CCHHS Finance Committee Meeting, May 24, 2013

The meeting was called to order by Chairman O’Donnell at 8:05 a.m.  Directors Carvalho, Michaels, and Ramirez were also present.

During the public comment period, a citizen complained about the lack of African-American Directors on the Board and the lack of representation and contracts for African-American citizens.

Gina Besenhofer, Supply Chain Operations, Executive Manager, presented contracts to be paid from appropriations:

1. $18,500,000 for 3^rd party administrative services for the 1115 Waiver for $18,500,000 to be paid to Automated Health Systems (AHS). 
2. $12,000,000 for pharmacy benefits and management services for $12,000,000 to be paid to Catamaran.   
3. $1,460,000 for amending and increasing a contract with Siemens for professional services, utilization, and recurring fee.
4. $549,557 for perinatal software maintenance from GE Healthcare, and 
5. $184,040 for service maintenance and repair for cooking, warehouse, and waste disposal equipment to Emerald Restaurant Services.

The Committee approved all contracts.

John Cookinham, CFO, reported on the Year-to-Date Financial Reports. He said amounts for free care were approximately $20,000,000 per month.  In Accounts Receivable, the outstanding days of Revenue Outstanding (Patient Days) was 116 days at the beginning of the year with a big improvement down to 110 days.  As of this last Friday it was 97 Days.  Currently self-pay statements are being suspended until County Care payments are fully payable and paid.

Mr. Cookinham pointed out that 30% of Medicaid patients had been converted to County Care (the Affordable Care Act 1115 Waiver) and that Commercial patients (those patients with their own personal insurance) was “really growing.”  Self Pay and Free Care patients stayed about the same.

Mr. Cookinham said the way to attract more Commercial patients was to improve Patient Experience by trying to schedule appointments, giving more telephone responses, giving more free service such as group screenings, and giving employee incentives to use hospital services.  Director Michaels echoed the need for excellent patient satisfaction as County Care enrolls people.

Mr. Cookinham noted that the Adjusted Patient Days are a little below budget due to the 14% decline in Patient Days.  Dr. Jay Shannon noted that when patients were there for observation they cannot charge them as a Patient Day.  Further discussion ensued on the low use of Provident Hospital because ambulance runs are not served there, and acutely ill patients are transferred to Stroger.  Mr. Cookinham further noted that ER was right on budget and Oak Forest was slightly below budget.

Board discussion ensued regarding patient length of stay.  Some patients are kept because they have no place to go.  The longest length of stay is from Commercial patients.  Provident is an outlier with some patients in need of continuous care.  Stoger has many long term patients in trauma and burn units.  Dr. Shannon said there would be improvement in patient length of stay if the records were better recorded.  This would affect Case Management which would impact Quality and Safety and Case modality.  Dr. Shannon said they need clarification each day on coding, which in the end, pays for itself.

Director Carvalho said the Case Mix Index is derived from coding and that there was some dissonance between data and incidents.  Dr. Shannon replied that Case Mix drives reimbursement. 

Susan Greene, Susan Greene Associates, stated that it would take a real cultural change to maintain the rate of patients choosing CCHHS as their medical home.  The Finance Committee agreed that Patient Satisfaction was paramount. Patients are signing up patients for the 1115 Waiver, but then going elsewhere.  Chairman O’Donnell said it is not acceptable that patients don’t like the way they are treated.

Susan Greene continued by saying that the good news is that they have signed up 56,000 applicants for the 1115 Waiver at the rate of 500 per day, and 8,450 in the first 24 days of May.  She said that in April the State of Illinois had 50 persons examining applications, and they have just added 17 more people, and that by June and July, the State will have 100 persons on the staff to process applications.  Ms. Greene stated that County Care members want and demand accurate diagnosis and really good care. To avoid no-show applicants for the Waiver, applicant workers try to fit into the patient’s schedule rather than the reverse situation.

Ms. Greene said that she hopes to transition her 1115 Waiver training team out by July.  She continued that 27% of approved applicants are couples new to the County and FQHC System, and they want to stay in the CCHH System.  Ms. Greene said there was a high demand for good Care and Coverage, and people were finding CCHHS.  She continued that the age distribution was constant with only 20% of applicants under the age of 25 and more women applying than men.  Race and ethnicity were not known.  Ms. Greene stated that older people need more health care and that those who need care sign up first.

                                                                                                                    

Ms. Besenhofer gave an update on Global Healthcare Exchange (GHX) and the need for full integration and said they will still need two to three years to fully implement the process.  She added that the double work was not sustainable much longer, but that the integration with County Care was easy. She hoped that HHS would have the same system as the County.  Dr. Hota said that Meaningful Use was over $15,000,000 for stations processing Medicaid and Medicare and that they need to increase the number of Procedures since they were dependant on Medical payers and providers.                                         

Mr. Cookinham gave a report on the gross changes in payer. The financial amounts paid by Commerical Insurance had dropped from 2.7% to 2.3%, even though the percentage of Commercial patients was rapidly growing.  The Medicaid and Medicare Managed Care are not growing, but they do not pay as much.  Dr. Raju reported that most of Medicare Managed Care will be moved to County Care, and that it was essential to have a good Managed Care department.  Director Carvalho stated that under the 1115 Waiver everyone is assigned to a Managed Care hospital and may not be assigned to CCHHS, but they want to come to CCHHS for opinions and special care so CCHHS must have a strategy for this situation.  Dr. Raju said the ER must serve patients that are not enrolled here, but then they must go to their home hospital.

Cookinham continued that CCHHS is ahead of the budget by $8,000,000 for collections over expenses. In the Operating Budget, they need to fill more positions.  Director Michaels said it was difficult to project Revenues and that made it necessary to manage the Expense side better.

The meeting was adjourned at 10 a.m..

---Submitted by Eleanor Prince, CCHHS Finance Board Observer

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May 22, 2013 Proceedings of CCHHS Quality and Patient Safety Committee

During the public comment period, a pair of nurses complained that unlicensed Medical Assistants were doing nursing work without supervision.

The meeting was dominated by a long report comparing various measures of hospital quality. The data aren’t consistent even within measures; the CIO is working to reconcile them. There were no data about the supply of Spanish-speaking staff; this will be provided at the next meeting.

Between arrival at the Emergency Department (ED) and actual admission to the hospital, it takes a total of 638 minutes---nearly 11 hours. Many ED patients, lacking primary care, require time-consuming evaluation before the admission decision can be made, but more than 4 hours is spent simply waiting for a hospital bed. All patients with real emergencies are given priority and seen in less than 6 hours. Those ultimately discharged also wait an unacceptably long time (170 minutes).

ED wait times have been calculated based on when a doctor completes his/her notes. But because notes are often delayed, future wait times will be based on when a doctor "signs up" for a patient, unless this is prohibited by the Center for Medicare and Medicaid services.

Consultations with specialists and waiting for MRI results account for most delays. CCHHS will examine other hospitals’ procedures and may call on colleges for process-engineering support.

Patient satisfaction surveys: 72% of patients rate CCHHS "very good" overall, which sounds
great til you learn this means 99% of the nation’s hospitals do better. The biggest difficulties were getting through on the phone or having a call returned, followed by wait time and lack of information about delays. Though wait times at certain clinics are down to 90 minutes, patients don’t perceive the improvement. Wait times for tests and specialty care also need to be reduced. Patients get good care once they can get to doctors but barriers to access are huge.

Dr. Stabile, in charge of the Patient-Centered Medical Home initiative, cited improvements including "patient panels" (care teams to help doctors manage patients) and computerized records. An RN Care Manager coordinates care; this should improve phone response. They’ve also revamped scheduling and hope to offer some 12-14 hour clinic days by year-end. Chairman Michael said, "Overall we’re doing badly and seem to be getting worse." The key problem is lack of respect for patients. "We give the impression we think we’re doing them a favor." Training won’t be enough to create a customer service ethic; incentives would be necessary. Dissatisfied patients represent loss of market share; neighboring hospitals are already pulling in County Care patients. But CCHHS can never be successful if it’s short-staffed.

---Submitted by Kelly Kleiman

May 8, 2013 Cook County Board Meeting

Public Comment Returns to All Meetings

Source of Income Amendment Passes

After several years of advocacy on the part of the League of Women Voters of Cook County, the Cook County Board amended its Rules of Organization and Procedure to return a public comment period to all its Board and Committee meetings.  In addition, the Board passed an amendment that eliminates a landlord’s right to refuse to rent to someone solely on the basis that that person participates in the Federal Section 8 housing assistance program.  The Cook County League has also been supporting the passage of this amendment known as the “Source of Income (SOI)” amendment.

In other business, the Board referred a proposed ordinance regulating the carrying of concealed weapons to the Legislation and Intergovernmental Affairs Committee.  Committee Chair and amendment sponsor Larry Suffredin explained that this proposed ordinance would be held in committee to see if the Illinois legislature and governor would enact a concealed weapon statute in conformance with a recent federal court order.  If the State does not act within the time limit specified by the court, then the Committee will take up this item, including holding hearings on this proposed ordinance. (This was New Item #4 on the agenda.)

The Board also approved the appointment of Shelly Banks as Cook County Auditor for a 5-year term. Ms. Banks is a CPA and has most recently served as the Chief Internal Auditor with the Illinois State Lottery.

Public Testimony

Under the Amendment to the Rules that was first discussed in the Legislation and Intergovernmental Affairs Committee on May 8 prior to the Board Meeting, in order to testify at a Board or Committee meeting, a speaker must register with the Secretary to the Board at least 24 hours in advance of the meeting.  Public testimony must be germane to a specific item or items on the agenda, and the testimony must not exceed three minutes.  Anyone failing to adhere to these conditions or failing to act appropriately when addressing the Board may be expelled from the meeting or may be disqualified from testifying in the future.  The Chair of the meeting may grant leave for someone who has not met the advance registration requirement to speak if conditions permit.  As Commissioner Suffredin explained to the League representatives present, one of the purposes of the advance notice requirement is so people have some idea as to how long public comment will take so that any necessary adjustments to the day’s schedule can be made.

As originally proposed, the amendment would have had public testimony come at the end of the meeting.  The League contacted the Commissioners to urge that testimony come prior to the Commissioners taking any action on an agenda item so the Commissioners would have the benefit of such testimony.  Following that contact, the League was informed that a substitute ordinance amendment would be introduced in Committee which provided for public testimony at the start of meetings as the normal order of business.  League Co-President Karin Hribar testified at the Committee meeting in favor of this substituted amendment, which was then passed by the Committee. The Committee Report for this May 8 meeting was then passed by the Board at the Board meeting that day.

SOI Amendment

In a meeting of the Board’s Human Relations Committee on July 24, 2012, the Committee approved a proposed amendment to Chapter 42, Sections 42-37 and 42-38 of the County Code which would eliminate a landlord’s ability to refuse to rent to someone who participated in the Federal Section 8 housing assistance program.  That Committee Report and the items contained therein, however, was not presented to the full Board until this May 8 meeting.  This particular item was pulled out from the report for separate discussion by the Board.  At the beginning of the Board meeting, public testimony was allowed with 9 speakers in favor of the amendment and two speakers opposing it.  Those in support argued that no one should be discriminated on the basis of their source of income and that anyone receiving Section 8 support should be allowed to live anywhere in Cook County.  It was pointed out that the city of Chicago did not allow a renter to be turned away solely because of Section 8 assistance.  Those who spoke in opposition expressed concerns that landlords would have additional paperwork and other requirements.  The League was one of the members of the group supporting this amendment.

The SOI amendment was approved 9 to 6.  Voting yes:  Butler, Fritchey, Gainer, Garcia, Moore, Reyes, Sims, Steele, and Suffredin.  Voting no:  Daley, Gorman, Goslin, Murphy, Schneider, and Silvestri.  Absent:  Collins and Tobolski.  Prior to the vote, President Preckwinkle stated that she would appreciate a vote in favor. 

-- submitted by Priscilla Mims, League Observer