Cook County Health and Hospital System Finance Meeting Feb. 15, 2013

The meeting was called to order by Chairman O’Donnell at 7:30 a.m..  During the public comment period, a citizen complained that the $149,000 contract for media outreach approved in January d was $1,000 short of the $150,000 needed for a vote by the Finance Board. Chairman O’Donnell replied that all issued contracts are in compliance with the law.

Gina Besenhofer, Executive Manager of Supply Chain Operations for CCHHS, introduced Jacky Gomez, the new director of Compliance, to the Board, and then proceeded to introduce Contracts and Procurement items for Board approval.

The first item was a grant increase of $35,004 from the U.S. HHS Administration for diagnosis, treatment, and rehabilitation of patients with Black Lung disease which would bring the total grant to $333,000.  

Item two was the approval of payment of $2,496,000 for the purchase of insurance covering against potential liability for the cost of services relating to organ transplants required by persons who enroll in the County Care Program.  Dr. Ram Raju, Chief Executive Officer of CCHHS, explained that the CCHHS hospitals do not do organ transplants, but would be required to do so by the Affordable Care Act 1115 waiver.  He said that having this insurance would enable CCHHS to send a County Care patient to a facility specializing in organ transplants if it was necessary, and the insurance would take care of the cost of the transplant.

Dr. Raju said it was unknown whether they could have zero or four transplants in a year.  The County Care plan only provides $313 per month per patient.  The transplant insurance allows CCHHS to control costs.  Director Michael asked if this was the best price for this type of insurance and Dr. Raju  said it was.

Payment to the Olenick Consulting Group, LLC for International Classification of Disease-10 (ICD-10) training and education was for $357,180.  This training was necessary to be ready for the huge investment and operation level of County Care.  CFO John Cookinham said the Coding Project was very detailed.  Dr. Raju said it was difficult to be doing the new County Care enrollment and the new Coding System simultaneously, but they could not postpone the Coding because they needed to move forward faster.  Director Michael asked how they could improve the Coding throughout the System.  Director Cookinham said it was necessary to reeducate the coders and that outside studies of the hospitals showed that in-patient coding had improved.

Payment for professional services from Health Management Associates for $718,363 is an amendment, extension, and increase to the original contract. Dr. Raju said he had underestimated the CCHHS needs, and that there was more that needed to be done than originally thought.  Director Michael thanked Dr. Raju for his explanation but said what was difficult to understand is why there was an urgency to extend the contract for a month, when they could just wait and see how much more was needed.  Dr. Raju assured him that they needed to pass the one month extension now because of the Waiver.

Payment for the professional services of Susan Greene and Associates at $540,000 is to enroll applicants in the County Care program under the 1115 Waiver. A contract with More Direct, Inc. for computer blade servers and storage was for $1,974,999.20.  A contract with More Direct, Inc. for Cisco network gear in Phase II of the Network Refresh Capital Project was for $944,915.  A GE Healthcare contract for DMS software maintenance was for $280,428.  A contract with More Direct, Inc. for Fujitsu 6130Z scanners was for $235,630.46. A contract for service of the MUSE/Mars Systems hardware and software maintenance was for $185,373.46.

In discussing the contracts, Director Michaels said they needed to do a write up for replacement of IT equipment since they are replacing very old equipment and there are risks.  

All of the contracts were approved by the Finance Committee.

Dorothy Loving, Executive Director of Finance, presented the January financial reports.  She said that Revenue was very low. Director Cookinham said that all County Clinics are now included within the 35 mile radius, except Sengstacke.  He also said the Budget needs further realignment.  Director O’Donnell said the Board has been working on decreasing Expenses.  Dr. Raju said they have been looking at re-alignment of the Expenses of Oak Forest since it is a huge campus and the Board is spending lots of money in maintenance.  He said in the next ten years the buildings will be much older.

Ms. Loving said there has been an uptick in the dismissal of final patient bill. Director Cookinham said the goal is to be at 100 days or less.  There was a need to continue meeting with Information Systems.  Dr. Raju said there is a built-in delay of a 90 day notice.  This year they are down to 109 days versus 279 days last year.  Dr. Raju does not think they will ever reach a 50-60 day level.  He said public hospitals vary by state with some at a 60 day notice.  

Director Carvalho said that when the Affordable Care Act begins, everyone must be enrolled in some program. Dr. Raju said some people do not want insurance and CCHHS needs to figure out what to do with 500,000 people and how to care for them.  Director O’Donnell said a Public Hospital must care for everyone, not only in the County, but also Statewide.  Director Carvalho replied that by October eligible residents must be enrolled under AFCA, Medicaid, or Carelink.  He said the State is going through some of the same process.  He asked if someone at 138% poverty level in the state will still have co-pays if Cook County doesn’t have co-pays.

Dr. Raju said it took 60 days to collect all the bills and submit them, and two weeks to get the money which gave CCHHS a two and a half month lag.  He said everyday the obligations and approvals must be tracked and that the complexity makes this a time-consuming job.  He said they have to understate their total obligations, but yet track every obligation. 

Chairman O’Donnell said that the Finance Committee needs a more useful financial tool.  Director Carvalho said they need to manage for oversight.  He said they need to have projections and know why they don’t come true.  Dr. Raju said they must create a model in the next several months.  Director Carvalho said that Price-Waterhouse was also offering to assist.  It was decided that Directors O’Donnell, Carvalho, and Michael will come up with a discussion and plan for projections and assessments.
 

Susan Greene reported on the Section 1115 Medicaid Waiver Demonstration Project known as County Care and said they have 12,000 applications completed.  The goal was to obtain 500 applications per day, but yesterday was the first day they attained that goal with 511 applications. Ms. Greene said they try to remove the burden from the applicant by having the office look up the birth certificate information. She said the Carelink targeted outreach has been very successful.  Those persons eligible for any type of insurance are not eligible for Carelink.  Ms. Greene said there had been a wide geographic enrollment and she will be training Cook County enrollers trying to get to the center of applicants.  She said at the point of application, people pick the site where they want care.  Ms. Greene continued that the approval rate by the State is exceeding 90% because of the excellent fill-outs and the training of the workers. Director Velasquez said they needed the enrollment numbers as soon as possible.  Dr. Raju added that there was 92% approval rate by the State.  Ms. Greene said there were 60 different application leaders who were supposed to report each Wednesday, but they often did not do so because they were waiting for the completion of more applications. Director O’Donnell inquired about those who were enrolled, but were getting care elsewhere.  Dr. Raju replied that 8% might be enrolled at Stroger but were getting care elsewhere and that this was something that had to be worked on.

Mr. Cookinham, Chief Financial Officer, presented the January financial report.  He thinks the Waiver is important, but only a portion of the overall Revenue budget.  He believes that at the end of February, due to the Waiver Enrollment, expenses might by higher.  Director Michael said that they didn’t know what the Revenue calendar was through the year.  Mr. Cookinham said he can provide a monthly projected Revenue, and also on a weekly basis.  He said these were Dashboard options.  Director Michael said he would like to see the Predicted Revenue and Variances, and the reasons for the Variances such as less usage, or delays. Director Carvalho said there are always Variances, but they must have explanations.  Dr. Raju said the Patient Revenue should be divided equally through the year, but there is a need for seasonal variation.  Director Carvalho said that predicted Revenues, Actual Revenues, and Variances shown with explanations on a monthly basis were necessary to see whether the System was in difficulty, or doing well.

Chairman O’Donnell adjourned the meeting at 9:30 a.m..

Submitted by Eleanor Prince

Cook County Forest Preserve meeting February 4

The meeting was opened with a particularly nice ecumenical prayer from the Rev. Clare Butterfield of Faith in Place.  Then there was a report and discussion of the extensive tree removal program that has been undertaken in reponse to the Emerald Ash Borer problem throughout the region.  Also, it was noted that the CCFP would be going to court later in the day to have the Shakman Degree lifted (this was successful).  A general discussion of finances followed.  The FP levy will be flat compared to 2012.  More fees for programs are being collected than in the past, and there is a catch-up on licensing which is generating revenues, but some expenses may rise too as vacancies in staffing are filled.  The CCFP is seeking to hire professional staff to ramp up the concession program.  This may take a couple of years.

An interesting development is the appointment of a New Century Plan Commission for the Forest Preserve, which is composed of prominent citizens and which will look forward and plan for the next century of Forest Preserve protection and growth.

Cook County Board Meeting February 5, 2013

The meeting was called to order at 11:20 p.m. by President Toni Preckwinkle.  All commissioners with the exception of Schneider, Simms, and Steele were in attendance. 

The meeting began with tributes to Hadiya Pendleton made by each board member.  She was the young lady tragically gunned down in a Chicago’s Kenwood Park shortly after her attendance at the US presidential inauguration. The board met recently with ten mothers who have also suffered the shooting deaths of children. Discussion followed about Chicago’s increasingly damaged reputation for gun violence.  999 people have died in Chicago since the beginning of 2011 from gun violence.

Special Meeting Friday February 8th  

Appointments for the Cook County Land Bank Authority Board of Directors were deferred to a meeting to be held this Friday along with a proposed resolution about feral cat colony management.

Probation Monitoring Improvements 

Many questions were raised about proposed GPS contracts for monitoring juveniles and radio frequency monitoring for adults in the probation departments.  The hope was to find one company that could provide both services; unfortunately that could not be accomplished prior to the end of the current contract.  The Board has approved new contracts with Sentinel and 3M saving the county a great deal of money while also providing better services and security for the general population. 

Juvenile Probation and Detention
 
An agreement was approved with Heartland Alliance Inc., which in turn, will subcontract with community and faith based organizations to provide more pro social housing and mentoring for minors in detention.

Collection of debts 

An intergovernmental agreement has been approved by the State of Illinois Comptrollers office, Clerk of the Circuit Court, and State's Attorney to collect unpaid debt owed such as: traffic court debt, fines, and other outstanding financial obligations from Department of Revenue income taxes. Those owing governmental agencies will be notified 60 days prior to deductions being made in their tax return to allow time for disputes to be resolved.

Office Of The State's Attorney

A grant was accepted from the Illinois Criminal Justice System for Community Justice Centers. The goals of these centers are to address life concerns that have an impact on the local communities such as prostitution, graffiti and drugs.

New Business Items

All items were referred to committees other than Item #1, a request from David Orr to enter into a contract with Dominion Voting for the equipment necessary to hold February and April elections.

 

The meeting was adjourned at 1:00 p.m.

Submitted by Pat Lind

Health and Hospital Systems Board Meeting February 1, 2013

The meeting was called to order by Chairman David Carvalho at 7:35. 

  

Quality and Patient Safety Committee chair Ed Michael reported challenges in implementing electronic health records, a possible need for more staff.  A full report is due to the CCHHS board on maximizing the use of Provident Hospital.  A short video stressed that transparency yields internal improvement.  If data are available to all, quality improves.  Customers/patients value candor sometimes over quality.  The board must set a clear policy on  transparency.  “Talk about your mistakes!”  He said more data will be on the CCHHS website, and  suggested Dr. Das update board members on performance data at a future meeting. 

Audit and Compliance Committee chair Dr. Luis Munoz reported that McKesson is monitoring physician billing; and the diagnostic coding system, key to bringing in revenue and determining quality measures, will be subject to more intense federal monitoring.  A survey will identify what relationships employees have with external providers, and a firewall will be put in the system to preserve CCHHS business integrity. 

Finance Committee chair Heather O’Donnell reported that under 6,000 new people have been enrolled in the new Countycare Medicaid program; patients are instead choosing Carelink, not realizing that Countycare provides better managed care over time. Patients rejected by Countycare (Medicaid) are eligible for Carelink.  A contracted PR firm, Prairie Group, will assist CCHHS, FQHCs in particular, with patient education and enrollment, hosting enrollment fairs, providing flyers, banners, and posters. 

Human Resources Committee chair Quin Golden reported that 343 vacancies were filled in 2012; 165 managers were trained in Shakman requirements.

William Luallen of Pricewaterhouse Coopers reported general findings on their 3-year association with CCHHS: - CCHHS needs to generate grants and have centers of excellence to compete with other health systems. - Many self created billing systems need coordination.  Currently co-pays can’t be collected at point of service because the Cerner system does not accept credit cards. - There are still paper charges and orders in the system; all needs to be electronic, and this process is about 75% complete. The$12m backlog in uncollected revenue is now down to $2m, similar to Rush and other hospitals.  The coding system has been improved, creating a clear claim for reimbursement.  There have been significant reductions in overtime since the $18m overtime payout.  Ambulatory Care Health Network (ACHN) clinics are not yet working in tandem with shared data. Carvalho asked what other public healthcare systems are doing to collect copays at payment point; NAPH has data on this.  The Cerner system holds all electronic medical records and links to Siemens which is the billing system, so all data should be on Cerner to maximize revenue collection.  Luallen said CCHHS needs a 501c(3) nonprofit foundation and offered to assist in creating such a foundation on a pro bono basis.

The meeting adjourned to closed session at 10:00.

Submitted by Linda Christianson

CCHHS Quality & Patient Safety Committee Meeting January 16, 2013

The Observer arrived after the meeting had started, and the Committee was watching a video focused on how to handle errors and accidents from the standpoint of public and legal exposure. The takeaway: "Choose your lawsuits wisely," be transparent, encourage discussion of mistakes by staff and Board and recognize that public attention, however painful, may bring improvement. Dr. Raju then noted that core data about adverse events will be posted on the CCHHS public Website.

Chairman Michael instructed the staff to provide the Committee with 2012 quality metrics for the next meeting, so it can settle the "Big Dots," overall goals for improvement during 2013.

Nursing Chief Russell reported that the system had fewer retirements than anticipated and thus is less short-staffed, so that "we didn’t have to shut anything down." CCHHS is vaccinating its staff against flu on a continuous basis and has had no outbreak to date.

Dr. Dave Barker reported on the Ruth Rothstein CORE Center, the comprehensive HIV/AIDS treatment facility now expanded to handle the needs of those with other infectious diseases. CORE Center did exceptionally well in 2012, or else its goals were set artificially low:

• Goal of 55,000 routines HIV tests; actually conducted 66,000. Ultimate goal 80,000, which would allow testing every five years of everyone in the relevant community.
• Goal of 99% access to primary care within 10 days; achieved 100%.
• Goal of 80%+ patient satisfaction; achieved 83%.
• Goal of 90% viral load below 1000; achieved 90%. (Those who fail have relapsed into IV drug use; 30% of the CORE Center’s patients have active substance abuse problems.)
• Goal of 75% patient-would-recommend; achieved 81%.
• Goal of 10% or fewer patients receiving meds at CORE; achieved 5.9%, which means budgetary savings.

Peer counselors administered the survey to 588 patients in the CORE waiting room, about 10% of the program’s clinical population. Waiting room patients are disproportionately walk-ins (who haven’t been treated) or the sickest patients (whose treatment is going badly) so it may over-sample problems. But the survey will be repeated in this fashion 3 times/year; CORE regards this as more representative than ‘press-ganging,’ or mass administration of a survey by mail, phone or e-mail. Barker was particularly proud of adjectives describing CORE as "excellent," "respectful" and "friendly," and in the reduction of descriptors such as "busy" and "rushed." Using electronic medical records (EMR) should free up more time for providers to spend with patients, but for the moment, according to Barker, "CORE provides good care and lousy documentation." There are too many providers and too few medical assistants. There should be 2.5-3.5 assistants per doctor, but CORE never exceeds 1:1. For the same reason, CORE has not yet completed the change away from written orders and prescriptions. Another doctor noted that this is a national problem: EMR software was designed to improve billing and not the quality of care. She asked for redoubled efforts to make EMR changes uniformly across the system, because every change affects the flow of care. "Flow should drive what happens with EMR rather than the other way around."

CORE did badly (30-40%) in assuring after-hours access to providers. Of its 80 primary care providers, many are part-time, and CORE has relied on their individual availability to patients. Now it has hired an answering service to improve responsiveness.

Goals for 2013:

• Secure certification as a Patient Centered Medical Home for HIV/AIDS.
• Gain access to special software to aid reporting and reduce personnel hours of data entry.
• Provide real-time Quality Assurance data to providers to promote improvement.
• Complete transition of the Social Services component of CORE to EMR.
• Complete implementation of a CCHHS-wide satisfaction survey for all HIV programs and patients.

Another doctor argued that HIV testing should occur whenever clinics do anything else. CCHHS should also be testing 100% of patients for TB.

Dr. Wakim reported that an all-staff Task Force has been created to consider Provident’s future. The Task Force will check in every two weeks and bring in a proposal whenever it develops one (there is no time-line). Provident’s ER experienced one "sentinel" (problematic) event and will bring the Committee a summary of that once Risk Management approves its description.

The Committee then approved its minutes, approved medical appointments and adjourned.

--Submitted by Kelly Kleiman