Category: Healthcare

Cook County Board Holds Hearing on Cook County Health Finances

9/30/2019

Cook County Board of Commissioners Health and Hospitals Committee
Public Hearing
September 26, 2019

This hearing was requested by the Cook County Board of Commissioners to note and understand discrepancies between the Inspector General (IG) Report and the rebuttal of Cook County Health (CCH) and the firm—Deloitte—hired by CCH to analyze the Inspector General's Report. The IG Report generally stated that CCH’s insurance program, County Care, was unsustainable and was being subsidized by Cook County taxpayers. The IG report looked at ALL of the CCH finances, not just County Care. CCH disputed this and hired Deloitte to analyze the IG report —mainly the viability of County Care—and report to the Cook County Board. Deloitte did NOT do an audit as this was done previously by another division at the firm. It also only looked at County Care and not all of CCH.

There was a lot of confusion by the Board on what was being stated by both the IG Office and Deloitte. Mainly this was because of the Accounting Systems used by CCH and the various ways accounts receivable, payable, assets, etc. can be interpreted. All parties are looking at the financials and cash flow differently. The main question of the Cook County Board was “Do we have any concerns about the stability and viability of CCH?”

Here are the basic findings as this Observer understood them:

Inspector General Report

CCH is using other assets to pay claims in County Care, so the “hospital system is subsidizing the County Care Insurance program.”
There is between $501-$700 million in outstanding bills -—not paid or paid late.
Vendors are not supplying some necessary hospital, medical items because they are not being paid.
Transparency of revenues and losses is an issue.

Deloitte Analysis--

Revenues from County Care (provided from governments state and county) have covered its expenses.
CCH needs to make more timely payments to providers (90% of claims are processed but not nearly that number are paid) and this is a concern
County Care is profitable and can run the program
Assets and Liabilities in County Care are sustainable
At any point in time, County Care will have a $500 million or so liability because as old bills are paid, new ones come in that need to be paid -a backlog.
Funds from the State and County are sometimes not timely, which puts payments behind.

Dr. Shannon (CEO of CCH) Statements:

The premiums that County Care receives are more than enough to pay its expenses in County Care and in fact subsidizes some of the charity care and other programs that CCH undertakes.
CCH has suffered reputitional damage due to the IG report. People will not be willing to use CCH if they don't feel confident in its sustainability and viability.
The State of Illinois needs to speed up its application process for Medicaid enrollees.
CCH is in deficit due to increased charity care and non-payment by individuals who have insurance—NOT because of County Care.

Cook County Budget Office:

CCH will be working with the Cook County Budget Office to use best practices and increased transparency in reporting between CCH and Cook County Board.
There is room for improvement on the cash/payments flow system and they are working on it.

Observer : Karin Hribar Length of Committee Hearing: 2 hours and 20 minutes

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Cook County Health (CCH) Focus of Cook County Board Mid-year Budget Review

7/26/2019

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Cook County Board of Commissioners - Finance Committee Meeting
Mid-year Budget Review - July 17, 2019

What did the Board decide?
Several commissioners requested follow up numbers from Cook County Health (CCH) on a number of issues.

Other Discussion:
Debra Carey (in the absence of Dr. Shannon, CCH CEO) presented the review of the budget and stated there is a projected shortage of $103M this year. She said they expect to be able to eliminate the deficit. They just received a payment of $77M from Medicaid for County Care and the rest they hope to cover by budget tightening and not filling open positions. Charity care is up for the first time since the implementation of the Affordable Care Act (ACA). This was blamed on a problem in Springfield because there is a backlog of eligibility determination and Medicaid is down 7%. The state is addressing this but it will take time.
It seems that coding and documentation is a big issue both for collecting revenue and the outside coding agencies are the delayed accounts payable cited by OIG. There was a lot of discussion on how this is being addressed.

Additional observations:
Commissioner Tobolski asked if there is a structural deficit for the hospital and wants CCH to pay more attention to the business aspect.

Observer - Lisa Slankard Observed for 1 hour

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Cook County Board Approves Resolution in Support of The Medicare for All Act - HR1384

6/15/2019

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Cook County Board of Commissioners Meeting - June 6, 2019
Commissioner Absent: Stanley Moore

What did the Board Decide:

The Board approved a Resolution in Support of HR1384 - The Medicare for All Act.
Rationale:

The United States spends nearly twice as much per capita on health care as all other comparable countries, yet ranks only 35th by global health standards.
The uninsured rate for U. S. adults has risen for four straight years up to nearly 30 million uninsured.
More than 40% of all U.S. adults under the age of 65 forego needed medical care, fail to fill a prescription or take less than the recommended dose of their medication.
The inability to pay medical bills continues to be a leading cause of personal bankruptcy.
55% of the uninsured are people of color.
Due to their profit incentive, private insurance companies deny up to one-fourth of all claims for care.

The Medicare for All Act supposedly will:

Establish guaranteed, universal health care to all U.S. residents, eliminating all costs for premiums, deductibles, copays and other out of pocket costs.
Ensure genuine patient choice of any doctor, hospital or clinic a patient chooses.
Reduce the cost of prescription drugs by authorizing Medicare to negotiate lower drug prices.

Other Items of Interest:

The meeting began with three public speakers, nurses at Stroger Hospital, in support of the above bill.
The Board referred to the Criminal Justice Committee a proposed ordinance to change the hours of the Law Library, to make it more accessible to the public for the purposes of legal research.
The Board approved the authorization to renew a Cook County States Attorney’s Office grant to provide funding for a total of 21 victim specialists to provide services to all crime victims throughout Cook County. - Grant amount: $2,250,000.00

Observer: – Beverly Graham Meeting Length: 55 minutes

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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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County Hospital System Resists Cutting $27M at Cook County Budget Hearing

11/12/2017

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Cook County Board of Commissioners Finance Committee - Departmental Budget Hearings
November 7, 2017

Cook County Health and Hospitals System (CCHHS)

Commissioners absent for all or most of the meetings: Moody
Commissioners present: Arroyo, Boykin, Butler (half the day), Daley, Deer, Fritchey (less than an hour), Gainer, Garcia, Goslin, Moore, Morrison, Schneider, Silvestri, Sims, Suffredin, Tobolski

Hospital System CEO Shannon’s letter outlined $12,430,000 in cuts of the $27 million requested (the amount allocated to CCHHS from Sweetened Beverage tax)

Closure of Oak Forest facility, patients transferred to other CCHHS sites
Overtime reductions by filling vacancies faster, & better coordination of staffing
Eliminate Tuberculosis Fund and lead monitoring & positions, with care transferred to Stroger
Eliminate Access to Care (suburban primary care)
Reduce pharmacy outpatient hours & positions
Transfer Child Advocacy Center to Stroger Hospital
Merge Morton East Clinic with Cicero Clinic
IT help desk consolidation, merge other departments, eliminate Grants
Merge substance abuse staffing with other departments
Eliminate vacancies that are unfilled for more than 2 years

Items of Interest at the Hearing:

Commissioners Morrison, Tobolski and Boykin asked the most probing questions, calling for the full $27 million in cuts out of the Hospital’s $2.4 billion budget, citing other County departments who were being forced to eliminate attorneys and other public safety and justice programs which were the responsibility of government. Shannon replied that any further cuts would have a detrimental impact on both revenue and care delivery due to decreased services. Commissioner Morrison responded that Shannon, not the Cook County Commissioners, is responsible for identifying cost savings and making the hard decisions on where to cut. “CCHHS needs the $403 million ($110 million direct subsidy plus $293 million pension and debt service) of tax payers’ funds for 2018 so they need to work collaboratively with the other Cook County departments to fill the $200 million deficit resulting from the loss of the beverage tax repeal” stated Morrison, echoed by Comm. Tobolski, Boykin and others.
Comm. Suffredin noted that $22 million of the DSH (**Disproportionate Share Hospital, CCHHS 2018 Budget on their website listed DSH total of $134.3 million) federal subsidy to indigent care hospitals was not included as revenue in the budget. Shannon replied that renewal of DSH had not been passed in Congress yet, but if paid, would be deducted from the $110 million CC hospital subsidy.
Comm. Boykin asked what the total expenditure on outside contracts/procurements was. Deputy CEO Elwell said he did not have that information immediately available and would get back, but agreed that it was a big dollar amount.
Comm. Boykin asked why the outpatient pharmacy wasn’t closed rather than just reducing hours, which would be greater cost savings. Shannon responded that the un-insured population don’t have access to medications at commercial pharmacies, so they need to obtain them at CCHHS.
Several Commissioners asked about employee salaries, including nurses, IT etc. noting that they were significantly higher than at comparable hospitals and that there seemed to be an excess of highly paid administrative staff. They were told they were all “justified based on CCHHS union pay scale, step increases, longevity & certifications”.
Comm. Boykin asked what the total “bad debt” was. When several different dollar amounts ranging from $90 to over $300 million were given to him, he asked why the CC Board was not being given an accurate number and what was being done to collect these accounts receivable. He was told that collections on bad medical debt was limited because most of the patients had no money and that very few companies would be interested in pursuing it. Comm. Sims asked for comparison of yield with prior debt collection vendors. The $90 million number is what is probably collectable.
Questions on why the 680 vacancy positions at CCHHS were not just eliminated, with cost savings. Shannon said that only 10% of the cost of these vacancies was included in the budget and that most of them were in the process of being filled. There is a normal turn-over of staff due to retirement, relocation etc. and no cost savings would result.
Commissioners asked what the number of staffed beds, RNs, RN/patient ratio and inpatient census were. Shannon said he thought there were 415 beds (**CCHHS website states 464) and didn’t know the exact number of RNs or census for Stroger or Provident. What is the ratio of clinical to non-clinical FTEs? Shannon said 35% non-clinical.
Comm. Garcia asked about the budget experience of the CCHHS independent Board and was told several were highly qualified in this area.
Many of the Commissioners asked whether CCHHS had ever shown a profit. The CEO provided a rather ambiguous response. (***CountyCare as a component of CCHHS per the published financials may have had an operating profit if pension & debt service were not factored in.)
What was the cost of the FHN (Family Health Network) acquisition which is expected to result in an additional 160,000 CountyCare members? A specific dollar amount was not provided, but CCHHS CEO expects most of the cost to be paid by the additional Medicaid capitated premiums and an additional 22 FTEs will be required to handle the increased volume of members. Comm. Schneider wondered if there was enough capacity at CCHHS for this large increase in patients which Shannon assured him there was more than enough capacity.
Comm. Tobolski asked for the risk profile of the new FHN members, annual cost and capitated income per member which the CEO did not know. What is the capitated rate and expense for the current CountyCare members. Shannon responded monthly payments are $626 for ACA Medicaid, Traditional Medicaid: in the low $200s and for seniors & persons with disability $1,150. Cost per member not mentioned. Several of the Commissioners questioned CCHHS on their risky uni-lateral decision to purchase Family Health Network without consulting with the CC Board, leaving the CC taxpayers as the deep pockets if this endeavor failed.

Observer - Dr. Susan Kern Length of Meeting - 7 hours

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Impending Real Estate Delinquent Tax Sale Brings Rev. Jesse Jackson Sr. to Cook County Board Meeting

3/23/2017

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Cook County Board of Commissioners Board Meeting - March 22, 2017

Significant Issue Discussed:

Real Estate Delinquent Tax Sale - Commissioners Gainer, Boykin, and Garcia along with Treasurer Maria Pappas brought the issue to Rev. Jesse Jackson Sr., who spoke at the CC Board meeting. He asked all commissioners to inform their constituents about Real Estate Tax Delinquency buyers:

50,000 Cook County citizens are in arrears on property taxes, of which 7,000 have never received the seven notices Treasurer Pappas has mailed them concerning their property’s impending tax sale.
The date for the sale has been moved up by the IL legislature from July to April 3.
Comm. Gainer says that tax delinquency buyers provide no service to Cook County and make between $25 million to $50 million each year, preying mostly on elderly home owners who must pay up to 18% interest on “loans” from these contract buyers, when loans from legitimate banks cost 4%.
Gainer claims most of this activity occurs in neighborhoods like Chatham, Gresham, and other parts of the city, where homeowners are able to scrape together money to pay off these “loans”. These tax buyers ignore much poorer parts of Cook County where they would end up owning the properties and the tax bills.
Both Republican and Democratic commissioners were upset with the practice and claim the reason it passed the legislature were strong lobbyists who profit from the practice.

Other items of interest discussed:

Cook County Health and Hospitals System (CCHHS)

The CC board is worried about CCHHS making its budget.
County Care enrollment is down for Affordable Care Act (ACA) adults, who tend to be more transient and not as involved in community services as families and women. More of these adult ACA enrollees have difficulty with mental illness and permanent addresses.
The proposed Trump healthcare overhaul requiring renewal of Medicaid every six months would most likely double the fall-off of enrollees. Dr. Jay Shannon projected there would be a smaller number of Medicaid plans operating in IL after this year.
In response to questions about poorly-rated dialysis treatment at County hospital, Dr. Shannon said they were investing in better equipment and a different model which relies on technicians rather than RNs for staffing. Stroger has recently hired 35 new nurses. Overtime costs are quite high in the Dialysis area due to “no-shows” and sick calls particularly for the night shift.

6B Tax Incentive

There was long discussion about revamping the “6B Tax Incentive” recommended by Cook County’s Dept of Economic Development. Michael Jasso, head of Econ. Development, has been working for 15 months on revamping the 6B designation to make revocation a possibility, and pushing responsibility down to the individual municipalities. (Agenda Item 17-0293)
The 6B Tax Incentive allows Cook County to compete with collar counties for jobs by equalizing tax rates. Without the 6B Incentive most employers would choose to locate outside of Cook County.
In the end the ordinance was passed with only Com. Schneider voting against.

Observer - Amy Little

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Cook County Board Holds Hearing on Cook County Health Finances

Cook County Health (CCH) Focus of Cook County Board Mid-year Budget Review

Cook County Board Approves Resolution in Support of The Medicare for All Act - HR1384

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

County Hospital System Resists Cutting $27M at Cook County Budget Hearing

Impending Real Estate Delinquent Tax Sale Brings Rev. Jesse Jackson Sr. to Cook County Board Meeting

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