Cook County Health and Hospital Systems Board Meeting October 30, 2015

Chairman Hill Hammock welcomed new board member Mary Richardson-Lowry.

Cook County Commissioner Robert Steele addressed the board as a public speaker. “Communication is HORRIBLE between this body and the Cook County board.  We are ONE!  I am the public face. I should be attuned; I am offering to be a communicator. It’s what I am here for as a public official.  It’s my responsibility to be your partner under chair Butler. I represent areas where clinics are slated to be redeveloped; I am here to help drive membership. Your culture, your staffing is NOT GOOD below here.  If we don’t get it right now, these buildings will be EMPTY.  I am your face in Washington, D.C.”

Committee Reports

Managed Care Executive Director Steven Glass reported that 99.7% of all CountyCare patients now had been assigned to a medical home; usage has increased; and ER admissions have decreased.  Claims reveal little change in use of services; 6 months are required to get a claim processed.   

Glass presented the results of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey, established by the US government in 1997 surveying patients on their experience with their healthcare plan and services, assessed primarily by mail in early 2015 with respondents about 50/50 male/female.  Of these, 2/3 rated their health good or excellent.  Of respondents, 75.2% reported that they received needed care; 79% reported getting care quickly; 89%, good doctor communication; 89%, good customer service; 76%, shared decision making; 83%, good coordination of care; 69% received needed information; 94% reported ease of filling out forms; 76% reported receiving health promotion and education.  

These outcomes compare favorably with other healthcare providers nationally, though Executive Director Dr. Jay Shannon cautioned that many of those surveyed may never have seen a specialist, and “the data are soft.”  CountyCare also compared favorably with other Illinois healthcare plans.

Finance. Deputy CEO Doug Elwell explained the 2 sole source contracts.  Clayco received a $946,410 contract to do the planning for the new $90m Fantus Clinic. CCHHS prepared the purchase order for this contract. The County will fund it, and it had joint approval. 

Elwell presented a summary of current CCHHS finances: it has 57 days of cash on hand vs. 96 days at the same point in 2014 due to slow state payments; overtime is slightly lower at 7% vs. 8% last year; bad debt has risen to $185,000 from $168,000 last year; inpatient days have decreased from 8700 in 2014 to 8400 this year; monthly ER visits have dropped from 12,800 last year to 12,420 this year.  The charity write-off has dropped from $279,000 last year to $217,300 this year.  He explained that a very low number of CCHHS employees use CCHHS because of their insurer.  “We’re going to fix that,” Elwell said.   

CountyCare has a $9.7m profit, and CCHHS as a whole is showing $14.7m in profit for the year.  Costs for Cermak Clinic and JTDC are due to rise from $62m to $85m to fill unfilled positions and raise psychiatry salaries. The CCHHS budget shows $125m received from the County, but it’s actually $164m including pension costs.   

Elwell discussed Capital Asset Management: CCHHS has not had a solid inventory of equipment, but a new document to be completed by June 2016 will detail the age and condition of equipment as a guide in upgrading and replacing dated equipment at the hospitals and clinics.

Human Resources.  Director Gladys Lopez showed a 55% increase in vacancies filled over the same period in 2014, 68% of which were clinical.  She is working with unions to move departing staff into existing positions, so there are fewer external candidates.  Filling an appointment now requires 122 days.  Lopez said there were 804 vacancies, but the budget shows 1100; Hammock asked her to clarify this discrepancy.  A concern is the high staff turnover at Cermak Clinic, Lopez explaining that staff there use Cermak as a gateway to the system.  She is preparing a customer satisfaction survey.

Board member Wayne Lerner praised Dr. Shannon for his presentation at the budget hearings, along with Communications Director Caryn Stancik.  Lerner expressed amazement at the challenges facing CCHHS.

Dr. Shannon said there would be a mid-November vote on the FY2016 budget, after the public hearings. He reported that CCHHS will begin a marketing campaign in multiple languages; in early 2016, a pilot community triage center will open; and there is now a 3-chair dental service at Prieto Clinic.

The meeting adjourned to closed session at 11:45.

Submitted by Linda Christianson

Cook County Health and Hospitals System Board of Directors Meeting, September 25, 2015

Chairman Hammock called the meeting to order at 9:00 am. Present were Directors Velasquez, Collens, Gugenheim, Lerner, Estrada, Marsh, Junge, Wiese and Commissioner Butler.

Public Speakers:  Mr. Blakemore complained that the CCHHS  Board Finance Committee for Sept. 2015 was cancelled.  He stated that he learns from this financial information which is supposed to be open to the public.  How could he, as a citizen, know how the money was being spent when the meeting is not held.  He asserted that leadership were political appointees, working with the unions. 

Board and Committee Reports

Finance Committee:  Doug Elwell indicated that the committee did not meet this month due to “timing issues”.

Contracts totaling close to $12 million were reviewed and approved.  All were by competitive selection method except for a $205,000 contract for micro catheters used in neuro-interventional cases and one for $187,605 for immunology testing which were sole source due to lack of comparable acceptable vendor.

A $7.5 million, 3-year, contract for marketing & advertising services to support CCHHS ($3.75 million) and CountyCare ($3.75 million) was awarded by RFP/competitive selection to Res Publica Group,LLC, Chicago. Director Estrada was concerned about the lack of minority representation on the Board and mid-management of this company.  Director Junge said that this company should reach out to the Labor Union leadership to support the ad campaign.  Director Wiese mentioned poor CountyCare advertising on the North Side.  Mr. Elwell responded that they use zip codes with the highest Medicaid populations as marketing priority areas.  

Mr. Elwell reported that due to the budget deadlock in Springfield, the State of IL has not paid CCHHS in 3 months with  $250,000,000 owed (primarily Medicaid).  In response,  CCHHS is withholding payments to IL (permissible per contract with the State).

Days of  cash on hand have dropped due to this situation.  The contract with the State requires CCHHS to pay Vendors for the 1^st 3 months of suspended payments from the State and employees but not Vendors after 3 months.

Bad debt/charity write-offs have dropped from over $300,000 in 2013 to around $152,000 in 2015.

Other Metrics:  ER visits continued to slowly drop; fewer inpatient days; steady to slightly decreased outpatient visits.  CountyCare total membership continues to drop slowly (trending for the last 5 months) but is leveling off at 168,968 and remains above Budget.  CountyCare’s goal is to capture $263,000,000 of Medicaid payments but is at $126,000,000 due to the use of non-CCHHS facilities by CountyCare members (CCHHS must pay these other hospitals/ERs/Clinics from the Medicaid payments).  Mr. Elwell noted that the FQHCs (Federally Qualified Health Centers) have outpaced CCHHS clinics in cleanliness, updated facilities, and front desk demeanor.

Cermak Health Services and the Dept. of Public Health show cost overruns due to salary & benefit expenses; CCHHS shows significant excess overtime use which is costly.

  
The Minutes of the Board of Directors Meeting 8-28-15 approved

 Human Resources Committee Meeting:  Gladys Lopez  reported a 6.2% employee turnover rate, which she said was within the industry standard.

 Audit and Compliance Committee:  Cathy Bodnar reported a program which includes better oversight of Vendor compliance including CountyCare vendors.
  
Managed Care Committee:  Mr. Elwell reported on CountyCare metrics:  
HIV patients: 34% use CCHHS pharmacy (goal 80%).  However, there is better utilization of CCHHS pharmacy by HIV patients on maintenance prescriptions with extended supply of 84 days:  56% (goal 85%).  100% of patients have been assigned a “medical home”.  Readmission within 30 days of discharge  is 22% (benchmark is 10%), mainly due to patients with substance abuse issues.   Director Lerner commented that the Metrics for CountyCare should have higher goals with tighter control going forward.  Director Marsh asked the proportion of patients admitted via the ED vs directed admissions from a physician/medical home.  Mr. Elwell and Dr. Shannon responded that close to 90% were admitted from the ED.

IlliniCare (the third party administrator for CountyCare) is now in competition for the same population as CountyCare.  They have 143,461 members vs CountyCare 165,848.  This is why the RFP for a new 3^rd party administrator restricts IlliniCare from bidding.

Quality and Patient Safety Committee:  Director Gugenheim reported that the Press Ganey survey questions (Center for Medicare and Medicaid Services instrument to measure patient perceptions of care and used to publicly report hospital performance)  always cite cleanliness as a problem area for CCHHS.  Dr. Das noted that they are embarking on a customer service training  intervention in response to low rates of patients recommending CCHHS.

An operating room performance project is underway with the goal of increasing on-time OR starts (goal 80%)  and decreasing the time to turn an OR room over for the next case (goal 30 min).  The main OR does 11,350 cases/year, of which, 20% are trauma related and are therefore a large component of the 28% of urgent cases (which complicates OR room scheduling).  Timed studies starting with patient arrival to patient being wheeled out of the OR have identified staffing opportunities to reduce delays, as well as facility and equipment issues that are being addressed.

Identifying the surgeon/anesthesiologist etc. who may be tardy, are being posted to encourage timeliness. 

Action Items

CCHHS submittal of documentation to the Illinois Health Facilities and Services Review Board  for:

• Provident Hospital to reduce ICU beds from 11 to 6 
• Provident Hospital to not re-open the Obstetrics Unit

Report from the Chairman of the Board:  Chair Hammock asked the Board to re-evaluate the metrics that are being used by their Committees to insure that they are still relevant, and identify new ones to add.  In particular, ambulatory care metrics should be included.

Report from Chief Executive Officer:  Dr. Shannon reiterated a pivot by CCHHS to focus on ambulatory care. He mentioned a partnership with The Greater Chicago Food Depository (GDFD) with their screening of children and families for “food insecurity” and working collaboratively to connect them with safety net organizations such as SNAP and WIC (food stamps).  GCFD fresh produce trucks will be stopping at CCHHS clinics to support nutrition/diet interventions.

Meeting adjourned to Closed Session at 11:55 am

Submitted by Susan Kern, MD

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