County pressed to give up control of health systemStroger's own panel expected to report troubled services need new outside leadership
Tuesday, October 16, 2007
by Judith Graham and Deborah L. Shelton
As the Cook County Board mulls a tax increase to plug a $300 million budget hole and shore up its clinics and hospitals, a growing number of critics are saying it's time for someone else to run the county's struggling health system.
The $810 million system -- the medical safety net for hundreds of thousands of people -- is currently operated by the County Board under the direction of the president's office. Critics say the arrangement invites political meddling and has become dangerously dysfunctional.
Such complaints have percolated for years, and any proposal for sweeping change is sure to encounter resistance. The health system is the second-largest unit of county government, a source of thousands of jobs and tens of millions of dollars in annual contracts.
But the issue has reached a boiling point recently as board President Todd Stroger and his hand-picked health chief, Dr. Robert Simon, have pushed through deep cuts in services, provoking a rising sense of alarm over the system's future.
On Tuesday, the issue will be in the spotlight as a blue ribbon committee appointed by Stroger delivers a report to the board that reportedly will call for professional health-care management at the system and improved governance.
The Institute of Medicine of Chicago, meanwhile, is circulating a petition in the local health-care community asking the county to shift control of the system immediately to an independent board charged with reversing what the institute calls a "precipitous decline" in services. And two county commissioners, Larry Suffredin and Gregg Goslin, are preparing proposals on the issue.
"We have to find a different way of running the health system," said Goslin. "The place is just a mess."
Among the symptoms of perpetually poor financial stewardship, critics say, is lack of revenue collection: The bureau failed to generate bills for nearly $250 million in medical services last year.
The perception of mismanagement also has threatened key support from the state's representatives in Washington. Several sources say privately that U.S. Sen. Dick Durbin (D-Ill.,) has made it clear that he will not seek additional federal financial support for the county health system unless Stroger and the board pay close attention to the panel's suggestions.
To be sure, a change in governance in and of itself will not solve the health system's many problems, notably the rising tide of uninsured patients, soaring health-care costs and shrinking government support, experts caution.
Yet critics cite evidence that county officials' response to these problems -- cutting services without developing a well-thought-out strategic plan -- has significantly weakened the health bureau's infrastructure and endangered public health by reducing access to care.
In their defense, Stroger and Simon repeatedly have said they have kept services running without interruption while adapting to an extremely difficult financial situation. Among the accomplishments they cite are new pharmacies, upgraded capacity to deliver urgent care, and the consolidation of major departments such as public relations and finance.
But there is precedent from other parts of the country for change. In Phoenix, the public health system has split off from Maricopa County, becoming a separate entity with a dedicated board of directors. Denver's public hospital has turned a yearly profit since becoming an authority independent from the city a decade ago.
In Minnesota, the legislature in 2005 passed a law creating a new public corporation to run Minneapolis' public hospital. And in Dallas, a seven-member board of managers runs the public hospital district, which is a separate legal entity with a dedicated funding stream.
In each of these cases, managers said public hospitals needed to free themselves from bureaucratic constraints and gain the flexibility to hire and fire medical staff, contract for medical equipment and supplies, develop ways of boosting revenues and respond flexibly to changing market conditions.
Suffredin wants the County Board to cede control to an independent trustee with substantial experience in operating a major public health system. The model is the board's recent agreement to transfer control of the juvenile temporary detention center to a nationally respected expert, he said.
"We need someone to come in and build up this system, not tear it down," Suffredin said.
In Cook County, however, many are skeptical of calls for change. Some note the controversial track record of a commission created in 1969 to operate Cook County's hospitals and disbanded 10 years later.
"We've had an independent commission once before, and where did it get us?" asked Commissioner Jerry Butler, who chairs the county's Health and Hospitals Committee.
"If we're not going to do juvenile detention and now you're saying we're not going to do the hospitals, then what is the board going to do?" he said. "If they keep taking pieces out of the job, pretty soon you won't need commissioners either."
Many of the bureau's problems predated Stroger, including the lack of billing. But even though new managers are addressing deficiencies, the health bureau estimates revenues will fall $88 million behind projections this year. Bureau spokesman Sean Howard attributes that to "a lack of staffing and a horrible lack of resources."
The previous administration also failed to come up with a strategy for dealing with sharp in supplemental Medicaid funds mandated by new federal laws. The county lost $139 million in these "intergovernmental transfer" funds in the last two fiscal years, and further reductions of $68 million are expected this year.
Still, it appears that Stroger's primary response to these problems, cutting the health bureau's budget, has alienated medical providers and created difficulties for patients.
New data from the county show notable declines in the number of patients seeking care at its facilities. Overall, as the county closed 12 community clinics, outpatient visits dropped 17 percent in the year ended July 30 compared with the prior year. It's not clear whether patients are getting care elsewhere or forgoing it.
Pediatric visits and visits for women seeking OB/gynecological care both plunged 24 percent. Primary care services at the Fantus Clinic across from Stroger Hospital fell 8 percent.
Both Stroger and Simon have cited the addition of a dozen screening rooms at Ambulatory Screening Clinic as a significant improvement. The ASC, as it's known, delivers mostly urgent care at the Fantus Clinic.
But visits at the ASC have plummeted 39 percent, with 37,189 visits recorded for the year ended July 30 compared with 61,327 visits the year before, according to county data.
Meanwhile, patients say the closing of community clinics and staff cutbacks have led to agonizingly long waits for care.
On a recent cold, gray morning, Newton Harris, a diabetic, arrived at the ambulatory screening clinic at Stroger Hospital at 6:30 hoping to beat the crowd. But two dozen people were already waiting.
Six hours and five lines later, he walked out without the insulin syringes that he desperately needed. About 50 people were queued up ahead of him when he finally got to the pharmacy to drop off his prescription. He was too tired to wait.
Harris, 51, faces standing in at least two more lines before he finally gets the syringes. For now, he's borrowing syringes from his diabetic mother.
Delores Brown understands Harris' frustration. She recently spent four hours in the waiting room of a Cook County outpatient clinic and never reached the exam room.
Brown, who suffers from diabetes, high blood pressure and osteoarthritis, was in too much pain to wait any longer and her medical van had arrived to pick her up, she said. She vows never to go back.
"Physically I can't do it," said Brown, 58, who uses a walker and takes insulin and nine medications for her ailments. "If something's not right, if the doctor can't tell me what to do over the phone, I'll go to the emergency room," she said.
Some county patients said they won't sit idly by and watch the clinics they depend on get scaled back or closed.
Earlier this year, the county-run Woodlawn Clinic where Robert Hart gets his care was slated for closing. He circulated petitions, attended meetings and wrote letters to legislators trying to save it. The clinic survived, but it wasn't left unscathed, Hart said.
"We used to get appointments every three months," said Hart, 69. "Now they stretch them out four months, sometimes five months."
Hart has started to collect signatures for another petition, this one calling for the County Board to refrain from making further cuts.
"We want to make sure that the system will be there for everybody," said Hart, who serves on the Woodlawn Clinic advisory board. "If it's gone, where are people going to go?"