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Cook County Board Seeks to Amend Health System Ordinance

3/3/2020

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Cook County Board -  Health & Hospital Committee Meeting
February 26, 2020

Meeting Report 
The CC Health & Hospital Committee had two items on its agenda:

Agenda Item 20-1118
went through two substitute iterations with the final dated February 24, 2020 and contains major amendment changes to the 2008 Health and Hospitalts System Enabling Ordinance that established the independence of the Hospital System from the County President and Board and set up the mechanism for appointing an independent board.   The chair of the committee, Dennis Deer, was not in attendance nor were Commissioners Moore and Tobolski.  Commissioner Arroyo, Vice-Chair, ran the meeting. 

  • All commissioners in attendance strongly supported the need for a viable and vibrant county public health care system and it was reflected in each of their remarks.
  • Agenda Item 20-1118 was passed out of Committee with the only exception to a unanimous vote being Alma Anaya who voted "present".  Her comments are below as are selected other commissioners:
  • Larry Suffredin:  Led off the discussion by stating that he strongly supports the amendments and considers them to allow for "re-balancing" of the relationship between the Cook County and System Boards as well as ensuring collaboration on executive hiring, financial, strategic planning, and labor relations issues.  He offered that the Cook County Board is the Health Board for the County; and he pointed to the large increase in uncompensated care; the two highly critical Inspector General reports; and the increased number of grievances and arbitration cases as reason for the need to re-balance.  
  • Sean Morrison:  Stated he often communicated belief that the problem lies with the executive team.
  • Bridget Gainer:  Stated that outward collaboration as well as between the Hospital and the CC Board is needed.
  • John Daley:  Strongly supportive and stated that nearby U of I Hospital and Rush Hospital are both expanding their ambulatory centers and that the HHS System needs more help from them.
  • Alma Anaya:  Stated she does not believe the amendments solves the root cause issues.  She advocates creating a process such as a task force to identify, dissect, and address the problems - particularly financial.  Wants to review and then change rather than "jumping the gun" with the proposed amendments. 
Agenda Item 20-1229 was deferred without discussion.  It would require top executive compensation and severance package approval by the President and County Board and because the matter is also covered in 20-1118, it may be withdrawn

Public testimony
  • ​Dr. Lindsay Ray Murray, Health & Medicine Policy Research Group.  Stated that the System cannot cut its way out of its financial deficits.  Called for a blue ribbon commission from a cross-section of health care professionals and experts to thoroughly explore the issues and make recommendations before approving changes to the 2008 enabling ordinance.  H&M Policy Research Group is a member of the nominating committee that provides HHS board nominations to President Preckwinkle for her and the CC Board approval.
  • Laurence Msall, Civic Federation.  His main objection is that 20-1118 gives the county board say over the selection and compensation of the CEO.  He said that he has heard of no explanation on how the proposed changes will correct the System’s financial problems. The Civic Federation is also a member on the nominating committee for HHS board nominations.
  • Susan Avila, Collaborative Health Equity.  She is also on the H & M Policy Board and worked at Stroger for a number of years.  She stated that there was not enough information before the changes were proposed and is for a comprehensive analysis of the problems and at what works best (Best Practices approach).
  • Mr. George Blakemore also spoke and is in favor of more County Board involvement.

Significant Amendment changes included in Agenda Item 20-1118
  • The System Board will no longer have sole authority to hire the CEO, or interim CEO, or fix the compensation.  Henceforth, it will recommend, subject to the advice and consent of the Cook County Board and the President’s departments on development of its three-year strategic plan as well as its operational and policy strategy. 
  • Requires the Hospital System Board to direct its CEO to collaborate with President Preckwinkle and her departments on development of the strategic plan as well as its operational and policy strategy.
  • Increased HHS board membership from 11 to 12 – The twelfth member will be hired by and reports directly to President Preckwinkle and will serve the same 4-year term as the other directors.  This appointee and the CC Board appointee, currently Dennis Deer, cannot serve as chair of the HHS Board.
  • Allows the System Board to recommend instead of fix compensation of employees and provides that the compensation must be in line with the county board’s budget appropriation.
  • Gives more responsibility to the Cook County Human Relations Bureau in handling grievance issues.
  • Provides that the HHS board shall meet 12 times a year.
  • Specifically states that the Cook County Board does not delegate Home Rule Authority to the System board.​
  • Sets a threshold for county approval for capital expenditures at above $150,000 with monthly reporting of such expenditures of $5,000 to $150,000.

Diane Edmundson - Observer
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Hospital System Responds to Cook County Commissioner Questions on $2.7B Proposed 2019 Budget

10/29/2018

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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.
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Departmental Budget Hearings Underway on $5.9Billion Cook County Budget

10/27/2018

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Cook County Board of Commissioners Finance Committee - Departmental Budget Hearings 
October 22, 2018


Bureau of Finance - Budget Overview
Office of the President
Office of the Independent Inspector General


Commissioners present at least most of the time:  Moody, Daley, Schneider, Suffredin, Boykin, Deer, Arroyo, Moore, Fritchey, Gainer. 

Overview of the Budget - Ammar Rizki, CFO, and  Tanya Anthony, Budget Director:
  • Budget is at $5.9 Billion and the $81.2 million deficit was closed by “structural changes.”  There is a 3% increase in the operating budget with a 32% increase in Cook County Health (CCH) due to increased enrollment in County Care.   About $500 million in uncompensated care accounts for much of this increase.  CCH receives a $102 million subsidy from the County.  A  .3% increase in FTE positions is mostly in Health area (CCH)—about 246 employees.  CCH anticipates balanced budgets for the next 3 years.
  • An increase in sales tax revenues is anticipated ($52 million more than 2018) due to the good economy.  The prediction is for a mild recession in 2020.  Cigarette, Clerk of the Court Office, Treasurer, and Sheriff revenue is down.  Supplemental funding toward pensions for County workers in the past few years has saved this liability.  The plan is to achieve 100% funding by 2047 if the county stays on track in making more supplemental payments.
  • Comm. Suffredin asked the Budget Dept. to consider charging municipalities a percentage for collecting their property taxes.  This would be a big hit for municipalities.  He also mentioned that the property tax levy for the County has stayed the same for many years.  He seems to suggest that these two areas are possible revenue sources in the future.
  • Comm. Boykin noted there are currently 725 vacant positions in the general fund plus the vacancies in CCH.  He asked about property tax rebates for poor homeowners and tax holidays. Comm. Schneider asked whether positions vacant for 12 months or more are really needed.
  • There is a new Policy Road Map which encompasses the following categories:
  1. Criminal Justice
  2. Health
  3. Economic Vitality
  4. Environmental Justice
  5. Public Infrastructure and Assets 
  6. Operational Stewardship (efficiency and cost effectiveness)

Comm. Daley several times reminded the other Commissioners to submit questions in writing that are not answered at the meeting.  The answers will then be posted on the website.

Office of the President  - Lanetta Hayes Turner, Chief of Staff:
  • This office encompasses only 5% of the County’s budget.  FTEs have increased by 24 since last year. 
  • The county has reduced debt by 11% since 2011; and reduced land holdings by sale, lease or demolition. 
  • In technology, the ERP (operations) and BUS (criminal justice) systems are well under way and being used by many departments.  This observer could not get exact numbers on this.  Key performance indicators are being stressed, so it appears that some form of performance management is being used. 
  • In the area of improved services, the county is formally checking its 5,000 rental units and mentoring minority and women businesses to be able to get county contracts.
  • Comm. Fritchey questioned the need for new positions in the President’s office and increases in personnel services, Veterans departments. 
  • Animal Control was a topic commented on by several commissioners—high kill rates, surplus budget of $7 million, opening new shelters, and doing more in this office for animals and their owners.

Office of the Independent Inspector General - Pat Blanchard, Independent Inspector General (IIG):
  • This office has investigated corruption, waste, misconduct, monitoring contracts, etc.  The office received 394 complaints and issued 50 reports just this year covering tax evasion, improvements in Cook County Health and Hospitals System (CCHHS) billing, political hiring and firing, etc. with many recommendations. 
  • The budget is about $2,200,000 with 16 FTEs.  The budget has been cut a lot over the past years. 
  • The cost savings for the County is very high because of this office’s work.
  • Discussion centered around the possibility of the IIG entering into an Intergovernmental Agreement with the  Metropolitan Water Reclamation District (MWRD) for his services.  A draft agreement has been written which would cover 2-3 years as an intergovernmental agreement if approved by the Boards of both entities.  Two employees plus hourly charges would be charged to MWRD.  Some commissioners looked to this agreement as a template for other municipalities and governments to subcontract IIG services and guidance.
  • Comm. Suffredin expressed concern about the confidentiality of the IIG reports and has submitted an ordinance penalizing those who leak the confidential information contained in the reports..

Observer - Karin Hribar
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Cook County Hospitals System Preliminary Budget gets Cook County Board Approval

9/24/2018

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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)
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Cook County Budget Hearings Continue for Second Day

7/30/2018

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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
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Cook County Board Holds Hearing on Billing and Collection Practices of Hospital System

6/11/2018

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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
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