Cook County Health and Hospitals System Board Meeting, August 23, 2013

A budget hearing preceded the board meeting.  Budget info: no service reductions or layoffs, a goal to improve infrastructure and clinic care, information systems, electronic medical records (EMRs).  Projected revenue increase of $238.6m to a total of $950.7m, Medicare revenue increase of $10m.  48% of new revenue to come from CountyCare. 93,000 new County Care applications (though State of IL has a 24,000 processing backlog), 100% reimbursement beginning in 2014; 6,745 full time employees.  Presenters spoke of need for more staff at ACHN, better equipment, nurse shortage in the Neonatal Intensive Care Unit.

Chairman Carvalho called the regular board meeting to order at 9 a.m.  Resolutions honoring Ruth Rothstein and Dr. Quentin Young were unanimously approved.  The proposed CCHHS FY2014 Preliminary Budget was discussed; Lewis Collens requested a capital budget containing capital needs before the final vote.  Hill Hammock requested metrics to show the increase in patient use.  Carvalho said that information should be part of the financial committee report, tracking progress on a dashboard.  Butler stressed need to get budget to full county board ASAP.  Collens complained about a recent Chicago Tribune editorial; Ramirez and Munoz commended Dr. Raju on transparency of the budget.   County board may send budget back for more work.  The preliminary budget was unanimously approved.

CCHHS will apply for status as Managed Care Community Network (MCCN), to replace CountyCare, similar to an HMO but specifically set up to serve a county, to begin January 1, 2014, serving the same network, to cover Medicaid patients.  Through a contract with Healthcare and Family Services there will be a specific rate for contracted services, with rates for risk-based capitated services.  MCCN will provide each patient with a "medical home."  The program may still be called CountyCare, FQHCs will be part of the network.

Carvalho announced new and continuing committee chairs: Munoz to chair audit, Butler continuing as finance chair; Wiese as Human Resources chair; Collens as chair of Quality and Patient Safety.  Carvalho announced 2 new work groups: Academic Affiliations, chaired by Hill Hammock, and Strategic Planning, chaired by Wayne Lerner.

Dr. Raju emphasized the need for investment to transform the system, to get more people in the system and keep them happy.

Meeting adjourned to closed session at 10:45.

--submitted by Linda Christianson

MINUTES OF THE COOK COUNTY HEALTH AND HOSPITAL SYSTEM FINANCE BOARD, AUGUST 16, 2013

The meeting was opened at 8:00 by Interim Chairman Jerry Butler.

During the public comment period, a citizen stated that CCHHS Board members needed to attend all Board and Committee meetings and be unbiased and prudent with the public’s money.  Furthermore, the person stated that Board members were not informed, not enlightened and not engaged. 

Two neonatal nurses objected to the limitation of neonatal beds for pregnant women to 28 beds, and capping the number of babies cared for at 54.  They felt this policy jeopardized the health of women, and minimized a program which is coveted by other hospitals, as well as shrinking the visibility of the program and sending people to other hospitals, which begins a downward spiral of total hospital care. Dr. Jay Shannon, Chief of Clinical Integration, said the hospital did a study earlier in the year to determine what was a safe level of operation while using aging nurses.  He answered affirmatively to Director Hammock’s question if all babies were covered by Medicaid.  Dr. Raju’s answer was that the caps were related not to a financial question but a safety issue. The nurses replied that there were no aging nurses.  Dr. Raju stated that the neonatal nurses were nearing retirement, had the highest overtime, and that overwork compromises the safety of patients.

Gina Besenhofer, Executive Director of Supply Chain Operations, stated that she would need extra time in the September meeting to explain the contracts process.  The first seven contract proposals were for renewals of grants.   All seven contracts carry a line on their deferred liability, the risk assumed in case the contract is not renewed.  This is determined by the operation, cost, and mandated health need, and is generally for six months.  These contracts were considered:  

• Contract renewal #1 was for $3,252,089 for Supplemental Nutrition for Women, Infants, and Children to be provided by the Illinois Dept. of Human Service.   
• Contract #2 renewal was for $272,614 for Supplemental Nutrition for Women, Infants, and Children, also to be provided   by the Illinois Department of Human Services.  
•  Contract renewal #3 is for $1,129,626 for Bioterrorism Preparedness and Response to be supplied by the Illinois Department of Public Health.
• Renewal grant #4 for $648,980 was for Case Management for High-Risk infants to be supplied by the Illinois Department of Human Services.  
•  Renewal grant # 5 for $153,878 from the IDPH was for the Cities Readiness Initiative.
• Renewal grant #6 for $77,338 from IDPH was for Lead Poisoning Case Management with Environmental Inspections and fees for service.  
•  Contract #7 was for $3,400 for Summer Food Inspections from the IDPH and will include fees for services.
• Contract #8 is an Amended and Increased contract for $304,380 for behavioral health management from PsycHealth.   
• Contract #9 is an Increased contract for $135,000 for temporary staffing services from Maxim Staffing Solutions to cover costs for CountyCare, the Medicaid Demonstration Project of which the Residential Mental Health unit will be a part.
• Contract  #10 for $32,359,335 with Siemens Medical solutions is for hosting, support, and consulting services.  
•  Contract #11 for $486,461 with UpToDate, Inc. is for clinical information access for physicians and other clinical staff, and
• Contract #12 for $486,461 with RelayHealth is for service on electronic pharmacy claims re submission.   

Discussion ensued on renewing contracts, particularly very large ones such as with Siemens.

Chairman Carvalho asked Ms. Besenhofer to compute how scopes of new contracts differ from past contracts. Ms. Besenhofer said initially CCHHS bought the Siemens System they immediately needed.  Director Carvalho said that subsequently they found the Siemens System purchased was grossly inadequate, and that the same thing occurred with the Cerner System, and now CCHHS was attempting to catch up to the needed point.   Mr. Oder, Ex-Officio Board Member, pointed out that this $32 million contract for Siemens is three times the past cost, and wondered if future revenue would be able to handle this escalating cost.  Dr. Raju pointed out there was dire need to build a system, and that there was need to have adequacy. 

It has also been determined, said Ms. Besenhofer, that the State of Illinois was incorrectly processing CCHHS claims, and that the State now owes CCHHS $7.1 million.  CCHHS is looking for a vendor to ensure that the State is reimbursing them correctly and in an up to date manner for their expenditures.  All hemophiliac care in the state is being moved to CCHHS and there will be more costs for the building of a County Residential Mental Health facility.   

After discussion concluded, all twelve contracts were passed unanimously.

Steven Glass, the new Director of Managed Care, said that as of August 11, 2013, 88,200 applications under the Affordable Care Act 1115 Waiver had been processed, 64% from the County, 31% from FQHC’s, and 5% from Cermak.  At the end of July, the State had processed 55,000 applications with an 88-90% approval rate. 500 applications are being submitted per day, and the State is processing 375 per day.  The turn down rate is mainly due to income discrepancies.  The CountyCare plan should be completed by April 1, 2014 for legislation by the State, with plans to have it fully operational by October 1, 2014.

Aaron Galeener, CCHHS Budget Director, presented the Preliminary 2014 CCHHS Budget, noting that this is the earliest presentation ever, and asked that the Board approve it by September 17^th so Dr. Raju could submit it to President Preckwinkle of the Cook County Board by September 23^rd.  He also noted that they must submit a bed count by September 11. Public Hearings will take place the week of August 19-23 and then the Budget will be submitted to the CCHHS Board on August 23^rd.  It is planned that the Board will submit the FY 2014 Budget to the Cook County Finance Committee by September 11.

Dr. Raju detailed the highlights of the 2014 Preliminary Budget.  First, there will be continued transfer to a patient centered delivery model with financial responsibility. Secondly there will be a 30% reduction of financial reliance on the County Board from $485 million to $175 million.  Third, there will be an investment in human resources for a robust and efficient human resources department with IT investment in real data, and investment in patient experience with adequate staffing.  Dr. Raju said with the expectation of CountyCare, they can fully implement a medical home, and that they have already hired a Nurse Recruiter.

Mr. Galeener said key principles of the 2014 CCHHS Budget showed no service reductions, an investment in Patient Experience, an improved infrastructure, reduced taxpayer burden and dependency on County funding.  Mr. Galeener said by 2014 they expect 100% federal reimbursement. He said total revenue will increase by $238.6 million due to CountyCare payments from the federal government increasing by $271.2 million.  BIPA (Benefits Improvement Act of 2000) will decrease by $30 million and there will be other decreases in DSH (Disproportionate Share), Meaningful Use Payments, and Medicaid patient fees as well as physician billing and contract revenues.  

The federally funded ACA CountyCare managed care program accounted for 48% of CCHHS revenue. The 2014 Budget is $150.3 million higher than the FY2013 Budget. Dr. Raju said they conservatively estimate the CountyCare population for 2014 at 56,131 patients, saying  that any extra monies received from the federal government must be returned to the County.  

 Mr. Oder said he had some major reservations on the FY 2014 budget because underpayments in 2012 added $75 million to the CCHHS Budget, and revenues were underestimated in the first 8 months of 2013 by $135 million.  He said there was a need to be realistic.  Dr. Raju replied that CCHHS had been $165 million short and that the shortage had now been decreased to about $75 million.  This problem, he said, has been due to the state cash flow.  Dr. Raju continued that with State Medicaid, CCHHS only received $.48 on the dollar of expense, but with the new federally funded CountyCare under the Affordable Care Act, expenses will be fully compensated. He added that the new Budget has no personnel lay-offs or reduced services.

Director Carvalho said there are huge opportunities and huge risks ahead, and that the numbers chosen were down the middle.  Dr.Raju said they are expecting 60,000 new enrollees for the CCHHS, and need even more to stave off leakage because it affects the cash flow.  Director Carvalho stated that the State is not only processing their claims, but CCHHS gave the state the money in advance, to set-up the unit to process the claims.

John Cookinham, Chief Financial Officer, presented the final July 2013 financial statements. Average patient days were 92 in May but were 103 in July because they had to write-off 15.7% of cost due to CountyCare patients already in System not being approved for membership, a Medicaid shortfall, and a $7 million shortfall in the Pharmacy.  In July 2013 costs were $322 million YTD and collection was $297 million YTD.  Mr. Cookinham said they were planning to get an advance of $30 million from DSH by November.  Statistics on page 32 of the July 2013 financial statement showed that 58% of the patients served were uninsured, and that adjusted patient days showed the System as being below budget.

In answering Director Carvalho’s question as to where the System is in terms of Expenses and Revenue, Mr. Cookinham said the Revenue to date is somewhat short of $24 million, but by year end Expenses will not exceed Revenue.  He said that this year they have come close to appropriations, but will have a cash discrepancy of $40 million by the EOY.  Answering Director Gugenheim’s question on self-pay, Mr. Cookinham said they only receive $5 to $6 million per year in true self pay. 

The meeting was adjourned at 10:35 by Acting Chairman Butler.

--Submitted by Eleanor Prince

August 14, 2013 Proceedings of the CCHHS Quality Assurance and Patient Safety Committee

The new Quality Assurance/Patient Safety Committee consists of chair Lew Collens and members Luis Munoz and Wayne Lerner. New Board member Ada Mary Gugenheim also attended though she’s not on the Committee. It’s an active and attentive group.

For 2014, Dr. Raju will create a schedule allowing most committees to meet on the same day as the Board, to minimize the use of staff time on Board work.

Dr. Das reviewed the regulatory regime under which CCHHS operates, describing its goals as safe, timely, effective, efficient, equitable and patient-centered care. When Gugenheim asked for a definition of patient-centered, Das gave her personal definition (treating patients with respect and allowing them to participate in their own medical decision-making) but acknowledged there was no universally accepted definition. Das also described the evolution of approaches to securing patient safety, from "Quality Assurance" (a retrospective review of outcomes) to QA/CQT (measuring improvement) to the current "Quality, Patient Safety and Improvement" approach, which also considers patient satisfaction. Though regulations come from a variety of sources (the Affordable Care Act, Medicare/Medicaid, the Joint Commission), Das stressed the Board’s ultimate accountability for the System’s performance.

Das then displayed the most recent HospitalCompare data, from 6-9 months ago. Collens asked why CCHHS had only 72% of the pneumonia treatments recommended; Das explained the System uses its own evidence-based approach based on antibiotic resistance in its particular population, rather than the one-size-fits-all recommendations. She also noted that CCHHS has a lower rate of central-line infection than the state average. While Emergency Department waiting time is 6 hours (vs. 91 minutes recommended), Dr. Raju argued the number is good when compared to similar hospitals (e.g. Bellevue) rather than suburban community hospitals. Gugenheim asked whether those times were adjusted for the acute status of individual patients and was assured they were.

Lerner lauded the number of patients who would definitely recommend the hospital but noted the System also needs to measure quality in outpatient services. He proposed measuring ‘kindness’ of providers, and figuring out a way to reflect the patients’ co-obligation for their own care.

The Committee approved proposed bylaws revisions for Provident with one exception, namely, that the draft improperly allowed accumulation of proxies in governance votes. Dr. Wakim explained that the intent was to permit those absent to cast their own vote by written instruction, and only for the election of officers, but the proposed revision wasn’t so limited. Collens suggested that Wakim look to corporate models for unanimous written consent in revising this provision, to achieve the actual purpose without permitting minority domination of voting.

--Submitted by Kelly Kleiman

Cook County Board Meeting July 31, 2013

The meeting began with three tributes of note. The first went for Father Greeley in honor of his good works for the city and nation. His family was present and were very pleased. Commissioner Silvestri called for a resolution honoring the Chicago Blackhawks and the President of the Blackhawks was most pleased to receive the honor. The third resolution was presented to Commissioner Joan P. Murphy for her hard work on transportation issues and family hugs and kisses made her day. A new resolution was presented stating that the “ Cook County President and Board of Commissioners does hereby reorganize the Cook County Commission on Women’s Issues to be a Commission no longer operating under the auspices of the Department of Human Rights, Ethics and Women’s Issue and now will be a stand-alone commission.”  Further information can be found in the agenda.

Commissioner Elizabeth Gorman proposed a resolution urging legislation that would require cell phone providers to keep identification of all cell phone users on file. This resolution's purpose is to address the problem of human trafficking. According to the resolution, someone is reported missing every thirty minutes in Chicago and suburban Cook County. There was a great deal of discussion about privacy and implementation. A woman spoke whose daughter has been missing since February 1, 2013. Action is also urged for the State and Federal consideration. It was approved.

Another issue of great interest was housing foreclosures and small banks. Comments from both the audience and members stressed community reinvestment, care when doing teardowns (mow grass, boarded up windows and prevention for other invitations to vandalism). Cook County will be using $17 million addressing this issue. A new parental leave policy (PLP) was passed which states that “the President and Board of Commissioners of Cook County does hereby direct the Chief of the Bureau of Human Resources to implement a PLP with an effective date of August 1, 2013". And finally the “ President and Members of the Cook County Board of Commissioners , do hereby authorize the President on behalf of Cook County and the Cook County Medical Examiner Advisory Committee to accept the donation of the engraved memorial stone and finalize an engraving that properly represents the President’s and Cook County Board of Commissioners’ sentiments of dignity and respect, and make the necessary arrangements for the placement of said stone to mark the graves of the Cook County indigent decedents."

Respectfully,

Carol Ginsburg

CCHHS Finance Committee Meeting, July 19, 2013

Finance Committee Chairman Jorge Ramirez called the meeting to order at 8:05. Also present were Board Chairman David Carvalho, Directors Lewis M. Collens and M. Hill Hammock, and Donald Oder, Ex-officio.

A citizen spoke saying that the Finance Board should plan for changes in advance and set up approaches to extending and increasing contracts.

Gina Besenhofer, Supply Chain Executive Manager, introduced three contracts for Extension and Increase.  The first contract was to AmeriSourceBergen Drug Corporation for $70,000,000 to continue medical and surgical needs for 15 months during an automation review to see which drug wholesaler will best suit the needs of the health system.  The second contract to Susan Greene and Associates for $698,550 was to increase and assure the coordination, and promote the quality and efficiency, rather than volume, in the 1115 Waiver Demonstration Project (CountyCare Program).  The third contract to Smith Medical Partners, LLC for $540,000 was for a medication which is only available through this manufacturer.  The increase on this contract was needed due to the increased demand from the patient population.

Discussion ensued on the first contract.  David Carvalho, Chairman of the CCHHS Board, wanted to know why the pharmacy automation review wasn’t done in 2012.  Ms. Besenhoffer stated that automation is continuing to change in the pharmacy market, and that there is a need to integrate this system with the current total system.  Ms. Besenhofer stated that CCHHS has a good partnership with AmeriSource and that CCHHS intends to implement the Pharmaceutical automation system as soon as possible. Rhonda Yates, Head of Pharmacy, said they need a year to observe all the options and determine which program is the optimum automation with the clinicians.

Susan Green, in response to Contract #2, said that as of July 12 they had taken 76,000 applications for the 1115 Waiver and now CCHHS needs to begin establishing a Managed Care System.  This extended contract will transfer knowledge to new payers in the months ahead as CCHHS transfers out of County Care, works with Dr. Shannon to set up the new program, and sets up a Demonstration Site with a Managed Care internal structure and funding determined through utilization management.  It was noted that all new expenditures over $10,000 must be approved by the Board, and those expenditures under $10,000 need only internal approval.

The three contracts were unanimously approved by the Board.

Susan Greene, stated that the 1115 Waiver applications have an 86-89% approval rate by the state and that the state has a backlog of 25,000 applications.  30% of the applications have been submitted by the FQHCs (Federally Qualified Health Centers).  As of last week the application rate was currently 550 a day and the State of Illinois has 103 processors on the CCHHS campus office on Hoyne where they are processing 373 applications per day.  Ms. Greene stated there are ongoing discussions with the state for the Demonstration Site, and that the new Executive Director of Managed Care will start next week.  Ms. Greene stated that this is her last meeting as Director of County Care.  The Board thanked Ms. Greene for her outstanding work.

Ms. Besenhofer reported on Emergency Purchases of personal computers for Managed Care, and temporary bus transportation since the bus company contracted has declared bankruptcy.

John Cookinham, CFO, said they hope to have the 2014 CCHHS preliminary Budget ready for agreement somewhere between the 1^st and 15^th of August. Budget Director, Aaron Galeener said Board approval would be needed by August 23^rd, before being sent to the President of Cook County in October for a final vote by November.  Chairman Carvalho said in 2012 the CCHHS Board had only one week to examine the 2013 budget before voting on it and this year they need more than a week. CFO Cookinham presented the Financial Report as of June 30, 2013, noting that the budget is on a cash basis and is loaded into the County's J.D. Edwards (JDE) electronic format.  Mr. Cookinham noted that CCHHS tries to stay in compliance with the Budget.  He said CCHHS prepares the bills and the County pays them.   Mr. Cookinham also said the County is trying to replace the JDE System, but that will take 2 to 3 years.

When asked about the discrepancy that $306,000,000 of free care was given in 2012, and $342,000,000 was written off in the same year, CFO Cookinham replied that 50,000 people were identified as not being able to pay and were placed in Carelink and not sent a bill. Other patients are sent three statements and if they don’t pay, the bill is sent to a collection agency and generally written off. He stated that the situation is much improved.  Several years ago few patients were screened, and they had to write off $2 billion. Difficulties continue to occur screening patients who come in at night. 

Most U.S. hospitals with a different patient mix have 68 Patient Days. At CCHHS accounts are written off at 120 Days. The CCHHS target at the beginning of the year was 100 days and by the end of June it was 97 days. Director Cullen said that in a corporate setting there was a huge difference between 68 and 97 Patient Days.  Cookinham replied that CCHHS was a stand alone hospital dealing with cash.  Two years ago the System was at 274 Patient Days and then at 112 at the end of 2012.  He said that 80% of Outpatients and 60% of Inpatients had no insurance.

The Cash Collections Reports YTD showed CCHHS was $7,500,000 behind Budget largely due to the cost of the 1115 Waiver applications not being processed quickly by the State of Illinois. Up to June 30, 2013, the CCHH System saw 344,500 patents with an average of 1,586 patients per day. Director Carvalho told the new Directors Cullen and Hammock their insight was needed on financial statements and problems inherent in the System.

Committee Chair Ramirez adjourned the meeting at 9:40 a.m..

--Submitted by Eleanor Prince.