Modern Healthcare - - NEWS - By Bob Her­man

CHICAGO— Un­til last year, Ray Robin­son never had health in­sur­ance.

Robin­son, 52, who grew up on Chicago’s South Side, ad­mits he used to sell and use heroin and par­tic­i­pated in sev­eral bur­glar­ies, which landed him in prison. Hav­ing health cov­er­age was not a pri­or­ity, nor was it a real op­tion.

Still, he had a lot of med­i­cal prob­lems. He was stabbed in gang fights and in­jured in car ac­ci­dents. He’s had asthma at­tacks. When­ever he needed care, Robin­son went to the emer­gency depart­ment at Cook County Health and Hos­pi­tals Sys­tem, the city’s pub­lic safety net sys­tem.

Then, last year, Robin­son worked through his sub­stance-abuse prob­lems and signed up for Coun­tyCare, the sys­tem’s Med­i­caid man­aged-care

plan, which launched in 2013. Since Robin­son got his Coun­tyCare card, he has gone reg­u­larly to a pri­mary-care clinic to see his doc­tor. He had a few bro­ken teeth that were ex­tracted the same day he called for a den­tist ap­point­ment. Most im­por­tant to him, he has built a re­la­tion­ship with providers who help him stay healthy.

“Coun­tyCare has changed my whole view on life in re­la­tion to health and other ar­eas,” said Robin­son, who now works part time and lives about a mile away from the hub of the Cook County sys­tem, John H. Stroger Jr. Hos­pi­tal. “Diet is im­por­tant, en­vi­ron­ment is im­por­tant, the way I take care of my­self is im­por­tant.”

The health plan also has im­proved the health of its par­ent sys­tem. Coun­tyCare and the state’s Med­i­caid ex­pan­sion to low-in­come adults drove the sys­tem’s fi­nan­cial gains last year, said Cook County Health CEO Dr. Jay Shan­non. “That has been a breath of life and really has been a driver of cul­tural trans­for­ma­tion within our health sys­tem,” he said. It has en­abled Cook County Health to move for­ward with a $100 mil­lion cap­i­tal spend­ing plan that will re­place an­ti­quated fa­cil­i­ties such as Fan­tus Clinic, an out­pa­tient cen­ter near the main hos­pi­tal that Shan­non ac­knowl­edges has the feel of a 1970s-era Grey­hound bus sta­tion.

Coun­tyCare, which re­ceives a monthly lump sum from the state for ev­ery cov­ered mem­ber, brought in rev­enue of more than $650 mil­lion in 2014. Cook County Health was able to de­crease its un­com­pen­sated care from more than $500 mil­lion to about $340 mil­lion, Shan­non said. His sys­tem ended the year with a $14.1 mil­lion sur­plus, count­ing tax rev­enue, a first for the sys­tem. That makes it an out­lier among safety net hos­pi­tals, which of­ten lose money.

So far, Coun­tyCare has en­rolled more than 183,000 mem­bers, making it one of the largest Med­i­caid plans in the Chicago area, where 15 plans com­pete. Last year, about 68% of Cook County Health’s pa­tients had health in­sur­ance, up from 46% in 2013, be­fore Illi­nois’ Med­i­caid ex­pan­sion un­der the Af­ford­able Care Act. Most of Cook County Health’s in­sured pa­tients are on Med­i­caid, which pays rel­a­tively low rates. But that’s bet­ter than no pay­ment at all.

As more Amer­i­cans gain Med­i­caid cov­er­age, in­vest­ing in a health plan is a po­ten­tial life­line for ur­ban safety net sys­tems. Hav­ing a health plan helps them bet­ter co­or­di­nate care. But safety net sys­tems like Cook County still have to fig­ure out how to com­pete ef­fec­tively with other, of­ten bet­ter-re­sourced in­sur­ers, and how to re­tain their newly in­sured pa­tients, who for the first time, have other care op­tions. On top of that, Cook County and other sys­tems still have to over­come fund­ing short­falls, tough po­lit­i­cal bud­get bat­tles, and so­cioe­co­nomic and racial in­equities.

“Safety net providers that own health plans may be the best po­si­tioned to shift their fo­cus to pop­u­la­tion health,” said Dr. Kather­ine Neuhausen, an as­sis­tant pro­fes­sor at Vir­ginia Com­mon­wealth Univer­sity. How­ever, she said, those sys­tems must have large fi­nan­cial re­serves, and “re­cruit enough mem­bers to sup­port in­vest­ments in in­no­va­tive case man­age­ment and care-co­or­di­na­tion pro­grams and health in­for­ma­tion tech­nol­ogy.”

Cook County Health, known sim­ply as County to most Chicagoans, has been a fix­ture in the city since be­fore the Civil War. Stroger Hos­pi­tal was built 13 years ago, af­ter a long po­lit­i­cal fight to re­place the old Cook County Hos­pi­tal, a gi­ant, or­nate Beaux Arts build­ing that opened in 1914, and now stands va­cant be­hind the new hos­pi­tal.

County has long meant life or death for hun­dreds of thou­sands of lower-in­come Chicagoans, and it has had to sur­vive on a shoe­string bud­get. Now the sys­tem is a vic­tim of Illi­nois’ months long bud­get stand­off be­tween Repub­li­can Gov. Bruce Rauner and Demo­cratic leg­isla­tive lead­ers. In July, a fed­eral judge or­dered the Rauner ad­min­is­tra­tion to keep pay­ing Med­i­caid providers in Cook County de­spite the im­passe.

Given th­ese chal­leng­ing con­di­tions through the years, County “was the most won­der­ful and most dif­fi­cult place to work,” said Dr. Peter Or­ris, a for­mer County oc­cu­pa­tional-medicine physi­cian who’s now at the Univer­sity of Illi­nois at Chicago. It has re­quired ide­al­is­tic providers to think of new ways to reach out and help their pa­tients.

The sys­tem’s doc­tor-pa­tient bonds have al­ways been strong. Dr. Gor­don Schiff, a County physi­cian who led clin­i­cal-qual­ity ini­tia­tives and now over­sees pa­tient-safety re­search at Brigham and Women’s Hos­pi­tal in Bos­ton, re­mem­bers tus­sling with a health in­surer for two hours to pay for a pa­tient’s prescription. He ul­ti­mately gave the pa­tient $30 to fill the or­der—a move that got him rep­ri­manded for “un­pro­fes­sional” be­hav­ior but brought him na­tional sup­port.

Dr. David Ansell, an in­ter­nal medicine physi­cian who worked



at County for 17 years and is now at nearby Rush Univer­sity Med­i­cal Cen­ter, re­calls see­ing an older black fe­male pa­tient whose blood pres­sure was sky high. Ansell asked her if she was feel­ing stressed. Tears welled up in her eyes be­fore she told him her two grand­chil­dren were re­cently shot and killed on her front porch. It was a bru­tal re­minder that so­cial and en­vi­ron­men­tal con­di­tions have a direct im­pact on in­di­vid­u­als’ health.

“Wit­ness­ing this de­gree of suf­fer­ing is not that easy to do,” said Ansell, who wrote a book about his ex­pe­ri­ences at County.

Eco­nomic dis­par­i­ties and racial dis­crim­i­na­tion came to the fore at Cook County Health dur­ing the wave of pa­tient dump­ing that occurred in the 1980s. Many of Chicago’s pri­vate hos­pi­tals redi­rected their unin­sured pa­tients to County. As many as 700 pa­tients a month were sent to County be­cause “they failed their wal­let biopsy,” Schiff said.

That dis­crim­i­na­tion hit hard in Chicago’s black com­mu­nity, whose mem­bers have viewed County as the safest and most re­li­able place for health­care. “If you were a black pa­tient in Chicago, you came to County even if you had the re­sources to go else­where,” Or­ris said.

Last year, Shan­non was named CEO of Cook County Health and has been part of the sys­tem for a large chunk of his ca­reer. He worked as a gen­eral in­ternist at the old hos­pi­tal and later was a clin­i­cal ed­u­ca­tor. “I orig­i­nally landed with the very green no­tion that, in my spe­cialty, I was go­ing to fix the world’s prob­lems,” he said. But af­ter wit­ness­ing “the sea of hu­man­ity” County treated on a daily ba­sis, he re­al­ized he couldn’t do it alone.

Af­ter a stint at Park­land Me­mo­rial Hos­pi­tal in Dal­las, Shan­non re­turned to County in 2012. His pre­de­ces­sor as CEO, Dr. Ram Raju, helped se­cure the fed­eral Med­i­caid waiver that cre­ated Coun­tyCare. With Illi­nois ex­pand­ing Med­i­caid un­der the ACA to adults with in­comes up to 138% of the fed­eral poverty level, County saw an op­por­tu­nity to be­come a provider of choice rather than the provider of last re­sort, as well as the chance to re­duce its bur­den of un­com­pen­sated care.

Coun­tyCare al­lows mem­bers to re­ceive care out of net­work and pays out­side providers go­ing Med­i­caid rates. But it en­cour­ages mem­bers to stay in-net­work, which is not an easy task, even though the plan has one of the broad­est net­works among lo­cal Med­i­caid plans. That net­work in­cludes all of County’s fa­cil­i­ties and more than 40 area hos­pi­tals. Many be­lieve County has to over­come its old im­age as a tat­tered provider of care to the poor to com­pete suc­cess­fully with other hos­pi­tals.

For fis­cal 2016, Shan­non has made it a top goal to keep more mem­bers in-net­work. He projects County will col­lect $310 mil­lion in rev­enue from Coun­tyCare mem­bers who go to the sys­tem’s doc­tors, hos­pi­tals and clin­ics. To keep pa­tients health­ier and re­duce costs, Coun­tyCare of­fi­cials have started to more closely mon­i­tor high-risk mem­bers and re­quire pa­tients to fill pre­scrip­tions for 90 days in­stead of 30.

An­other part of the so­lu­tion will be ex­pand­ing re­la­tion­ships with Chicago’s in­de­pen­dent char­ity-care clin­ics and sign­ing up the thou­sands of Cook County res­i­dents who are el­i­gi­ble for Med­i­caid but haven’t yet en­rolled. Ju­dith Haa­sis, ex­ec­u­tive di­rec­tor of Com­mu­ni­tyHealth, a phil­an­thropic or­ga­ni­za­tion that runs two free lo­cal med­i­cal clin­ics, said she works with Shan­non reg­u­larly.

Shan­non also wants to make sure Coun­tyCare mem­bers don’t lose cov­er­age dur­ing their an­nual re­de­ter­mi­na­tion pe­riod, which can be con­fus­ing for peo­ple un­fa­mil­iar with in­sur­ance. “You’re talk­ing about peo­ple who may have had no mod­el­ing of what it’s like to have in­sur­ance for two or three gen­er­a­tions,” Shan­non said. “You’ve got to de­velop th­ese ca­pac­i­ties and skills.”

A ma­jor ques­tion is whether County will lose pa­tients if it moves for­ward with its con­tro­ver­sial pro­posal to close Stroger’s in­pa­tient pe­di­atrics unit. Fur­ther, re­tain­ing old mem­bers and at­tract­ing new ones means County will have to im­prove pa­tient sat­is­fac­tion and con­nect more reg­u­larly with lo­cal res­i­dents. It’s al­ready try­ing to do that through new Satur­day hours at com­mu­nity clin­ics, an ex­panded pa­tient call cen­ter, bet­ter park­ing and cus­tomer-ser­vice train­ing for staff.

But some ob­servers say it won’t be easy for County to keep pa­tients in-house and com­pete with ma­jor in­sur­ers such as Blue Cross and Blue Shield of Illi­nois. “Coun­tyCare is a great ac­com­plish­ment, but it will feel like push­ing a rock up­hill for a long time,” said Jonathan Dopkeen, a health pol­icy pro­fes­sor at the Univer­sity of Illi­nois at Chicago.

Like other safety net sys­tems, County faces ad­di­tional threats, in­clud­ing the ACA’s read­mis­sions and value-based pur­chas­ing pro­grams for Medi­care. So­cial de­ter­mi­nants out­side of the hos­pi­tal’s con­trol, such as in­ad­e­quate hous­ing and food, of­ten push low-in­come se­niors back to the in­pa­tient set­ting. And the loss of fed­eral dis­pro­por­tion­ate-share hos­pi­tal pay­ments could be a larger prob­lem, said Ja­son Hockenberry, a health pol­icy pro­fes­sor at Emory Univer­sity. County es­ti­mates DSH pay­ments will rep­re­sent 11% of its rev­enue in 2016, down from 12% for 2015.

There also are de­mo­graphic is­sues. Rapid gen­tri­fi­ca­tion in the West Loop neigh­bor­hoods near Stroger Hos­pi­tal is push­ing County’s lower-in­come pa­tient pop­u­la­tion away from the sys­tem’s nu­cleus, making in­vest­ments in new am­bu­la­tory sites even more im­por­tant. But Shan­non be­lieves his sys­tem has “a leg up” on the com­pe­ti­tion be­cause it has a “cul­tural com­pe­tence and an un­der­stand­ing of the com­mu­ni­ties we’ve served.”

De­spite all the ob­sta­cles, supporters say Coun­tyCare is a ma­jor ad­vance in pro­vid­ing cov­er­age and care to Chicago res­i­dents. Ray Robin­son said one of his friends had lost most of her teeth be­cause of drug ad­dic­tion, and would al­ways look at the ground when she spoke, em­bar­rassed to show her mouth. But af­ter she signed up for Coun­tyCare, she was able to go to the den­tist, who gave her a new smile. It was in­cred­i­bly lib­er­at­ing for her.

“She said, ‘Coun­tyCare, baby,’ ” Robin­son said. “It gave her con­fi­dence.”


Dr. Jay Shan­non is CEO of Cook County Health and Hos­pi­tals, and has been part of the sys­tem for a large part of his ca­reer.


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