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Hard to Heal

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"Grace Hill has some very good programs that they run out of the neighborhood health centers." he says. "The problem is that the people have to get to those health centers, which can be difficult. They do a good work in the community. I am not disputing that at all. I just thought they could do better in regard to the homeless."

When Rottnek was voted in as president of the Health Care for the Homeless Coalition, the advisory board Grace Hill had brought into its fold, he saw an opportunity to voice his concerns.

But he never anticipated how prickly things would get. Or how fast they would get that way.

For several years, the HCH advisory board hummed along nicely.

"We had a lot of good people on board," Appoo says. "The meetings were nice, and we did a lot of sharing."

Ideas and nice meetings weren't the only thing shared by board members.

Grace Hill held the strings on federal funds for homeless-health-care programs, deciding who would get the money and who wouldn't. Most members of the HCH board worked for agencies getting money from Grace Hill.

"Too many providers were on the board," says Laura Drake, a former board member. "It was somewhat of a conflict of interest."

By Appoo's own admission, the board was passive. But when Barbara Weakley, director of mental-health programs at St. Patrick's Center, a homeless shelter, stepped down as board president and Rottnek was voted in, those nice meetings became contentious affairs.

And the sharing centered on hard words and mistrust.

Rottnek brought Sandra Duvic onto the board. Duvic, a seasoned, no-nonsense administrator at the Institute for Research and Education in Family Medicine, where Rottnek still works, became board treasurer. Another ally with ties to the institute was Drake, who was elected vice president of the board.

"When those three came on board, the meetings, which used to be so good, turned contentious," Appoo says. "Three people from one organization were creating a very negative atmosphere, and all of them were from Family Institute."

Duvic says she was simply asking questions about how money was being spent. She demanded clear answers on the number of homeless patients served by Harbor Light and other agencies.

"I couldn't understand that if the clinic at Harbor Light was carrying the lion's share of providing care to the homeless, how come the funding didn't reflect that," Duvic says. "It only makes sense that if one site had an increase in patients, the funds should be shifted to better meet that need.... The numbers never added up. We kept asking for the same things, and they would always bring something in but never what we asked for."

Appoo cringes when Duvic's name is mentioned.

"I was so glad not to have anything more to do with her," she says with a roll of her eyes.

She also presents a far different slant on the boardroom infighting.

"We did provide them with all the information," Appoo says. "At every meeting, we were providing lists of things. My goodness, it starting getting to us: Why, when we are spending so much money on total health care, are they wanting these pieces of information?"

Rottnek only cared about the homeless he was trying to serve.

Case in point: Grace Hill continually reported cost overruns on prescriptions for the homeless that were tapping out the grant and preventing some patients from getting any medication. Rottnek pressed for a price list of prescriptions so he could suggest cheaper alternatives but kept running into a stone wall. He kept asking. When the board finally got a printout of prescription costs, some members were shocked at what they found.

Grace Hill was charging a $9.75 dispensing fee on every prescription the agency filled. The fee, tacked onto every prescription, meant that a $5 bottle of Motrin ended up costing the grant $14.75.

"I was appalled," Duvic says. "On one hand, they are saying they can't fill some prescriptions because they are over budget, but it is because they are charging this huge fee. Basically they were charging $9.75 for a bottle and label. I found places that would do it for $3, but Grace Hill said they couldn't do that because they would lose their funding."

The dispensing fee is a fairly standard budget gambit; however, the federal Department of Health and Human Services, which oversees the homeless grant, says dispensing fees shouldn't be higher than those for Medicaid patients. In Missouri, commercial pharmacies can't charge more than $5 to fill a Medicaid prescription.

Those rules don't apply to Grace Hill, Appoo says. As a federally approved health clinic, Grace Hill is allowed to have higher fees.

"When we fill a prescription, it includes others things we provide, like transportation," she says. "The important thing is that whatever we do is audited and approved. Our fees are right in line with other clinics' throughout the country."

Besides, she says: "No homeless person ever had to pay that fee."

Maybe not, Rottnek and his allies say, but money for these overhead costs did come out of the grant. And fewer homeless patients were served as a result.

"Instead of three people getting medicine, only one person is getting it," Duvic says, "all because Grace Hill is charging a $9.75 dispensing fee on a bottle of aspirin. Someone is paying for it -- and it's the ones who need it the most."

Appoo bristles at the notion that Grace Hill was doing anything wrong. She accuses Rottnek, Duvic and Drake of having a hidden agenda.

"Our record speaks for itself. What was their agenda? Now, that is really the question that needs to be asked," she says.

The central problem of the advisory board was its lack of real bureaucratic clout, says Drake.

"We were just interested in people getting the services they needed most," she said. "I think some people were threatened by the questions being asked. If Grace Hill is controlling all funds, then what funds are we really responsible for? Were we just expected to rubber-stamp everything? It wasn't being antagonistic; it was just being honest."

Duvic wonders whether Grace Hill has lost touch with the people it claims it wants to serve.

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