Hard to Heal

Fred Rottnek, doctor to the downtrodden, tried his luck playing the boardroom politics of one of the city's most prestigious charities, Grace Hill. He lost. So did the homeless of St. Louis.

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.

Jennifer Silverberg
Dr. Fred Rottnek: "I don't necessarily love medicine. I just love what I can do with medicine."
Jennifer Silverberg
Dr. Fred Rottnek: "I don't necessarily love medicine. I just love what I can do with medicine."

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 theiragenda? 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.

"At one point, they got a grant to provide diabetes education to the homeless, and one of the suggestions was refrigerator magnets about healthy eating," Duvic says with a snort. "Refrigerator magnets? How many homeless people do you know that even have a refrigerator? And, I'm sorry -- if given the choice between a cream pie and going hungry, I'm sure a homeless person will choose the cream pie, diabetes or not."

For Rottnek, the discovery of the dispensing fee was the last straw. He resigned from the board in December of 1999. The advisory board disbanded one month later -- because its services were no longer needed, says Appoo. Nevertheless, Grace Hill recently formed a new advisory board -- minus Duvic and Rottnek.

Bureaucratic warfare left an aftertaste that reminded Rottnek of the corporate medicine he left so long ago -- only much more bitter because it was served up by an organization created to serve the poor and the homeless.

"I don't know who is making decisions," he says. "I don't think it is malicious. Sometimes I think it would make me feel better if it was. It would make it easier to stomach. I think there is a void in leadership. There are not a lot of leaders in health care today that have a fire in their belly on pursuing what they should, especially when it comes to taking care of a bunch of homeless people."


Despite the rift with Grace Hill, Rottnek was still committed to the clinic at Harbor Light. He continued to operate for a year-and-a-half without any financial support or prescription privileges from the charity giant.

Other volunteer doctors also continued to serve, despite their disillusions. Bic Stafford, a podiatrist, dipped into her own pocket to buy medication.

"It is just not fair," she says. "Grace Hill has money to do this. I was just a volunteer. I shouldn't have to treat the patient and buy the medication."

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