CCH Board Observer Reports

Cook County Health Hires AArete Consulting to Help with Financial Strategy

3/3/2020

Cook County Health (CCH) Board Meeting - February 28, 2020

Board Reports and Discussion:

Public speaker- one person representing a vendor requested more timely payment.
Staffing - 750 of the positions left vacant have been deleted from the budget. The board discussed the impact on care from staff cuts. Positions are only being cut through attrition, no lay offs planned.
CountyCare membership is up. A partnership with the Chicago Public Schools has helped drive students to join CountyCare. The automatic assignment of patients to CountyCare will now be 50%.. There is a problem in payments to CountyCare and other vendors.
The Audit and Compliance Committee shared results from the outside audit on coding. They found that there is improvement since the last audit but there is still a significant problem with coding and it is a whole house issue involving multiple people and departments.

The Finance Committee stated that there are multiple problems with income streams.

CountyCare is waiting for payment of $350 million dollars. The claims are adjudicated but not paid. Uncompensated care is an increasing problem.
Robert Sumter will be the interim CFO.
There were changes made to the organizational chart for the area.
It is felt that there is a significant problem in cash flow, including a lack of clarity and communication with Cook County board. Need to set up more meetings with the Cook County Commissioners.
Better integration is needed between the accrual-based accounting of Cook County Health and the modified cash based accounting used by the Cook County Board.
Bob Clark, a CPA from AArete Consulting, will be hired to help with financial strategy and bring in a clear set of eyes. He is highly experienced in health care entities.
Contracts and procurement items were voted on.

West Side United presented an overview of their plans. Six hospitals on the west side have joined together to address social determinants of health. The life expectancy on the west side is 16 years shorter than in the Loop that is just a couple miles away. They hope to halve the difference by 2030. They just completed a 1000-day plan and will be starting the next 1000-day strategic plan. They are convening with the community on March 5, 2020.

Dr. Sharon Welbel, epidemiologist at Stroger and Dr. Kiran Joshi of CC department of public health presented a COVID-19 update. Cook County has testing capabilities and does not need to use CDC kits. CCH has been actively preparing for an influx of cases and have implemented a rapid identification plan and set aside 2 ER rooms for suspected COVID-19 cases that are not in proximity to other rooms. Over 1000 healthcare workers have already been trained.

Board President Hammock report:

The CCH Board has been working closely with Cook County Board.
Otis Story has been appointed to the CCH board by President Preckwinkle to help educate the Cook County Commissioners on health issues.
The search for a new CEO has started. A proposed position profile for the CEO was shared and discussed. It will be sent to the CC board for use in hiring the CEO.

Items to Watch for in the Future:

Many changes are anticipated to correct financial problems.

Observer- Lisa Slankard Meeting Length: 2 hours 40 minutes then meeting went to closed session

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Cook County Health Board Hears Update from Department of Public Health

2/4/2020

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Cook County Health (CCH) Board Meeting
January 31, 2020

Reports to the Board:
The Cook County Department of Public Health (CCDPH) - is at the command center for Chicago's coronavirus case, along with the Illinois State Department of Public Health and the Centers for Disease Control. The CCDPH website has links for coronavirus and flu information. Cook County Health has been screening for coronavirus. CCDPH also presented their 2019 Quality Improvement Projects. These projects result from Planning, Testing, Study, Implementation. The goal of planning is to understand and analyze a problem, potential solutions are pilot tested, afterward studied/evaluated, then the new process is implemented.
The 2019 CCDPH Quality Projects are:

Investigation of Food-borne Disease and Outbreaks
Promotion of Smoke-Free Multi-Unit Housing
Improving Tuberculosis Direct Observation Therapy- cost effective way of a video picture of patient taking their medication
Annual School Health Conference Check-Out Process
Improving Access to Services in the Illinois Breast and Cervical Cancer Program
Environmental Health Services Digitization: Forms
Improving Perinatal Hepatitis B Post Exposure Prophylaxis
Adverse Pregnancy Outcomes Reporting System Program face-to Face Contacts

Human Resources - starting out 2020 with approximately 526 vacant positions with 308 positions in the hiring process. They have a Position Control Committee that receives requests to hire. These requests must meet patient safety and quality standards, regulatory requirements, need to generate revenue and reduce expenses. If a position is approved by this committee, it goes for budget approval and then is posted on Taleo (the county's on line application site).

CountyCare - as of 1/2/2020 has 318,000 members, 10.6% of members using CCH clinics. Next Level Health, a Managed Care Organization (MCO) only available in Cook County, was recently purchased by Molina Healthcare. Molina is increasing its presence in the county. Over the past year, CountyCare membership has held steady with its 31.5% of total CC Medicaid members. In 2019 there has been an overall drop in total Medicaid members, and CountyCare membership has followed this trend. Auto-assignment of Medicaid enrollees into MCO health plans happens when a member does not choose a health plan/primary physician within the specified time. CountyCare auto-assignment has been increased from 35% to 50% starting April 1, 2020 and is open-ended. This increase is a result of CountyCare's innovations, quality and housing program. The 2020 projected enrollment is 326,000 members.

Quality and Patient Safety Committee - reports good results at the end of 2019 for decreased hospital acquired pressure injuries due to a focused nursing campaign. The aim is to sustain this decreased number with continuing preventive measures.

Other Business:

The CCH North Riverside Health Center, replacing the Cicero clinic, opened for patients January 27, 2020. CCH is installing posters, distributing flyers at all facilities to raise awareness of the 2020 Census.
The CC Board of Commissioners proposed changes to the 2008 Ordinance Establishing the Cook County Health and Hospitals System. The original ordinance can be found HERE. The proposed changes are in the Ordinance Amendment. (Cook County Board Agenda Item 20-1118) Members of the CCH Board discussed the proposed changes and decided to meet with the CC Board of Commissioners and present the CCH board's point of view on the proposed changes.

Observed by Michele Niccolai Meeting Length: 2 hours and 30 minutes

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Outgoing Cook County Health CEO Begins Strategic Discussion On Self-Pay For Medical Services

1/2/2020

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Cook County Health Board Meeting - December 20, 2019

Following up on the 2020 budget deliberations and the very real issue of the increased cost for charity care, Dr. Shannon, presiding at his final board meeting before leaving the system, led a discussion on “self-pay” and how other major public hospitals across the country handle it.

For purposes of discussion, self-pay is used in place of charity care. There was a 17% increase in year-over-year charges from FY 2018 to 2019 from $158 million to $185 million. The percentage of self-pay was 1.2% in 2018 but dropped to .4% in 2019. The largest service increases are: Radiation Therapy [75%], Family Practice [50%], Gynecology [33%] and Surgery [29%].

Comparisons of NY Health & Hospitals; Jackson Memorial [N. Texas & Oklahoma]; Parkland [Dallas]; and Grady [Atlanta]; self-pay plans were passed to the Board and include:

Sliding scale fees based on Federal Poverty Levels
All or a portion of the patient responsibility paid in advance
Services covered limited to emergent [emergency]
Six months residency required to qualify for charity care

Dr. Shannon listed several strategic considerations:

Continuous improvement in revenue cycle process
Refine and update self-pay policies and procedures to include collection of co-pays from insured or payment for others [self-pay].
Refine and update policies on taking self-pay transfers from other healthcare facilities
Build-out point of service collections/payment capacity including:

1. Online payments as part of patient portal improvements
2. Kiosks with payment options
3. Training staff to collect/swipe cash or credit/debit cards
This would be a major change in policy for CCH as well as culture. Several board members questioned whether the County Commissioners and President would accept this concept. President Hammock responded that the System should provide an analysis and recommendations so that both it and the County elected officials have a base to work from including possibly deciding to provide more revenue to CCH to handle charity care.

Laurence Msall, President of the Civic Federation stated in public comments “The Civic Federation remains adamant in our support of this [volunteer] board…..” He also recommended that the System steer clear of initiatives that do not fit with its core strategy, but did not state what they might be.

Observer - Diane Edmundson Meeting Length: 2 ½ Hrs.

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Cook County Health CEO Jay Shannon Leaving at Year’s End

12/3/2019

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Cook County Health (CCH) Board of Directors Meeting
November 22, 2019

The vote by the Cook County Health Board to not renew CEO Shannon’s contract transpired after the Public portion of the Board meeting had adjourned and was reported by the media Friday afternoon November 22, 2019. Chicago Sun Times, Crain’s Chicago Business and WBEZ, NPR News Station reported that the Board named Debra Carey, deputy CEO, as Interim CEO beginning Jan. 1, 2020 while the Hospital System searches for a permanent replacement.

Board Discussion

CountyCare members 318,196 which is below budgeted numbers, resulted in decreased revenue and decreased expenses, net contribution of $144 million vs budgeted $269 million to CCH. Backlog of Medicaid applications of nearly 100,000 at the State Level is contributing to the lower enrollment.
Medicaid enrollment has decreased by 15% countywide, a trend seen Statewide as well as nationally, attributed to fewer “navigators” assisting in enrollment of Medicaid individuals under the PPACA explained Kiamos of CountyCare.
Net year end 2019 loss for CCH as a whole is projected at $156 million vs the budgeted loss of $180 million, which is a positive.
Charity Care is projected to total $377 million and an additional $167 million in bad debt, severely stressing CCH finances. CEO Shannon stated that this trend was unsustainable.
Shannon noted that patients who come for elective services such as expensive MRI/CT take advantage of the free care and he suggested that the Board should consider implementing partial pre-payment prior to the service which is the policy at other hospitals.
CEO Shannon reported that the CCH 2020 budget had been approved by the Cook County Board.
New Provident Hospital update, $240 million budget ($205 million in bonds and $35 million in furniture and fixtures from CCH); groundbreaking Fall 2020, fully open for business end of 2023; 42 med-surgical and 6 ICU beds (vs currently staffed 25 beds and average daily census 13)
CCH research indicates the Provident service area is in need of surgical and specialty services and has a better payer mix than Stroger Hospital
Director Thomas cautioned that the New Provident Hospital would be a difficult sell to the community as they had been told for years to use Stroger. He also warned that the University of Chicago would likely "dump" patients on Provident whenever they were on “bypass”.

Observed by: Susan Kern, MD Meeting Length: 3 hours

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Cook County Health Continues to Have Funding Challenges

10/25/2019

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Cook County Health (CCH) Board of Directors Meeting
October 25, 2019

Board Discussion:
CEO Dr. Jay Shannon summarized recent Cook County Health (CCH) positive developments:

The IL Health Facilities Board has approved the application for a new Provident Hospital;
The National Committee for Quality Assurance (NCQA) has given CountyCare high approval ratings;
The US Congress passed a continuing resolution through November 21, to continue the current $157m in “Disadvantaged Share Hospital” (DSH) funding to CCH, though, he cautioned, this agreement must be monitored.

But CCH faces serious funding challenges: it is $30m over budget in charity care despite $25m in new revenue this year. In 2020 CCH anticipates providing $590m in uncompensated care, for which the only designated funding sources are the federal DSH ($157m) and BIPA ($132m) allocations. The demand for charity care has grown by $100m since 2017. CCH is now providing about 60% of all charity care in Cook County. Of Stroger Hospital’s total patients, 47% are on Medicaid, 15% Medicare, 5% insured, and 35% uninsured. The possible solutions to the funding gap do not inspire hope: more state and federal funding, possibly County funding from a sales tax.

Committee Reports:

Human Resources: Of 757 vacancies filled, 541 were external; average 101 days to hire.
Managed Care: 320,177 CountyCare members as of 10/6/19, 31% of the total 1,012,425 managed care members in IL. 83% of CountyCare members choose to re-enroll in the program. Since January 2018 managed care enrollment has diminished by 180,000. An estimated 200,000 IL residents are eligible for Medicaid, but have not submitted applications. 96% of CountyCare claims are adjudicated within 30 days, but only 32% are paid within 30 days.
Quality and Patient Safety: 72% of patients are now willing to recommend the Stroger Hospital. The hospital’s readmission rate is currently 9.7%, vs. a 15% national average.
Finance: operating revenue is 23% below budget for 2019; the state is 2 months behind in payments. Primary care visits are up by 10%, specialty care up 6%, Emergency Room visits down 2%, deliveries up 5%.

Significant contract awards:

Cerner Corporation for software support - $191m for 5 years, $38.2m per year
Medline Industries for medical and surgical supplies - $70m for 36 months;
Paschen Ashlaur Joint Venture to construct Belmont-Cragin Health Center - $12m.

Observed by: Linda Christianson Meeting Length: 3 hours

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Cook County Health Board Transfers Millions from Special Purpose and Wage Funds to Cover External Provider Claims

10/4/2019

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Cook County Health (CCH) Board of Directors Meeting
September 27, 2019

What did the Board Decide:

Cook County Health (CCH), CEO Shannon explained that underestimation of external claims from non-CCH Network providers of the Managed Medicaid/CountyCare program exceeded the total appropriated dollars. Payment of these bills necessitates transfer of funds from other CCH budgeted items still showing a positive balance. Over $80M was transferred form special Purpose and Wage Funds to cover the claims.

The Board voted to purchase a renovated Blue Island building replacing the closing Oak Forest Clinic for $15.3 million, a savings over a 10 year $17.3 million lease.

Located at 12757 S. Western Ave. servicing the same population as Oak Forest Clinic/hospital, it will be a multi-disciplinary clinic including radiology, lab, specialty and primary care services.
Several Board Directors expressed concerns over the lack of parking and access as the nearby L station is slated to be shuttered. Administration pointed out that “L” station closing would open up their parking lot, and an adjacent building might be purchased for parking.

What else did the Board discuss or refer to committee?

New vendor using “Big Data” and algorithms identified $1.9 million in overpayments which CCH hopes to recoup.
Cultural Competency course & training program for CCH staff in development. Leadership are contributing components. Director Gugenheim urged that all levels of the organization be involved in its creation.
Dr. Mason, CEO of Cook County Dept. of Public Health reported adoption of the Good Food Purchasing Program (GFPP) by Chicago Public Schools; soon to extend to the County Sheriff’s Office and Juvenile Detention Center. It is a national organization and movement to bring ecologically positive changes to food sourcing including: 1) locally grown food 2) animal welfare and nutrition 3) environmental sustainability such as compostable cutlery and plates
Public Speaker, Laurie Cohen, of the Chicago Civic Federation called for greater transparency in presentation of CCH's finances. She alluded to the Board’s Sept. Finance Com. discussion & PowerPoint which states : CountyCare-CCH reimbursement rate has been adjusted to 100% of the Medicaid rate for current fiscal year. There was no explanation of how this impacted the system or budget.

CEO Shannon responded at the end of the meeting: Medicaid rate education would be considered. This response does not seem to address Ms. Cohen’s concerns that the consequences of various financial metric variations are not elaborated on to the public.

Observed by: Susan Kern, MD and Megan Kennedy Meeting Length: 2 hours and 45 minutes

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Cook County Health Hires AArete Consulting to Help with Financial Strategy

Cook County Health Board Hears Update from Department of Public Health

Outgoing Cook County Health CEO Begins Strategic Discussion On Self-Pay For Medical Services

Cook County Health CEO Jay Shannon Leaving at Year’s End

Cook County Health Continues to Have Funding Challenges

Cook County Health Board Transfers Millions from Special Purpose and Wage Funds to Cover External Provider Claims

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