The Cook County Bureau of Health is trying to close a budget deficit. Currently the round peg of $835M in health system expenditures has to fit into the square hole of a $730M target. An historic closing of County-run community clinics combined with one of the largest layoffs of doctors and nurse practitioners has created repercussions across the region. The problem? No strategic plan, no governance by health care experts.
Meanwhile, the response by Cook County managers is to strangle prevention efforts and to cut resources that allow people to get health care close to home, at a neighborhood clinic. Let's keep the emergency department free to see true emergencies instead of clogging it up with folks who just need a refill on their diabeted medication.
Paradoxically, cutting back on neighborhood-based care will put more stress on the system by forcing patient to stand in line for routine services at Stroger Hospital. Or worse, wait until they are too sick and end up with costly hospitalization.
Can someone do the math?
Sunday, May 27, 2007
Cutting off a system for community to hospital referrals saves money and time. So why cut it?
Testimony of
Lee Francis, MD, MPH
Interim CEO, Erie Family Health Center
May 23, 2007
Erie Family Health Center is a federally qualified health center celebrating its 50th year. With 8 service locations ranging from North Lawndale, West Town, Humboldt Park, and Logan Square all the way to Albany Park, we provide over 120,000 patient visits annually to over 30,000 patients. On a budget of $20M we employ 260 health care workers. Although we are located in Chicago, approximately 10% of our patients come from Suburban Cook County, the rest from the City.
On March 27, 2007 Dr. Robert Simon, Interim Chief, Cook County Bureau of Health Services, notified community health centers participating in the cooperative computerized specialty referral system called IRIS that our patients would no longer be able to access services for specialty consultations and testing effective April 16, 2007. He stated that a task force had been formed to evaluate the issue and would report back to him in 1-1.5 months. After over a month of requests through various high level channels, Dr. Simon finally met with us last week and some sort of work group with our input was formed. The first meeting will be in early June. Meanwhile patients go without services. We are asked to refer them to the ER for simple and complex problems alike that are best sorted out directly between primary care doctor and specialist.
Shortly after IRIS was cut off, I saw Sra. C. in my clinic. She has terrible diabetes and sees the diabetes and kidney specialists at Fantus Clinic. Her colon cancer was diagnosed and cured by the skilled surgeons at the hospital. She attends the eye clinic because she has diabetic eye disease and the ear nose and throat clinic because she has lost much of her hearing. She complained of chest pain and I felt that she needed a stress test. Stroger Hospital is her health care provider of choice. She chooses. Yet, for the first time in over 10 years, since the Stroger ER first referred her to me, I could not link her with an appointment for a stress test. Here’s the kicker – she has both Medicare and Medicaid, and she is choosing the County for her health care. Should I send her to the ASC so another doctor, who doesn’t know her, can decide if she needs a stress test or not? Or to another hospital who is more eager to bill for the service?
This decision has left thousands of Cook County residents out in the cold – residents who have a right to Bureau services.
IRIS is part of the Neighborhood Referral Program, a system with almost 20 years history. It creates a successful exchange relationship between tertiary care hospital and its specialty clinics and neighborhood health centers such as ours which specialize in primary care.
In 2006, Erie made 2,907 referrals for services on the Stroger Hospital campus, 84% of which were scheduled for service. Seven percent of patients referred actually had good solid health insurance. In exchange, Erie has accepted over 400 new patients per year from Stroger ER and the ASC walk in clinic – taken them under our wing and provided them affordable, high quality comprehensive primary care services – regardless of their ability to pay. We have been doing this for over 10 years; we have accepted over 4,000 into our system. Multiply these numbers by 10 or 20 to get an idea of the number of patients unloaded from the Stroger campus and able to receive care in their communities. We are talking 40,000 – 80,000 people who are being helped right in their own neighborhoods.
When we accept patients through NRP, we accept the financial burden. Each visit costs us $153. Our Federal grant accounts for only 23% of our income. Medicaid and Medicare pay about $120 per visit, only 60% of what the County receives per Medicaid visit. We fundraise the rest. If the patient is uninsured, we ask for a reasonable fee of $30 per visit. The average patient currently pays about $18, or 60% of our self-pay fee. We ask a small fee of $4 for medications we supply. We know how to compassionately collect self-pay fees, we know how to bill Medicaid and Medicare and other payers. We even accept Visa and Master Card!
Dr. Simon has stated that community health center use of the IRIS system costs the County $20M per year. No one has any idea where this number comes from. Community clinics account for only 16% of IRIS referrals. If this 16% costs $20M then, the other 84% of usage from Bureau clinics must cost $105M for a total cost of the IRIS system of $125M. Please ask Dr. Simon to show on paper how the IRIS system, for all users, costs a total of $125M per year out of a total expense line of approximately $853M (total per Dr. Simon).
More important: What is the “cost of waste” of not having such a system? What is the additional cost of thousands of new emergency room and ASC visits at over $200 per visit. What about preventable heart attacks, cancers, strokes at tens of thousands of dollars each? From the standpoint of the public good, this question deserves an answer from the financial experts at the Bureau.
We requested that the IRIS system be turned back on while we work together as partners to evaluate the system and increase efficiencies. So far the answer has been “no”. We all agree that we can and must improve efficiencies in the system. At least turn on the most vital parts of the system and restore access to the most needed services.
Lee Francis, MD, MPH
Interim CEO, Erie Family Health Center
May 23, 2007
Erie Family Health Center is a federally qualified health center celebrating its 50th year. With 8 service locations ranging from North Lawndale, West Town, Humboldt Park, and Logan Square all the way to Albany Park, we provide over 120,000 patient visits annually to over 30,000 patients. On a budget of $20M we employ 260 health care workers. Although we are located in Chicago, approximately 10% of our patients come from Suburban Cook County, the rest from the City.
On March 27, 2007 Dr. Robert Simon, Interim Chief, Cook County Bureau of Health Services, notified community health centers participating in the cooperative computerized specialty referral system called IRIS that our patients would no longer be able to access services for specialty consultations and testing effective April 16, 2007. He stated that a task force had been formed to evaluate the issue and would report back to him in 1-1.5 months. After over a month of requests through various high level channels, Dr. Simon finally met with us last week and some sort of work group with our input was formed. The first meeting will be in early June. Meanwhile patients go without services. We are asked to refer them to the ER for simple and complex problems alike that are best sorted out directly between primary care doctor and specialist.
Shortly after IRIS was cut off, I saw Sra. C. in my clinic. She has terrible diabetes and sees the diabetes and kidney specialists at Fantus Clinic. Her colon cancer was diagnosed and cured by the skilled surgeons at the hospital. She attends the eye clinic because she has diabetic eye disease and the ear nose and throat clinic because she has lost much of her hearing. She complained of chest pain and I felt that she needed a stress test. Stroger Hospital is her health care provider of choice. She chooses. Yet, for the first time in over 10 years, since the Stroger ER first referred her to me, I could not link her with an appointment for a stress test. Here’s the kicker – she has both Medicare and Medicaid, and she is choosing the County for her health care. Should I send her to the ASC so another doctor, who doesn’t know her, can decide if she needs a stress test or not? Or to another hospital who is more eager to bill for the service?
This decision has left thousands of Cook County residents out in the cold – residents who have a right to Bureau services.
IRIS is part of the Neighborhood Referral Program, a system with almost 20 years history. It creates a successful exchange relationship between tertiary care hospital and its specialty clinics and neighborhood health centers such as ours which specialize in primary care.
In 2006, Erie made 2,907 referrals for services on the Stroger Hospital campus, 84% of which were scheduled for service. Seven percent of patients referred actually had good solid health insurance. In exchange, Erie has accepted over 400 new patients per year from Stroger ER and the ASC walk in clinic – taken them under our wing and provided them affordable, high quality comprehensive primary care services – regardless of their ability to pay. We have been doing this for over 10 years; we have accepted over 4,000 into our system. Multiply these numbers by 10 or 20 to get an idea of the number of patients unloaded from the Stroger campus and able to receive care in their communities. We are talking 40,000 – 80,000 people who are being helped right in their own neighborhoods.
When we accept patients through NRP, we accept the financial burden. Each visit costs us $153. Our Federal grant accounts for only 23% of our income. Medicaid and Medicare pay about $120 per visit, only 60% of what the County receives per Medicaid visit. We fundraise the rest. If the patient is uninsured, we ask for a reasonable fee of $30 per visit. The average patient currently pays about $18, or 60% of our self-pay fee. We ask a small fee of $4 for medications we supply. We know how to compassionately collect self-pay fees, we know how to bill Medicaid and Medicare and other payers. We even accept Visa and Master Card!
Dr. Simon has stated that community health center use of the IRIS system costs the County $20M per year. No one has any idea where this number comes from. Community clinics account for only 16% of IRIS referrals. If this 16% costs $20M then, the other 84% of usage from Bureau clinics must cost $105M for a total cost of the IRIS system of $125M. Please ask Dr. Simon to show on paper how the IRIS system, for all users, costs a total of $125M per year out of a total expense line of approximately $853M (total per Dr. Simon).
More important: What is the “cost of waste” of not having such a system? What is the additional cost of thousands of new emergency room and ASC visits at over $200 per visit. What about preventable heart attacks, cancers, strokes at tens of thousands of dollars each? From the standpoint of the public good, this question deserves an answer from the financial experts at the Bureau.
We requested that the IRIS system be turned back on while we work together as partners to evaluate the system and increase efficiencies. So far the answer has been “no”. We all agree that we can and must improve efficiencies in the system. At least turn on the most vital parts of the system and restore access to the most needed services.
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