Cook County Board Finance Committee - Departmental Budget Hearings
October 25, 2018

Cook County Health and Hospitals System
 
Commissioners present:  Boykin, Fritchie, Goslin, Morrison, Schneider, Silvestri, Suffredin, Daley
​
Cook County Health and Hospitals System (HHS) – Jay Shannon, CEO
Remarks:   

• The proposed 2019 budget is $2.7 billion of which $102 million or >3% is a tax allocation from Cook County.  The $102 million is earmarked for correctional health at the Cook County Jail and the Cook County Dept. of Public Health.  These are services that the County is required to provide but is unable to bill.  [Note:  HHS is generating 97% of its operating revenue]
• For the last 3 years, HHS has assumed responsibility for its new capital expenses and for depreciation of current and new capital expenditures which amounts to approximately $25 million annually.  Additionally, it assumed $30 million in pension costs in its 2018 and 2019 budgets.
• The FY 19 budget is driven by the HHS 2017-19 strategic plan which includes investing in behavioral health, care management, social determinants of health, and addressing issues in the justice-involved population.
• HHS partners with the Greater Chicago Food Depository to distribute more than 400,000 pounds of fresh produce that impacts 58,000 household members.  These households are identified in the HHS clinics as “food insecure”.
• Deaths related to opioids today in Cook County [avg. 3 per day], are more common than those attributed to guns or motor vehicle accidents.  HHS is initiating programs to address some of the serious Public Health threats impacting Cook County communities.
• “HHS is the linchpin of the county’s health ecosystem that could collapse without it”. 

Questions/Answers

Suffredin:  Is there a way to get the other 68 hospitals in Cook County to pick up a fairer share of charity care?  The latest statistics from state government shows that Stroger and Provident handle almost 50% of the care while the other 68 cover the remaining 50%. In 2016, the system expended $265.7 million in uncompensated charity care. The next closest hospital, Northwestern, was listed at 7% in 2016. He also expressed the possibility “while draconian” to consider the county charging property taxes for those hospitals that don’t increase their share.  Ans:  Shannon said that the hospital can lead by example and "moral suasion".  Legal incentives would be up to the county, city, and state.
Suffredin: How can the system grow its Medicare numbers?   Ans:  Each year 4% of the system’s Medicaid patients turn 65.  HHS is reaching out to these members and encouraging retention within the system by promoting the benefits of continuity of care, the expansion of care management, and the specialty services available at the ambulatory clinics and Provident. 
Suffredin:  Do you have a target for increasing the percentage of County Care members that will choose to use the system’s services rather than go elsewhere:  Ans:  18-20% based on aggressive meetings with other provider services, marketing, and improved care and specialty services being available at the ambulatory care centers.

Morrison: What is the definition of “charity care”?  Ans:  At HHS, charity care is lumped under Uncompensated Care with two subsets:  1) Individuals that cannot afford to pay and have completed the paper work for Care Link which qualifies them for 100%, 75%, or 50% forgiveness depending on their income situation.  2) Bad Debt includes charity individuals who cannot pay but did not fill out the Care Link paperwork.
Morrison:  Asked for a breakout of the 243 FTE’s included in the 2019 budget.  Ans:  101 due to the expansion of clinical care management required to serve FHN and Aetna member acquisitions as well as the expansion of care management such as health risk assessments, expanded operating room services at Provident and Stroger, and new hemodialysis services at Provident.  HHS will also bring in house advanced imaging services and advanced cardiac rhythmic services; 50 nurses and techs to support the clinical staff; 30 for the Juvenile Detention Center [new for 2019]; 12 community health workers; and 55 for environmental service workers for the hospital and new professional building.
Morrison:  What is the cost of the adding 243 FTE’s in 2019.  Ans:  $20 million.
Morrison:  We have met with you over these past months to discuss the revenue cycle and uncollected receivables.  Where do we stand?   Ans:  in 2018 HHS reduced by 25% the number of days a bill is in accounts receivable [AR]; it has reduced by 40% the time it takes between patient discharge and the bill going out the door; and it has reduced claim denials by 40%.  These improvements have and will continue to occur because of the in-house hiring and training emphasis not only for clerical staff but also for doctors and technicians; the hiring of “at elbow”  contractor employees to help train on 3rd party billing and denials management and other institutional and clinical coding, training, and process needs as identified.  

Boykin: What efforts are under way to increase the representation of black minority contractors, particularly prime contractors?   Ans:  Vendor fairs; work with  President Preckwinkle’s outside provider to increase the roster of qualified minority owned businesses; and break bigger projects into sub-contracts.  Shannon noted a 40% increase above 2017 in minority contracts awarded.  Shannon also stated that HHS is one of the anchor institutions on the West side of Chicago whose goal is to improve economic health, physical health, and local hiring.
Boykin: Is there an opportunity for HHS to work with the sheriff on the west side where he has an interest in putting more officers?  Ans:  West side triage has a mobile health team that can go to a home or join the police at an incident site where there might be a mental or behavioral health issue.  Shannon noted that the system is averaging 2-3 gun-shot patients a day at Stroger.  “Gun violence and opioids are a symptom not the cause”.

Goslin:   Asked if the Access to Care services in the northern suburbs is still a relevant model.  Ans:  More than 2/3 of the budget of Access to Care is funded by HHS.  Shannon noted that it was set up prior to the Affordable Care Act and noted that it is not a registered provider required to provide information to the state and federal governments.  He said he could not comment on the quality of care.   He did mention the new Arlington Heights Ambulatory Care facility with state of the art services to be opened yet this year. Shannon went on to say that ophthalmology and mammography services are being expanded at Provident along with GYN, hand surgery, ENT surgery, and other elective outpatient services.  Provident is also offering free Lasik surgery.  

Fritchie: Was there any thought given to use outside contractors for the 55 new environmental worker positions rather than going with the Union and who made the decision?  Shannon:  “yes and I made the decision”.  It came down to cost and local control.  Fritchie asked if a comparison was done on internal vs external and wants any internal documents regarding the decision.  He also asked if any staff had been contacted by Preckwinkle’s office.  Shannon said he was not aware of any staff contact.

Schneider:  Reflected on the idea of charging property taxes for hospitals that don’t take their fair share of charity care.  What should Suburban Commissioners do to get the suburban hospitals to step up?  Ans:  Encourage Access to Care and other advocacy organizations to band together to encourage the hospitals; hold direct conversations with hospital administrators, and review relevant laws.
Schneider:  Why was the Arlington Heights site picked for the new clinic?  Ans:  Demographics, transportation, other comparable services, affordable space, and the last hurdle is bureaucratic and political.    Shannon took this opportunity to mention that the new 2018 transportation fleet set up to get patients to their doctor appointments has been very successful and popular.  Cost is about $500,000 for 2018.

Silvestri:  Why does the hiring process take so long?  Ans:  HHS has a very complicated hiring process accentuated by market competition; there is a shortage of specific skills and skill sets.  Shannon noted that compensation for nurses is competitive when salary and benefits are combined.  In the case of physicians, HHS is woefully not competitive with private hospitals in certain areas and specialties.

Daley:  Urged continued improvement with in-house retention of County Care members and stated that it is incumbent on each Commissioner to meet with and urge hospitals in their districts to take on more charity care.

Observer - Diane Edmundson                                                 Meeting Length:  2 Hrs.

Cook County Board of Commissioners Meeting - September 12, 2018

What the Board Decided:
The following Items were approved: 

• Cook County Health and Hospitals System (CCHHS) Preliminary Budget (Agenda Item 18-1619) 
• Contract Compliance Proposal to create a Small Business Commission (Agenda Item 18-4541)
• Report of the Bureau of Technology - IT Consolidation Report (Agenda Item 18-4828)
• An Amendment to the Ordinance that established the CCHHS Board dealing with the scope and distribution of clinical services that require approval or notification to President and the Cook County Board (Agenda Item 18-1126)
• Independent Auditor’s report of the financial statements of the Clerk of the Circuit Court of Cook County for period ended on 11/30/2017 (Agenda Item 18-4734)
• An Ordinance preventing the detention of juveniles under the age of 13 (Agenda Item 18-4955

The following item was referred to committee:

• Ordinance Amendment on IT Consolidation was referred to the Technology and Innovation Committee (Agenda Item 18-5634)

The following items were Deferred:

• Proposed Ordinance Amendment of CC Board of Review Operation and Administrative Fund was deferred again as done on July 25.(Agenda Item 16-6437)
• Creating a Bulk User Fee for the Board of Review (Agenda Item 18-5013).  
• Propose that Commissioners create a preference for businesses owned by people with disabilities under Procurement Ordinance (Agenda Item 18-4162). 

The following item was Withdrawn

• Authorization for the Office of the County Clerk to purchase election equipment from Dominion Voting Systems.(Agenda Item 18-2409)

Other Observations  

• Before the Board Meeting I observed the last quarter hour of the Budget Meeting where Dr. Jay Shannon spoke about the CCHHS.  Their aim is to “save lives while saving money”.  He spoke for the approval of 18-1619--specifically the needs for continued modest gains and equipment upgrades.  The CCHHS provides 50% of charity care in Cook County.  Commissioner Gainer inquired about the turnover.  Dr. Shannon replied that it is between 5 to 8 % monthly. 
• Regarding 18-2409 Election Equipment, the Clerk’s office is working to diminish threats to elections.  They are aiming for the highest quality for the lowest price.  There will be an eventual staged rollout.  “You can’t have all new equipment at once.” 

 Observer - Jill Althage                                     Meeting Length - 1 hour and 20 minutes (11:10am to 12:30pm)

Cook County Board Finance Committee - July 24, 2018 
Midyear Budget Hearing - Day 2 - Morning Session

 I arrived right at 9AM for the hearings and there were 2 commissioners present (Suffredin and Morrison) other than Chariman Daley. Seven more arrived by 9:30AM and 3 more by 11AM. Absent for the entire morning session were Commissioners Goslin, Gainer, Butler, and Fritchey.  Commissioner Sims asked everyone the core mission of his or her department and if there was any waste to cut. She did this even when both questions were answered in the original presentation. Commissioner Morrison asked everyone what new taxes they would propose, if any. Most took no stand on this issue.

Board of Review (BoR): I came in just as their presentation was wrapping up, but  I heard all of the questions.

• Their budget is only 1% of the whole county’s budget so any increase in personnel should be considered, according to the 3 BoR Commissioners present (Patlak, Rogers, and Cabonargi).
• Their biggest problem was losing experienced analysts in the past year. They would like 11 new ones.
• Their staff picked up 16,00 extra overtime hours in the past year and were not given more money for this. This was equal to 13 FTE’s.
• Most of the hearing was about community events called workshops in which the tax appeals  process was explained to the public. Many commissioners participated in these events. Also the B of R said it was a good way for staff to see the properties that were being discussed. More appeals are to be expected this year.

The Assessor: This presentation and Q and A session was extremely short. It lasted maybe 15 minutes.

• Assessor Berrios said he would have no trouble keeping within his budget this year due to new technology. This has helped to eliminate positions that became unnecessary.
• Commissioners seemed focused on Senior exemptions and the process that it entails. Ways of simplifying the process were mentioned.

Cook County Health and Hospitals System (CCHHS): A short report was given to each commissioner.

• Dr. Shannon said that no new revenues would be requested this year or for FY 2019. They will live within their budget mainly due to the fact that they now have 330,000 new patients enrolled in County Care (up from 270,000). Most new patients come with Medicaid funds which includes federal reimbursement for now.
• They have been able to solve any deficit spending by renegotiating contracts with vendors.
• Some of their proudest achievements other than the above include getting Cermak hospital out from under its consent decree (this is the jail hospital at Cook County Jail), a technology award for having all patient records electronically filed, and for expanding its charity care (care to those with no insurance at all). 
• In addition, the future looks to be one of 5-6% growth for a number of reasons. They expect more community centered clinics, especially those that deal with dialysis and dental care, and they have taken on the mental health services for kids in the JTDC (juvenile detention).
• They also hope to get to the underlying causes of bad health such as poor diet, housing and lack of job opportunity. He did not say exactly how a health care system would manage those issues, but he is working to obtain grants to study these issues.
• He is working on a better system of bill collection to alleviate previous problems.
• Comm. Boykin asked about the issue of gun violence as a health epidemic and what CCHHS was doing about it. Dr. Shannon listed many solutions. He said that he agreed with the commissioner and cited last weekend’s shooting statistics: 20 of 35 shooting victims were taken to Stroger.
• He said that in the case of a juvenile detainee, CCHHS was linking services he was getting while incarcerated with those out in the community once he was released.
• CCHHS is expanding its care under Mental and Behavioral issues in order to treat the whole person. This would include linking that patient with substance abuse programs and programs for depression or anxiety.
• CCHHS is working with Westside United and Rush Hospital in order to improve health in several west side neighborhoods.

At one point the hearing got a bit controversial as Commissioner Moore asked about a lawsuit against a doctor in a malpractice case. States Attorney Kim Foxx, who was on deck to speak next, answered that this matter was in litigation and could not be discussed in open hearing. Chairman Daley stifled any more conversation on this issue.

State’s Attorney:  Presentation was given by Cook County States Attorney Kim Foxx.

• Ms. Foxx said that this past year has been tough because last summer she missed an entire hiring cycle. Most of her new hires come in the summer after new grads finish law school and the bar exam. She was down in staff since her office did not have enough money to hire last summer. This summer is better and she is trying to live within her current budget.
• In FY 2019 she would like $1.97M more to hire 20 FTE’s.
• On civil cases she needs more experienced lawyers since she represents every county employee who needs defending. The conviction integrity unit has only 5 attorneys and 268 new cases came in this year. Her attorneys have 2-4x the amount of cases recommended by the American Bar Association.
• The SA Office also has attorneys working with the Chicago Police Department (CPD)  on intelligence gathering in the Englewood and Harrison districts in order to solve gun crimes. Training CPD and suburban police chiefs in how to gather evidence can save money if there are less faulty convictions.
• Comm. Suffredin commended her for doing a good job. 
• Ms. Foxx appealed to simple math often. Hiring outside counsel, she said would cost anywhere from $300 to $500 per hour on civil cases. Her attorneys cost about $90 per hour.

The Public Defender (PD): Presentation given by Cook County Public Defender Amy Campanell. She put up a big poster board with her core mission and with a list of some of the duties performed by her office.

• Ms. Campanelli  said that in FY2018 positions that were vacant for a long time were slowly being filled and that she was on target to live within her current budget.
• She wanted more staff in FY 2019  especially to start a mental health unit, but did not give a specific price tag unless asked.  She said that she had asked for this several years in a row . She now had a business plan worked up in which she would use student interns who were psychology or social work majors at local universities to help. Their assistance would be at no cost to the county. Early psych evaluations can also speed up the disposition of many cases. Comm. Deer asked her how much a mental health unit would cost the county. She said that she could do it for a mere $225,000. This would save money at trial since many psych professionals testify at a cost of $500 per hour.
• She also noted that now the PD is on call for arrestees in every police district in Chicago. She even gave out the PD phone number several times. A recent survey of 120 arrestees showed that 22 were released because the arrests should never have happened. This saves the county money. PD’s helped this to happen.
• She has also asked for more grant money to employ social workers and more lawyers to work with detainees awaiting trial who might be in danger of losing custody of their children.

Observer - Jan Goldberg

Cook County Board Finance Committee Hearing - June 5, 2018, 4:00 p.m.
Purpose : Discussion of the billing, collection, and accounts payable practices of the Cook County Health and Hospitals System (CCHHS)

Quick Points Summary of the meeting:
When the Cook County Health and Hospitals System (CCHHS) CFO, Ekerete Akpan, was asked what is yet needed to improve collectability, he responded:

• More negotiations with unions on standards, work rules, and performance accountability after repeated re-training.
• Each step of the intake, coding, denial review, and accountability has to improve.
• More staff
• More training
• Better IT systems to detail/code individual patient’s conditions and treatment.

There was a consensus on the board that resolving the collectibles issues is a high priority, and the mandate was made clear to the CCHHS senior staff.  

Commissioner Morrison believes there has been and is a systematic failure of management and called for more discussion on best practices and standards.  He cited a lack of urgency in resolving problems.

Commissioner Schneider called for a discussion on the issue of getting more County Care insurance subscribers to use the CCHHS services and facilities.

Background for the Hearing: 
Following a critical report from the Cook County Inspector General’s Office in April of 2018, Commissioners Daley and Suffredin called for this hearing to discuss in more depth the billing, collections, and accounts payable practices of CCHHS.  Chairman Daley was absent from the meeting due to a hospitalization.  Commissioner Sims chaired the meeting which started three hours after its scheduled time.

Comm. Suffredin opened the meeting stating that he and Daley recognized that Senior Management and the board understand the need to address changes in its coding, billing, and collection systems brought about by the Affordable Care Act [ACA] and the State of Illinois changes from a Managed Care fee per visit [fee for service] to charging for each type of service.  He specifically charged the Commissioners use this hearing to deal with direct services provided by Stroger and Provident Hospitals, and the CCHHS ambulatory clinics.  County Care issues were not a subject for this hearing and as it turned out, time did not allow for a discussion on accounts payable practices except a brief mention on the delay of payment due to the delay in receivables.

Public Speaker: Helen Thornton, Union Representative from AFSCME Council #31 [administrative/clerical workers], stated the union is committed to making the hospital and its membership successful.  It called for: 1) the same training for all; and 2) cross training.

Hill Hammock, Chair of the CCHHS Board of Directors reported all the System changes made since the ACA was enacted:  1) New Sr. Management; 2) New four-year Strategic Plan adopted in 2016 and implemented in 2017; 3) New Systems; 4) New Metrics and Standards; and 5) Training to work for a cultural change to a “Patient First” model.  Why?  Because 60% of HHS patients now have insurance and can choose a different service provider.  Prior to ACA, 70% of CCHHS patients had no insurance.

Dr. Shannon, CCHHS CEO, commented that in 2017 the System absorbed $250M (At the May 25, 2018 CCHHS Board meeting he pegged the number at $300M) in charity care while budgeted to receive $102M from county taxpayers out of a $2 billion plus budget for 2018.  According to CCHHS, this $102M covers the Jail’s Cermac Health Center, the Cook County Public Health Department, and the Juvenile Detention Facility’s health needs.  He noted that the System has started to cover part of its pension obligation while reducing reliance on county taxes by 75% since 2009.  That said he and his team recognize the need to improve collectables by reducing insurance denials, more accurate coding, better training, and more staff.  Specifically he noted:

• Since the ACA and the changes in State Medicaid payment practices, the number of billing codes increased from 17,000 to 140,000.
• Every encounter leads to generating a bill whether for insured, uninsured, or charity care.  CCHHS sent out 4.5 million bills in 2017.
• Coders work first on insured services and higher reimbursable procedures.
• Charges captured have gone up by 60%, but the internal staff has not reached the internal goals of both accurate and prompt coding. 
• The goal is to have charges coded within 1-2 days of service.
• Yet needed and being negotiated with unions are daily expectation standards and process of review for work rules.
• CCHHS has more than 20 contracts with various managed care providers including medical, dental, and prescription services, some with unique codes to be learned.

Commissioner Suffredin asked how many coders CCHHS has on staff.  Answer:  37 internal staff with 15 more in the hiring process plus contracted coders.  Commissioner Deer said that the number isn’t enough for the size of CCHHS.  It needs an “army” of coders and verifiers at multiple levels.

Additional “Accounts Receivable [collectibles]” information:

• CCHHS reported that about 50% of non-collectible accounts receivable is due to errors that can be improved.  Its denial rate decreased by 40% between 2016 and 2017.
• All hospitals are experiencing a higher bad debt due to the changes in billing and coding; and the competition for experienced coders is fierce.  
• Of the 76-78 hospitals in Cook County, 50% of the charity care county wide is handled by the two CCHHS Hospitals and 17 clinics.
• Private hospitals have a much better “payer mix”.  I.e., more patients with private and Medicare insurance.  CCHHS has primarily Medicaid insurance and its payer mix is between 25-40%.   Therefore private hospitals have a higher  accounts receivable collection rate.
• The Inspector General's report focused on “charges” when determining the amount lost in potentially collectable receivables.  Insurers pay adjusted and negotiated rates which are much lower than actual charges.  
• Dr. Shannon gave an historical recapture metric for collectibles [40%] that may be helpful to understanding what may be realistically possible for its debt collection.  Example for 2017:  Of the $66M in charges that were deemed to be collectible if coded on time and accurately, $25M should have been collected.  In 2016, the numbers are $108M deemed collectible of which $45M could have been recovered.

Observer - Diane Edmundson                                         Meeting Length:    2 Hours

Cook County Board of Commissioners Finance Committee and Board Meeting  
May 16, 2018 

FINANCE COMMITTEE MEETING 
​Public Speaker at the meeting - Mike Belsky, Executive Director Center for Municipal Finance, Harris School of Public Policy, University of Chicago, spoke in favor of the ordinance to establish a Consensus Revenue Forecasting Commission for Cook County.

Significant Topics Discussed
1. Cook County Health and Hospitals (CCHHS) Quarterly Report was presented and filed.

• Commissioner Daley announced that there would be a Special Hearing on June 5, 2018, 9:00 am to discuss the issues presented in the Inspector General’s Report, and failure to bill properly.  
• Commissioners are deferring questions to this meeting.
• Chairman of the CCHHS Board, all CCHHS Board Members and the Cook County Financial Team including the CFO of Cook County have been invited to attend.  
• There was discussion as to whether to include a representative such as a Union member to represent employees at this hearing. This could cause the meeting to go to Executive Session. It was decided that the purpose of this Special Hearing was to discuss the issues in the Inspector General’s Report and if employee issues arise a separate meeting would be organized to deal with employees

2.  A Resolution establishing a foundation for the benefit of the sheriff’s Office of Cook County was passed. 

• A not-for-profit Foundation to be created to accept charitable contributions either financial or gifts in kind to support the missions of the Sheriff’s Office. 
• Gifts will be used to improve the life of those incarcerated and those who are being released.
• Example of gift in kind, The Dr. Willie Wilson Foundation donated Feminine Hygiene products to the CC Sheriffs office to be donated to detainees and those recently released from jail.

3. An Ordinance to establish a Consensus Revenue Forecasting Commission for Cook County, which was deferred to the next meeting or later for further study. (Garcia, Boykin, Suffredin)

• The Commission will be responsible for evaluating and forecasting revenue including but not limited to Sale Taxes, Property Taxes, Cigarette Taxes, Fuel Taxes and other sources of County Revenue.
• The forecast will be completed by September 15 of each fiscal year and will be updated quarterly
• Commission will have seven members appointed by the County Board President and confirmed by the Cook county Board to include Chairman of the Business & Economic Development, Chairman of the Pension Committee, Chairman of the finance Committee, the CFO of Cook county, an economist working at the Federal Reserve Bank of Chicago, an academic economist working at the university in Cook County, and one member of the public with expertise in public finance. This will be a 3-year term. 
• Pros, when you can forecast   the revenues it is easier to create a budget and shortfalls could be determined earlier.   This will provide for a more open and transparent budget process.
• Cons, Commissioners believe this is already done and do not need a separate Commission. Budget process should begin earlier for there to be more time to question the budget.  

COOK COUNTY BOARD MEETING

Highlights from the meeting:
1. Ordinance Amendment increasing fines for Public Morals Violations - referred to Criminal Justice Committee.  

• This ordinance would increase the fines for public nuisance issues such as public urination and public drinking.
• It also added Community Service for those who could not pay the fines

2. Proposed Ordinance Amendment authorizing Video Gaming in Unincorporated Cook County - referred to the Finance Committee.

Committee Items Requiring Board Action

• Resolution creating Cook County Prevailing Wage Advisory Task Force passed with no discussion or public comment on this issue
• Resolution creating a Funeral and Cemetery Violence Task Force passed. This creates a task force to deal with the violence that occurs with Gang related funerals. 

Items to Watch for in the Future

• Special Hearing June 5 for CCHHS and the Inspector General Report
• Ordinance to establish a Consensus Revenue Forecast Commission. This was deferred for more study. Look for this in the near future possibly in June.

Observer: Nancy Marcus                                                                  Length of meeting -  5 hours with a lunch break