to implement those ideas dealing with accounting procedures and the development of a meaningful data base.
The board, in its capacity as policy making body, agreed to undertake the following changes:
1. Develop charges for no shows
2. Set pharmacy on a cash and carry basis
3. Close registration to new fee-for-service patients.
4. Revise upward the sliding fee scale.
5. Implement stronger collection and bad debt policy.
6. Hire a collection agency to go after unpaid bills.
7. Approve a minimum payment policy.
8. Approve tighter medical policies for referral and hospitalizations.
9. Charge for co-payment of Medicare prescriptions.
10. Discontinue over the counter drugs and supplies.
Additionally, the union allowed El Rio to use its offset press. Also, after the ratification
by the union membership, retirement contributions would be suspended for a period of six
months. If El Rio met its goal of reducing the budget deficit by $200,000, the employees'
retirement contribution would be turned over for El Rio's use and then paid back within five years
or within six months if an employee's work terminated.
September 22, 1982
Medical Accounts Payable
Larsen returned to work after a two-month absence. During her absence, few if any bills had been processed. For several months, Larsen attempted to alert the administration to the growing problems in medical accounts payable. When unsuccessful, she began putting monthly reports of the conditions in a more formal form on paper. She called these monthly reports, "Recommendations Leading to Policy and Procedure Changes." Shortly after returning to work, she produced the next report. When Stringer ordered her not to use valuable working hours making any reports, Larsen began preparing the reports during her own time. Larsen repeatedly tried to alert the administrators to the growing problems. Still, her reports suffered some major flaws:
September 23, 1982
Medical Director's Report
A review of hospitalizations showed that there were close to 2,000 hospital days where El Rio physicians had encounters with their patients but were not counted. This resulted in a total loss of $174,620 over 19 months for which El Rio could bill Medicare. It also meant that the BCRR report could be amended dramatically.
Harriet Hand, a registered nurse whose new job responsibility involved monitoring outside utilization of health care services, discovered that no prior authorization existed for visits to the University Hospital for admissions and also for ER visits. Controls needed to be developed to change that situation.
Other issues involved IHS audits showed improvements in quality of care. A utilization
review studied patients in the community medicine HMO.
September 24, 1982
Memo to Union Members from AFSCME - El Rio Negotiations Committee
After much consideration, the Negotiation Committee decided to NOT allow the suspension of the retirement fund. "THE RETIREMENT FUND WILL NOT BE FROZEN."
October 1982 - Medicare through AHCCCS Comes to Arizona.
Starting in October 1982
El Rio Gains Contract with the Arizona Health Care Cost Containment System (AHCCCS).
After months of planning the AHCCCS program is implemented. The plan was structured so that there was an array of programs some of which provided services to meet the needs of people in small businesses in addition to the indigent. Unfortunately, because AHCCCS just began, insufficient data existed for estimating appropriate costs. Health care centers or facilities had to bid against their competitor in order to get a state award. El Rio gave the lowest bid (what the state had to pay to El Rio) for the sickest patient group and received a state AHCCCS contract.
At that time, the AHCCCS benefits provided by El Rio included:
Indigent people, who wanted to enter the program, had to establish their eligibility at a County office. After each patient established eligibility, the state prepaid the health facility on some per capita basis (established through the bidding system) and then the health facility had to provide all included benefits if authorized by a "gate keeper," usually a qualified El Rio physician.
In emergency situations, the hospital still needed to get authorization if they wanted to be reimbursed. The major difference for indigent patients under AHCCCS involved their need to reestablish eligibility status periodically, which proved to be an on going hassle.
Herlinda Valenzuela remembered that while they had problems dealing with the patients before AHCCCS, the addition of AHCCCS patients caused the problems to grow dramatically.
October 1, 1982
Union Contract
At this time, because the inflation rate was high, the management team suffered in disarray and ambivalence in dealing with their financial difficulties. All employees (both in and out of the union) pressed hard on the issue of wages, so the union successfully negotiated a large wage increase.
"Retroactive to October 1, 1982, all employees shall receive a 15% raise in the current
salary to defray the rise in the cost of living."
The new employees who came to the clinic and joined the union, did so without knowing or understanding the original goals.
Many of the other long term employees were battle weary. Larsen, who might have
sought to soften the high increase, remained tied up in her own personal battles with ill health and
her new growing union responsibilities outside of El Rio.
October 7, 1982
Harassment Survives
Larsen and one of the stewards met with Mejia to discuss the grievance. Although the
board had ruled in favor of Larsen, a resolution to the problems still eluded them as the problems
were allowed to continue. Little appeared to have changed. Stringer suffered only a slap on the
wrist.
Mid October 1982
Mejia's Termination
Growing dissatisfaction with Mejia's handling of administrative problems led Gaxiola to
work toward securing Mejia's termination. About this time, Mejia took vacation leave. When
Mejia returned, the board requested his resignation and if he did not do this, he would be fired. It
would be a few months before Mejia actually left.
Throughout October 1982
Union Meetings
The stewards held several meetings. At meeting one such meeting, candidates running for
slots on the Board of Directors were endorsed.
November 1982 - Board's Annual Election
November 3, 1982
Union's Election Committee Prepares for Board Elections
This committee, reestablished in response to concern with the election of representatives
to the Board of Directors, had the responsibility to review the candidates for the up coming board
elections. Union members needed to confirm or reject the recommendations of the Election
Committee. After the membership confirmed the recommendations, they began leafleting,
phoning and contacting other employees. On November 10, two of the candidates supported by
the union, Isabel Garcia and Fernando Gaxiola were reelected. Shortly afterward the employees
celebrated the board elections at a party at the union hall.
Throughout November 1982
Union Meetings
The Career Ladder Committee met several times at noon at local restaurants. As the committee began to study their potentials for incorporating the concept of a career ladder in negotiations, the clinic's financial situation steadily deteriorated and eventually most of the ideas emerging had to be dropped. Still there were some good things that did come out of the work put in by the committee. In a few years, family health workers with the help of the union devised a program where they could get additional education leading them to increased incomes.
The main topic at one general membership meeting discussed "Health Care Costs." Because those costs were rising so dramatically, health care benefits were increasingly being brought to negotiations by managements who wanted radical changes. Because El Rio provided health care services, employees viewed health care as a benefit with greater importance than perhaps at other job sites. El Rio employees would soon also need to protect health care as a benefit. The union wanted the employees to be aware of this trend.
The union's Negotiations Committee held several meetings in preparation for the next
round of negotiations.
Sometime in November 1982
James "Jim" Lynch assumed the position of Interim Executive Director. Few employees
outside of administration knew much about Lynch.
December 1982 - El Rio's Annual Report
December 1, 1982
The Negotiation Committee met at 5:30 p.m. in the AFSCME office.
Mid December 1982
Union Committees
The union's Negotiation Committee continued to hold meetings in preparation for the next round of negotiations.
The Health and Safety Committee met and focused on "Stress in the Workplace." The
conflict at El Rio, insecurity about jobs, the financial squeeze all contributed to a highly volatile
work place. The committee's workshop responded to these serious problems.
End of 1982
1982 Annual Report
El Rio received a 30% cut in federal funding due to the Reagan Administrations reduced funding for social service programs. Additional austerity actions were implemented by the board in an attempt to reduce the cost of purchased medical services.
El Rio successfully bid to secure AHCCCS funds to service up to 10,000 patients. But they won the contract by being the lowest bidder. They later discovered their bid fell below the actual cost to the clinic, so in the long run it further hurt the financial situation.
Under the direction of Olson, a major reorganization of the triage clinic took place and referrals to outside specialists were reduced.
The HMO had grown by 28% in 1982.
". . . by 1983, El Rio expects to have eliminated the deficit incurred in 1981 and 1982. . . "
This amounted to a totally unrealistic expectation and contributed to the ambiguity surrounding
the deficit.
Union Newsletter
This edition of the newsletter outlined the accomplishments of the Health and Safety Committee. The committee, a joint labor and management effort, had been chaired by union member Dr. Barbara Warren.
Celaya believed that Warren brought a lot of sophistication to the bargaining unit, but like another earlier employee, he thought that Warren's advocated more for the physicians then for the rest of the bargaining unit. That idea proved a bit ironic, because the same thing could be said for Celaya and others. Most employees advocated for the general area in which they worked because that was what they knew best. Family health workers advocated for family health workers, physicians for physicians, pharmacists for pharmacists and so on. Before negotiations, all of these interest groups got together among themselves, determined their issues, set priorities and then brought them to the full group to negotiate as one team. The coming together after determining their specific need made these negotiations unique and special. Once that broke down, there were real problems.
Zora Zemsky, a family nurse practitioner and union member, served as the new Chair of the Health and Education Committee. Zemsky, a caring, vivacious person had been a long time progressive activist especially in family planning and women's rights.
These then were the 1982 accomplishments of the Health and Safety Committee:
"--The establishment of the Fire Plan for the NHC.
--Representatives from the state offices of OSHA were invited to identify
safety hazards in the clinic area.
--The establishment of a Health and Safety Education Schedule for employees.
--The establishment of a program to review employee medical records to
Update immunizations, screenings and examinations.
--Review of chemical hazards by the industrial hygienist from the
State Compensation Fund.
--The establishment of protocols for infectious disease hazard management.
--Health & Safety questionnaire developed for all employees
--Development of fact sheets for information on various hazards by
departments within the health center.
--Changes in the Health Care facility regarding infection control
--Development of an Infection Control Program for the entire Health Center
for both employees and patients."
At the National Level in 1982
The budget of the National Institute for Occupational Safety and Health decreased 25% from 1980 to 1982.