Health and Hospital Systems Board Meeting March 28, 2014

Once committee reports were approved, all without disagreement, most of the meeting consisted of a presentation by Steven Glass, Executive Director, Managed Care, on the board approval request for services by IlliniCare Health Plan, Inc. to provide third party administrative services, managed care, and clinical services for CountyCare at a cost not to exceed $1,795,970,071.00 over the five year contract term.  Dr. Raju prefaced the presentation by explaining that CCHHS anticipates having more than 100,000 patients enrolled in CountyCare, but lacks the expertise to manage this population.  The funding will come from the federal government, and 88% of funds will be used for patient care, rather than administration.  Already 567,000 claims have been validated for CountyCare services.

In his presentation, Glass explained that, under this contract, IlliniCare Health Plan, Inc. will provide managed care expertise and services as well as business support for the operations of CountyCare. The contract consolidates and transitions three existing contracts for: claims processing and payment, provider and member services; behavioral health benefits management services; and pharmacy benefits management services into one.  Since optometry is now a Medicaid approved service, optometry benefits management is also included in this contract.  The four pieces of the contract are:

1.  Administrative services, including claims adjudication, processing and payment; financial reporting and support; provider and member services.  These and similar services total 11.8% or an estimated $212,744,000 over the 5-year contract term, calculated on a per member per month (PMPM) assuming 115,000 CountyCare members.
2. Managed Care Services and Support. As CountyCare's TPA (Third Party Administrator), IlliniCare will provide care coordination and case management, nurse hotline, quality assurance, and utilization management, totaling 14.4% or an estimated $257,646,000 over the 5-year contract term, again assuming a PMPM payment basis for 115,000 CountyCare members.
3. IlliniCare subcontracted benefits management services: IlliniCare will subcontract for benefits management services for pharmacy, behavioral health and optometry through the existing subsidiaries' management networks of IlliniCare's parent company, Centene Corp.  These services total 7.2% or an estimated $129,168,000 over the 5-year contract term.
4. Payments to CountyCare network providers and approved out-of-network  providers.  IlliniCare will transmit payments owed by CountyCare to network providers, including contracted FQHCs, participating hospitals, ancillary providers, pharmacies, as well as to approved out-of-network providers.  These costs represent 66.6% or an estimated $1,195,850,842 over the 5-year contract term.

Once board member questions were addressed, the approval request was unanimously approved.  During the second quarter of 2014 CountyCare will transition to a Managed Care Community Network (MCCN), and additional contract and procurement item requests were approved without disagreement to process claims payments and provide managed care services through June 30, 2014. 

Currently, 147,000 CountyCare applications have been initiated, 118,000 submitted, and 87,000 approved.  CountyCare is compensated at a per member payment rate of $632.48 x 87,000 current members = approximately $70,000,000 per month to cover all services.  CountyCare has 138 primary care sites and 38 hospitals in its network

Currently: 43+% of care provided by CCHHS is uncompensated; 22+% is covered by Medicaid; 20+% by CountyCare, and 11+% by Medicare.

Dr. Raju, departing now for his new position as CEO of New York City's health and hospital system, spoke movingly of his experience with CCHHS as the "greatest job of my professional career" and acknowledged the board for its support in maintaining the CCHHS mission of service while getting its financial house in order.  Chairman Carvalho introduced a resolution of appreciation to Dr. Raju, as board members affirmed Dr. Raju's transformation of CCHHS in his 2 1/2 years and warmly applauded his contribution.  Dr. Raju received a rousing standing ovation by all meeting attendees before the meeting adjourned to closed session at 10:30.

submitted by Linda Christianson

CCHHS Quality Assurance and Patient Safety Committee Meeting March 26, 2014

Attending:  Chairman Collens, Directors Lerner, Guggenheim and Hammock; and a new non-Board member of the Committee, Patrick Driscoll.

Cook County's Public Health Department was accredited for the next five years by the Public Health Accreditation Board.

Surveyors from the Joint Commission made a surprise visit to the Ambulatory Care Center and, though the report is not final, issued only 10 citations (of need for correction) out of 1000 standards.  They made a point of telling the staff the visit had been "excellent."

CCHHS Chief Operating Officer Daniels reported on the system's new Capacity Management Project. The Project is focused on four areas: patient flow through the Emergency Department, bed management, the discharge process and patient acuity. The first is most important because CCHHS gets 72% of its patients through the ED, vs. an industry standard of 50-60%. It’s hoped that under the Affordable Care Act fewer patients will use the ED for primary care, but meanwhile the ED divides its patients into 5 levels of acuity, with 1 being the most serious. 1s are seen "within minutes," 2s and 3s are in the ED appropriately, and 4s and 5s should receive urgent care in another setting. For the moment, the ED has created its own "Doctor Quick" section to treat 4s and 5s.

Some internal goals have already been met: a 20% improvement over FY2013 3rd Quarter; only 6% of patients left without being seen; patients are treated and released within 4 hours or treated and admitted within 8 hours. National goals (3%, 3 hours and 6 hours respectively) will now be adopted.

Daniels credited the improvements to collaboration among all the departments, especially nursing initiatives coupledwith IT analysis which identified bottlenecks and administrative fixes which eliminated them. The next step is a "pilot program in Six-Sigma and Lean," two corporate-based programs which use detailed data simulations to map and fix all processes involved in a system (here, a patient’s progress through stages of care). Daniels acknowledged they’ve "hit a plateau and must push through it" to improve further. The goal is to integrate flow in and out of the ED with the System’s overall care strategy. They’ve already decided to create a "Bed Czar" position to improve bed turnover and availability, and are considering a Short Stay and Observation Unit to "decompress the ED."

Chairman Collens urged dissemination of these metrics to all doctors and nurses, and was assured they’d be widely distributed; they’re apparently already displayed at certain nursing stations. Director Lerner congratulation Daniels but urged him to consider using outside advice and to set higher goals "insiders create fewer stretch goals." He added, "Our benchmarks can’t be public hospitals or people will go elsewhere [now that they can]." Collens expressed concern that the Dr. Quick service would encourage patients to continue to receive primary care in the Emergency Department. Stroger’s Dr. Uchowa responded that only by providing patients with a good experience in their new "medical homes" will they be willing to remain in them.

Provident reported that its medical staff had identified patient registration as a bottleneck, so they’re working with Daniels to figure out how to provide bedside registration. Provident’s lab and pathology departments have just been re-accredited for two years. Provident is not in the program of intensive oversight and weekly meetings.

Submitted by Kelly Kleiman

March 12, 2014 Cook County Board Meeting

The Commissioners approved a $2.4 million study for redevelopment of the Stroger Hospital site. There was testimony regarding Stroger Campus and opportunities for development that will help to establish a vibrant mixed use campus to draw in the local population and integrate the medical and educational communities.  The commissioners were very positive on the potential and stated this could be transformative for the West side and indeed the entire city.  The study will take place through the summer, RFPs for developers are expected to go out in early fall and redevelopment plans are expected to be firmed up in Spring 2015.  The Commissioners emphasized that expanded hospital needs because of providing more mental health care and County Care under the Affordable Care Act should be considered before space was given up for other purposes.  Dr. Gray Shannon of the HHS said that they were comfortable that this was being done appropriately.

Significant changes to the County’s procurement ordinance were approved.  They are designed to provide greater transparency in the procurement process and greater participation of Minority and Women Owned business enterprises (M/WBEs). These updates give the County more tools to promote and enforce these goals by adding stronger enforcement measures and establish more stringent penalties for those violating the rules.

Companies who make false statements regarding the contractual participation or status of M/WBEs will be potentially liable for a $2,500 fine, their contract may be subject to termination, and their company may be subject to disqualification for up to five years. Companies who fail to meet participation goals may be required to pay the difference between the goal and the actual spending amount that took place. The penalties that are levied by the County will be streamlined through the Administrative Hearing process, rather than being played out in the court system. If a company is found to be ineligible as an M/WBE by the County, it now will have to wait at least one year to re-apply, rather than 6 months.  The ordinance cracks down on pass-through and other businesses that would inappropriately take advantage of M/WBE status. The process by which Veteran-Owned Businesses and companies who employ veterans can participate in County contracts is clarified. The proposal also codifies past and current practices regarding M/WBE participation in bond transactions.  

There was a long debate on an ordinance allowing for the creation of a municipal inspector general, set up through the Sheriff’s office, who would be authorized to conduct an investigation of municipalities who fail to file two consecutive annual audit reports or annual financial reports with the Comptroller. There are currently 3 such municipalities, 2 of which have new mayors who inherited the problem.  All three are very poor communities and they may have to choose between paying for an audit and providing basic services such as fire and police protection, clean water etc. Gene Williams, the mayor from Lynwood, gave public testimony to say that this is a bad ordinance and may actually be illegal.  The commissioners then questioned whether the county had the authority or if the responsibility belonged to the state. It was suggested that an opinion should come from the state’s attorney.  It was mentioned that the ordinance also covers special districts, such as mosquito abatement. Commissioner Suffredin said that he thought the problem would be better solved by the General Assembly in Springfield but they had thus far failed to do anything and he hoped that by introducing the ordinance in Cook County they would actually be encouraged to act. Commissioner Suffredin stated that he had introduced a revised ordinance, #14-1557 and asked that it be referred it to the next finance committee.  This was done.

A report was given about the Health and Hospital System discussing the increased revenue. Dr. Raju was recognized and congratulated on his amazing success in helping to turn around the Health and Hospital System.  In 2 1/2 years, Dr. Raju was instrumental in putting HHS on a more sustainable financial position, helping to create a true public hospital system that is a safety net system, while contributing to improved morale among employees.  Commissioners congratulated Dr. Raju and his wife, and wished him well in his new job back in New York.

One public speaker addressed changes to Camp Sullivan regarding improved camp grounds and access to the camp, and how it will affect the folks who live across the street.  There was a lot of debate regarding responsiveness to the constituent’s concerns.  Some discussion addressed the issue that the forest preserve meeting was the day before and it was unfortunate that the constituent had not been there.  It was determined that some of the concerns had been addressed because large RV campers would not be allowed at that camp. Further, it was determined that the ingress/egress could not be changed due to IDOT and utility issues.

  

Testimony was given regarding Provident Hospital and the removal of 2-underground storage tanks that were used to store fuel for the Hospital’s emergency generators.  The City of Chicago and Bureau of Fire Protection issued notice in September 2008 that the 5,000 gallon tank failed the tank tightness test. An engineering firm was contracted to remove the 5,000 tank. Subsequently, the 15,000 gallon tank was determined to have corroded piping and possible contamination to the site. The request before the board was to approve funding to pay for the 2nd tank which had been removed in August 2012.  Commissioners questioned the speaker regarding the history of when the tanks were first discovered to have problems and why the funding for removal of the second tank had not come before the board. Commissioner Schneider asked about the level of contamination at the site. The Commissioners asked for a letter to explain the history of the situation in order to place it in the record. Item #14-1806 was not approved at this time.

--submitted by Laura Davis and Lali Watt

Meeting of the Finance Committee of the HHS Board February 21, 2014

Meeting called to order at 8:45 am.

CONTRACTS AND PROCUREMENT ITEMS

Gina Besenhofer, System Director of Supply Chain Management, provided a summary of requests for grant, intergovernmental agreement, and contract renewals and initial requests for funding.  The $219,000, one-year grant renewal for HIV/AIDS surveillance/prevention services was submitted to the Illinois Dept. of Public Health. The grant will provide funding to maintain surveillance in suburban Cook County and to provide services to reduce HIV/AIDS through linkages to sexually transmitted infection treatment, HIV care, case management services, behavioral interventions, and  partner notification services.  Board Chairman Carvalho stated that the Board needs to be advised on whether the grant-related services  are mandated or optional.  In the ensuing discussion, Cook County Dept. of Public Health COO Terry Mason, MD, sponsor of the grant renewal request, offered to provide a presentation that gives a broad overview of grants.  Chairman Carvalho reminded the Board of the need to assure grant compliance and management, which should be included in the future educational session.  

Other grants and service agreements and contracts were approved:    

• Great Lakes Hemophilia Foundation to conduct public health surveillance at CCHHS on congenital bleeding disorders and determine best practices for treatment ($13,031); 
• Inspection of Food Service Establishments and Retail Food Stores in 34 suburban Cook municipalities ($205,000);  
•  Rental of new/updated Blood Culture systems including  blood culture bottles and full service for 36 months ($841,068) and  
• Maintenance/Repair of Provident Hospital building controls for 24 months ($203,650) 

Board member Ada Gugenheim questioned the assertion by the vendor of Micro-fiber Mops/floor cleaning supplies ($311,688, 12-month contract) that it effectively eliminates 99.9% of microbes.
 

Besenhofer and Linda Shapiro, CCHHS Chief Strategy Officer, answered questions on the request for contract renewal and increased payment ($550,000 for 2014 vs $500,000 in 2013) for Prairie Group Consulting. The contractor provides outreach campaign services for promotional and educational events aimed at individuals who become eligible for the CountyCare program. 

Concerned Citizen George Blakemore mentioned during his comments that this consulting group provided events at shelters/churches etc. but was not responsible for registering individuals into CountyCare. He was concerned that there was no accountability on their effectiveness as recruiters for CCHHS. He asked, as an example, why individuals who were being registered were not asked how they became aware of CountyCare, so that there would be a mechanism to track the actual contribution of the consulting group’s efforts.

UPDATE ON SECTION 1115 MEDICAID WAIVER DEMONSTRATION PROJECT/COUNTYCARE

Steve Glass, Executive Director of Managed Care, stated that CountyCare continues to operate under a temporary 90 day extension of the 1115 Medicaid Waiver which expires on March 31, 2014.  The State of Illinois (holder of the 1115 Waiver) has been told that an additional 90 days may be requested, which would extend the Waiver to June 30. Illiniois has not yet heard if the second extension is approved.  Prior to the Waiver expiration, CCHHS must have entered into a contract with the State of Illinois to become a Managed Care Community Network (MCCN). The State provided CCHHS with a draft MCCN agreement. CCHHS is working through a request for proposal process to select a new third party administrator for this MCCN.  Glass stated that he hoped the contract would be finalized in a few weeks.

Glass stated that to date, 141,000 CountyCare applications have been initiated, with 113,000 submitted to the State of Illinois Dept. of Human Services. He predicts that  81,000 applicants will be approved by the State by the end of Feb. 2014.  Recruitment into CountyCare is going well with approximately 6800 applications to be submitted to the State this month for processing.  Thus far, the State has approved  83% of applications submitted by CCHHS (17% found not eligible).  Board members discussed the importance of continuing to recruit applicants for CountyCare as CCHHS budget is dependent on a constant number of enrolled.

REPORT FROM CHIEF FINANCIAL OFFICER

John Cookinham, CCHHS CFO, reported that year to date (Dec, 2013—Jan, 2014) cash collections were $139,683,958 which is slightly over $39.3MM in excess of the budget.  Most of this represents 1115 Waiver/CountyCare payments owed from 2013 ($33,960,380 of the total 1115 Waiver payments of $59,387,346) as well as regular Medicaid ($35,953,892), a large portion that was owed from 2013.  However, Medicare collections were also slightly above budget ($938,651) which is a good sign.  Disproportionate Hospital Share (supplemental payments for hospitals serving a large Medicaid population) payments were also increased ($27,056,372), due to the one year postponement of its expected reduction in 2014. 

The budget for 2014 planned on an average of 56,350 CountyCare members for a full year at $629/per member per month capitated payment.  Jan—Nov 2014 capitated payment will be paid 100% to CountyCare (100% federal payment starting 1-2014 via PPACA).  Dec 2013 will be paid 50% (under 1115 Waiver federal and State share payments 50/50)

The 2014 budget assumed that there would be $70,000,000 of 2013 budget paid in fiscal year 2014, delayed due to the State's processing backlog of about 18,000 applications. CCHHS will be paid retroactively to the date of submission of application. Of this $70MM, nearly ½ has already been collected and the rest is expected to be paid over the next 6 months from 2013 owed. 

Of note, only cash collections, no expenses, were reported in the CFO documents for the Board meeting.  Thus, it is not known what the actual financial condition of CCHHS is.  However, it appears to be far improved from previous years.

Meeting adjourned at 10 am

Submitted by Susan Kern

Health and Hospitals System Board Meeting February 28, 2014

Committee Reports 
The Quality and Patient Safety committee requested that inpatient operational efficiency at Stroger and Provident be measured.  

The board discussed concerns that financial statements for CountyCare have not been published.  CFO John Cookinham explained that though $70 million in costs were incurred in 2013, the funds are not refunded by the federal government until 2014, in irregular block amounts, resulting in misleading accounting.  Dr. Raju reassured the board that CountyCare is still in its infancy, and once it becomes an HMO this will work itself out.  Board member Wayne Lerner: "This problem should have been part of the planning up front...revenue and expenses are just an estimate, but do we know what we're expending?  Let's get this in shape so we have confidence in the reports coming in." Chairman Carvalho said the finance committee needs a review of what resources we have and don't have, and what needs to be done.  Auditing is on an accrual basis, CountyCare must be coordinated similarly.

Action Items

John Daley and Dr. Robert Weinstein were approved as reappointments, and Dr. Jay Shannon as a new appointment to the CORE Foundation board, as proposed by President Preckwinkle.

The Chicago Consultants Studio, Inc. presented a request to develop a program for the enhancement and value creation of the Stroger Campus, incorporating (a) revenue generating opportunities and (b) clinical components.  The request must be approved by the County Board, and calls for 90 days to develop a strategic plan for a 12-14 month project overall.  Board member Wayne Lerner cautioned that we're already running 2 organizations, provider and payer, this will be a big change; the clinical portion of the RFP must be carefully vetted. The hope is that there will be minimal cost to CCHHS.  The plan was approved to go forward to the County Board.

Olenik Consulting was approved to receive $641,250 to provide ICD (International Classification of Diseases) training, including Web-based training, and education for a nine month period, with project management included.  There are now 17,000 codes and diagnoses, a big job for coders.  "Do we have the capacity to be trained?" Chairman Carvalho asked.  Often trainers come in, realize staff don't have capacity to acquire skills, and wind up doing the work themselves. Cookinham responded that new coders are being hired so the bulk of them are CCHHS staff.  

Chairman's Report

The Cerner system has been updated so that new patients can present data to determine their eligibility for charity care, for which they are eligible if they are at 200% of poverty - $23,340 for a single person.  Illinois state law makes these persons eligible regardless of where they live, so, as Carvalho pointed out, Illinois may become a "medical tourism" destination.  The hope is to enroll eligible residents in CountyCare or Carelink.

CEO Raju Report  

1. The 1115 Medicaid waiver was extended for 90 days to the end of March 2014, allowing CountyCare enrollment to continue. Currently there are 141,000 CountyCare applications, 113,000 turned over to the state for approval, 81,000 applications approved. The 2013 goal was 56,000, so the goal was exceeded.
2. As an outcome of a survey on patient safety, senior leaders will now make periodic rounds to find out what patients safety issues they've encountered, then understand and correct them.
3. A preliminary public health January site visit found CCHHS fully compliant on 77 measures and largely compliant on an additional 20 measures, for accreditation by the national board.
4. The Stroger Hospital cafeteria will be updated to include a famer's market beginning this spring.
5. Cook County University has now trained 35 senior managers on what works, what doesn't work, and how to manage.  All middle managers are now to be trained. 
6. At mycookcountyhealth.com,CCHHS patients can create their own portal and have access to their health records which they will be able to take with them from one caregiver to another. 
7. A feature on Stroger Hospital's trauma center will be shown on CNN on March 6 at 9 am. 
8. Dr. Courtney Hollowell was honored for his participation in the men's health forum at Trinity Church, featured on ABC news. 
9. The state of Illinois is seeking a 1115 waiver from the federal government to provide funds to bring the state healthcare infrastructure up to date to accommodate new Medicaid patients and to provide for care coordination, including community health workers, educators, substance abuse counselors, psychotherapy and counseling.  If approved, the state will receive funds to build health care capacity statewide,  including a specific request for $200,000,000 annually to expand training of health professionals at Stroger and U of I hospitals. The proposal calls for funds for CCHHS to collaborate with the UIC nursing curriculum to offer specialized nursing education and training to address CCHHS competency and nursing shortages.  Also, CountyCare will introduce population screening to identify and treat patients with mild to moderate depression and behavior disorders. To address continuity of care for Cook County jail detainees, the 7500 jail detainees now enrolled in CountyCare, and new enrollees, will be assisted in obtaining health benefits and in coordinating their healthcare once they are released.

The meeting adjourned to closed session at 10 a.m.

submitted by Linda Christianson