Cook County Health and Hospital Services Board Meeting August 29, 2014

Directors Jerry Butler, David Carvalho, and Carlos Ramirez were not in attendance (Calvin Morris has resigned).  Members of the public commended Stroger  Hospital for care in emergencies, pleaded for additional funding for mental health, affirmed care for incarcerated persons and for new mental and dental health services, and criticized the county for continuing to care for undocumented immigrants.  CEO Dr. Jay Shannon recognized several  outstanding employees.

COMMITTEE REPORTS: (1) Human Resources: Director Gladys Lopez will require more staff to maintain compliance with new regulations. (2) Quality/Patient Safety:  the Stroger Emergency Dept. wait time has diminished from 140 to 48 minutes.

ACTION ITEMS:  

A. Budget Review.  Dr. Shannon summarized that the budget is now twice as big as when CCHHS began in 2008, primarily because of the health plan allowing CCHHS to keep patients while decreasing the burden on county taxpayers.  CCHHS now serves a patient population that is primarily insured.  Because the patients will have a choice, the services must be of high quality in a clean, safe environment.  Investments are required in information technology and evaluation.   

Budget Director Aaron Galeener presented the budget's goals: to (1) maintain the mission (2) improve financial stability (3) expand CountyCare to new populations, (4) improve operational effectiveness, and (5) fulfill the Department of Justice requirements for the Cermak Clinic.   

Revenues and expenses are both higher and expected to break even at $1,536 million.  Specific goals include (1) improved access through a 24-hour call center; (2) centralized scheduling; (3) optimized staffing levels across the organization; (4) improved supply chain; (5) standardized data reporting,  a "single scorecard"; (6) maximized use of CCHHS mail order pharmacy; and (7) improved network utilization within CountyCare.  Capital investment will improve patient care.  CountyCare represents 67% of total revenue, with a decline in Medicaid patient fees.  CountyCare now serves 3 population groups: (1)  Affordable Care Act Adults, (2)  those covered by the Family Health Plan, and (3)  Seniors and Persons with Disabilities.

                                             ACA Adults            Fam. Health Plan                  Seniors/Disability

Membership                         79,500                              65,000                                     4,700

Projected revenue                $602 m                              $223 m                                     $88m

Projected expense                $306m                              $159m                                       $31m

Admin. expense                   $37m                                $17m                                         $7m

$348m reimbursement from CountyCare to CCHHS.

The budget increases by 9% due to (1) increase in membership in CountyCare (2) additional costs allocated to mail order pharmacy, and (3) pharmaceutical supply.   CountyCare members have 2 opportunities to be dropped from the system: (1) through redetermination of their eligibility, which occurs on the anniversary of their enrolling; and (2) during open enrollment when they may choose another provider.  Doreen Wiese emphasized the need to stay in communication with members and help them through the redetermination procedure.  The proposed preliminary budget was unanimously approved.

B. Contract Procurement.  1. IlliniCare Health Plan, Inc, contracted by CCHHS to provide managed care admin and clinical services for the CountyCare health Plan, will have the length of its contract reduced from five years to three years with the option to exercise two one-year extensions, and the requested total not-to-exceed amount will be reduced by $216,702,316 to $1,578,707,012.  The revised terms of the contract specify that IlliniCare will serve all Medicaid populations including seniors and persons with disabilities (SPDs) starting on September 1, 2014 and Family Health Plan (FHP) members starting on October 1, 2014. Lewis Collens pointed out that this contract can be terminated at any time. 2. A 3-year contract cost of $9,199,750 to provide operational services for Stroger and Provident Hospital parking garages as well as shuttle bus service between Stroger and JTDC.

CCHHS Chairman Hill Hammock reported that 3 members will be moving off the CCHHS board, and President Preckwinkle is now choosing new members (including a replacement for Calvin Morris), with the announcement due at the end of September.

Dr. Shannon reported that pending legislation, if approved, will allow jail detainees to be eligible for funded  mental health and substance abuse treatment.

The board adjourned to closed session at 10:15.

 
Submitted by Linda Christianson

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

CCHHS Finance Committee Meeting, May 24, 2013

The meeting was called to order by Chairman O’Donnell at 8:05 a.m.  Directors Carvalho, Michaels, and Ramirez were also present.

During the public comment period, a citizen complained about the lack of African-American Directors on the Board and the lack of representation and contracts for African-American citizens.

Gina Besenhofer, Supply Chain Operations, Executive Manager, presented contracts to be paid from appropriations:

1. $18,500,000 for 3^rd party administrative services for the 1115 Waiver for $18,500,000 to be paid to Automated Health Systems (AHS). 
2. $12,000,000 for pharmacy benefits and management services for $12,000,000 to be paid to Catamaran.   
3. $1,460,000 for amending and increasing a contract with Siemens for professional services, utilization, and recurring fee.
4. $549,557 for perinatal software maintenance from GE Healthcare, and 
5. $184,040 for service maintenance and repair for cooking, warehouse, and waste disposal equipment to Emerald Restaurant Services.

The Committee approved all contracts.

John Cookinham, CFO, reported on the Year-to-Date Financial Reports. He said amounts for free care were approximately $20,000,000 per month.  In Accounts Receivable, the outstanding days of Revenue Outstanding (Patient Days) was 116 days at the beginning of the year with a big improvement down to 110 days.  As of this last Friday it was 97 Days.  Currently self-pay statements are being suspended until County Care payments are fully payable and paid.

Mr. Cookinham pointed out that 30% of Medicaid patients had been converted to County Care (the Affordable Care Act 1115 Waiver) and that Commercial patients (those patients with their own personal insurance) was “really growing.”  Self Pay and Free Care patients stayed about the same.

Mr. Cookinham said the way to attract more Commercial patients was to improve Patient Experience by trying to schedule appointments, giving more telephone responses, giving more free service such as group screenings, and giving employee incentives to use hospital services.  Director Michaels echoed the need for excellent patient satisfaction as County Care enrolls people.

Mr. Cookinham noted that the Adjusted Patient Days are a little below budget due to the 14% decline in Patient Days.  Dr. Jay Shannon noted that when patients were there for observation they cannot charge them as a Patient Day.  Further discussion ensued on the low use of Provident Hospital because ambulance runs are not served there, and acutely ill patients are transferred to Stroger.  Mr. Cookinham further noted that ER was right on budget and Oak Forest was slightly below budget.

Board discussion ensued regarding patient length of stay.  Some patients are kept because they have no place to go.  The longest length of stay is from Commercial patients.  Provident is an outlier with some patients in need of continuous care.  Stoger has many long term patients in trauma and burn units.  Dr. Shannon said there would be improvement in patient length of stay if the records were better recorded.  This would affect Case Management which would impact Quality and Safety and Case modality.  Dr. Shannon said they need clarification each day on coding, which in the end, pays for itself.

Director Carvalho said the Case Mix Index is derived from coding and that there was some dissonance between data and incidents.  Dr. Shannon replied that Case Mix drives reimbursement. 

Susan Greene, Susan Greene Associates, stated that it would take a real cultural change to maintain the rate of patients choosing CCHHS as their medical home.  The Finance Committee agreed that Patient Satisfaction was paramount. Patients are signing up patients for the 1115 Waiver, but then going elsewhere.  Chairman O’Donnell said it is not acceptable that patients don’t like the way they are treated.

Susan Greene continued by saying that the good news is that they have signed up 56,000 applicants for the 1115 Waiver at the rate of 500 per day, and 8,450 in the first 24 days of May.  She said that in April the State of Illinois had 50 persons examining applications, and they have just added 17 more people, and that by June and July, the State will have 100 persons on the staff to process applications.  Ms. Greene stated that County Care members want and demand accurate diagnosis and really good care. To avoid no-show applicants for the Waiver, applicant workers try to fit into the patient’s schedule rather than the reverse situation.

Ms. Greene said that she hopes to transition her 1115 Waiver training team out by July.  She continued that 27% of approved applicants are couples new to the County and FQHC System, and they want to stay in the CCHH System.  Ms. Greene said there was a high demand for good Care and Coverage, and people were finding CCHHS.  She continued that the age distribution was constant with only 20% of applicants under the age of 25 and more women applying than men.  Race and ethnicity were not known.  Ms. Greene stated that older people need more health care and that those who need care sign up first.

                                                                                                                    

Ms. Besenhofer gave an update on Global Healthcare Exchange (GHX) and the need for full integration and said they will still need two to three years to fully implement the process.  She added that the double work was not sustainable much longer, but that the integration with County Care was easy. She hoped that HHS would have the same system as the County.  Dr. Hota said that Meaningful Use was over $15,000,000 for stations processing Medicaid and Medicare and that they need to increase the number of Procedures since they were dependant on Medical payers and providers.                                         

Mr. Cookinham gave a report on the gross changes in payer. The financial amounts paid by Commerical Insurance had dropped from 2.7% to 2.3%, even though the percentage of Commercial patients was rapidly growing.  The Medicaid and Medicare Managed Care are not growing, but they do not pay as much.  Dr. Raju reported that most of Medicare Managed Care will be moved to County Care, and that it was essential to have a good Managed Care department.  Director Carvalho stated that under the 1115 Waiver everyone is assigned to a Managed Care hospital and may not be assigned to CCHHS, but they want to come to CCHHS for opinions and special care so CCHHS must have a strategy for this situation.  Dr. Raju said the ER must serve patients that are not enrolled here, but then they must go to their home hospital.

Cookinham continued that CCHHS is ahead of the budget by $8,000,000 for collections over expenses. In the Operating Budget, they need to fill more positions.  Director Michaels said it was difficult to project Revenues and that made it necessary to manage the Expense side better.

The meeting was adjourned at 10 a.m..

---Submitted by Eleanor Prince, CCHHS Finance Board Observer

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