Cook County Health and Hospital Systems Board Meeting August 28, 2015

Ten public speakers spoke in support of retaining the pediatric unit at Stroger Hospital, defending its specialized care of HIV-infected babies and moms that might not be available to these lower-income patients elsewhere, its high quality training provided for interns, and drawing attention to the loss of revenue should the unit be closed. CCHHS chair Hill Hammock responded, “We have not taken any action on this yet.  We depend on hospital staff for input.”

COMMITTEE REPORTS

Quality and Patient Safety:  Safety Officer Dr. Krishna Das presented metrics showing on-time surgeries at 50%; 66% willing to recommend Stroger Hospital; 63% of ACHN (Community Clinics) patients satisfied with their move through their patient visit.  Dr. Das said staff are receiving ongoing customer service training.

Human Resources: HR Director Gladys Lopez reported 88 vacancies filled in July and anticipates filling another 300 this year.  The average time to hire was down from 133 to 127 days in the 3^rd quarter.

Managed Care: Steven Glass, E.D. of CountyCare, reported 170,834 members in July, a decrease he attributed to the arduous annual recertification process.  99.6% of members are now assigned to a “medical home;” more are being kept out of the ER.  Hill Hammock asked for comparative data to other U.S. public hospitals.  One in five patients is readmitted for the same affliction within 30 days, most often detox.  Eighteen percent of CountyCare members are currently assigned to ACHN clinics; many new ACA adults already had another medical home, but the hope is to make the ACHN clinics the “clinics of choice” for CountyCare patients.

Finance: Deputy CEO Doug Elwell explained large contracts, $185m to Cerner Systems for additional modules including remote hosting; $295m for pharmaceutical distribution including negotiated drug purchases; $3m to Access to Care program, possibly to be reduced to $1.5m, a program providing low-cost primary health care services to uninsured persons at 200% or greater of poverty in suburban Cook County.

Budget: Finance Chair Lewis Collens reported that CCHHS held two modestly-attended budget hearings, with speakers supporting the CORE and Prieto centers, as well as the Access to Care program, and proposing budget cuts to $1.5b.  Dr. Shannon said CCHHS will need to make changes quickly to survive financially, including the need for a greater percentage of insured patients, and credited better managed care for the improvements already made.

Doug Elwell led the board through CCHHS accomplishments, priorities, budget drivers and assumptions before presenting the numbers.  Among CCHHS accomplishments are (1) improvements in filled vacancies; (2) expansion of CountyCare; (3) improved access to outpatient services; (4)  the new Patient Support Center receiving 1300 calls per day, with extended hours, nursing support, and scheduling of community-based primary care appointments; (5) the new MRI and linear accelerators allowing for 7000 MRIs annually and 50-100 radiation treatments daily; (6) 1.9m prescriptions filled annually; (7) 14-bed four flex unit opened for short stays; (8) decreased Stroger Hospital wait time 35%; (9) Cermak Clinic residential treatment unit fully operational, housing 1,000 detainees daily. 

CCHHS Priorities for FY16: (1) improve utilization of CCHHS services by County; (2) relocate/improve community-based clinical services; (3) expand behavioral health services; (4) use more efficient inpatient and outpatient staffing modules; (5) find opportunities to bring services in-house, save $5m by maximizing the effectiveness of existing contracts; (6) new facility investment on central campus.

FY16 Budget Drivers: (1) maintain the mission to serve all in need; (2) unprecedented competition for 70% of our patients who are insured; (3) increase outpatient capacity; (4) continue to improve CCHHS financial position; (5) reduce percentage of detainees with mental/behavioral health issues.

2016 projected Payer Mix: self pay 32%, Medicaid 43%, Medicare 11%, commercial insurance 4.5%.

Budget Assumptions for FY16: (1) inpatient volume to drop 5%; (2) outpatient volume to increase 15%; (3) ER visits to stabilize; (4) CountyCare membership to stabilize at 180,000.  Board member Wayne Lerner pointed out the need to be aggressive in keeping CCHHS market share growing.  Hill Hammock asked about ability to retain annual $160m Disproportionate Share Hospital (DSH) payment.  Board member Emilie Junge spoke of the need for adequate parking.  (5) lower direct support from Cook County taxes post ACA; (6) invest in new clinical services to remain competitive; (7) new Fantus Clinic to be located within Stroger Hospital at a cost of about $10m; (8) new regional ambulatory center to serve Provident community projected to cost $40-$50m (County has funds set aside for this) to open after 2016; (9) identify options for a more efficient cost effective regional ambulatory center to serve south suburban population; (10) expand behavioral health services to reduce ED visits/hospitalizations.  The hope is to replace 3 clinics per year; the new third party CountyCare administrator is expected to yield savings; more care coordination is beginning to be done at the provider level, particularly by nurses.

Revenue Assumptions: (1) CCHHS offers the best ophthalmology care in Cook County; this service can grow; (2) outpatient specialty surgeries can grow; (3) operations improvements can save money.  $276m in fee for service revenue is anticipated in FY16. The per-patient-per-month fee is negotiated with Medicare each year.

Revenue Enhancement: (1) improve preauthorization for Medicaid; (2) put coders in clinical areas to capture more accurate diagnoses; (3) e-consult for early communication between CCHHS specialists and other primary care physicians; (4) increase number of exam rooms; (5) open clinics on Saturdays.

Revenue by Source: CountyCare $952,421,286, accounting for 62% of FY16 budget; Cook County Health Fund Allocation $125m, down from $164m in 2015;

Revenue by Expense: (1) FTE estimated count 6,736 (stable, but to include more coders); (2) $13m maintenance and utility cost; (3) pharmacy and medical supply price up; (4) unreimbursed care costs include $86m for correctional health, $15m for public health, and $370m in uncompensated care.

EXPENDITURES

FY2014: $1,371b          FY2015: $1,712b          Projected FY2016: $1,714 billion 

FY2016 by category:

Hospital Based Services $716m; CountyCare $646m; Admin $128m; Ambulatory Services $123m; Correctional Health $86m; Public Health $15m.

Projected Budget stable 2017-2018 based on (1) hospital-based population drop (2) CountyCare income drop; (3) admin same; (4) ambulatory care increase; (5) correctional health decrease due to decreased jail population; (6) public health increase.

Board Chair Hill Hammock commended Elwell and budget team for its carefully considered projections: “This is the most thorough, transparent, effective budget I’ve seen; it’s the way we’re going to get through this ACA transformation.”   Budget was unanimously approved by the board and must now have final approval by the Cook County Board.

ACTION ITEMS: request for board approval of CCHHS administration’s submittal of documentation for Provident Hospital to the Illinois Health Facilities and Services Review Board for the following: (1) Notice of intent – to continue intensive care unit (ICU) service with reduction from 11 to 6 beds; (2) certificate of exemption – not to re-open the Obstetrics Unit; change status of services from suspended to discontinued.

Dr. Shannon explained that in 2011, Provident suspended critical care; no ambulances stop at their ED;  Provident can’t compete with FQHCs and other hospitals in Obstetrics, only serving 800 patients per year at Stroger. Women now don’t choose Provident; a critical number of deliveries is needed to justify the cost.  Board member Carmen Velasquez opposed closing the unit; board member Emilie Junge said she had not been given enough information to make a confident decision.  Collens pointed out that these services have not been available for 4 years, and patients have found other sources during those years; data indicate that adequate services are available at other area health facilities; the budget would be impacted by continuing these services.  Since the Illinois health Facilities Review board won’t meet again until November, it was decided to postpone the decisions on Provident until the September CCHHS board meeting, and to provide more data on this matter to board members.

submitted by Linda Christianson

Cook County Health and Hospitals System Board of Directors Meeting July 31, 2015

Chairman Hammock called the meeting to order at 9:00 am

Public Speakers:  Over 10 speakers representing the Pediatrics Department at CCHHS, including Attending Pediatricians, Residents, medical students, newly graduated residents, pediatricians from the community, pediatric nurses, representatives of faith-based organizations (United Methodist Church, and the Pastor of the Oak Forest Hospital), representative from child protective services, and a Hispanic member of the community who presented her comments via an interpreter rose to object to the rumored closure of the Pediatric in-patient department.  They alluded to an article printed in Crain’s Chicago Business, July 20, 2015 “Kids are Skipping Stroger;Cook County hospital considers phasing out its pediatrics ward” which reported that CCHHS is considering phasing out its inpatient pediatric unit at Stroger and was weighing whether to consolidate its residency training program in pediatrics into another program and focusing its primary pediatric care at outpatient sites.  It reported that the Stroger pediatric unit of 40 staffed beds had an average occupancy of 26%.

The public speakers stressed that: the Pediatric Unit was cost effective and brings in revenue;  Claims were made that the Rush Children’s Hospital (next door to Stroger) “was sucking patients from CCHHS”;  lauded the Stroger Burn and trauma care for children, supported the pediatric residency which trained physicians who would take care of the indigent.  

CEO of CCHHS, Dr. Shannon responded (after 45 minutes of public speakers) that ”the future of CCHHS is ambulatory care, in the Medicaid managed care model, not highly specialized in- patient care.  No Board decisions on the pediatric unit have been made at this time.  The Board will act on behalf of the entire community.”

Picketers with placards and police presence were present outside of the building.  The Board room was packed with members of the pediatric department with a prominent media presence including videotaping of the presentations.

Employee Recognition:  Graduates of the Leadership Development Project were present and acknowledged by the Board.

Annual Meeting Business:  Chairman Hammock was affirmed as Chair of CCHHS Board of Directors and Commissioner Butler as Vice-Chair.

Board and Committee Reports 

 

Quality and Patient Safety Committee

Director Guggenheim and Dr. Das reviewed the May, 2015 Metrics for Stroger Hospital which show that there continues to be a challenge in improving quality metrics including: surgery start on-time (52%) and OR room turn around time, influenza and pneumococcal vaccination (48 %) and patient experience/willingness to recommend the hospital  (71%).  The metrics are little changed from May 2014.

The CORE Center for HIV/Hepatitis /other infectious diseases shows excellent metrics.

Managed Care Committee

Director Lerner and Steven Glass reviewed a few key Metrics:  County Care membership has been drifting lower over the last 4 months from a high of 183,415 in May to 172,873 in July 2015 which are primarily ACA adults and fewer FHP patients.  This is attributed in part, to failure of members to complete the redetermination process which Medicaid requires to insure that they are still eligible for the program.  Membership is still 10% over the budget which is a positive.  More competition may be entering the marketplace in competition with CountyCare as other large health organizations are forming managed care organizations.

Audit and Compliance Committee

Cathy Bodnar reported that the CCHHS audited financial statements for the year ended November 30, 2014 showed exceptional audit results. 

Human Resources Committee

Gladys Lopez reported that nurse hires are higher this year (249) vs 2014 (139) and that the “time to hire” has decreased to 127 days.

Finance Committee

Director Collens and Doug Elwell reported that the 2016 CCHHS budget was being worked on. 

Mr. Elwell noted that CCHHS needed to grow its Medicare business; recent salary contract agreements would result in increased expense to CCHHS; the CCHHS facilities and equipment were aging and would require capital improvements; prescriptions, especially newer very expensive drugs, will be difficult to purchase at a discount and will result in increased cost to CCHHS; uncompensated care will continue to be expensive.  He suggested that CCHHS units that were unused for many years could be closed vs converted to ambulatory care vs consolidated with other units.  Janitorial services which have repeatedly received poor patient ratings on surveys should be assessed for the FTEs per space they clean and outside vendors should be investigated. 

Director Wiese asked whether the Board could be given data on the number of “contract employees” vs. CCHHS employees there were and the cost. Mr. Elwell stated that vendors are paid according to industry standards.  Director Wiese also noted that there were significant parking problems on the CCHHS campus with up to “300 patients a day turned away”. 

Director Junge asked whether there was a proposal to decrease FTEs at CCHHS?  Mr. Elwell responded that the goal was to staff with FTE numbers that were the industry standard.  Dr. Shannon added that they were looking at utilization of services and staffing accordingly. 

 

Mr. Elwell reported that the cost of Cermak is increasing because of enhanced services provided via CCHHS.  The cost of the CC Public Health Department (administratively under CCHHS) was increasing because they were not being awarded sufficient new grants which would contribute to the income.  He added that they were not garnering sufficient grants because of their difficulty in fulfilling them in the past.  Director Marsh requested an overview presentation on the Public Health grant process.  Director Gugenheim responded “why not combine the CC Dept. of Public Health with the Chicago Dept. of Public Health which has been proposed since 1989!  Nothing happens.”

Action Items

Dr. Fagen noted that Stroger Hospital Department Chairs need to be reappointed every 2 years according to the JCAHO standards.  There has been a lapse in reappointments which she recommended the Board to undertake at this time.  The Board moved to reappoint the Chairs.

Report of the CEO

Strategic Plan Update:  CEO, Dr. Shannon explained that the population that CCHHS was serving had changed over the decades despite the same physical facility.  CCHHS needs to change with the different demographics, healthcare industry and local standards.

Provident Hospital has been part of CCHHS for 22 years.  In the past it was a busy hospital but currently its 25 acute care beds have an average occupancy of less than 50% with a $36 million annual loss.  The ER is well used with 36,000 visits a year.  They have a prestigious eye facility.  Much of the building is not in use. The facility and equipment are old and would require $19 million in upgrades plus $11 million to purchase diagnostic imaging equipment.  Analysis shows that the catchment service area around Provident contains 682,000 individuals with good Medicare/dual eligibility/CountyCare mix. 

Dr. Shannon suggested that Provident be repurposed into a regional outpatient center focused on the Eye center, diagnostic imaging, bariatric surgery, orthopedics and prenatal care.  The cost of a new, “green” building which would be more cost effective to operate and equipment is projected to be $50 million. Directors Marsh and Lerner asked “why not partner with an existing hospital rather than going it alone?”  Director Estrada asked whether the Cook County Planning Commission had reviewed this proposal and evaluated the demographics of the area to make sure this was a good idea.  Director Junge questioned whether the ER visit numbers were not really “clinic type medical needs vs. a true ER level of health care need”.  Dr. Shannon replied that “this is an opening discussion, no firm decisions made”.

The meeting was adjourned to closed session at 11:45am.

Submitted by Susan Kern, MD

July 29, 2015 Cook County Board and Committee Meetings

12 Committee Meetings and a Board Meeting

Make for a Long Day Prior to the August “Recess”

Citizen George Blakemore, who speaks during the public comment period of almost all committee and board meetings, pointed out that having so many meetings on one day did not make sense.  He urged that the committee meetings be held on a separate day or days so that the Commissioners and the public would not be so tired and have time to consider the items on the agendas.  Meetings ran from 8:45 am to 3:10 pm that day with no break.

The newly appointed Commissioner for the 17^th District, Sean Morrison, who replaced Comm. Gorman who announced her resignation at the July 15 Board Meeting, was at the meetings.

Following are a few items of interest from this marathon day.  Note that all reports referred to are available on the Cook County web site;  go to http://cook-county.legistar.com and click on “Meeting Details” for the appropriate Committee on July 29 to gain access to the report. The Board and Committees are not scheduled to meet again until September.

Contract Compliance Committee:  Received the 2014 Cook County Annual Business Diversity Report detailing the different County departments’ compliance with including minority and women-owned businesses (“MBEs” and “WBEs”) in contracts awarded by the County.  Comm. Sims asked what the Health & Hospitals System  was planning to do so that more MBEs and WBEs would have the opportunity to get contracts.  The HHS representative said that HHS was having a vendor fair in September for both their large suppliers and MBEs and WBEs to help them network and for them to learn what contracts are expected to be awarded in the 2016 fiscal year.

Workforce, Housing, & Community Development Committee:  Met to hear speakers on various viewpoints to discuss the issue of paid leave.  Mr. Blakemore pointed out that the notice for this Committee meeting did not specify that this topic was going to be the focus, and he urged that in the future that the notice should be include this information.  The Committee recommended (which the Board later approved) a pre-apprentice program for inmates at the Juvenile Temporary Detention Center, with thanks to the painters’ union.

Audit Committee:  Received several department audits by the County Auditor, as well as the 2014 Audits of the HHS and the County performed by outside auditors. In response to a question by Chair Daley, the County Auditor said that none of the other County Elected Officials have raised any questions about the right of the County Auditor to audit their departments.  The Independent Auditors mentioned that they were pleased that the deadline of May 31 for the 2014 audits was met; and that HHS had net income for the first time, but also stated that some of the costs attributable to HHS are not included, and if they were, then HHS would have had a loss.

Legislation & Intergovernmental Relations:  Recommended the appointment of Tanya Anthony as Director of Budget & Mgt. Services, which the Board subsequently approved.

Finance Committee:  Received the Revenue Report through May 31, 2015, the HHS Monthly Report for June, and the Projected 2015 Year-End Revenues and Expenditures Report.  There was concern about the Clerk of the Court’s revenues being down below those budgeted.  The CFO for the Clerk of the Court stated that this was partly due to fewer court filings (which is out of the control of the Clerk) and partly due to amounts due but not yet collected.  Some of the receivables have been assigned to a second collection agency.

Human Relations Committee:  The proposed amendment to the Human Rights Ordinance (15-4214) that  would prohibit employers and the County from inquiring about a candidate for employment’s past criminal record until after the candidate has been found to be qualified for the position was recommended (and later passed by the Board).  The amendment includes exceptions for positions for which there is an occupational requirement for a clean criminal record.  However, this was first amended to eliminate the requirement that employers must provide a written explanation as to why the candidate was not hired.

The proposed ordinance to prohibit a company that has been found guilty or has settled a claim of discrimination or sexual harassment from receiving a “Cook County economic incentive” was “received and filed.”  From the discussion, it appears that this proposal as written is dead, but Chair Boykin stated that he looks forward to working with the Assessor’s and President’s offices to craft a new proposed ordinance.  Comm. Fritchey mentioned his concern over including companies when there was a settlement, as opposed to an actual finding of guilt.

Board Meeting:

15-4648 (Proposal by Comm. Boykin to create a Gun Violence Czar and Committee to make recommendations to the County in 6 months) was referred to the Criminal Justice Committee.

15-4318 (Proposed contract for an Enterprise Resource Planning, ”ERP,” system that will allow for process improvements, best practices, streamlined and automated workflows, and real time reporting and analytics for finance and human resources functions across the County) was referred to Technology Committee.  Comm. Fritchey urged all Commissioners to attend this Committee meeting to learn more about this.  Total cost is listed as $66 million.

15-4067 (Proposed contract for a new Integrated Property Tax & Mass Appraisal System) was referred to Technology.  Total cost is $30 million.

15-4713 (Proposed ordinance amendment to require any increase in sales occupational tax, i.e., sales tax, to require 2/3’s approval by Board) and 15-4716 (Proposed ordinance amendment to require any increase in the retailer’s occupation tax to require 2/3’s approval by Board) were referred to Finance Committee.  Commissioner Fritchey’s proposed ordinance amendments to reduce the recently passed increase in the sales tax in 2017 to 1.25% (from 1/75%) and back to .75% in 2018 failed for lack of a second to the motion to refer these to Finance.

Submitted by Priscilla Mims, League Observer