Health and Hospital Systems Board Meeting March 28, 2014

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

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

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

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

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

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

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

submitted by Linda Christianson

Health and Hospitals System Board Meeting January 24, 2014

Chair David Carvalho announced that Dr. Raju is likely to be confirmed as the new head of the New York City Health and Hospital System, so an interim CEO will be needed for CCHHS, as well as a permanent CEO.  "There is no process beyond this board for selecting a new CEO," Carvalho said. After a closed session Jay Shannon, current Chief of Clinical Integration, was chosen by the CCHHS board as Interim CEO.

During discussion of a NuCare Service contract for $5,435,854, Carvalho explained that because Oak Forest no longer provides long term care, an RFP was issued and NuCare was selected to provide custodial care for 45-50 patients. The quality of their care is to be monitored by scheduled and unscheduled visits. Lerner cautioned that there should be clear performance criteria, penalties for noncompliance, and good linkage between CCHHS and NuCare staff to coordinate services. Recipients of these services will be patients ineligible for Medicare or Medicaid (primarily undocumented residents); "We don't apologize for that," Carvalho said.

An intergovernmental agreement with the Forest Preserve District will allow for an ADA-compliant, accessible, paved walking trail on the former Oak Forest Hospital property, as well as a facility to explain the history of the property as a former poor farm.

Former CCHHS chair Warren Batts now heads the new CCHHS Foundation. Batts is currently filling board positions and developing strategy for the new Foundation.

Dr. Raju reported:

1. There will be a 90-day extension of CountyCare so patients can receive care during the rollout of ACA; 
2. 72,716 patients were approved for CountyCare as of January 22, a total of 103,000 applications filed (state backlog of nearly 30,000)
3. 80 people are now hired each month, up from 30
4. A contract monitoring team has been added.  A joint planning team of the Illinois Medical District will coordinate the redesign and reconstruction of the Fantus Clinic to become an ambulatory care clinic linked to Stroger Hospital.  Dr Raju recognized Dr. DuMont, who heads palliative care, for her excellence.  Dr. Raju also commended CCHHS board member Carmen Velasquez, retiring as CEO of Alivio Medical Center at the end of January.

Linda Diamond Shapiro, new Chief Strategy Officer, explained her priorities are to find opportunities to improve the system, build leadership, and improve patient experience.  She plans to pull together communications, media, intergovernmental affairs, community relations, policy decision support, and marketing.  Her team will be active in recommending that the County, through CCHHS, hold an HMO license, and by so doing become Provider, Plan, Payer and monitor of Population Health.

Carvalho explained that though there will be new leadership at CCHHS, the plan is in place, and no changes in strategy are anticipated: "The board is committed to the direction we've been on."

Meeting adjourned to closed session at 9:40.    

 Submitted by Linda Christianson

Cook County Health and Hospital System Finance Meeting Feb. 15, 2013

The meeting was called to order by Chairman O’Donnell at 7:30 a.m..  During the public comment period, a citizen complained that the $149,000 contract for media outreach approved in January d was $1,000 short of the $150,000 needed for a vote by the Finance Board. Chairman O’Donnell replied that all issued contracts are in compliance with the law.

Gina Besenhofer, Executive Manager of Supply Chain Operations for CCHHS, introduced Jacky Gomez, the new director of Compliance, to the Board, and then proceeded to introduce Contracts and Procurement items for Board approval.

The first item was a grant increase of $35,004 from the U.S. HHS Administration for diagnosis, treatment, and rehabilitation of patients with Black Lung disease which would bring the total grant to $333,000.  

Item two was the approval of payment of $2,496,000 for the purchase of insurance covering against potential liability for the cost of services relating to organ transplants required by persons who enroll in the County Care Program.  Dr. Ram Raju, Chief Executive Officer of CCHHS, explained that the CCHHS hospitals do not do organ transplants, but would be required to do so by the Affordable Care Act 1115 waiver.  He said that having this insurance would enable CCHHS to send a County Care patient to a facility specializing in organ transplants if it was necessary, and the insurance would take care of the cost of the transplant.

Dr. Raju said it was unknown whether they could have zero or four transplants in a year.  The County Care plan only provides $313 per month per patient.  The transplant insurance allows CCHHS to control costs.  Director Michael asked if this was the best price for this type of insurance and Dr. Raju  said it was.

Payment to the Olenick Consulting Group, LLC for International Classification of Disease-10 (ICD-10) training and education was for $357,180.  This training was necessary to be ready for the huge investment and operation level of County Care.  CFO John Cookinham said the Coding Project was very detailed.  Dr. Raju said it was difficult to be doing the new County Care enrollment and the new Coding System simultaneously, but they could not postpone the Coding because they needed to move forward faster.  Director Michael asked how they could improve the Coding throughout the System.  Director Cookinham said it was necessary to reeducate the coders and that outside studies of the hospitals showed that in-patient coding had improved.

Payment for professional services from Health Management Associates for $718,363 is an amendment, extension, and increase to the original contract. Dr. Raju said he had underestimated the CCHHS needs, and that there was more that needed to be done than originally thought.  Director Michael thanked Dr. Raju for his explanation but said what was difficult to understand is why there was an urgency to extend the contract for a month, when they could just wait and see how much more was needed.  Dr. Raju assured him that they needed to pass the one month extension now because of the Waiver.

Payment for the professional services of Susan Greene and Associates at $540,000 is to enroll applicants in the County Care program under the 1115 Waiver. A contract with More Direct, Inc. for computer blade servers and storage was for $1,974,999.20.  A contract with More Direct, Inc. for Cisco network gear in Phase II of the Network Refresh Capital Project was for $944,915.  A GE Healthcare contract for DMS software maintenance was for $280,428.  A contract with More Direct, Inc. for Fujitsu 6130Z scanners was for $235,630.46. A contract for service of the MUSE/Mars Systems hardware and software maintenance was for $185,373.46.

In discussing the contracts, Director Michaels said they needed to do a write up for replacement of IT equipment since they are replacing very old equipment and there are risks.  

All of the contracts were approved by the Finance Committee.

Dorothy Loving, Executive Director of Finance, presented the January financial reports.  She said that Revenue was very low. Director Cookinham said that all County Clinics are now included within the 35 mile radius, except Sengstacke.  He also said the Budget needs further realignment.  Director O’Donnell said the Board has been working on decreasing Expenses.  Dr. Raju said they have been looking at re-alignment of the Expenses of Oak Forest since it is a huge campus and the Board is spending lots of money in maintenance.  He said in the next ten years the buildings will be much older.

Ms. Loving said there has been an uptick in the dismissal of final patient bill. Director Cookinham said the goal is to be at 100 days or less.  There was a need to continue meeting with Information Systems.  Dr. Raju said there is a built-in delay of a 90 day notice.  This year they are down to 109 days versus 279 days last year.  Dr. Raju does not think they will ever reach a 50-60 day level.  He said public hospitals vary by state with some at a 60 day notice.  

Director Carvalho said that when the Affordable Care Act begins, everyone must be enrolled in some program. Dr. Raju said some people do not want insurance and CCHHS needs to figure out what to do with 500,000 people and how to care for them.  Director O’Donnell said a Public Hospital must care for everyone, not only in the County, but also Statewide.  Director Carvalho replied that by October eligible residents must be enrolled under AFCA, Medicaid, or Carelink.  He said the State is going through some of the same process.  He asked if someone at 138% poverty level in the state will still have co-pays if Cook County doesn’t have co-pays.

Dr. Raju said it took 60 days to collect all the bills and submit them, and two weeks to get the money which gave CCHHS a two and a half month lag.  He said everyday the obligations and approvals must be tracked and that the complexity makes this a time-consuming job.  He said they have to understate their total obligations, but yet track every obligation. 

Chairman O’Donnell said that the Finance Committee needs a more useful financial tool.  Director Carvalho said they need to manage for oversight.  He said they need to have projections and know why they don’t come true.  Dr. Raju said they must create a model in the next several months.  Director Carvalho said that Price-Waterhouse was also offering to assist.  It was decided that Directors O’Donnell, Carvalho, and Michael will come up with a discussion and plan for projections and assessments.
 

Susan Greene reported on the Section 1115 Medicaid Waiver Demonstration Project known as County Care and said they have 12,000 applications completed.  The goal was to obtain 500 applications per day, but yesterday was the first day they attained that goal with 511 applications. Ms. Greene said they try to remove the burden from the applicant by having the office look up the birth certificate information. She said the Carelink targeted outreach has been very successful.  Those persons eligible for any type of insurance are not eligible for Carelink.  Ms. Greene said there had been a wide geographic enrollment and she will be training Cook County enrollers trying to get to the center of applicants.  She said at the point of application, people pick the site where they want care.  Ms. Greene continued that the approval rate by the State is exceeding 90% because of the excellent fill-outs and the training of the workers. Director Velasquez said they needed the enrollment numbers as soon as possible.  Dr. Raju added that there was 92% approval rate by the State.  Ms. Greene said there were 60 different application leaders who were supposed to report each Wednesday, but they often did not do so because they were waiting for the completion of more applications. Director O’Donnell inquired about those who were enrolled, but were getting care elsewhere.  Dr. Raju replied that 8% might be enrolled at Stroger but were getting care elsewhere and that this was something that had to be worked on.

Mr. Cookinham, Chief Financial Officer, presented the January financial report.  He thinks the Waiver is important, but only a portion of the overall Revenue budget.  He believes that at the end of February, due to the Waiver Enrollment, expenses might by higher.  Director Michael said that they didn’t know what the Revenue calendar was through the year.  Mr. Cookinham said he can provide a monthly projected Revenue, and also on a weekly basis.  He said these were Dashboard options.  Director Michael said he would like to see the Predicted Revenue and Variances, and the reasons for the Variances such as less usage, or delays. Director Carvalho said there are always Variances, but they must have explanations.  Dr. Raju said the Patient Revenue should be divided equally through the year, but there is a need for seasonal variation.  Director Carvalho said that predicted Revenues, Actual Revenues, and Variances shown with explanations on a monthly basis were necessary to see whether the System was in difficulty, or doing well.

Chairman O’Donnell adjourned the meeting at 9:30 a.m..

Submitted by Eleanor Prince

Cook County Board Meeting on June 19, 2012

Board Approves New HHS Board Members and Redistricting Map

New HHS Board Members

By voting to accept the report of the Legislation and Intergovernmental Relations Committee meeting held earlier that morning, the Board approved Rev. Calvin S. Morris, Carmen Velasquez, and Dorene P. Wiese to new 3-year terms through June 30, 2015 to the Health & Hospitals Board.  Also approved was Edward L. Michael to complete the one-year remaining on term of a Board Member who resigned.  These appointments add to the diversity of the Board as the new members are an African American man, an Hispanic woman, a Native American woman, and a Caucasian man.

Separately, as part of the Revenue Report presented by the Comptroller to the Finance Committee, the CEO of the HHS, Dr. Raju, said that the current projection is for the HHS to be down $60 million from budgeted revenues for the fiscal year, though revenues, as compared to last year at this time, are up by 11%.  But he expects further strains on the system with people no longer being eligible for Medicaid under new Illinois legislation.

New Commissioner Districts for the 2014 Election

By accepting the report of the 2010 Redistricting Committee (see the Cook County Observer Blog report from the June 15 meeting), the Board adopted an ordinance creating new districts for the 17 Commissioners effective with the 2014 election. 

Proposed Amendment regarding Source of Income (SOI)

Item 10 on the New Items agenda is a proposed amendment to the County’s Fair Housing ordinance which would eliminate wording that allows a landlord to refuse to rent to people who want to use Federal Section 8 assistance as their source of income (SOI).  Commissioner Garcia, one of the sponsors, moved that the proposed amendment be sent to the Human Relations Committee, which was approved.  The League of Women Voters of Cook County is supporting this amendment.

Proposal for County Cemetery for Burying Unclaimed Deceased

Probably the most time during the Finance Committee portion of the meeting was spent on a resolution sponsored by Commissioner Fritchey to study creating a County cemetery to bury those in the County morgue who have not been claimed for burial elsewhere.  Commissioner Fritchey obviously felt that he had been given misleading or incorrect information by members of the Administration, and he took quite a bit of time to question Robin Kelly, the Chief Administrator of the County.  Commissioner Fritchey favored situating the proposed cemetery on part of the Oak Forest Hospital campus that is up for sale by the County, and which portion of the land is adjacent to an old cemetery.  However, it was clear from the statements of the other Commissioners that Commissioner Fritchey had no support for this resolution, and he withdrew it.

New Items

Several new items, not available to review prior to the meeting on the County’s web sites, were referred to Committees, including (New Item 15) a proposed change in the Procurement Ordinance to provide flexibility with the goal of having more Minority, Women-owned, and small businesses obtain contracts from the County; (New Item 16) a proposal to establish a Land  Bank Advisory Committee to advise on creation of a Cook County Land  Bank to help redevelop vacant and tax-delinquent properties; and (New Item 20) proposed appointments to the Medical Examiner’s Advisory Committee.

To watch the video of this meeting and/or to view the agenda items for this meeting and the committee meetings held before and during this Board Meeting, go to http://blog.cookcountyil.gov/secretarytotheboard.

-- submitted by Priscilla Mims

November 9, 2011 - Budget Hearings - Health and Hospitals System

The Cook County Finance Committee held this hearing to again review the budget for the Health and Hospitals System that is included in the proposed 2012 Executive Budget. Dr. Raju, CEO for the System gave a brief overview of the budget request which now stands at $894m. Dr. Raju stated that he is hopeful that there will be no further cuts to this request as this budget is necessary to carry out the strategic plan for the system which will put in place the infrastructure to maximize future revenue collection and in future years will decrease the systems dependence on subsidy from the county. He stated that his financial staff worked closely with the President's office to reach the present compromise on the $894m budget.

Commissioner questions focused on revenue concerns - why the system continues to be unable to collect patient fees in a timely and efficient manner. There continue to be issues with multiple contractors doing billing for different types of fees and coordinating the efforts has been an ongoing challenge. Physicians have not billed for their services until recently so this is a cultural change within the system and providing the software and training to facilitate this process is now underway. State reimbursement for Medicaide continues to be problematic. Dr. Raju expressed his commitment to ensuring that the revenue collection system will be optimized and that fees will be collected from those patients who have an ability to pay. He also stated that he is committed to reviewing all contracts with outside vendors to ensure that they are necessary. He would like to have as many of the system functions be internal as possible.

Another area of concern for the commissioners was HR with questions focused on vacant positions, hiring, and layoffs. There was also discussion of how personnel within the system were deemed essential so that they were not required to take the unpaid furlough days. Dr. Raju said that they needed to work out a system of sharing more equitably if furlough days were going to be required but most of the employees within the system belonged to unions that had not agreed to the furlough days. There was discussion of the President's offer to the unions to take 6 unpaid holidays to mitigate the number of layoffs - but it was uncertain if the unions would agree to this. Andrea Gibson, CC Budget Director, was asked how much money could be saved if no raises were given in 2012 and she stated that it was about $50m. Hiring within the system continues to be challenging and Deborah Tate, head of HR for the system, reported that over the last year 235 persons had been hired - but as she explained the number it included 163 medical students, 44 physicians, 61 people at Cermak, and 40 nurses who had been "processed" including 23 internal candidates - so the numbers did not seem to add up. There are union regulations about filling vacancies, displacement, bumping and layoffs that need to be considered in hiring. Ms. Tate stated that the displacement process involved with the changes in personnel needs as a result of the strategic plan should be completed by November 30.

Other issues raised were:

• need to reinstate rape crisis counselors in Stroger ER ($275,000)
• ensuring that clinics throughout the county are not being closed - according to Dr. Martinez they are not
• phasing in the change of MH2 positions to licensed MH3 positions at Cermak so as not to be disruptive to the patients - and providing training for MH2s who want to become licensed MH3s
• need to increase funding for Access to Care, a suburban program that provides access to primary care physicians for the uninsured

Dr. Raju and has staff provided answers to the commissioners on the issues that they raised. Dr. Raju, who has only been in his position of CEO for 1 month, assured the committee that he is dedicated to improving the revenue stream of CCHHS and he will be vigilant in monitoring contracts in the coming year. He also stated that the system will need to tweak its financial model as health care reform continues towards 2014. Since very little specific information relating to numbers was discussed in this three hour session it was unclear to the observer whether amendments to this part of the budget would be forthcoming.

Cynthia Schilsky

LWVCC Observer