Hearing on Opiate Addiction and Usage, Legislative Committee of the Cook County Board, April 29, 2015

The Legislative Committee held hearings on Opiate Addiction and Usage on April 29, 2015 at 2:25 pm.    A complete video of the testimony by various experts may be viewed below.

http://cook-county.granicus.com/MediaPlayer.php?view_id=3&clip_id=1134

Commissioners Gorman and Suffredin called the hearings to try to understand opiate addiction to be able to address cost and treatment issues for the Criminal Justice System and HHS in Cook County.

Commissioners Butler, Boykin, Sims, and Garcia were also present, although nearly everyone had left by the end of the meeting almost 2 hours later. 

The hearings called many experts in Cook County and beyond to help explain the patterns and origins of opiate addiction.  Drug poisoning has overtaken motor vehicle accidents for deaths in Illinois and around the nation.

Usage is well distributed all over suburban Cook County, according to Dr. Mason, a specialist in treatment for non-Chicago Cook County area hospitals.

Opiate addicts typically start using and abusing OTC (over the counter) opioids like Vicodin, Tylenol 3, Oxycontin.  When they can no longer justify a medical excuse for obtaining OTC “legal” opioids, they switch to heroin.

Dr. Timothy Condon works with TASC as the Chief Science Officer, and is at the National Institute of Drug Abuse:  Drug abuse is a disease which is treatable.  It is a brain disease.  Death rates from opiates in the Northeast and Midwest are six times higher than in 2006-2007.  Nationally abuse is concentrated in non-Hispanic Whites and Black users.  We now have tools to deal with opiate addiction, which we did not in the past.  It doesn’t matter what is in the syringe, whether it is heroin or an opiate prescription drug, the user is still an addict, and has to be treated.

Narcan or Naloxone is a powerful “new” drug that can revive people who ordinarily would have died from an opiate overdose, but Narcan does not treat the addiction.

The drug of choice for treating opiate addiction is Naltrexone.  Unlike the imperfect Methadone “treatment” that likewise created dependency, Naltrexone is an addiction agonist so it blocks the euphoria that the opiate creates in the brain.  Vivitrol is the time-release version of Naltrexone.

Dr. Eka Jones is with the Sheriff’s office inside the Women’s Justice program for mental health and drug treatment within Cook County Jail.  More than 50% of her enrollees cited heroin as their drug of choice.  Drug treatment has to be tailored to meet individual needs.

Dr. Minella, the Head of Cermak Mental Health Clinic at the Cook County Jail, has been there since 1991.  Everyone gets screened for physical and mental issues during Cook County jail intake, and about 80% have substance histories.  12% actively use heroin of the intake population at the jail.  Of the 500 people in the Detox unit every month, about 80% are heroin users, committing crimes to get heroin.  The inmates are very vulnerable when in detox and the issue is that they don’t stay long enough to get off the substance.  25% leave within 2 days, and 50% leave within 12 days.  6 weeks is considered the proper amount of time to get someone off of opiate addiction.

Judge Charles Byrne from 26^th Street courthouse has the Drug Treatment Court.  Addicts have to be dealt with differently from young people who are caught for the first time.  80% of addicts are heroin “frequent fliers” where they have been in and out of jail and the penitentiary between 5 and fifteen times.  You have to try to get them clean.  Every $1 spent in treatment saves $2 later.  They are typically using $200 to $300 in heroin each day.  They need to be supervised in a sober environment.  If they complete the treatment program, 85% of them stay out of the criminal justice system for at least one year.  74% non-recitivism after three years.  They need jobs as well so they can be able to make money.  Everyone who graduates from the program gets their case dismissed.  Many groups now, including the CTA, have a felon-hiring program.  The drug treatment program gets funded from Judge Evans’ budget.

Dr. Aix, a Stroger Emergency Room doctor and head of Toxicology at Stroger, says we are in the middle of an opioid epidemic.  It began to take off in 2000 when there was over-prescription of opioid OTC drugs.  The opiate prescription drugs lure teens into experimentation.

At Stroger ER there are 5000 patients admitted for drug overdoses in a year, with 20% of them repeat overdosers.

There needs to be an increase in Detox and addiction facilities. 

There are two pilot programs being tested by the State of Illinois in Winnebago County and Madison County.  Both use Vivitrol for long term easing off of opiates, and both use community treatment and outreach to maintain the link to support once the person has left jail.  They use Medicaid to treat people in jail.

Another speaker, Joel Johnson, at HRDI, Human Resources Development Institute, said it was very hard to get Medicaid to pay for Vivitrol treatment, even though it has proven successful.

Chief Scofield, Fire Chief in Orland Park, testified that Orland Park went from 3 to 70 overdoses in the last ten years.  The families are embarrassed and hide their kids and the addiction from the public.

Chief Roberts, head of the Cook County Forest Preserve police, lost his son to a heroin overdose in 2009.  There were 7000 deaths in the nation in 2007, 43,000 in 2014.  He is happy to see the Cook County Board doing something proactive.

Dr. Dan Lustig of the Haymarket Center said that heroin addicts need 6 or 7 treatments of Vivitrol before “freedom from opiates” can take hold.

Sally Thorin, Executive Director of Gateway Foundations, says there are three key parts of treatment.  Proper diagnosis, therapeutic mindfulness, and Vivitrol treatment.

Respectfully submitted by Amy Little

CCHHS Finance Committee Meeting, July 19, 2013

Finance Committee Chairman Jorge Ramirez called the meeting to order at 8:05. Also present were Board Chairman David Carvalho, Directors Lewis M. Collens and M. Hill Hammock, and Donald Oder, Ex-officio.

A citizen spoke saying that the Finance Board should plan for changes in advance and set up approaches to extending and increasing contracts.

Gina Besenhofer, Supply Chain Executive Manager, introduced three contracts for Extension and Increase.  The first contract was to AmeriSourceBergen Drug Corporation for $70,000,000 to continue medical and surgical needs for 15 months during an automation review to see which drug wholesaler will best suit the needs of the health system.  The second contract to Susan Greene and Associates for $698,550 was to increase and assure the coordination, and promote the quality and efficiency, rather than volume, in the 1115 Waiver Demonstration Project (CountyCare Program).  The third contract to Smith Medical Partners, LLC for $540,000 was for a medication which is only available through this manufacturer.  The increase on this contract was needed due to the increased demand from the patient population.

Discussion ensued on the first contract.  David Carvalho, Chairman of the CCHHS Board, wanted to know why the pharmacy automation review wasn’t done in 2012.  Ms. Besenhoffer stated that automation is continuing to change in the pharmacy market, and that there is a need to integrate this system with the current total system.  Ms. Besenhofer stated that CCHHS has a good partnership with AmeriSource and that CCHHS intends to implement the Pharmaceutical automation system as soon as possible. Rhonda Yates, Head of Pharmacy, said they need a year to observe all the options and determine which program is the optimum automation with the clinicians.

Susan Green, in response to Contract #2, said that as of July 12 they had taken 76,000 applications for the 1115 Waiver and now CCHHS needs to begin establishing a Managed Care System.  This extended contract will transfer knowledge to new payers in the months ahead as CCHHS transfers out of County Care, works with Dr. Shannon to set up the new program, and sets up a Demonstration Site with a Managed Care internal structure and funding determined through utilization management.  It was noted that all new expenditures over $10,000 must be approved by the Board, and those expenditures under $10,000 need only internal approval.

The three contracts were unanimously approved by the Board.

Susan Greene, stated that the 1115 Waiver applications have an 86-89% approval rate by the state and that the state has a backlog of 25,000 applications.  30% of the applications have been submitted by the FQHCs (Federally Qualified Health Centers).  As of last week the application rate was currently 550 a day and the State of Illinois has 103 processors on the CCHHS campus office on Hoyne where they are processing 373 applications per day.  Ms. Greene stated there are ongoing discussions with the state for the Demonstration Site, and that the new Executive Director of Managed Care will start next week.  Ms. Greene stated that this is her last meeting as Director of County Care.  The Board thanked Ms. Greene for her outstanding work.

Ms. Besenhofer reported on Emergency Purchases of personal computers for Managed Care, and temporary bus transportation since the bus company contracted has declared bankruptcy.

John Cookinham, CFO, said they hope to have the 2014 CCHHS preliminary Budget ready for agreement somewhere between the 1^st and 15^th of August. Budget Director, Aaron Galeener said Board approval would be needed by August 23^rd, before being sent to the President of Cook County in October for a final vote by November.  Chairman Carvalho said in 2012 the CCHHS Board had only one week to examine the 2013 budget before voting on it and this year they need more than a week. CFO Cookinham presented the Financial Report as of June 30, 2013, noting that the budget is on a cash basis and is loaded into the County's J.D. Edwards (JDE) electronic format.  Mr. Cookinham noted that CCHHS tries to stay in compliance with the Budget.  He said CCHHS prepares the bills and the County pays them.   Mr. Cookinham also said the County is trying to replace the JDE System, but that will take 2 to 3 years.

When asked about the discrepancy that $306,000,000 of free care was given in 2012, and $342,000,000 was written off in the same year, CFO Cookinham replied that 50,000 people were identified as not being able to pay and were placed in Carelink and not sent a bill. Other patients are sent three statements and if they don’t pay, the bill is sent to a collection agency and generally written off. He stated that the situation is much improved.  Several years ago few patients were screened, and they had to write off $2 billion. Difficulties continue to occur screening patients who come in at night. 

Most U.S. hospitals with a different patient mix have 68 Patient Days. At CCHHS accounts are written off at 120 Days. The CCHHS target at the beginning of the year was 100 days and by the end of June it was 97 days. Director Cullen said that in a corporate setting there was a huge difference between 68 and 97 Patient Days.  Cookinham replied that CCHHS was a stand alone hospital dealing with cash.  Two years ago the System was at 274 Patient Days and then at 112 at the end of 2012.  He said that 80% of Outpatients and 60% of Inpatients had no insurance.

The Cash Collections Reports YTD showed CCHHS was $7,500,000 behind Budget largely due to the cost of the 1115 Waiver applications not being processed quickly by the State of Illinois. Up to June 30, 2013, the CCHH System saw 344,500 patents with an average of 1,586 patients per day. Director Carvalho told the new Directors Cullen and Hammock their insight was needed on financial statements and problems inherent in the System.

Committee Chair Ramirez adjourned the meeting at 9:40 a.m..

--Submitted by Eleanor Prince.

June 12, 2013 Proceedings of the CCHHS Quality Assurance and Patient Safety Committee

Headline News: Edward Michael, QA Committee chair, leaves that post at the end of June to assume an as-yet-unspecified, but apparently paid, role with CCHHS.

Subordinate headline: CCHHS is preparing to hire a "Patient Safety Officer," though Dr. Das (head of Quality Assurance) and her new boss Dr. Shannon (Director of Clinical Integration, including overseeing patient safety) are both already charged with this role.

These items came up as asides at a meeting consisting entirely of "Committee Education," a lecture from Das on how the hospital does and/or should respond to adverse events, ones "leading to the serious injury or death of a patient unrelated to the patient’s underlying illness." (The Joint Commission uses the term "sentinel events.") To deal with these events, hospitals search for correctable systemic flaws rather than punishing care providers.

Issues in dealing with medical error:

• If/when to disclose errors to the patient and if/when to report them to the public: the Joint Commission favors disclosure and reporting, and the State of Illinois requires reporting "but that law is never enforced."
• Three categories of error: violations (intentional), lapses (habitual because tired) and mistakes (cognitive). To handle the latter two, hospitals search for "error traps" and eliminate them or build in redundancies, so only 10% of errors reach patients. Of these, half are preventable.
• Common types of error: adverse drug reactions, procedural complications and hospital acquired conditions. In addition to "Sentinel Events," the Joint Commission publishes a list of 29 "Never Events," occurrences which will prevent reimbursement of the hospital by Medicare/Medicaid.
• CCHHS catches errors when they’re reported by providers, by phone or through the MERS computer system. It also uses surveillance, reviewing all deaths and serious injuries for signs of error. At the time of an event, the doctor calls the Medical Director who assembles a team to talk to the patient and notifies Risk Management and Quality Assurance (Das).

The System take five steps to manage an event:

1. Care for the patient. Be empathetic and apologize but don't admit liability.  Only 1/4 of errors are disclosed, but after disclosure patients perceive they’re receiving higher-quality care.
2. Conduct initial fact-finding.
3. Care for the care-giver, who’s probably upset about the error.
4. Notify the insurance company.
5. Conduct a root cause analysis.

The Joint Commission provides a detailed outline of how to conduct root cause analysis so that all potential sites of error can be identified.: the provider, communications systems, work environment, organizational culture. Unless the error is intentional, the approach avoids blaming a single provider. Experience shows that removing individuals doesn’t solve the problem, and providers won’t report errors at all if they’re punished for doing so. If there’s no problem of criminality or substance abuse, the key test for responsibility is whether another provider faced with the same situation would have done the same thing.

• The System corrects errors using strong interventions (like technology and work flow). Though it talks about avoiding weak interventions like counseling providers, counseling is actually what the System uses most often.
• Solutions are designed collaboratively, responsibility is assigned, and the initial reporters of the incident are informed of results to reinforce their willingness to report.

When Michael asked how to determine if interventions are effective, Das responded that it was too much work to find out (though the Joint Commission requires some investigation so "we try to do it:), and Shannon noted that with only 7% of adverse incidents coming to the System's attention, there's too little data to tell.

When pressed, Das said the anti-error initiatives they’ve devised will require more staffing. Shannon offered that CCHHS’s electronic systems were better than most (for data-crunching) and that this month the System will begin a baseline "culture-of-safety" survey. Michael urged them to work with Dr. Hoda (IT) to determine what enhancements to the system will catch problems automatically. Das noted there are standard interventions already in place concerning allergies and prescriptions but argued that each site requires a system tailored to its activities.

Shannon added that the System uses the "time out" technique, starting every procedure by having participants identify themselves and review their understanding of what they’re going to do, a practice which substantially reduces errors. There is one right way to do many medical procedures and using a checklist based on that right way keeps doctors from having to reinvent the wheel and risk harming the patient.

Dr. Ukoha from Stroger reported great progress in providing translation services there: the hospital now uses a phone interpretation service covering more languages than before, as well as video interpretation and interpreters on-site. Though certain "strategic areas" require a person on the spot, video and audio can plug many of the gaps. The task now is to make sure the entire medical staff is aware of the availability of this service.

--Submitted by Kelly Kleiman

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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