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 - 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)  

1. Closure of Oak Forest facility, patients transferred to other CCHHS sites
2. Overtime reductions by filling vacancies faster, & better coordination of staffing
3. Eliminate Tuberculosis Fund and lead monitoring & positions, with care transferred to Stroger
4. Eliminate Access to Care (suburban primary care)
5. Reduce pharmacy outpatient hours & positions
6. Transfer Child Advocacy Center to Stroger Hospital
7. ​Merge Morton East Clinic with Cicero Clinic
8. IT help desk consolidation, merge other departments, eliminate Grants
9. Merge substance abuse staffing with other departments
10. 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

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

January 13, 2016 Cook County Commissioners’ Board Meeting

County Commissioners called for a special hearing during the February Finance Committee meeting to determine the impact on grant revenues because of the failure of Illinois’ government to pass a 2016 Budget. At least $75 million dollars are at risk for human services grants that have been awarded by the County with the expectation that they would receive state funding in 2016 [Resolution 16-1090].

Criminal Justice issues were also very prominent.  Approved was the call to appoint a Special State’s Attorney to handle the prosecution of Officer Jason Van Dyke [#16-0577] and to expand the Justice Department’s examination of Chicago policy practices to include the detention facility known as Homan Square.  Emotional public testimony was given by lawyers and advocates in support of this Resolution [16-0964].

A resolution to establish a CC Task Force to research the expansion of affordable and quality healthcare to uninsured residents of Cook County [16-0690] was presented by the Workforce, Housing & Community Development Committee and approved by the full Board. Both human need and the cost of providing emergency room services were cited.   

Other Resolutions referred to Committee:  

• League of Women Voters (LWVCC) recommendations for improving the CC Criminal Court’s pre-trial operations was sent to the Criminal Justice Committee [#16-1023].
• A Call for the dignified treatment of Central American asylum seekers was also sent to the Criminal Justice Committee [#16-1065 as amended].
• While deferred within the CC Finance Committee, a $500,000 and above legal settlement would trigger an ordinance-required report from the State’s Attorney to the Committee [16-0692].

Observed by:  Diane Edmundson
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