DENVER HEALTH & HOSPITAL AUTHORITY BUDGET REVIEW OCTOBER 2, 2013 2014 BUDGET

Denver Health & Hospital Authority Priorities for 2014 and dB Beyond d
Citywide Vision: Level 1 Care for All

Mission of the Denver Health and Hospital Authority (CRS 25-29-101) 1. Provides access to quality preventive, acute and chronic health care for all of the citizens of Denver regardless of ability to pay pay. 2. Provides high quality emergency medical services to the citizens of Denver and the Rocky Mountain region. 3 Fulfills 3. F lfills p public blic health f functions nctions as dictated b by the Den Denver er charter and the needs of the citizens of Denver. 4. Provides health education for patients and participates in the education of the next generation of health care professionals; and 5. Engages in research which enhances its ability to meet the health care needs of patients of the Denver Health system.

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Denver Health & Hospital Authority (DHHA) Mi i Level Mission L l Metrics M ti

Priority M ti Metrics Unsponsored care (millions) Inpatient admissions Outpatient p visits Medicaid managed care Medicaid patients (FFS) DHMP Exchange 2011 2012 2013 P j t d Projected 2014 Projected

$441.6 26,047

$429.9 25,244

$454.0 24,000

$495.0 24,000

455,370

469,140

469,000

488,800

48,587

51,490

53,144

70,800

35,000

37,000

45,000

62,000

2,500

% Insured business
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66.2%

68.8%

69.9%

73.4%
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Denver Health Organization Chart

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Denver Health Base Budget g Overview

Expenditures
General Fund/DIA/DHS Medically Indigent Capital Improvement Fund (includes bond) TOTAL

2011 Actual
$23 012 693 $23,012,693 $27,977,300 $0 $50 989 993 $50,989,993

2012 Actual
$23 348 050 $23,348,050 $27,977,300 $673,000 $51 998 350 $51,998,350

2013 Revised
$23 874 600 $23,874,600 $27,977,300 $2,123,000 $53 974 900 $53,974,900

2014 Proposed Base

$25 328 400 $25,328,400 $30,777,300 $1,850,000 $57 955 700 $57,955,700

Variance
$1 454 000 $1,454,000 $2,800,000 ($273,000) $13 219 996 $13,219,996

Summary of 2014 Budget Proposal Expenditures

Medically Indigent Payment-$2,800,000 increase Denver C C.A.R.E.S.-$143,101 A R E S $143 101 Payments for Inmate Care at Denver Health, $200,000 Jail Medical-$338,741 Community Correction Program-$290,000 (part of Medically Indigent payment)

Revenue
None

2011 Actual

2012 Actual

2013 Revised

2014 Proposed Base

Variance

Summary of 2014 Budget Proposal Revenues

None

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2014 Budget Highlights for Denver Health

Medically Indigent Payment - Key Expansion Proposal
Description: esc pt o Base ase increase c ease in C City ty pay payment e t for o pat patient e t ca care e se services. ces Financial Impact: $2,800,000 Performance Metrics: Unsponsored Care (millions)
2011 Actual Workload Metric: Mission Level Metric Impact: Improve waitlist performance for primary/specialty care $441.6M 2012 Actual $429.9 2013 Estimated $454M 2014 Projected (First 6 months) $248M 2014 Projected (End of Year) $248M

Risks and Considerations: Affordable Care Act (ACA) will result in a portion of the population
covered by this payment enrolling in an insurance plan. However it is difficult to project the impact, and corresponding payments (e.g. Disproportionate Share, DSH) will decrease, and DSH has already now been restricted to hospital care only with no payment allocable to clinic or physician cost.

ROI: This payment continues to be essential for provision of basic health services to the Citys most
vulnerable populations. Denver Health provides high quality cost-effective service particularly in the area of primary care which saves overall healthcare cost.
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2014 Budget Highlights for Denver Health

Medically Indigent Payment
Total Uncompensated Care Vs City Payment Trend
600 000 000 600,000,000

500,000,000

400,000,000

300,000,000

200,000,000

100,000,000

Total Unsponsored Care

City Payment

Denver Health Total OOC Uninsured by Year

Facility + Physician Billing Charges
$50,000,000

$45,000,000

$40,000,000

$35,000,000 6% 76% 72%

$30,000,000

75%

$25,000,000

69% 73%

$20,000,000

$15,000,000

$10,000,000

$5,000,000

$0 2009 Peak Performance 2010 Total OOC Uninsured Charges 2011 2012 2013 Annualized -9Total Charges from visits w/ ED charges >$0

2014 Budget Highlights for Denver Health

Jail Medical - Key Expansion Proposal
Title: Building 1 Denver County Jail 3.0 FTE Registered Nurses Description: It has become necessary for Denver Sheriffs to open Building 1 at the Denver County Jail to
accommodate the increased population at the Denver Detention Center. The increase is 64 beds. Staffing is minimal on nights and weekends and cannot be absorbed with the current staffing of 2 RN per shift, so a staffing plan increase of 1 RN per shift is requested for nights and weekends. This translates to 3.0 FTE.

Financial Impact: $238,578 Performance Metrics:

2011 Actual Workload Metric: Building 1 opened May 2013 Mission Level Metric Impact: N/A 2012 Actual N/A 2013 Estimated Recruitment for 3.00 RN FTEs 2014 Projected (First 6 months) Additional nurses added on nights and weekends Must meet requirements of inmate health care and medication administration 2014 Projected (End of Year) To be fully-staffed

Must have ability to respond to emergencies within 4 minutes

Risks and Considerations: Safe Medication Administration ROI: Avoidance of medical errors and improperly administered medications results in high quality of care and thus lower cost.
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2014 Budget Highlights for Denver Health

Jail Medical - Key Expansion Proposal
Title: Denver County Jail Dental Services 0.20 FTE Dentist Description: Dental Services need to increase one day a week at the Denver County Jail (DCJ). During the opening of the DDC dental services were expanded but the dentist hours were not increased. Dental started completed x-rays and extractions which were new services saving money and transport time. The services offered at DDC and DCJ need to be comparable. The DDC is able to provide services on average in 10 days and the county jail is an average on 4 weeks as currently there is a dentist available 6 times per month at the DDC but only 2 times per month at DCJ. Financial Impact: $38,039 Performance Metrics: Dental Visits
2011 Actual Workload Metric: Mission Level Metric Impact: 1,647 2012 Actual 1,472 2013 Estimated 1,185-annualized May 2014 Projected (First 6 months) Add another day at Denver County Jail Achieve minimum 10 day wait for the dentist at Denver County Jail 2014 Projected (End of Year) Equal services between facilities Cost savings for dental services seeing inmates onsite

Risks and Considerations: Providing Safe Dental Care ROI:

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2014 Budget Highlights for Denver Health

Jail Medical - Key Expansion Proposal
Title: Mental Health Unit Transition Case Manager Description: Based on the operating agreement when Denver Health assumed supervision of psychology services positions through attrition of vacancies would convert to authority positions. This is not a new position but the current employee was CSA and has been promoted. Financial Impact: $62,124 $ Performance Metrics:
2011 Actual Workload Metric: N/A 2012 Actual N/A 2013 Estimated Recruiting for position 2014 Projected (First 6 months) Fulltime case management for mental health transition unit at Denver County Jail Reduce recidivism for mental health patients 2014 Projected (End of Year) Providing Services to higher acuity patients

Mission Level Metric Impact:

Reduce suicide risks

Risks and Considerations: This position provides counseling, monitoring, and case management to transition patients back into society. society ROI: Replacement of existing position.
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2014 Budget Highlights for Denver Health

Denver CARES - Key Expansion Proposal
Title: Replacement Emergency Services Patrol Van (ESP/Detox) Description: New ESP van to replace much older van with 200,000+ miles Financial Impact: $143,101 Performance Metrics: Denver CARES Community Detox Census and ESP Transports
2011 Actual Workload Metric: g Daily y Average Census (Year Census) Mission Level Metric Impact: 72 (26,294) 2012 Actual 75 (27,643) 2013 Estimated 80 (29,000) 2014 Projected (First 6 months) 40 (14,500) 2014 Projected (End of Year) 40 (14,500)

The number of admissions has remained high with the ESP van hours @ 16 h hours per d day

2014 census estimates are based on an average daily census of 80 if admissions d i i remain i flat.

Risks and Considerations: There are generally two ESP vans running on the weekend, nights, and on
special events. Repairs and maintenance to the old van is costly.

ROI: Not required replacement capital.

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2014 Budget Highlights for Denver Health

Community Corrections Program - Key Expansion Proposal
Description: As a safety-net facility, Denver Health is currently providing healthcare services for residents of half-way houses. Denver Health saw 1,003 uninsured residents in 2012. Financial Impact: $290,000 Performance Metrics:

2011 A Actual t l Workload Metric:

2012 A Actual t l

2013 E Estimated ti t d

2014 P Projected j t d (First 6 months) Cover the costs for half-way house residents Half-way house residents access to primary care

2014 P Projected j t d (End of Year)

Mission Level Metric Impact:

Risks and Considerations: This payment would be for those who do not qualify for Medicaid Medicaid. ROI: Provision of medical services to this population is necessary due to EMTALA and directing patients toward the most cost effective means (primary care) is also desirable.
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2014 Budget Highlights for Denver Health

Capital Expansion Proposals
Description: Request of $1.6 million which represents 50% of debt service to build a new clinic in West Denver to supplement the Westside Family Health Center ($950,000 identified). Capital payment of $450K budgeted in 2014. Financial Impact: $450,000 Performance Metrics:
2011 Actual Workload Metric: Additional clinic visits, , reduction in wait list Mission Level Metric Impact: Expand access to primary care i increase visits i it 22,237 Lowry visits 71,084 Westside 2012 Actual 19,822 Lowry visits 74,796 Westside 2013 Estimated 19,000 Lowry visits Lowry waitlist 911 75,000 , Westside visits Westside waitlist 2183 See above 2014 Projected (First 6 months) 2,000 addnl 2014 Projected (End of Year) 4,500 addnl

See above

See above

See above

See above

ROI: Increased access to care for newly insured patients under health reform and d access to t care for f current t demand. d d Increased I d visits, i it payments t and d hospital referrals.
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2013 Accomplishments
Denver Heath (DH) continues to rank in the top 5 out of 115 national academic medical centers for quality with a mortality rate 45% below these academic medical centers. DH Jail Medical will obtain CALEA (Advanced Law Enforcement Accreditation) and complete DSD goal of becoming Triple Crown(American Correctional AssociationACA, National Commission on Correctional Health CareNCCHC, and CALEA) Additional community health clinic in southwest Denver planning in process Co Complete p ete remodel e ode of o Lowry o y Health ea t Center Ce te is su underway de ay t that at will result in improved facility and additional capacity DH obtained grants for patient outreach and navigation under the Health Insurance Exchange g Connect Colorado for $958K $
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2013/2014 Challenges
Uninsured patients 30% of total business. Observation patients occupy inpatient beds and little or no reimbursement - $4.8 million impact year-to-date June, 2013. Long-stay patients, average length of stay 57 days due to inability to obtain safe discharge, with payment received for approximately 5 days or zero. In 2012, DH wrote off $42.9 Million for this population. Need to provide safe staffing regardless of status of above patients State funding reductions since 2009 now impact DH approximately $18M per year; Sequestration impacted $5 million This has resulted in $6.6 million operating loss year to date Budget action plan in place including reducing personnel by approximately 300 FTE including some layoffs
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2013/2014 Challenges

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Impact of Health Reform

Increase in eligibility under Medicaid for Adults without Dependent p Children in many y cases up p to 138% of Federal Poverty Level (FPL). DH projects additional 33,000 Medicaid enrollees to seek care in our system. y This includes newly y eligible g seen currently y as uninsured patients at DH as well as those who have not accessed the system. This drives a need to increase system capacity, especially in primary care. DHMP will offer an insurance product, Elevate, as part of the ConnectForHealth Colorado Insurance Exchange. Federal Disproportionate Share (DSH) funding will start to decrease in 2014 under federal health reform. There e e will be more o e peop people ee enrolled o ed in Medicaid, ed ca d, but the t e gap between Medicaid cost and payment will remain.
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Initiatives and Strategic Planning process

Strategic planning underway including
Growth plan p Workforce plan Master facilities/capital plan Quality Q y and Safety y Ambulatory plan Financial feasibility plan

The strategic plan will likely include a proposal for a strong partnership City and our managed care plan, DHMP that can result in cost savings g to the City y and shore up p the financial viability of Denver Health. Citys s participation and support in the capital/master plan The City will also be essential.
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Thanks to the City and County of Denver for your ongoing support!

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