Hospital System Responds to Cook County Commissioner Questions on $2.7B Proposed 2019 Budget

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
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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.