The price of change
Haight Ashbury Free Medical Clinic's management style and transition to sliding scale trigger staff exodus

By Nicolas Gattig

Beginning in the hippie heyday of 1967, the Haight Ashbury Free Medical Clinic brought a communal spirit to its mission of offering free medical care to the city's poor. But today, with a $14 million budget and 11 offshoot programs outside the main clinic at the corner of Haight and Cole Streets, Haight Ashbury Free Clinics Inc. is using a stronger managerial hand to grapple with financial problems and the demands of modern managed health care.

Not only will the clinic break with tradition next month when it caves in to federal demands and institutes a sliding-scale payment system for its clients, but also the autocratic manner in which that and other changes have been made has triggered internal unrest and an almost total staff turnover at the clinic.

The Bay Guardian spoke to eight former staff members, who are perplexed and saddened by what they see as a management out of touch with the clinic's old values. "The loss of institutional knowledge has been devastating," contract manager Erik Johnson wrote in his resignation letter last month. "The damage done to the medical program will take years to repair."

Forced fees

Darryl Inaba, the company's CEO and one of the clinic's founding members, told us the sliding scale has been a federal mandate for many years and was already looming when he took office in 1998. Sixty percent of the annual medical funding ($700,000) comes from the San Francisco Community Clinic Consortium, which disburses federal money.

Having worked around the mandate for many years, the clinic last September was finally put on probation by the SFCCC: if the sliding-scale system isn't in place by February, the medical program will lose a vast chunk of its funding.

"We have no other choice," Inaba told us. "But most clients are really unable to pay, and so we won't charge them. No services will be refused, and the amount of free care should remain about the same."

While the former staffers feel uneasy about the sliding scale, most of their resentment comes from how this change was implemented. Inaba didn't seek staff input for the fee change or during last summer's process of hiring program director John Grima, who now manages the clinic.

Without being given a clearly outlined procedure, employees and volunteers had to sign a pledge to comply with the sliding scale and were warned that refusal would lead to automatic termination. Indeed, Grima fired a front office worker and a volunteer doctor after they objected, causing tension among the remaining staff.

In addition, the departed employees say Grima told staff members that everyone was replaceable, a notion opposed to the clinic's former supportive team spirit. When he reduced staff meetings from four meetings a month to one, communication all but shut down.

Grima defended the pledge and dismissals as being necessary to secure vital funding. "The pledge was to ensure that all staff and volunteers were aboard with the requirements and adhere to our contracts. The two individuals refused to participate in correcting the issues for which we are on probation, and so the decision to move on was made."

Staff exodus

The full scope of the staff exodus is immense. In the last 11 months, the clinic's medical section has lost all but two of its 23 employees, including the entire management team and front office staff, as well as all medical providers, several of whom have served clinic patients for more than 10 years.

According to the former staffers, the management made no effort to retain people who were ready to quit. Despite long-standing, excellent performance, none of them were asked about their reasons for leaving or possible ways to keep them at the clinic.

Joe Elson, who was the medical director for 12 years until he left in 2003, told us, "There was no debriefing, no exit interview. My phone calls to board members and the management team were not returned. Of course I was hurt."

Three months ago a group of 10 staffers made passionate pleas at a company board meeting, warning about the steep decline in staff morale and strongly urging that communication improve. Board president Tim Covington did not return our calls seeking comment.

Grima said he regrets the losses but not his approach: "My hope was that all staff would stay to help work on the issues that had been created a number of years ago. I am saddened, as is the agency, to see this group of individuals leave."

Asked about the exodus, Inaba said, "I think people were unhappy about management changes" but would not elaborate.

Moving forward

Despite all the turmoil, the CEO remains hopeful for the clinic's future and even plans for it to expand and move to a larger site. Johnson, however, gives a pessimistic financial prognosis: "Every day the clinic continues to lose money. The current strategy of management will eventually result in, at least, a temporary clinic closure and the loss of many more services."

Far less profitable than it was a year ago and continuing to lose more money as the number of annual visits declines from a high of 17,000, the medical program has already trimmed 12 hours a week off the time it is open and has begun to reduce services like HIV testing. The changes have chased some patients away.

"I can't afford to be in a situation where suddenly something doesn't work," said Michael Holland, an HIV patient who left the clinic a year ago after being without a supervising doctor for two months.

It is still unclear how the sliding scale will affect clients or impact the medical program in the long run. The management hasn't worked out the details yet, but Inaba said income background checks and collection agencies will not be involved, unless they become federal mandates as well. In the meantime, management and the board of directors intend to look for more funding sources.

As for the remains of the medical program, the once familylike environment is now torn by anger and distrust. "In the past it was an honor to work there," said Suzy Goldsmith, a former senior management member. "But now it's a mere shell of what it used to be. The management destroyed the culture of care."