Cook County Health and Hospital System Board Meeting Friday, October 4, 2014

During the Public Comment period, a member of the public complained that using outside contracted staff equates to institutional corruption, a practice that has been going on for years.

Committee Reports:    

Finance Committee chair Jerry Butler reported that all contract requests had been approved, including a $775,000 request for supplementary HR staff to fill hard-to-fill positions.

Quality and Patient Safety chair Lewis Collens reported that the American College of Surgeons approved Stroger Hospital's cancer center; the plan for Patient Safety at Stroger has been approved.

HR chair Doreen Weise said their committee has been given a review on filling vacancies. Director Wayne Lerner suggested an external review of CCHHS salary, benefit, and severance policies as they are inconsistent with national standards.  Ramirez cautioned that the private sector is not where we want to benchmark. Chairman Hammock asked Wiese and HR director Gladys Lopez to put this review on their HR committee agenda.

Asset Management CFO Ivan Sannstein presented an asset marketing plan to identify real estate and public-facing assets that can be leveraged to benefit the county, the Forest Preserve District, and CCHHS.  A committee with reps from FPD, CCHHS, and Cook County board will form a committee and collaborate with a to-be-chosen marketing manager to create a plan to leverage resources,  including highway billboards, corporate sponsorships, websites, and naming rights.  The organization receives a flat fee of $200,000, then a 20% commission on all assets.

CEO Dr. Jay Shannon reported on the 3-year accreditation of Stroger Hospital's cancer center by the American College of Surgeons, significant because CCHHS has many late-stage presenting patients yet outcomes compare favorably with any university hospital. CCDPH COO Terry Mason received a 3-year grant to work collaboratively with community organizations to improve community health, encouraging strategies like smoke free housing and physical activity.  Shannon reassured the board that CCHHS is prepared if ebola arrives in Chicago: emergency services, communicable diseases, and public health are prepared and working in conjunction with CDC recommendations.  A big push this year to reduce morbidity from influenza, staff vaccinations mandatory.  

This month a redevelopment plan for the central campus will come before the Cook County board, including a retail development plan for the old hospital.   

Next month 4 new CCHHS board members will be introduced, replacing retiring members Dr. Calvin Morris, David Carvalho, Dr. Carlos Munoz, and  Jorge Ramirez. Chairman Hammock commended the retiring members, citing their dedication and expertise.  Munoz, Ramirez, and Carvalho all spoke movingly of their experience on the CCHHS board, which, all concurred, they are leaving stronger then when they began their tenure 6 years ago.

The meeting adjourned to closed session at 9:50, to be followed by a reception to honor departing board members.

submitted by Linda Christianson

Cook County Health & Hospitals System Board of Directors Meeting, May 30, 2014

The meeting was called to order by Vice Chair Ramirez.  

Committee Reports:

      Human Resources Committee Meeting 5-16-14:  Minutes of this meeting included a report by Chief of HR, Gladys Lopes, who presented a comparison of CCHHS job vacancies filled for fiscal year 2013 Dec--April [269 ] and 2014 Dec--April [216].  The graphical data was confusing to me and I was uncertain of the  number of total vacancies  that became available or the % of vacancies filled/ time to fill vacancies. Board Chairman Carvalho requested that information be provided on the number of new nurses hired from outside the organization. Update on labor negotiations was conducted in closed session.

      Finance Committee Minutes, 5-16-14:  Update on 1115 Medicaid Waiver/CountyCare by Steven Glass, Executive Director of Managed Care. For the most recent 6 months, applications initiated fluctuate month to month, with a decrease in April. Applications submitted are slightly increased or level (7000—8000/month).  Applications approved fluctuate wildly month to month but appear to be decreasing (from 9000/month in Nov. 13 to 7000/month in April 14. 

• CountyCare members by age group are: 60-64 (12%), 50-59 (32%), 40-49 (18%), 30-39 (13%), 19-29 (25%).  49.1% are female, 50.9% male. 
• Ethnicity was not reported by 56.3% of CountyCare members. Of those reporting:  28.4% black,  12.6% white, 2% Asian, 0.4% Hispanic, 0.3% American Indian. 
• Health Needs Assessment: 59% no medical home, 51% have not seen provider in 12 months, 85% unable to obtain medications, 24% hospitalized in past 6 months,19% concerned about  “place to stay tonight”.
• Top 10 Diagnoses in descending order:   hypertension, high cholesterol, diabetes, tobacco use, general medical exam, obesity, asthma, depression, sexually transmitted disease.   

The number of CountyCare prescriptions filled has increased over the last 12 months from 5379/month to 125,799/month requiring a transfer of funds ($13,330,817) to the Managed Care Dept. to cover the increased expenditures with average per member per month drug cost of $95.     

Board Chair Carvalho noted that as patients become eligible for Medicare, there is some data that CountyCare/Medicaid loses these patients who are free to use any medical provider. A strategy of retention should be considered. He also asked Steven Glass and Dr. Shannon how the System would be able to provide quality care at a reduced cost per person. They indicated that now that they have identified “high risk” populations from the above data on diagnosis, pharmacy use and health needs assessment, they can focus on preventative care to these groups.

    

CCHHS Chief Financial Officer presented a Financial Report:

There was a net operating loss year-to-date as of 1-31-14 of $49,447,000, but when added to the non-operating revenue, the net loss was reduced to $17,924,000.  CCHHS cumulative patient income breaks down by source as: Medicaid 68% (43% of which is CountyCare/1115 Waiver), Medicare 23%, Commercial 8% and Self-pay 1%.

Quality and Patient Safety Committee Minutes, May 27, 2014:  Joint Commission survey of the Ambulatory and Community Health Network of Cook County cited a number of deficiencies which are being promptly addressed and corrective action reports have already been submitted to JCAHO.

  

Dr. Michael Kelly, Chief of the Division of Neurology, provided a presentation on a Stroke Program.  For CCHHS to become a certified primary stroke center a number of upgrades to the radiology suite, ICU and specialist physician/provider staffing 24/7.

Director Lerner asked how the CountyCare population would be managed for stroke prevention.  Dr. Kelly responded that perhaps the incidence of stroke could be cut in half if all of its patients were within range with their blood pressure, diabetes and cholesterol, and did not practice risky behaviors with drugs.  He stated that the mean age of stroke patients at Stroger Hospital is 58 and nationally 70, that 12% of Stroger stroke patients are under the age of 45.

Dr. Ukoha, President of the Stroger Medical Staff reported that the creation of an internet portal for use by patients to access their medical records is being implemented. He raised the concerns of the medical staff regarding proposed changes to the County’s pension plan which is being discussed by legislators in Springfield.  The changes may lead to poor retention of physicians. This concern was echoed by Dr. Wakim of Provident Hospital .

Contracts and Procurement Action Items : Discussion on a new contract for janitorial cleaning management service by the Board indicated that the previous contract was not acceptable resulting in  several JCAHO deficiencies at the Community Care Clinics related to janitorial services.  

Vice Chair Ramirez indicated that he would be working with Dr. Fagen, Chief Medical Officer, Department Chairs and Clinics on the budget, particularly the “pension/early retirement issue”.

Interim CEO of CCHHS, Dr. Shannon reported:  
The Illinois Dept Public Health inspection of the dialysis unit led to a 3 year re-certification.

 
 Fresh produce purveyors will be providing produce “at cost” to the cafeterias and CountyCare Clinics to improve the diet and health of patrons. 

 Dr. Shannon introduced and acknowledged the physician of the year, the nurses of the year and resident’s research day winners who were presented to the Board.

The meeting adjourned to a  closed session.

Submitted by Susan Kern

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 October 11, 2013

The meeting was called to order by Chairman Jerry Butler. During the public comment period, a private citizen stated that the unions and the staff were motivated by money. A representative from Local 231 ASMF representing staff computer coders stated that they wanted to do coding work in house and not have the work sub-contracted out to 2015.

Since a quorum was not yet present, CFO John Cookinham summarized the August 31, 2013 financial reports.  On a cash basis, CCHHS was behind $40 million, but on the Operational side they were almost on mark and expected to end the year slightly ahead in Operational Expenses.  In August there was a 28.4% decline in Carelink due to the increase in Revenues from CountyCare.

Continuing his discussion of the August, 2013 balance sheet, Mr. Cookinham stated that the Capitation Revenue was 57% from Medicaid and 31% from Medicare.  August CountyCare revenue was under budget with $12.9 million, but CountyCare Revenue is expected to be $17.9 million in September and $23 million in October.  Admission rates have been 1.6% below budget and Adjusted Patient Days are 12.7% below budget.  Emergency visits averaged 462 visits per day and clinic visits were 1% below average at 623 visits per day. 

Don Oder, Ex-Officio member, stated that having an Income/Revenue statement showing actual figures compared to Budget would give some clues as to what would happen at the end of the year.  Mr. Cookinham replied that CCHHS has great difficulty getting any information from the County Accounting Department, especially on Non-Operating Income, and that financial information from the County is often far behind.

Director Hammock joined the meeting by phone, so the Committee now had a quorum with Butler, Wiese, and Ramirez.

Gina Besenhofer, Executive Director of Supply Chain Operations, presented 25 Grants and Contracts for approval, including a $1,804,204 contract with K-Force, Inc. for medical records and coding staffing for three years from November 1, 2012. Board members wanted to know why $1.8 million had to be spent for coders.  Ms. Besenhofer said the need for coders to keep up with compliance was much greater than expected. After additional discussion, Mr. Cookinham explained that CCHHS has about 28 coders and they are doing in-house training.

The Finance Committee voted unanimously for all 25 contracts.

Steven Glass, Executive Director of Managed Care under the 1115 Waiver, stated that they have filled out 107,000 applications, with the majority originating from the Call Center. 76,000 applications have been submitted to the State with an 85% approval level.  He said that the State has increased its processing to 530 applications per day, but that the backlog is still 27,000. The State is currently training more processors.

Mr. Glass brought a map indicating 1115 Waiver applications per zip code according to the request at the last Finance meeting.  Applications have been received from every zip code in Cook County, although the greatest concentrations of applications were from the South, Southeast, and West sides of the city. 

 

Dr. Bala Hota, Director of Meaningful Use, gave a presentation on the federal government’s intent and goal under the Affordable Care Act, to create platforms of functional areas across the United States during the 2011-2015 period of implementation.  There are incentives for each area to have federal certification and after 2015 there will be sanctions. 

Commissioner Butler stated that the Cook County Accounting Department is asking for $40 million to upgrade and integrate the computer systems of all its branches, because they are not currently integrated.  The meeting was adjourned at 10:25 am.

Submitted by Eleanor Prince 

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