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Conversations with Health Policy Leaders #1--The Status of the County Health System

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Dr. Ramanathan Raju, new CEO of CCHHS recently spoke at HMPRG… on the Status of Medicaid Waiver  and on the current state of health care in the county.

With a strong clinical and management background — he was a trauma surgeon, specialist in vascular surgery, and administrator — Dr. Ramanathan Raju served for six years as the Chief Medical Officer of the New York City Health and Hospitals Corporation and as  the system’s Chief Operating Officer, a position he held for two years.

As the new CEO of the Cook County Health and Hospital Systems October, 2011,   he sees this as a time, not only of crisis and challenge, but for creativity:

“This is the best time to be in healthcare in this country because we have the chance to shift the way we deliver care to our patients and to put an end to the unconscionable disparity in access to care. Over the years, we have weakened our primary care system for the sake of enhancing specialty care. Today, we have the opportunity to go back and to rebuild our primary care system the way it should be, the way it needs to be if we are truly to provide quality care to all of our residents.”

According to Dr. Raju, the Cook County system is both similar to other public hospital systems and also unique.

“Like most public hospitals, we have many of the same problems we’ve had for years – lack of resources, aging physical plants, and financial constraints. Some onlookers have opined that it’s an inefficient system and customer unfriendly. To a certain extent, these criticisms are valid - we could be better and we are committed to doing better. But the fact remains that even if we do everything correctly, bill and collect every dime we are owed, there will still be a large deficit that the County will face because there will still be people who can’t pay. The real question is: What can we do to make the system work for all of our patients?”

Dr. Raju says that 55-60% of CCHHS patients have no insurance – including 80-85% of outpatients. He points out that, In New York City, patients are eligible for Medicaid if they fall under a certain income rate, so the uninsured rate is higher here for the public hospital system than there.

"We have always maintained that we are not just a safety net for patients who are medically indigent, mentally ill or substance abusers. We are a safety net for all high-end medical systems in this region.”

Dr. Raju believes it’s no secret that there is a 2-tier system in this country. People who can afford it get high end care. The problem we are facing with all the budget cuts is that they affect the whole spectrum- the high-end tier and low-end tier and then the safety net institutions which is taking care of everyone in the middle.

“It’s not fair that someone has to wait for 2 years to get a diagnostic colonoscopy. Or 3 years for a mammography. Right now there is not enough money available in the city, the county or the state to fix this problem. The Medicaid Waiver for Cook County would be a “win-win” for everybody. The Waiver is funded entirely by the Federal government.  Neither the State nor the County will have to pay for the Waiver.  If someone is eligible for Medicaid in 20 months, we would treat them today and get them healthy earlier, rather than making them wait, while getting sicker and sicker, and ultimately costing the system more.  With the 1115 Waiver, Cook County would place these vulnerable patients into a coordinated care program now-- which would be a win for everyone, the County, the State, the Federal Government, and most importantly, the patient.”

According to Dr. Raju, the essence of “managed care” is the bonafide managing of care, not cost.

“When patients come into the ER with a headache, they’re given a CT scan in order promptly to rule out a worse case scenario.  That is the nature of the care they provide.  Emergency Rooms work from the top down. Primary care works from the bottom up. People are worried about managed care. But it’s really about managing care, not cost. Care must be coordinated. Patients do not know how to access care. The measurement of the savings is in keeping patients out of the ERs. Which is also a win because of the matching dollars: for every dollar billed, the County gets $0.48 of federal match monies. The state has no matching Medicaid dollars in play. So it’s better for the State that these Medicaid patients to stay in the County system.”

Dr. Raju explains that, in 2014 – when Medicaid expansion goes into effect -- people without insurance will crowd the system and push out the people who are currently on Medicaid.

“Actually it is better for the state if people currently on Medicaid remain in the County system. Why? For every dollar the state spends for non-County Medicaid patients, it has to give the Feds $1 in return. It’s far better for the state if the County to keep these Medicaid patients in the County system because the state does not have to give the Feds the $1 match. Moreover, Cook County has 100,000 people who are being treated as uninsured who will be eligible for Medicaid in 2014. If we keep them in the County system – we are then entitled to significant Medicaid supplemental dollars --which will help us begin to manage our structural deficit.”

Still, Dr. Raju warns that there are important systemic changes that need to occur.

“Right now, the system is very much doctor-centric. We need it to become care coordinated and patient centered. Every patient has the right to get the best care possible. And, if that is what we are working towards, it gives us the opportunity to change the system. The ACA calls for an expansion of Medicaid. We had a discussion with CMS and are hoping to get the waiver to implement the expansion sooner.  If we can get this patient-centered care model implemented in a public hospital system that will show it can be done.  Which gives CMS a great opportunity to showcase our efforts.

If you keep people healthy, you make money. The system will be able to enroll people who are poor but healthy if Medicaid is expanded. But CCHHS ultimately has to be self-sustaining.

Look at the distribution of charity care dollars. If the Medicaid money follows the patients, it will work. There is still a way of leveraging the federal dollars to do what we want and need to do. Historically we have not been good at controlling cost. So now we will be forced to think a different way.”

According to Raju, when the stock market crashed there was a lot of appetite for the safer investments and the HHC bonds became more popular investment. There is always an opportunity in every crisis.

Dr. Raju was asked about some thoughts on how the delivery side can be reconfigured to accommodate these changes:

“– The new health care delivery system (post ACA) requires the health systems to keep patients healthy. That’s what is going to save money at the end of the day. In concept, this idea is similar to a health insurance exchange or IT exchange for medical records.

These new concepts give us an opportunity to think of the needs of the community. How much private, specialty, or primary care is needed? And where is the best place for the patient to get the care he or she needs? People are getting primary care in specialty clinics now. For example, a guy who had a heart attack 5 years ago is still seeing a cardiologist. The cardiologist is really not interested in giving primary care. The delivery of care needs to be shared.”

Dr. Raju also discussed a need to assess the kinds of specialty care delivered within the broader community and address possible costly duplication of services:

“We need to have a real conversation with hospitals to see what the care needs in our communities are.

If Rush is doing cardiac surgery then why do I also want to do cardiac at my hospital?  Instead, we should double up on primary care and birth centers - don't duplicate on specialties and, instead, use the extra money for other things.”

“We also need to look at restructuring the financing of specialty care as well, by trying to make specialty services more equal in price and reimbursement to primary care services. Right now, reimbursement is based on complexity of procedures, risk exposure, years of physician training as opposed to what good the service does for the patient. We are the only national health care system that pays for people to get sick. Doctors get paid more based on how severe the problem is. From asthma all the way to tracheotomies. That is why we cannot pay for mammography today.”

Dr. Raju said that one of the ways private hospitals can help the public system is by addressing waiting lists for diagnostic testing.

“By way of example, they can operate the high-end services within the public system as their charity care contribution, if you believe that everybody has to give charity care for being a not for profit. But this is easier said than done.  It is difficult to serve a different market than the one you are used to serving.

When asked about the reasons why the County System asks questions about immigration status, Dr. Raju’ had a different take than most:

“Hospitals ask your immigration status because some people are eligible for more governmental aid than they are getting at the present time. They inquire about your immigration status only because they want to put you in right program. If you do not tell them, you might be missing out on aid to which you otherwise entitled. At County, we treat you the same way whether you are undocumented or documented. We need that kind of sophisticated communication with our patients – we need them to understand that we will not give info to the federal government regarding their immigration status. During the Bush administration, I testified before Congress that I saw this as a fundamental right.”

In closing, Dr. Raju said it is important to accumulate reliable data on patients served in part to demonstrate to the broader public that the system does more than just provide a lot of Medicaid.

“We are cosponsoring a forum for the public to hear about County's plans. We need to get across the idea that public health systems are an investment and bring significant value to all residents. We all pay for fire insurance though we may never have a fire. People in the city don't want to pay tax dollars toward a County system they have never entered. In fact, it is much more likely that they will get in an accident while driving through Cook County and be sent to the county public health system.”