2015 Proposed Executive Budget, Finance Committee’s Meeting with the Cook County Health & Hospitals System, October 17, 2014

CCHHS Executive Director Dr. Jay Shannon justified the FY 2015 budget to a few assembled members of the Cook County board, explaining that the 92,000 new members of CountyCare can now choose their health care providers. As a result, CCHHS must respond with high quality services to retain its new patient population that have insurance. The plan is to upgrade the 130 "medical  homes" with Saturday appointments, mental health services, and a patient portal allowing patients to access test results. CCHHS is developing a call center and centralized scheduling. Investments are also planned for new equipment. Also CCHHS must now market itself to compete with other providers. Five thousand jail detainees enrolled in CountyCare will receive covered services once they depart the jail.

CCHHS can now boast that more of its patients are insured than uninsured, for the first time in its history.  But many patients continue to be uninsured, including jail detainees and undocumented immigrants.  The proposed budget requires $164 million from Cook County taxpayers to balance, as opposed to $175 million in 2014.
 

Cook County Department of Public Health Chairman Terry Mason reported that CCHHS is working with all other Chicago hospitals in a "robust coalition" to prepare for any ebola patients, using the "Nebraska standard" involving lots of training, with new materials on order.  He reported that there is no evidence that ebola is airborne.  Nurses are now being trained but did not know how many had received training.  Dr. Mason also stressed that every year 37,000 people in the U.S. die from the flu, and urged everyone to get flu shots.
 

Commissioner Jesus Garcia complained about the lack of Latinos being hired, particularly in upper positions.  Dr. Shannon responded that HR Director Gladys Lopez (a Latina, he noted) is putting together a "hiring plan" that should address this problem, with monthly reports on how many vacancies have been filled.

Commissioner Jeff Tobolski complained about the salary increases for executive and director-level staff, as well as the level of salaries for new director hires, while lower level staff only received $1.25 step increases in pay - with applause by nurses attending the hearing.  Dr. Shannon responded that executive salaries at CCHHS are lower than at private hospitals; many staff salaries are determined by labor negotiations; and CCHHS can't afford to be cheap in this competitive environment and must hire top quality executive leadership in order to fulfill its mission effectively.  Chairman Daley pointed out that the ongoing contractual negotiations with the nurses and other employees fall under the responsibility of the President’s office, not HHS.
 

Commissioner Deborah Sims commented that nurses were excluded from conversations about the movement of their services when clinics changed locations.
 

Commissioner Bridget Gainer asked about the bidding process for the key contract of administering the managed care aspect of County Care - length of time to bid, number of bidders, extent of advertising for bids.  Departing CCHHS budget director John Cookinham promised to respond to her questions.  Gainer also questioned the marketing plan, wondering what measures would be used to evaluate the plan.

submitted by Linda Christianson

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

Health and Hospital Systems Board Meeting February 1, 2013

The meeting was called to order by Chairman David Carvalho at 7:35. 

  

Quality and Patient Safety Committee chair Ed Michael reported challenges in implementing electronic health records, a possible need for more staff.  A full report is due to the CCHHS board on maximizing the use of Provident Hospital.  A short video stressed that transparency yields internal improvement.  If data are available to all, quality improves.  Customers/patients value candor sometimes over quality.  The board must set a clear policy on  transparency.  “Talk about your mistakes!”  He said more data will be on the CCHHS website, and  suggested Dr. Das update board members on performance data at a future meeting. 

Audit and Compliance Committee chair Dr. Luis Munoz reported that McKesson is monitoring physician billing; and the diagnostic coding system, key to bringing in revenue and determining quality measures, will be subject to more intense federal monitoring.  A survey will identify what relationships employees have with external providers, and a firewall will be put in the system to preserve CCHHS business integrity. 

Finance Committee chair Heather O’Donnell reported that under 6,000 new people have been enrolled in the new Countycare Medicaid program; patients are instead choosing Carelink, not realizing that Countycare provides better managed care over time. Patients rejected by Countycare (Medicaid) are eligible for Carelink.  A contracted PR firm, Prairie Group, will assist CCHHS, FQHCs in particular, with patient education and enrollment, hosting enrollment fairs, providing flyers, banners, and posters. 

Human Resources Committee chair Quin Golden reported that 343 vacancies were filled in 2012; 165 managers were trained in Shakman requirements.

William Luallen of Pricewaterhouse Coopers reported general findings on their 3-year association with CCHHS: - CCHHS needs to generate grants and have centers of excellence to compete with other health systems. - Many self created billing systems need coordination.  Currently co-pays can’t be collected at point of service because the Cerner system does not accept credit cards. - There are still paper charges and orders in the system; all needs to be electronic, and this process is about 75% complete. The$12m backlog in uncollected revenue is now down to $2m, similar to Rush and other hospitals.  The coding system has been improved, creating a clear claim for reimbursement.  There have been significant reductions in overtime since the $18m overtime payout.  Ambulatory Care Health Network (ACHN) clinics are not yet working in tandem with shared data. Carvalho asked what other public healthcare systems are doing to collect copays at payment point; NAPH has data on this.  The Cerner system holds all electronic medical records and links to Siemens which is the billing system, so all data should be on Cerner to maximize revenue collection.  Luallen said CCHHS needs a 501c(3) nonprofit foundation and offered to assist in creating such a foundation on a pro bono basis.

The meeting adjourned to closed session at 10:00.

Submitted by Linda Christianson

Health and Hospitals Systems Board Meeting November 29, 2012

The meeting was called to order by Chairman David Carvalho at 7:40 am.  Michael Newman of AFSCME complained during the public comment period that the union was not notified of the need for additional staff once the Medicaid waiver was approved.

Board/Committee Reports: 

Quality and Patient Safety Committee chair Ed Michael congratulated staff on the overall positive finding by Joint Commission on Accreditation of Hospitals (JCAH). He also reported on the development of a Quality Dashboard to focus the entire organization on “big dot” items needed in the coming year.  Heather O’Donnell, finance committee chair, reported that Automated Health Systems will facilitate the Medicaid waiver, an $8m contract.  Human Resources committee chair Quin Golden reported that hiring is moving forward, labor contracts have been approved.  Carvalho said “all resources of the county system will be brought to bear” on hiring.

Action Items:  

Dr. Raju said that hiring is moving forward quickly. The goal is to hire 500 FTEs into the system in the next 3 months, then 400 FTEs in the 4 months after that.  With respect to revenue collection, “Jumpstarting is so vital, we cannot fall back on our current collection process.”  Carvalho explained that the 3-year contracts with temp workers have a cancellation feature.  The county does not have to spend all the funds. If FTEs can come on earlier, the county can release temps, but the key is BILLING.  Carvalho pointed out that coders are not certified and have low accuracy, and that skilled coders are critical now that Medicaid reimbursement is based on accurate codes for services provided. The Medicaid reimbursement rate was readjusted last July.  System Chief Financial Officer John Cookinham explained that reimbursement has focused on inpatients and needs now to focus on outpatients.  The county now has 120 days of revenue outstanding and is far short of $42m goal in patient revenue as it continues to serve 4,000 patients per day.  

The board recognized Dr. Michael Puisis, Chief Operating Officer of Cermak Clinic, for his 30 years of service to the county and for providing “excellent quality to the patient population.”

JCAH Consultant Roberta Fruth spoke of JCAH history going back to 1910, and how the organization partners with Centers of Medicare/Medicaid Services (CMS).  JCAH was given “deeming” status in 1965 when the US government funded Medicare/Medicaid but did not have expertise to evaluate services they were funding. The board’s role is to assure patient safety and quality, and has ultimate oversight over licensed professionals.

Dr. Raju spoke of the impact of caring for patients who live outside the county, amounting to 7% of total system care/  The cost of this care is not billable.  He also mentioned the disproportionate amount of charity care provided by CCHHS as a whole, emphasizing that this burden should be shared.

Susan Greene, Interim Director of the Office of Managed Care and Clinical Tranformation, spoke about the implementation of CountyCare, which will provide services for the newly-eligible Medicaid recipients.  To be eligible patients must live in Cook County, be 19-64, have an income below 133% of poverty, not be eligible for state-plan Medicaid or be on Medicare, have a Social Security number, be a legal immigrant or US citizen.  The covered services mirror standard Medicaid and include hospital ER, inpatient services, drugs, lab, x-ray, hospice services, and dental services for 19-21 year olds.  Patients will have a “patient-centered medical home” at one of 13 selected Federally Qualified Health Centers and be linked to a pharmacy.

--Submitted by Linda Christenson

Cook County Departmental Budget Hearings October 29, 2012

Health & Hospitals System’s Budget Balanced Thanks to Receiving 1115 Waiver from Fed. Govt. 

David Carvalho, Chair of the Board of the Cook County Health & Hospitals System (HHS), and Dr. Ram Raju, Chief Executive Officer of HHS, both expressed their great pleasure and relief that they were able to announce that the HHS had received an 1115 Medicaid Waiver from the Federal Government allowing them to enroll people now with incomes less than 133% of the poverty level and receive the Medicaid portion from the Federal Government, which is 48 cents on the dollar billed.  Currently, HHS might not be receiving even that amount.  In 2014, when the Affordable Health Care Act goes into effect, HHS will receive 100 cents on the dollar from the Federal Government for these people for 3 years, when it will drop down to 90 cents on the dollar.  (The State of Illinois is supposed to be supplying the remaining portion, but given the State’s financial condition, HHS is not expecting to receive any amount any time soon.)

As a result of this Waiver, HHS was presenting a balanced budget to the Cook County Board, albeit with a continuing subsidy from the County.  HHS expects to net $99 million over the costs of implementing the Waiver.  Absent the Waiver, HHS would have had a $99 million budget shortfall.  However, HHS has to do several things to maintain the Waiver, including signing up 115,000 people under the program.  HHS already has 67,000 qualifying people in its system and there are another 47,000 people in other federally qualified programs.  HHS estimates that there are 215,000 people in Cook County who would qualify under the program, meaning there are another 100,000 or so people that HHS could potentially sign up.  Work is underway to develop methods for reaching out to these people.

2013 Critical to Transforming HHS

Dr. Raju said that the 2013 budget presented to the Board is critical to transforming the health care system under the County to a patient-centered model.  When the Affordable Care Act goes into effect in 2014, many of the patients Cook County currently serves will now have health insurance and thus will have more options for care.  In order to keep patients with insurance who can pay for the care HHS provides, it is critical that they view HHS as an attractive option.  Otherwise, HHS will be left with only those patients who do not qualify to obtain insurance. 

While HHS continues to need significant dollars from the County to balance the HHS budget, Dr. Raju pointed to improvements in the HHS collecting fees from patients.  Revenues are up $100,000 more than in 2011, and physicians are at last billing for their services, with $5.2 million collected already thus far in 2012, and $12 million projected in 2013.  In addition, significant cost savings are being realized due to supply chain improvements.

Dr. Raju said that HHS needs to hire 444 people this year, with 144 positions needing to be filled in the next 8 to 10 weeks, and a plan to hire about 30 new people a month beyond that.  Dr. Raju stressed that HHS actually needs more people, but this budget reflects what can realistically be done during the course of the year.  He also stressed that he has eliminated all positions that won’t be filled this year.  (Often, departments maintain approved positions, but carry them at a $1/year salary.  All such positions have been eliminated from this HHS budget.)

Mr. Carvahlo stressed that one problem facing HHS is that the upper level salaries are not competitive enough to attract the talent needed.  HHS is working with Human Resources and the Shakman Compliance Officer to streamline the hiring process.

Patients from Outside Cook County

Based on a past survey, about 7% of the population being served through HHS comes from outside of the County, which amounts to about $25 to $30 million in costs.  In the past, HHS has not done a good job of keeping track of these people, but expects to do so in the future.  A new Illinois law prohibits a hospital that provides care from billing a patient whose income is less than 200% of poverty, no matter where the patient lives.  But a hospital is not obligated to provide care, except in emergency situations to save the patient’s life.  Currently, HHS provides all care.  The HHS Board is starting to have discussions as to whether there needs to be a change in policy for patients who come from outside the County.  Commissioner Tobolski stressed that Cook County taxpayers cannot continue to be asked to pay for care given to people from outside the County.

--Submitted by Priscilla Mims