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Greetings, Dr. Raju Welcome to one of the toughest jobs in Cook County

Sunday, July 31, 2011
Chicago Tribune

Memo to: Dr. Ramanathan Raju, CEO of Cook County Health and Hospitals System

RE: Your new job.

Glad you're on board, Dr. Raju. You look to have the management credentials and political moxie required to run the county's troubled health system.

Coming from New York, you're acquainted with the enormous financial pressures bearing down on public health systems. It's promising that you've been part of a team that's curbing costs and increasing efficiency to chip away at a $1.2 billion deficit in New York City's health system. You'll need all that experience to tackle the festering problems in the Cook County health system's $911 million budget.

There are a few things you'll find out quickly.

We imagine that in your former job, as executive vice president of the New York system, you knew the basics of who was coming in the front door of your far-flung hospitals and clinics: How many patients were poor, uninsured, undocumented, on Medicaid.

We don't know some of that here. Here's what we know: A growing number of county patients — about 57 percent — are classified as "self-pay." That's a euphemism because most of them can't or won't pay. The county picks up the tab for almost all of them.

Here's what else we don't know:

•How many patients come from other counties to Cook County for treatment. You need to know, so you can determine what, if any, reimbursement could be sought from those counties.

•How many undocumented residents — who are generally ineligible for Medicaid — rely on the county for care.

To the extent that undocumented people receive services for which there is no conceivable reimbursement, then we can factor that into the system's budget; we can't blame a hospital for not collecting from a foreign government. By the same token, if there is an existing or potential way for the county to get reimbursed for taking care of non-citizens, Cook County can't pursue that until it knows the scope of the need.

•Why so many Medicaid patients shun Stroger Hospital, taking their business elsewhere. The answer is critical if the county's health system is to regain vital Medicaid dollars and boost its cash flow.

You probably do know the system ran $52 million short of expected revenue for the first half of fiscal 2011. The shortfall is projected at $96 million for the full year. There's a lot of finger-pointing on this. County health officials blame the state and its sludge-like processing of new Medicaid applicants for about half the shortfall. They blame the county's long-running computer upgrade for the rest.

Some history here: More than four years ago we learned that Cook County hospitals weren't even trying to bill some patients. The computers still aren't up to speed. The county and its health system still can't communicate effectively.

Bottom line: It shouldn't take so long to ensure that patients are billed for care they receive at Cook County's hospitals and clinics. Boosting the billing system to full efficiency should be at the top of your "to do" list.

A final word about that revenue shortfall. The system ran short of revenue projections last year, too. The health panel and your predecessor should have seen it coming this year. Maybe they didn't look hard enough. Or maybe they indulged in wishful thinking about what revenues would materialize. Either way, over-promising and under-delivering can't continue.

Cook County Board President Toni Preckwinkle is at work on next year's budget. She needs — you need — realistic numbers to run the system effectively.

One of your new bosses, independent health panel chief Warren Batts, bluntly outlined the challenges ahead: "This is going to be a bitch of a job because this system is so resistant to change and they have so many bureaucratic processes and procedures to keep things from changing. It is like pounding your head against the wall to move an inch."

We don't expect you took this job believing it would be easy. It won't. But it could be the most rewarding of your career. Thousands of people depend on the county's health system to deliver quality care every day. That's your system now. Take good care of it.



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