Cook County Health and Hospital Systems Board Meeting November 22, 2013

Committee reports.
Director Collens reported that 2014 Quality Indicators for Provident Hospital are 2 months behind.

Chairman Carvalho reported that a grant proposal will be submitted in January to get additional federal funds for system delivery, including funds for a system to collect payment data.

The Illinois Hospital Report Card has some data, but inaccurate, Dr. Raju stated. Claims data
does not adjust for socioeconomic status. Carvalho responded that CCHHS needs to code its claims
data properly.

Few Medicare patients are in the CCHHS system; people leave when they become Medicare-eligible. New system will help CCHHS find out where they go.

Chairman Report
Chairman Carvalho reported on a Milwaukee Sentinel article regarding the blood drop taken from babies to test for diseases, looking nationally at (1) are specimens satisfactory? and (2) how long does it take to evaluate specimens? CCHHS was rated unsatisfactory due to incomplete data, but not bad specimens.

Discussion about dates and times for 2014 board and committee meetings.

CEO Report
Dr Raju reported:
● 2014 budget adopted with no amendments, to commence December 1.
● CountyCare has now enrolled more than 57,000 new patients.
● CountyCare has 119,000 applications, 72% initiated through call centers, others through FQHCs. The approval rate is 85%, with a backlog of 27,000.
● CountyCare can now move seamlessly from a "demonstration" project to a fully functioning operation.
● The Leadership Institute, or Cook County University, has successfully completed its first ten-week session of goal setting, management performance expectations, problem solving, and senior leadership. Participants were asked to identify one major issue and use their new learning to solve it. Graduation of first group December 17. Next, 200-300 middle managers to be trained. The first class was handpicked so they can teach the next group.
● ACHNs (Ambulatory and Community Health Network) are committed to reduce wait times and make their centers more welcoming.
● The Call Center reduced dropped calls from 13% to 6.6%.
● Dr. Raju hired 2 more senior officers, Peter Daniels to serve as Chief Operating Officer for Cermak, Provident and Stroger; and a new Chief Nursing Officer.
● Two new dental chairs will go into Stroger soon.
● The state legislature must approve CCHHS proposal to allow CountyCare to function as an HMO, taking responsibility for insurance.

Chairman Carvalho noted that there will be a hearing this week on Chicago's 6 trauma centers (are more than 2 needed on south side?), and noted that U of C Hospital's "bypass rate" (rejecting patients) has declined from 30% to 12%.

Meeting adjourned to closed session at 9:20.

submitted by Linda Christianson

Departmental Review Meetings for 2014 CC Proposed Budget: Monday, Oct. 28

Public  Hearing, State's Attorney's Office

The meeting began with a Public Hearing on the budget. There were 26 public speakers. First was Lawrence Msall of the Civic Federation and he stated that his organization's analysis of the proposed budget is available on their website at www.civicfederation.org. He raised at least 2 concerns – one being the uncertainty of the Medicaid revenue within the HHS budget, and the other being a needed long term plan for dealing with the pension issue which soon will be critical. Karin Hribar, LWVCC Co-President, gave testimony commending the board for improving the budget process in line with recommendations that the League has provided over the past several years. Her testimony is available on the LWVCC website at www.cookcounty.il.lwvnet.org.  Veterans organizations were well represented as well, and requested additional money for the Veterans Assistance Commission. The remaining speakers represented various non-profit and business organizations and were for the most part in favor of the budget and commended the President for various programs and for not introducing any new taxes.

Departmental reviews continued with Anita Alvarez, CC States Attorney, presenting for her office. She first reviewed the achievements of her office citing their focus on gang and gun violence that are their most significant issues and require the bulk of their budget. She stated that over the past five years they have had staff reductions due to budget constraints while their workload has continued to increase. Prosecutors have very heavy caseloads, a factor in the length of time required for adjudication of cases. She also stated that she does not have adequate staff to provide coverage for misdemeanor court at all times. She had requested funding for 34 new positions and the proposed budget includes funding for 12 new positions. 

Ms. Alvarez said that her office wants to work towards President Preckwinkle’s goals of decreasing the jail population by seeking alternatives to incarceration. All parties involved need to come to the table to work on the issues of bond court, diversion programs, and treatment courts. She stated that every part of the justice system needs to have the resources to hold up their end of the system so they can do what is necessary to make the justice system work better. 

Commissioner Suffredin commended Ms. Alvarez for her endorsement of a holistic view of the concerns and asked if she could put a value on the savings from the diversion programs. She stated that $15 million savings had been realized in all the diversion programs. 

Commissioner Fritchey wanted to know why only 8% of those arrested were being released on I-bonds while the numbers for NYC were 70% and for Wash. DC were 80%. He asked that since the SA’s provide information to the judge so that a decision can be made about bond, what can be done to ensure that people are not being held in jail who could be out on bond?  He also stated that the number of pre-trial detainees in the CC jail is 50% higher than in other major systems and that $44 million had been paid for cases that were eventually dropped. Ms. Alvarez said that she was not certain about his numbers but that the efforts to work on these issues will continue. 

Commissioners also wanted to know if the ticketing for marijuana offenses had made a difference in the workload for her office and she stated that there did not seem to have been a significant impact.

Cynthia Schilsky, LWVCC Observer

CCHHS Budget Review, October 22, 2013

Cook County Health and Hospital System Chairman David Carvalho summarized that primary and preventive care are now at the forefront; the System's "failures" go to the hospital. This change requires new and different job skills, new and different job titles, new and different salaries as we compete in the marketplace.  Dr Raju added that the task is to create a viable, sustainable health care system while serving our mission of providing care.  Dr Raju stressed the intangible but very significant value of CountyCare participants' having a healthcare card, providing them with security and pride.  As services improve, more patients will choose CCHHS and resources will be maximized.

VISION:

•  Build a HMO to go on the market by October 2014 providing a variety of health care plan options, so that as participants' needs change, they can adapt their plans and still choose to receive care through CCHHS.  In that way, CCHHS can become (1) Plan, (2) Provider, (3) Payer, and (4) Manager, and the result will be an AFFORDABLE plan because there will be many participants. 
•  Make sure every vendor contract has deliverables and accountability by vendor. 
• Invest in IT. Better documentation and reporting by physicians will result in increased revenue collection.  (In the past this was not necessarily true.)
• Transform Provident to a regional ambulatory care center by 2015.  Currently only 10% of Provident bed capacity is in use, diminishing each year.
• Improve dental care.  Next year 11-16 dental care providers will be located across the County.

ACCOMPLISHMENTS

• As of October 22, 2013, 115,000 CountyCare applications have been filed.  Of these 48,000 have been approved by the State, which can now approve 500 applications per day.
• The ACA is allowing CCHHS to be reimbursed for serving a segment of the population that we were already caring for, so the increased revenues can be used to improve the system.
• The wait time has been reduced to 110 minutes in the Stroger ER 
•  729 positions were filled this year, vs. 420 last year. 
•  Thanks to an IT investment, CCHHS has been awarded Level 1 Meaningful Use and brought in $8 million in federal funds for IT improvements. 
•  $46 million/month will accrue to CCHHS due to the CountyCare program
• There are now 138 primary access points for healthcare in Cook County.
• New CountyCare patients choose Federally Qualified Health Centers for care by a 2 to 1 margin.  Most CCHHS CountyCare patients have chosen to stay with CCHHS.

CONCERNS

• Cook County jail has an estimated 2500 mentally ill detainees.  22 mental health workers are to be added at Cermak Clinic, but that number may be insufficient.  Tobolski cautioned that for the county as a whole it is the state's job to provide mental health and they should be held accountable to do that, not CCHHS.
• There will still be uninsured people in Cook County (including undocumented), and CCHHS will have to provide care for them.  We can't eliminate the subsidy needed to provide this care, but to continue to provide $500 million in uncompensated care is a danger to the system's sustainability. 
•  Stroger Hospital needs to improve its image in order to attract more paying customers.  Stroger's  reputation as a burn, trauma, and wound center is unparalleled, but many are not aware of the high quality of services in other areas.

ACCOLADES

Most commissioners strongly commended Dr. Raju, David Carvalho and the CCHHS board for their many accomplishments in the last two years - improving financial stability, improving information systems,  improving healthcare services, and making these services available and affordable for a much larger segment of Cook County's population.

submitted by Linda Christianson

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