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One Michigan Avenue Building 120 North Washington Square Suite 705 Lansing, Michigan 48933 Telephone: (517) 482-9236

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180 North LaSalle Street Suite 2305 Chicago, Illinois 60601 Telephone: (312) 641-5007 Fax: (312) 649-6678

100 East Broad St Suite 1400 Columbus, Ohio 34215 Telephone: (614) 464-4466

Long Range Planning Issues for the Dallas County Hospital District

8888 Keystone Crossing Suite 1300 Indianapolis, Indiana 46240 Telephone: (317) 575-4080

Prepared for: The Dallas County Commissioners Court By: H EA LTH M AN A GEM ENT A SSOCIATES

1015 18 Street, N.W. Suite 210 Washington, D. C. 20036 Telephone: (202) 785-3669 Fax: (202) 833-8932

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Kleman Plaza 301 South Bronough Street Suite 500 Tallahassee, Florida 32301 Telephone: (850) 222-0310 Fax: (850) 222-0318

180 North LaSalle Street Suite 2305 Chicago, Illinois 60601 Telephone: (312) 641-5007 Fax: (312) 641-6678

Long Range Planning Issues for the Dallas County Hospital District

Introduction
In May of 2004, the Dallas County Commissioners Court contracted with Health Management Associates (HMA) to develop a “Long Range Planning and Policy Analysis for the Dallas County Hospital District.” HMA assembled a team of ten senior staff and seven sub-contractors to thoroughly evaluate the strategic priorities for Dallas County as they relate to the financing, operation, clinical focus and governance of the health care delivery system for low-income people in Dallas County. Over the course of the past six months, HMA has interacted with over 250 people (see list in the Appendices), reviewed all previous consultant reports, analyzed financial and demographic and utilization data, met with government officials in counties adjacent to Dallas and in Austin, participated in meetings and forums, reviewed public health system models in comparable communities, and spent considerable time with the leadership of the County and the Parkland Health and Hospital System to assure that our conclusions were accurate and our recommendations were feasible. HMA approached this project as one that would have significant consequence for the Dallas community. We attempted to take into account the unique history, relationships, and other cultural and environmental issues that would mean the difference between a report that was technically correct but not likely to be implemented and one that is essentially a work plan to take a highly regarded and vitally important health system successfully through the next decade when there will be mounting pressures and challenges. The report that follows documents key findings and recommendations based on the analysis of the last several months. Additional supportive information is included in the Appendices. HMA would like to thank the Dallas County Commissioners Court for the opportunity to have contributed to this important initiative. Pat Terrell, Project Manager Doug Elwell, Finance Leader Terry Conway, MD, Health Services Leader Dave Ferguson Gaylee Morgan Jane Longo Matt Powers Larry Bara Donna Strugar-Fritsch David Fosdick We would also like to acknowledge the contributions of our sub-contractors: Susan Greene, ESI, Robin Herskowitz, Linda Wertz, Jon Hockenyos and Travis James, and Ann Kitchen. Finally, we want to thank Colleen Porter and Kathryn McRay for their invaluable administrative support.

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Table of Contents
Executive Summary ...........................................................................................4 Chapter 1: What is the Current Health of Dallas County? ................................ 14 A. The Population to be Served ....................................................................................................... 14 The Dallas County Population ................................................................................................... 14 The Parkland Patient Population ............................................................................................... 16 Future Demographic Trends ...................................................................................................... 17 B. The Health Status of Dallas County ........................................................................................... 18 What is “Health Status?”............................................................................................................. 18 Health Status of Dallas County .................................................................................................. 19 Health Status of the Parkland Population ................................................................................ 20 Key Health Conditions to be Addressed .................................................................................. 21 C. The Dallas County Economic Climate and the Impact on Health Care................................ 22 Characteristics of the Dallas County Economy........................................................................ 22 Health Care and the Dallas Economy ....................................................................................... 23 D. Expenditures on Low-income Health Care in Dallas County................................................ 25 Medicaid/SCHIP.......................................................................................................................... 26 Medicare ........................................................................................................................................ 27 Tax Support................................................................................................................................... 27 Other Public Support ................................................................................................................... 27 Parkland Foundation ................................................................................................................... 28 Private Hospital Charity Care .................................................................................................... 28 E. Health Care Providers Serving Low-Income Patients in Dallas County .............................. 28 The Parkland System ................................................................................................................... 28 Private Hospitals .......................................................................................................................... 29 F. Financing Low-income Health Care in Dallas County ............................................................ 31 Medicaid/SCHIP.......................................................................................................................... 31 County Subsidies.......................................................................................................................... 31 Chapter 2: How Effective is the Public Health and Hospital System in Dallas?33 A. The Dallas County Hospital District as a System of Care ...................................................... 33 System-Wide Priorities ................................................................................................................ 33 Primary Care ................................................................................................................................. 36 Specialty Care ............................................................................................................................... 44 Emergency Care............................................................................................................................ 49 Inpatient Care ............................................................................................................................... 53 Gaps in the Current System of Care .......................................................................................... 57 Disease Management ................................................................................................................... 58 B. The Relationship of Parkland to the University of Texas Southwestern School of Medicine ............................................................................................................................................. 63 History ........................................................................................................................................... 63 The Faculty Contract.................................................................................................................... 64 Medical Staff Leadership............................................................................................................. 68
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Long-Term Planning Issues ........................................................................................................ 70 Conclusion..................................................................................................................................... 71 C. The Financing of the Parkland System ...................................................................................... 71 Adequate Leveraging of Local Tax Revenue............................................................................ 72 Maintenance of Adequate Local Tax Revenue and Taxpayer Equity................................... 76 Out-of-County Care Provided By Parkland ............................................................................. 77 Operational Effectiveness of the Parkland System.................................................................. 79 Financial Management and Information Technology............................................................. 83 Contract for Medical Staff ........................................................................................................... 86 Additional Service Opportunities.............................................................................................. 89 Conclusion..................................................................................................................................... 90 D. The Physical Facilities Challenges for the Parkland System .................................................. 91 Moving Forward on a Capital Master Plan .............................................................................. 91 Next Step: A “Blue-Ribbon” Panel............................................................................................. 93 E. Potential Provider Partnerships for the Parkland System ...................................................... 94 Private Hospitals .......................................................................................................................... 94 Children’s Medical Center .......................................................................................................... 96 Veteran’s Administration/North Texas Region ...................................................................... 97 Community Primary Care........................................................................................................... 98 Other Health Care Agencies ....................................................................................................... 99 F. Governance Effectiveness Issues for Dallas County, the Dallas County Hospital District and the Parkland Health and Hospital System............................................................. 100 Background ................................................................................................................................. 100 The Role of the Dallas County Commissioners Court .......................................................... 101 The Role of the Dallas County Hospital District.................................................................... 102 Conclusion................................................................................................................................... 102 Chapter 3: Recommendations for Long-Range Planning Priorities for the Dallas County Hospital District ............................................................................... 103 Priorities for Parkland System Clinical Operations.................................................................... 103 System-Wide Issues ................................................................................................................... 103 Primary Care ............................................................................................................................... 104 Specialty Care ............................................................................................................................. 104 Emergency Services ................................................................................................................... 105 Inpatient Care ............................................................................................................................. 105 Gaps in the Current System ...................................................................................................... 106 Disease Management ................................................................................................................. 106 Medical Staff Relationship ........................................................................................................ 106 Physical Plant Issues .................................................................................................................. 107 Priorities for Health Care Financing ............................................................................................. 108 System Financial Strategies....................................................................................................... 108 Financial Management .............................................................................................................. 109 Priorities For Partnership Development and Expansion ........................................................... 110 Priorities for an Effective Health System Governance ............................................................... 110

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APPENDICES ................................................................................................ 112 A. Project Interview/Interaction Listing B. Maps C. Private Hospital Data Profiles D. Project Access, FQHCs, Free Clinics, and Public Health Departments E. Parkland Health & Hospital System, Uncompensated & Undocumented Health Care Analysis (Economic Projections) F. Medicaid Reimbursement Comparisons G. Pharmacy Issue Paper H. Parkland Community Health Plan Report I. Finance Deliverables J. Revenue Cycle Report K. COPC Assessment Report K-1. COPC Assessment K-2. COPC Maps K-3. Community Clinic Profiles K-4. Operations Plan performance COPC Service Standards Financial Management Tool Care Team Roles K-5. COPC Staffing Tool June 2004 MGMA 2002 Benchmarks K-6. EPIC Newborn Appointments COPC

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EXECUTIVE SUMMARY
The Approach
Health Management Associates (HMA) approached its task of developing long range planning issues for the Dallas County Hospital District in several stages. First, the current situation was documented. What is the population of low-income people that are or most likely will become patients cared for by the Parkland Health and Hospital System? Where do they live and what are their health care needs? What are the demographic and economic trends that will impact this population in the future? What is spent on low-income health care services? Who are the health care providers delivering that care? Finally, what are the strategies in place to finance this delivery system? The second stage of the analysis focused on the ability of the current health care delivery system to most effectively meet the challenges posed by the growing low-income population. Is Parkland functioning as a seamless system of care, utilizing every level of service delivery appropriately? Are there gaps in the system that result in either operational inefficiencies or less than optimal health outcomes? Is the relationship between Parkland and the University of Texas Southwestern School of Medicine resulting in high quality and cost-effective clinical care and are there longer-term concerns that need to be addressed related to the synergy between the two institutions? What are critical financing strategies that need to be implemented to maximize the impact of the County contribution to health care? What is the quantifiable impact of out-of-county use of Parkland’s health services? What are the capital investment issues that the system faces both now and in the future? Are there creative partnerships that could be created to strengthen the overall health care “safety net” in the community? Finally, what are the key issues related to the assurance of a strong, accountable and effective governance for publicly supported health services in Dallas County? Over the past six months, HMA has attempted to answer all of these questions. We have interacted with more than 250 government officials, health care and business leaders, civic and advocacy group representatives, doctors, patients, and other front line clinical and

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administrative staff. We went on inpatient rounds and observed in the Parkland clinics and Emergency Department. We reviewed all recent consultant reports related to the Parkland system. We attended meetings organized by key business, civic and advocacy constituencies. We analyzed financial, demographic and health care utilization data. We traveled to all of the surrounding counties and to Austin to talk with relevant officials about the issues being faced in Dallas. We worked with senior staff at Parkland, at the University of Texas Southwestern (UTSW), with private hospitals and other key components of the formal and informal network of institutions and individuals committed to providing health care services for the people of Dallas. This Report is the cumulative result of all of these efforts.

Key Findings
Although these findings are addressed in much greater depth in the body of the Report, the following information related to the delivery of health care services for low-income people in Dallas drives the ultimate recommendations for planning priorities for the Dallas County Hospital District: • There is an unusual and exemplary level of interest in and commitment to assuring health care services for low-income people in Dallas County. HMA found that the expression of support for continuing to assure access to health care services for the residents of the community was consistent and universal. While it was clear that those services should be provided in the most cost-effective way possible, there was an unwavering sense from the business, health care, civic, religious and advocacy communities that those services needed to be provided. In fact, it was a measure of pride for the Dallas community. • Dallas County is a growing and changing community. The population in Dallas County grew by 20% between 1990 and 2000 and that growth continues, largely due to a near doubling of the Hispanic population during that same period. The County is also economically diverse, with both a higher per capita income than Texas as a whole and a higher proportion of low-income individuals, now one in three residents. Approximately 25% of the non-elderly population of Dallas County is uninsured, a statistic that is not likely to improve as the economic correction now underway is due

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largely to growth in the service sector, which is traditionally less likely to provide health insurance benefits. • The demand on the Parkland Health and Hospital System will only increase. Growth in both total population and the uninsured will likely result in further demand on the Parkland system for health care services, particularly by chronically ill adults whose care is disproportionately expensive. The Parkland system now accounts for about half of all of the uncompensated health care services delivered to residents of Dallas County. Several private hospitals in the community have experienced significant increases in Emergency Department visits by people who are either uninsured or covered by Medicaid. Two Federally Qualified Health Centers (FQHCs), Project Access and a growing number of free clinics located throughout the County have attempted to meet some of the need, but the Parkland is still the linchpin for the entire “safety net” in Dallas County. • Dallas County is providing a significant contribution to health care for low-income people but that contribution is not fully leveraged. The total expenditures on health care services for low-income people in Dallas County—from all sources—totaled more than $1.7 billion in 2002. Of that amount, the County subsidy to the Dallas County Hospital District was approximately $311 million. While the County contributes more money to health care services per capita than most other local governments around the country, it has been less successful in leveraging that contribution to generate the federal matching dollars for which it is eligible. Today, Dallas County leaves $150 million unmatched. • The Parkland Health and Hospital System is a major community resource. Parkland is widely considered to be one of the best public health care delivery systems in the nation. Through its partnership with UTSW, it provides high quality clinical services. It has made enormous strides in operating cost-effectively and in generating revenue. It has attempted to rationalize care by treating people in community-based settings before they get sick enough to need more expensive services at the hospital. It is the trauma resource relied upon by the entire greater Dallas community. The Parkland system has had a significant impact on the health status of the overall Dallas community, particularly in the area of maternal and infant health care.
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Specific strategic initiatives should be undertaken to assure that Parkland operates effectively in the face of growing pressures. There are significant organizational, financial, clinical and policy issues related to both the current and future operation of the health system that must be addressed if Parkland is to function effectively in light of mounting demand for its services. Hard decisions will need to be made involving the health system’s leadership, its Board, its medical school partner and the broader community to ensure that the system will be able to continue to function at a high level of both quality and efficiency. The recommendations contained in the report address these specific issues.

Recommendations
The list of recommendations that follow are explained more fully within the Report.

Priorities for Parkland System Clinical Operations 1) Make the recruitment of a Chief Operating Officer a priority for the Parkland system. 2) Begin, in partnership with the University of Texas Southwestern (UTSW), a process to reassess policies and procedures and allocation of clinical resources that were developed to facilitate teaching in Parkland but now may inhibit effective operation of the health system. 3) Address operational problems that discourage Parkland patients from staying in the system when they become insured. 4) Initiate serious and specific discussions with other health care providers to identify areas of potential collaboration. 5) Make the improvement of access to the COPC clinics a primary focus of the Parkland system. 6) Better integrate the health services delivered at the COPCs with the specific needs of the communities that they serve by coordinating with other agencies, assessing the potential

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for expansion or contraction of clinics based on population growth or movement, and maintaining the ongoing role of community advisory boards. 7) Ensure that the COPCs are seen as an essential component of the continuum of care by the entire Parkland system, including the clinical leadership. Issues of referrals, admission procedures, policies, medical staff communication and resource allocation for the COPCs must be viewed for their impact on every aspect of the Parkland system. 8) Initiate an immediate and thorough assessment of the clinical resources and space needed to provide accessible specialty outpatient services for the patients who depend upon the Parkland system for that care who otherwise would utilize the Parkland Emergency Department (ED) or be admitted for services that could have been provided in specialty clinics. 9) Develop a plan to reallocate or, where necessary, expand resources dedicated to certain specialty areas where there is a current deficit. 10) Develop a referral system, based on sound clinical guidelines, that will assure ease of access to specialty services, the appropriateness of referrals to specialty care, and return to primary care after the specialty consult to avoid misuse of scarce resources. 11) Explore the potential for partnering with other hospitals and/or physician groups to expand accessibility to specialty outpatient services, particularly in less expensive and more accessible community-based settings. 12) Initiate a major overhaul of the Parkland admissions processes, specifically addressing the unnecessary logjam in the Parkland ED. 13) Develop an effective referral system to allow ED physicians to send patients needing ongoing care to COPC or specialty clinics. 14) Explore the potential for establishing Observation Bed capacity adjacent to the ED to minimize unnecessary admissions into the hospital. 15) Begin a review of clinical policies that may adversely impact efforts to prevent unnecessary return visits to the ED and may assist in efforts to develop system-wide disease management protocols.

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16) Establish bed control as an institutional priority, building on recommendations from previous consultant reports and involving clinical as well as administrative leadership. 17) Rationalize the current logjam in the operating rooms by reassessing the management structure (including reassigning case managers who had been replaced by residents), moving forward on the construction of the Ambulatory Surgery Center, and exploring the potential for an interim strategy for moving outpatient surgeries into a temporary location at another institution. 18) Initiate a process, with clinical leadership in OB/Gyne, to restructure the inpatient units assigned to Labor and Delivery to assure the most effective utilization of all inpatient beds while, at the same time, maintaining the protocols that have resulted in such impressive outcomes. 19) Investigate the potential for immediate conversion of unused space within Parkland to expand the capacity for rehabilitation services at Parkland, allowing for the retention of current paying patients who are now being sent to other institutions. 20) Develop a comprehensive plan, perhaps in connection with the VA or other providers, for access to long-term care for Parkland patients. 21) Implement a disease management approach throughout the Parkland system, targeting those chronic conditions (i.e., diabetes, asthma, hypertension) that have the greatest impact on Parkland resources and its patients. 22) Begin to develop a new Master Affiliation Agreement between the Parkland and UTSW that will reconfirm the importance of the relationship and will address medical leadership, operational issues related to the teaching model, future approaches to cost reimbursement, and long-term planning issues which will impact both institutions. 23) Initiate discussion now between Parkland and the Dallas County Hospital District about the development of a Master Capital Plan for the Parkland system. 24) Determine capital project priorities for the current system that will either assure greater efficiency or allow for the generation of increased revenue. Priority areas should include the construction of the Irving COPC and the Ambulatory Surgery Center, and the

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renovation of existing space for the establishment of increased rehabilitation capacity and observation beds adjacent to the ED. 25) Establish a “blue ribbon panel,” appointed by the Dallas County Court of Commissioners and the Dallas County Hospital District, made up of key health care, civic and business leaders. This panel would be charged with overseeing the development, with Parkland leadership, of a Master Capital Plan for the system, including the scope of and financing for a facilities replacement strategy for Parkland hospital.

Priorities for Health Care Financing 1) Leverage available Dallas County funds through a variety of special financing mechanisms, including the following. It is important to note that the leadership of the Court and the support of the local business community will be critical to garnering State support for these efforts. • Take advantage of additional Upper Payment Limit (UPL) payments by increasing Parkland’s charge structure. (Estimated impact = $ 16 million currently, although further data analysis may lower that figure) • Secure a federal waiver for Medicaid to cover the costs of prenatal care for undocumented immigrants. (Estimated impact = $5 to $7 million) • • Increase Medicaid payments to Parkland and UTSW physicians. Secure increased Medicaid managed care rates through risk adjustment and/or increasing the base rate on which the managed care rates are set. (Estimated impact = $5.6 million) • Utilize the Upper Payment Limit (UPL) capacity of other private hospitals in Dallas County that serve large numbers of Medicaid and uninsured patients. (Estimated potential= $225 million; $105 million if Children’s is excluded) 2) Explore the creation of a 501 ( c) (3) entity to help fund charity care at Parkland and other organizations in the community.

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3)

Work with the counties contiguous to Dallas and the State to establish a regional trauma network that would help finance trauma care provided by Parkland to out-ofcounty patients by leveraging current County Indigent Health Care Program (CIHCP) expenditures. (Estimated impact = $10 million)

4) Convert Parkland’s COPC clinics to Federally Qualified Health Centers (FQHCs). (Estimated impact = $9.3 million) 5) Carefully evaluate new service opportunities for their potential to be successful given Parkland’s demographics and payor mix. These include rehabilitation, long-term care and psychiatry. 6) Ensure that Parkland has a long-term strategic business plan in place that reflects the collective input of the operational, financial and medical leadership. The strategic plan should be supported by a long-range capital plan and an information technology (IT) plan. All of these documents are needed to help the Board make decisions based on the best available information and the long-range goals of the organization. 7) Resolve the current FY2005 faculty contract between Parkland and UTSW and view it as a transition agreement, beginning immediately to negotiate the contract for FY2006 based on covering appropriate costs, verifiability, and adequate payment for all clinical service expansions. 8) Continue to build on revenue cycle improvements by increasing conversion of patients to funded sources, improving time-of-service collections and implementing a stronger denial management and collections strategy. (Estimated impact = $6 to $8 million). 9) Begin to consider the mutual benefits of a combined revenue management entity that combines the hospital and the medical school revenue management processes, including medical records, billing and collections. Improve the position of the Parkland Community Health Plan by reducing administrative costs to the industry standard, reducing payment rates to the Medicaid rate, and reducing payments for non-participating providers. (Estimated impact = $8.2 million)

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10) Ensure that Parkland is positioned to take advantage of pharmacy opportunities afforded by the Medicare Modernization Act (MMA), including the discount card program, low-income subsidies, and mail order, potentially through a partnership with the VA Hospital. (Estimated impact = up to $11.7 million, not including mail order).

Priorities For Partnership Development and Expansion 1) Initiate discussions with the leadership of private hospitals in the Dallas community to determine the potential areas of collaboration for current and future health services provided for low-income residents of the County including, but certainly not limited to: support (financial or service) for existing or expanded COPCs, collaboration on the provision of community-based specialty outpatient services, joint development of service lines (i.e., rehabilitation services), and the delivery of tertiary services for Parkland patients. 2) Develop expanded collaboration with Children’s Medical Center, particularly focusing on: enhancing access into the COPC clinics for patients coming to the Children’s ED for primary care; collaborating on expanded community-based pediatric specialty care access; exploring the potential of co-locating Children’s physicians in COPC facilities; and better coordinating facilities and support service planning on the medical center campus. 3) Enter into serious discussions with the Veteran’s Administration Hospital system in Dallas to explore potential partnerships in such areas as: participating in the VA’s mail order pharmaceutical program, one of the most effective in the country; connecting to the VA-affiliated network of nursing home providers and contracting with its home health services, both efforts to assure that patients do not stay in inpatient beds unnecessarily; entering into an agreement whereby the VA would contract with the COPCs for primary care for its veterans; and planning for a collaborative approach to mental health services.

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Priorities for an Effective Health System Governance 1) Ensure that the roles and responsibilities of the Dallas County Commissioners Court and the Dallas County Hospital District be clearly defined and duplication should be eliminated whenever possible. 2) Empower the Dallas County Commissioners Court to appoint a civic “nominating committee,” made up of health care, business, civic and community leaders, to screen potential candidates for the Dallas County Hospital District for skills and expertise outlined in a clear job description for Board membership. This committee would present a slate of a number of candidates that they have deemed to be “qualified” from which the Court would select the Board’s membership. This process would go far in assuring that the members of the District Board were committed, skilled and as unaffected as possible by political pressure, real or perceived.

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CHAPTER 1: WHAT IS THE CURRENT HEALTH OF DALLAS COUNTY?
A. The Population to be Served
In order to plan for the delivery and financing of health care services for low-income people, it is imperative that the target population is fully understood. Where are the current and developing communities of people who will need health care services subsidized by the public sector? What are their ages and ethnicities and health conditions? Do they have access to other health care services? What are the demographic trends for these indicators? These questions need to be addressed to fully comprehend the long range planning issues for Dallas County, the Parkland Health and Hospital System and the broader community.

The Dallas County Population The Dallas area is growing at a rapid pace. The population of the Dallas Metropolitan Statistical Area, comprised of Dallas County and its surrounding counties, increased by nearly a third between 1990 and 2000. Dallas County is growing too, but at a slower rate. An estimated 2,283,953 persons lived in Dallas County in 2002. Census data indicates 20 percent growth in the County between 1990 and 2000 and continued expansion through 2002. Demographers expect Dallas County’s population to continue growing for decades to come. Dallas County is slightly younger and more racially diverse than Texas and the U.S. as a whole. It has proportionally more children less than 15 years of age and fewer adults over 65 years of age than does the State of Texas or the nation. Data from the 2000 census indicates that nonwhite residents make up 55 percent of the County’s population. As Table 1 shows, Hispanics are the fastest growing segment of the population, more than doubling between 1990 and 2000, while the number of people in the “other” racial/ethnic group (Asians, American Indians, etc.) and the African American segment also grew at the same time that the County’s white population decreased.

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Table 1 Percentage Change in Dallas County Population by Race/Ethnic Group 1990 to 2000 White -10% Hispanic +110% African American +25% Other +73% Total +20%

Dallas County’s overall high per capita income masks a wide disparity in income distribution. It has both a large number of wealthy residents and a large portion of poor residents. In 1999, household and per capita income for Dallas County residents were higher than in Texas or the U.S., but its median family income was lower than that of the rest of the country. This appears to result from the fact that Dallas County has a larger portion of higher income individuals living in non-family households. In Dallas County, family households make up a slightly smaller portion of the population than in Texas or the rest of the country. Despite the County’s higher per capita income, low-income individuals (those with incomes less than 200 percent of the Federal Poverty Level) make up a larger portion of the population than in the U.S. One in three persons in Dallas County is considered to be “low- income.” Lowincome persons live in all parts of the County and make up a substantial portion of all of Dallas County’s twelve service areas (as defined by the Dallas County Hospital District). In the northern part of the County, the service area with nearly twice the County’s average per capita income, one in five persons are still considered low- income. In all other service areas, lowincome persons make up an even larger portion of the population. The three service areas with the highest proportion of low-income individuals are South Dallas, West Dallas and South Oak Cliff. Statistics on health insurance coverage indicate that 25 percent of the non-elderly Dallas County population did not have health insurance in 1999. National data indicate that Hispanics have the highest rates of un-insurance, followed by African Americans. Thus, Dallas County, with growing Hispanic and African-American populations, can expect to see the current level of uninsurance increase. Because Medicare provides the majority of health benefits to senior citizens and Medicaid and the State Children’s Health Insurance Program (SCHIP) to predominately

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pregnant women and children, the group with the highest rates of un-insurance is nonpregnant adults between the ages of 18 and 64.

The Parkland Patient Population The patients that utilize the Parkland System and those likely to use Parkland in the future can be referred to as the Parkland target population. In general, the Parkland target population is low-income, uninsured and is predominately Hispanic or African American. Data on Parkland patients show that these characteristics vary by the way in which they access health care services. For example, a greater proportion of white patients visit the Parkland Emergency Department (ED) than come to the hospital as inpatients or are patients of the Community Oriented Primary Care (COPC) clinics (although still only one in five patients). Inpatients are predominately Hispanic, while COPC patients are most likely to be Hispanic or African American. Reflecting the large volume of obstetric patients at Parkland, inpatient admissions are nearly twice as likely to be for a woman as for a man. ED patients tend to be neither younger nor older, with three out of four between 18 and 49 years of age. Again as a result of the large volume of obstetrical cases, one in four inpatient admissions is for a baby and 43 percent are for 18 to 39 year olds. These ages are significant as it is the 18 to 64 year old range that is most heavily uninsured. As Table 2 shows, the Parkland ED has a higher portion of self-pay patients as compared to inpatient or COPC patients. Inpatient visits are most likely to be reimbursed by Medicaid or SCHIP and COPC visits are evenly split between Medicaid/SCHIP and self-pay or charity.
Table 2 Percent of Parkland Encounters by Payor Source ED Inpatient Medicare 8% 8% Medicaid/SCHIP 17% 62% Self-pay 67% 22% Other 8% 7%

COPC 10% 39% 38% 13%

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Future Demographic Trends In twenty years, it is predicted that Dallas County will be appreciably older and more Hispanic. These two demographic trends will have a major impact on the Parkland target population and on the Parkland health care system. It will impact scope of services to be provided, location of clinics, connections for support and specialty services, and ability to generate revenue to cover the cost of the delivery of care. Substantial growth in the Hispanic population is expected to continue. Estimates from the Texas State Data Center indicate that the Hispanic portion of the County’s population could grow by 170 percent between 2000 and 2020, with further growth over the subsequent two decades. This population, which represented 30 percent of the residents of Dallas County in 2000, is expected to comprise 38 percent of the County’s population in 2010, 47 percent in 2020, 55 percent in 2030 and 63 percent in 2040. Much of this growth will be among the young under 19 and among adults over 45. It should be clear that this growth is not only an issue of undocumented residents (whose growth is relatively flat) but also of a new generation of Hispanic Americans born in the U.S. and the County. The Parkland system, and Dallas County, will need to plan for an effective approach to caring for the health care needs of this population and, as a greater proportion of Hispanics are uninsured, there will be an increasing need to find the revenue to pay for that care. The aging of Dallas County, like the rest of the country, has further implications for the makeup of the Parkland target population. Even in the lowest population growth scenarios from the Texas State Data Center, the portion of Dallas County residents who are over 45 years of age, currently 27 percent, will grow to 41 percent in 2020 and 45 percent in 2040. If Parkland continues to only capture the uninsured population of adults who have costly chronic health care problems without also attracting patients in the growing group over 65 years of age, the system could be crippled by the cost of this treating this population of adults without experiencing the benefit of reimbursement generated from paying Medicare patients. Understanding this population growth should direct the development of resources to both effectively manage those patients that Parkland will be most likely to care for as well as maintaining those patients in the Parkland system when they reach their 65th birthdays.

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B. The Health Status of Dallas County

What is “Health Status?” “Health status” is the level of health of an individual, group, or population as assessed by either objective indicators or by more subjective measures such as data on how individuals perceive their own level of health. These perceptions may include the range of manifestations of disease in a given patient population including symptoms, functional limitations, and effect on quality of life. Improving health status should be the basis for designing the types and volume of health services in a public health system like Parkland. Health status should also be a leading indicator of the effectiveness of a public health system. Although health status is a very useful basis for projecting long term needs of the Parkland health system, several provisos should be recognized. There are certain difficulties that are encountered when describing health status of a community or population. Much of the information that is available to describe health status comes from reported data garnered from birth and death records and reportable infectious diseases. While this is very useful, it may obscure helpful insights from a health care planning or evaluation perspective. For example, most persons with diabetes are likely to die from cardiovascular disease while the chronic and treatable condition of diabetes may never be noted. There are also selected surveys and registries that contain information on specific conditions, although the list is not exhaustive. In addition, the data is often from databases on very large populations and it can, at times, make it difficult to examine even a very large neighborhood or ethnic population in a useful way. Finally, the population of Dallas is certainly not a static phenomenon. It has grown and will continue to grow in a way that will impact health status. Planning based on a snapshot taken today is likely to be faulty. The last ten years have seen a remarkable growth in Dallas County, particularly due to immigration and largely by persons of Mexican origin. To a much smaller extent, the growth of the Asian, Pacific Islander, and American Indian population has increased. Anticipating the change in health status due to continued immigration is important. Immigrants initially tend to have better health status than natives of the United States. However, as time is spent in the U.S. and adoption of certain unhealthy lifestyle behaviors increases, the immigrant populations develop more chronic illness and health status worsens.

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Health Status of Dallas County Dallas County residents are, as compared to similar counties and to the nation as a whole, relatively healthy. For example, the prevalence of chronic conditions in Dallas County in 2001 compares favorably with the U.S. and Texas for the four conditions of diabetes, asthma, high blood pressure, and high cholesterol (2002 Dallas County Health Checkup). However, several health issues are worthy of note. In 2002, the Health Resources and Services Administration of the US Department of Health and Human Services (HRSA) compared Dallas County to other counties nationwide that were similar in size and socio-demographic features. HRSA ranked Dallas County death rates for colon cancer, coronary heart disease, homicide, lung cancer, motor vehicle injuries, stroke, suicide and female breast cancer as unfavorable relative to peer counties. Pediatric asthma and diabetes hospitalizations are higher than the rest of Texas. It is notable that many of the conditions that are unfavorable within Dallas are amenable to prevention or management by medical care in such a way that death, disability and cost are favorably impacted. When asked, Dallas County residents ranked their health as very good or excellent as often as residents of Texas but less often than residents of the U.S. The average life expectancy for Dallas County residents is unfavorable, being slightly worse than the U.S., and considered unfavorable when compared to similar counties by HRSA. The statistics for reproductive health in Dallas County are noteworthy for the positive picture they present. Neonatal and infant mortality rates in Dallas County are impressively low compared to the U.S. This is even more striking when the comparison is targeted to Parkland’s patients.
Table 3 2002 Infant/Neonatal Mortality (Rate per 1,000 live births) Infant Mortality Neonatal Mortality Dallas U.S. Parkland* Race/Ethnicity U.S. County All Births 7.0 6.6 4.7 2.7 White 5.8 5.3 3.9 2.9 African – Am. 14.3 11.8 9.4 5.2 Hispanic 5.7 3.8 2.4
Source: PHHS and National Center for Health Statistics *For live births to women with prenatal care in PHHS system.

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Health Status of the Parkland Population Although patients from every community in Dallas County are served by the Parkland system, the great majority of patients live in communities that are heavily populated by minorities and are of low socioeconomic status. (See maps in the Appendices). The health status of these communities is usually significantly worse than the rest of the county and contributes negatively to overall community health status. However, the impressive reproductive health statistics discussed above show that health status can be improved by planning and targeted programs. The effort of a systematic, population-focused program based at Parkland, Women’s and Infants Specialty Healthcare (WISH), has improved the outcomes of pregnant women and their newborns from these same communities and populations. The benefits are great enough to improve the overall community’s infant mortality rate. The benefits seen in infant mortality are not enjoyed by all of Parkland’s service lines. Chronic illnesses are more prevalent in the communities in which Parkland has located its COPC clinics. For example, the South Oak Cliff neighborhood has a prevalence of high blood pressure that is 52 percent higher than Dallas County. Diabetes is 43 percent and stroke is 42 percent more common. The number of residents of Oak Cliff that suffer from asthma is 82 percent higher than for the overall population. Although the numbers differ in each community, the likelihood of finding excess chronic illness is related to the percentage of poor and minority persons who live in the community (Source: National Research Corp. Market Guide, 2001). This same disparity in health is seen in the death rates for these communities. Heart disease is the number one reason for death in Dallas County, as it is throughout the U.S. However, age adjusted figures from 2001 reveal markedly elevated deaths from heart disease in South Oak Cliff compared to the rest of Dallas County (331 versus 231, per 100,000 of population). Cancer, stroke, HIV/AIDS, kidney disease, respiratory conditions and homicide are notable as causes of excess deaths. Although impressive community gains have been made, rates of infant mortality and low birthweight babies are higher in areas that are predominantly African American. The excess deaths and increased prevalence of chronic illnesses are related. This is true not only for the population that Parkland serves, but for the whole United States. It has been noted that most of the health care delivered in the nation is related to chronic illness. More than 75 percent

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of the money spent for health care in the U.S. is for persons with a chronic illness. (A Portrait of the Chronically Ill in America, 2001: Robert Wood Johnson Foundation). High blood pressure, diabetes, elevated cholesterol, along with smoking, are at the root of premature heart disease. The disparity in the health of poor and minority populations is due to a higher level of chronic illness. There may be some genetic reasons for these disparities. For example, for the same level of obesity, African Americans are more likely to develop diabetes than whites. However, the clear consensus is that the major factors causing these disparities are related to poverty itself, decreased access to care, cultural and communication barriers, and unequal treatment within the medical system.

Key Health Conditions to be Addressed The growth of Dallas County is largely due to growth in the Hispanic population. While the first generation of immigrants is healthier than the general population, in time their health status approaches that of the native population. In other words, chronic illness is likely to increase in the County. It is recognized that Hispanics of Mexican origin have a rate of diabetes that is twice the general population (Office of Minority Health, CDC 2003.) This condition leads to heart disease, kidney failure, amputations, blindness, and excess deaths. In addition to increased diabetes, the African American population suffers disproportionately from hypertension and heart disease. The excess deaths from stroke are due to elevated hypertension as is an increase in kidney failure. In addition, asthma and HIV/AIDS are higher in the African American community. Cancer of the prostate and colon are higher in this population as well. Infant mortality remains higher in African Americans in Dallas County as it is in the United States. The conditions above are chronic and have demonstrated interventions that reduce suffering and death as well as reduce total health care costs. If the Parkland Health and Hospital System is organized and operated as an integrated continuum of care to address these conditions, the health of the community of Dallas County can be improved over time. Several health service targets have the potential to become problem areas if current efforts are not maintained and strengthened. One such area is immunizations. The immunization rate in Dallas County is below state and federal standards (Beyond ABC: Growing Up in Dallas County, 2002). This situation puts the residents of Dallas County at risk for epidemics that can be

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avoided. Further, as the Hispanic population begins to acquire the negative lifestyle behaviors of other Americans, the impact on prenatal and other reproductive care could be significant and there could be a decline in maternal and child health indicators. It will be important for the Parkland system to remain vigilant about assuring the quality of its maternal health approach, an approach that currently ranks as one of the most effective in the nation.

C. The Dallas County Economic Climate and the Impact on Health Care

Characteristics of the Dallas County Economy The population that health systems serve is largely driven by the economic health of the region. (See a full discussion of the Dallas economic climate and uncompensated cost pressures in the Appendices). The scope and quality of a local health system has a strong relationship with the number and types of jobs supported by the local economy. The Dallas area economy has followed many trends that the national economy has experienced over the last decade. This has been characterized by strong growth during the 1990s, a substantial drop off in economic growth in the last quarter of 2001 and in 2002, and continued urban and suburban migration patterns. The Dallas economy is a diversified economy. The high-tech sector has been a leading industry in the region’s economy, in addition to healthcare and the service industry.
Figure 1

D a lla s A r e a In d u s t r y C o m p o s it io n

M a n u f a c tu r in g 1 0 % C o n s t r u c tio n 5 %

T r a d e , tr a n s p o r ta tio n , u t ilit ie s 22%

G ov ernment 12% In f o r m a tio n 4 %

O th e r s e r v ic e s 4 %

F in a n c ia l a c t iv itie s 9 %

L e is u r e & h s o p ita lity 9 % P r o f e s s io n a l & b u s in e s s s e r v ic e s 1 5 %

E d u c a t io n & h e a lt h s e r v ic e s 10%

Source: Texas Workforce Commission, Texas Monthly Employment Review by MSA, August 2004

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Dallas area employment grew consistently through the 1990s – typically averaging approximately 4 percent payroll growth, until a substantial downturn in 2001. This sharp downturn was followed by continued sluggish quarters until the past few quarters showed increases. Top private employers from the Dallas area show the strength and diversity of the economy and the significant presence of the service economy. Nationally, job growth over the past decades has been driven by the service and retail sectors. Specific job types that have driven the service and retail sector growth include leisure and hospitality, health care, social service, and retail store workers. For many of these jobs, health insurance coverage has eroded or been eliminated over time. Services approach half of the nation’s current gross domestic product relative to about a quarter of the nation’s gross domestic product in the 1960s. Durable goods continue to comprise a smaller portion of the nation’s gross domestic product. The value of Parkland’s annual economic activity to the region is clear. The hospital system’s total impact generates $1.3 billion in total output, $635.6 million of which is employee wages. The Parkland system directly and indirectly supports 13,200 full and part-time local jobs.

Health Care and the Dallas Economy Public health care systems have a unique perspective regarding the relationship of economics and the workforce to health care delivery and the community. The demand for public sector health care services is largely a function of access to private health insurance. As a result, changes in local economic activity, overall employment, benefits provided by local business, and the cost of individual health insurance to a large extent determine changes in demand for publicly delivered health care services. This relationship is especially true over an extended period of time. National statistics (Holohan, Kaiser sources) begin to tell the story of how public providers feel the impact of an economic downturn: • Over 80 percent of the uninsured came from working families in 2002 – with 70 percent of families having one or more full-time workers and 12 percent part-time workers.

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64 percent of the uninsured have incomes less than 200 percent of the federal poverty level. Between 2000 and 2003, approximately 75 percent of the increase in the uninsured came from adults with incomes less than 200 percent of the federal poverty level.

44 percent of uninsured workers were employed by businesses with fewer than 25 workers. Between 2000 and 2003, the workforce moved from large and medium sized firms to small firms where in which the likelihood of employer-sponsored insurance was lower and uninsured rates were higher.

40 percent of the uninsured in 2002 were adults between the ages of 19 and 34. About 60 percent of the growth in the uninsured between 2000 and 2003 occurred among young adults.

• •

Over half of the growth in the uninsured between 200 and 2003 was in southern states. 8 states implemented freezes in SCHIP during 2003 and 2004. As a result, SCHIP enrollment fell for the first time, largely due nationally to program reductions in Texas.
Figure 2

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The uninsured have a particularly significant effect on safety net providers – primarily hospital Emergency Departments and clinics serving low-income patients. The Parkland Health and Hospital System is the primary provider of these services for Dallas County. As Dallas County’s only public and tax-supported hospital, Parkland is the leading provider of uncompensated care for the community. In 2002, Parkland provided over $410 million in uncompensated care (charges based on charity care and bad debt). This represents nearly 50 percent of all uncompensated care provided by Dallas County acute care hospitals. From 1998-2002, Parkland’s total uncompensated care charges increased 33 percent or a compound annual growth rate of 7.3 percent. The undocumented are a noteworthy component of uncompensated care costs for the Dallas community. It is estimated that approximately 20 percent of uncompensated Parkland health care is provided to undocumented persons (emergency and non-emergency treatment), a figure consistent with other published studies. However, this percentage is likely to remain fairly static over the next ten years. For example, the ongoing overall disparity between the Mexican and U.S. economies suggests that the U.S. will continue to be viewed as the land of economic opportunity, especially in light of domestic trends such as greater female labor force participation, a shortage of blue-collar workers in the trades, and the general aging of the population. All of these factors would suggest greater in-migration. On the other hand, border security has been heightened in the wake of 9/11 (both in terms of policy and enforcement), which will tend to dampen movement of undocumented persons northward. As a result, the percentage of uncompensated care attributable to undocumented persons is likely to be held constant over the forecast horizon.

D. Expenditures on Low-income Health Care in Dallas County
In 2002, the most recent year for which complete data is available, more than $1.7 billion was expended for low-income health care in Dallas County. Table 4 below details expenditures by major funding source (see Appendices for a more detailed discussion of expenditures for lowincome care).

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Long Range Planning Issues for the Dallas County Hospital District Table 4 Expenditures for Low-Income Healthcare in Dallas County (2002) 2002 Dallas County 2002 Program Source Expenditures Enrollment Medicaid $1,202,119,500 190,000 Health and Human Services Commission SCHIP $54,962,100 47,800 Health and Human Services Commission Medicare DSH $34,454,800 NA Centers for Medicare and Medicaid Svcs. Tax Support $310,763,000 NA 2002 Dallas County Budget Other Public $20,153,800 NA NA Texas Department of Health Tobacco Settlement $3,380,300 NA 2002 Dallas City Budget Dallas City $5,241,800 NA 2002 Dallas County Budget Dallas County Health $11,531,700 Dept. Parkland Foundation $8,163,600 NA Parkland Foundation Private Hospital Charity $98,556,936 NA HMA estimate from self-reported data from Care DMR member hospitals Total $1,729,173,736 237,800

Medicaid/SCHIP Medicaid accounted for the vast majority of available funding for low-income health care in Dallas County at a little over $1.2 billion in 2002. This figure includes Medicaid Disproportionate Share Hospitals (DSH) payments, additional reimbursement targeted to providers who deliver services to heavy volumes of Medicaid and uninsured patients. Medicaid is a joint state and federally funded program targeting low-income families, those receiving cash benefits through other federal programs and low-income elderly and disabled individuals. It is important to note that while Medicaid is an important financial partner for Parkland, rates are significantly lower than other payment sources. The rates at Parkland drove a 2003 Medicaid shortfall of $72 million. Texas State Children’s Health Insurance Program (SCHIP) funds accounted for about $55 million to providers in Dallas County in fiscal year 2002. SCHIP is another joint state and federally funded health insurance program. This program provides health insurance coverage for children up to age 19 ineligible for Medicaid with family income below 200 percent of the Federal Poverty Level (FPL).

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Medicare Medicare is not a means-tested program, and reliable data on Medicare spending on lowincome beneficiaries is not readily available. Therefore, this analysis includes only those Medicare resources expended in Dallas County through the Medicare Disproportionate Share Hospital (DSH) program, which funds hospitals that serve a large proportion of Medicaid patients and low-income Medicare patients. Dallas County hospitals received Medicare Disproportionate Share (DSH) payments from the federal government in excess of $34 million in fiscal year 2002.

Tax Support The Dallas County Hospital District (Parkland Hospital and Health System) received $311 million in tax support in 2002 for indigent health care. This is based on the current rate of $0.254 per $100 of assessed value.

Other Public Support The City of Dallas spent slightly more than $5 million on low-income health care services. The majority of this spending came from the city’s general fund to finance neighborhood clinics providing health screening and immunization services. The city also received about $725,000 in grant funding from the Texas Department of Health (TDH) for disease screening, immunization and lead abatement initiatives. The Dallas County Health Department accounted for about $11.5 million of the total resources dedicated to low-income health care in the county. The department expended about $7.2 million of general fund dollars to health administration, public health and disease prevention efforts and administered an additional $4.3 million in grant funding for disease prevention, training and immunization efforts. The Dallas County Hospital District received $3.4 million in 2002 from tobacco settlement proceeds, pursuant to the settlement agreement dated July 18, 1998. Under the agreement, "all hospital districts, other local political subdivisions owning and maintaining public hospitals,

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and counties of the State of Texas responsible for providing indigent care to the general public” are eligible to receive funds.

Parkland Foundation The Parkland Foundation is a nonprofit corporation organized in Texas in 1985 to support and benefit Parkland exclusively. Expenditures represented in the table are the support for lowincome patients channeled directly or through the Parkland Foundation to Parkland Health and Hospital System in 2002.

Private Hospital Charity Care In 2002, the major private hospitals in Dallas County provided approximately $99 million in uncompensated care to self-pay and charity care patients, based on self-reported data.

E. Health Care Providers Serving Low-Income Patients in Dallas County

The Parkland System The Parkland Health and Hospital System is by far the largest provider of low-income health care in Dallas County, delivering services through its hospital, its COPC clinics, its specialty care clinics and its Emergency Department and Level 1 Trauma service. The system provides approximately half of the uncompensated care in the County. In fiscal year 2003, Parkland provided $445 million in unfunded care (self-pay and charity care), representing 37 percent of total hospital charges. Self-pay and charity care represented approximately 6 percent of total charges among the other large hospitals in the County. In the same year, Parkland provided $383 million in care (total charges) to Medicaid patients and had a Medicaid shortfall (Medicaid costs minus Medicaid base payments and net UPL payments) of approximately $72 million. This constitutes roughly one-third of the Medicaid care provided in the County. Thirty-two percent of Parkland’s business was from Medicaid, compared to approximately 16 percent for other large hospitals in the County (10 percent if Children’s is excluded).

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Private Hospitals Private hospitals located in Dallas County constitute a significant resource in the provision of health care services for the medically indigent, including both Medicaid/SCHIP and uninsured patients. Children’s Medical Center, for example, delivers over 90,000 ED visits annually, with 72 percent of them either Medicaid/SCHIP or uninsured. As determined by volume of Medicaid or uninsured services provided, the key private hospitals in the County “safety net” include Baylor (University, Irving and Garland campuses), Presbyterian and Methodist (Dallas Medical center and Charlton campuses). These institutions all operate EDs that: 1) are very busy (between 41,000 and 61,000 visits annually); 2) have heavy and increasing volumes of uninsured patients (between 25 percent and 37 percent); 3) have heavy and increasing volumes of Medicaid patients (between 13 percent and 17 percent); and 4) experience significant utilization for primary rather than emergent care, based on presenting diagnoses and relatively low hospital admission rates. Further data on private hospitals are included in the Appendices. Private hospitals in the County also often provided significant amounts of care to low-income patients, as summarized in Table 5 and Table 6 below.
Table 5 2003 Self-Pay/Charity Care Provided by Large Private Hospitals in Dallas County (Inpatient and Outpatient) Self-Pay/ Charity as Self-Pay/Charity Care Total percent of Total Charges Hospital Charges Cost Payments Children's $16,009,463 $7,593,146 $3,329,091 1.98% Presbyterian $45,057,967 $16,883,220 $2,459,299 4.54% Methodist Charlton $20,663,284 $9,228,223 $949,885 8.35% Methodist Dallas $47,132,153 $22,543,309 $2,663,241 10.65% Baylor University Medical Center $85,987,373 $31,359,595 $4,675,916 6.02% Baylor Irving $25,495,045 $10,491,211 $1,391,191 6.78% Baylor Garland $23,646,724 $9,184,388 $1,154,918 7.82% Medical City* $45,596,411 $11,399,103 3.62% St. Paul $21,469,507 $9,130,981 $1,549,539 5.44% Zale Lipshy $2,859,575 $1,305,110 $989,167 1.35% Total $288,321,091 $117,719,183 $19,162,247 5.54%
Source: self-reported data *Note: Medical City is excluded from totals due to insufficient information

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Long Range Planning Issues for the Dallas County Hospital District Table 6 2003 Medicaid Provided by Large Private Hospitals in Dallas County (Inpatient and Outpatient) Hospital Children's Presbyterian Methodist Charlton Methodist Dallas Baylor University Medical Center Baylor Irving Baylor Garland Medical City* St. Paul Zale Lipshy Total Charges $433,306,059 $83,069,692 $27,534,810 $67,506,431 $139,479,297 $28,848,810 $22,684,158 $87,586,611 $46,798,003 $4,504,683 $853,731,943 Medicaid Total Cost Payments $205,517,064 $166,715,101 $33,143,678 $28,669,836 $12,297,046 $10,554,513 $32,288,326 $28,858,351 $50,868,100 $53,036,655 $11,871,285 $11,389,820 $8,810,527 $9,155,392 $21,896,653 $19,903,191 $16,163,144 $2,055,937 $1,452,284 $376,755,154 $325,995,096 Medicaid as % of Total Charges 53.52% 8.37% 11.13% 15.25% 9.76% 7.67% 7.50% 6.96% 11.86% 2.13% 16.40%

Source: self-reported data *Note: Medical City is excluded from totals due to insufficient information

Other Providers In addition to the major hospitals of Dallas County, the low-income population accesses care through: two Federally Qualified Health Centers (FQHCs), Martin Luther King Family Center and Los Barrios Unidos; local clinics often established by faith-based groups; and via Project Access, a program managed by the Dallas County Medical Society operated through a network of volunteer physicians and hospitals. While these providers serve a small number of patients relative to the Parkland system and other major medical centers, they are a critical piece of the Dallas County safety net, especially for hard-to-reach populations (e.g., the homeless, undocumented, and those lacking access to transportation). See Appendices for more information on Dallas County Project Access, FQHCs and free clinics. The public health departments of both the City of Dallas and Dallas County are significant providers of health care services, concentrating on maternal and child health, immunizations and communicable diseases (tuberculosis, sexually transmitted diseases and HIV/AIDS). In addition, many physicians provide free care to patients in their offices, but there is no way to quantify how much care they are providing.

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Finally, the Veterans’ Administration operates a hospital and a network of primary and specialty care clinics in Dallas and surrounding counties, delivering nearly one million outpatient visits to predominately low-income people in the broader community.

F. Financing Low-income Health Care in Dallas County

Medicaid/SCHIP Relative to non-Texas peer institutions, Parkland’s Medicaid reimbursement, including base Medicaid payments and net Upper Payment Limit (UPL) and DSH payments, is very low. See Appendices for data comparing Parkland to similar hospitals. Poor payment rates are compounded by the State’s failure to capture appropriate levels of Federal matching funds. In 2003, Parkland received gross DSH payments of $137 million and gross UPL payments of $105. Parkland transferred a total of approximately $165 million to the state as part of these transactions and netted approximately $77 million in DSH and UPL payments. If all of the $68 million in overmatch was used to reimburse other hospitals, the net benefit to those hospitals was approximately $170 million. Under the current reimbursement system, Parkland still has approximately $150 million in unmatched local tax dollars. Other counties have been much more successful in leveraging local tax dollars to support their public hospitals. For example, in 2002 Cook County (Chicago) received approximately $240 million in Federal matching funds, net of amounts kept by the State, on local tax contributions of $273 million. Wishard (Indianapolis) received approximately $80 million on total tax revenue of $95 million, which includes amounts transferred to the local public health department. It is important to note that both Cook County and Wishard use a variety of matching opportunities to capture the appropriate amount of Federal match.

County Subsidies Relative to peer hospitals, Parkland is heavily supported by local tax dollars. The following table summarizes the tax support of Parkland and several other large public hospitals. As noted above, almost half of Parkland’s tax dollars are unmatched.

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Long Range Planning Issues for the Dallas County Hospital District Table 7 State/Local Subsidies to Selected Public Hospitals (2002) Subsidy 2002 State/Local per Person 2002 County Subsidy < 100% Subsidies to Population Hospital per Capita FPL 5,264,413 $273,090,254 $52 $372 547,174 $26,900,004 $49 $299 3,505,268 $320,417,000 $91 $626 2,280,605 $250,028,809 $110 $600 1,496,373 $171,573,000 $115 $990 9,578,096 $239,082,858 $25 $156 2,243,385 $310,763,284 $139 $910 842,236 $52,309,399 $62 $548 25,757,550 $1,644,164,608 $64 $422

Hospital Cook County Denver Health Harris County Jackson Memorial JPS Health Network LA County – USC Parkland Wishard Total/Average

Subsidy per Person < 200% FPL $170 $134 $260 $259 $428 $66 $381 $216 $193

Source: National Association of Public Hospitals (2002 Annual Member Survey) and US Census Bureau (2002 American Community Survey)

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CHAPTER 2: HOW EFFECTIVE IS THE PUBLIC HEALTH AND HOSPITAL SYSTEM IN DALLAS?
To best understand both the current and future priorities of the Dallas County Hospital District, it is important to fully comprehend the complexity of the health care delivery system that it is charged with administering. This Chapter will address: • the effective integration of the Parkland component parts into an seamless continuum of care; • specific priorities for each level of care (primary, specialty, emergency, inpatient services); • • gaps in the current system which may impact its optimum efficiency; the need for clinical disease management to cost-effectively care for the patient population most likely to seek services through the Parkland system; • the relationship of the Parkland system to its medical staff, primarily to the University of Texas Southwestern School of Medicine; • • • • current and future financial management and strategy priorities for the system; physical facilities challenges, including the building priority issues for the system; potential partnerships with other Dallas health care providers; and the governance issues that shape the Parkland Health and Hospital System.

A. The Dallas County Hospital District as a System of Care

System-Wide Priorities The Parkland Health and Hospital System is widely viewed to be one of the nation’s most respected deliverers of health care for low-income populations and communities. Over a decade ago, Parkland was one of the first public hospitals to understand that a hospital alone cannot

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meet the needs of a medically vulnerable population and it moved care out into the neighborhoods where its patients live by opening the Community Oriented Primary Care (COPC) clinics. Through its partnership with the University of Texas Southwestern University School of Medicine (UTSW), Parkland has excellent medical care providers and is a unique training ground, producing many of the physicians now practicing throughout Dallas. It has effectively struggled to remain cost-effective in light of a state Medicaid system that is one of the lowest payers in the country and in the face of the pressures caused by growing numbers of uninsured patients. The challenges in the health care industry today, though, demand more aggressive creativity than ever before, particularly for public hospitals. Parkland has all of the building blocks of an effective system of care and needs now to focus on the operational issues necessary to make “the trains run on time” as well as to continue to provide comprehensive health care services for a growing medically underserved population. Significant progress has been made in reining in costs, securing revenue, assuring quality of care and functioning efficiently in the midst of enormous demands. There are several broader system issues that need to be addressed, however, to continue to operate as an effective health care delivery system. The discussion on the pages that follow will address specific aspects of the Parkland health system. However, there are over-arching management and, even, philosophical issues inherent in the operation of the Parkland system that will impact the resolution of any of these more targeted concerns. These issues must be addressed in order to be successful in navigating through the obstacles that Parkland will face in the years ahead. In order to be most effective, both clinically and financially, the Parkland system needs to function as a seamless continuum of care, avoiding the “silos” of management that may be administrated independently and are not connected to the larger mission and operational priorities. The services provided within the Parkland system need to be built around the needs of the target patient population, the operations need to be designed to best assure the efficiency of care provided to that population, and planning efforts need to integrate the financial, administrative and clinical aspects of the service delivery system. There are very competent clinical and administrative senior leaders throughout the Parkland system, but there appears to be less cohesiveness than is necessary for optimal efficiency. It is important for all of these

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leaders, including medical staff leadership, to have a clear understanding of the role of the COPC clinics, the accessibility of specialty care, the financial state of the system, utilization trends, and other issues impacting the entire system. It must be clear, for example, that decisions made about the Emergency Department (ED) admission procedures or guidelines to access certain specialty clinics or financial screening at COPC clinics or new research initiatives undertaken at Parkland can have profound effects on areas of the system that may not have been anticipated. The entire system must be viewed in the context of the whole, not as isolated individual parts. A key element to assuring this coordinated and collaborative management focus is the selection and appointment of a Chief Operating Officer for the Parkland system, an effort currently in process. The foundation of the clinical care delivered at Parkland is built on the “teaching model” wherein the training needs of residents essentially guide policy and practice related to such operational issues as admission policies, transfer decisions, specialty care allocation, and other initiatives that should be determined by the leadership of the Parkland system, based on the requirements for an effective clinical delivery system. Residency Review Committees (RRCs) have already mandated that residents must function more like physicians-in-training and significant strides have been made by UTSW and Parkland administration to assure greater faculty supervision. The next step is to move away from the dominance of the teaching model shaping clinical care by looking intensively and critically at policies and procedures and lines of communication that have evolved over time that were developed to facilitate teaching rather than efficient patient care. Across the country, other hospitals are working with their medical school partners to take back some of the authority over the management of medical services which had been for decades ceded to teaching programs. This is an enormous undertaking and permeates most aspects of care delivered within the Parkland system, but the transition needs to be tackled more aggressively in the years to come. It is also an effort that needs to be driven collaboratively by both Parkland and UTSW, as neither is solely responsible for the current situation and neither can change it alone. While HMA does not believe, based on the evidence from public hospitals across the country, that the Parkland system will ever resolve its financial stresses by significantly increasing the proportion of privately insured patients that come to its clinics or hospital for their care, a

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priority should be established and embraced to do everything possible to retain the paying patients that currently use the Parkland system. There are specific operational policies and procedures documented on the pages that follow that point to deterrents to retaining insured patients, primarily Medicare patients, who initially come to Parkland for health services. There are also particular service lines that attract significant numbers of paying patients that Parkland must now refer to other hospitals because of their lack of capacity. Retention of current paying patients to lessen the burden on taxpayers subsidizing the care of the uninsured should be a goal of the system as a whole and should be coordinated centrally. Finally, it is clear that Parkland Health and Hospital System cannot meet all of the needs of the medically underserved of Dallas County alone. There needs to be constant evaluation of the potential for creating new relationships and alliances that can result in a “virtual safety net” for low-income people in Dallas County. While Parkland and the Dallas County Hospital District must be vigilant to assure that they are not being inefficient within their own system, they also must acknowledge that they need to develop partnerships with other providers to assure that the respected model that they have built is sustainable in the longer term. All health care providers, as well as the broader civic community, will continue to feel the pressure of the growing number of uninsured. The key will be for Parkland to play a leadership role in building rational connections that minimize duplication, equitably distribute responsibility and most effectively meet the health care needs of the residents of Dallas County.

Primary Care Most people in the United States receive the great majority of their health care in ambulatory or outpatient settings. However, the growth of ambulatory care is a relatively recent phenomenon. Less than a century ago hospitals were little more than almshouses and persons of even modest means received most of their formal health care in their homes by the visiting solo practitioner physician. Today outpatient visits include preventive care, involve addressing acute problems, chronic disease management, and increasingly, procedures previously performed only in hospitals. Public health systems have been slower than private health care in providing significant ambulatory care as they have remained in the role of provider of last resort, dominated by

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inpatient facilities and emergency departments that attempt to catch the seriously ill who have fallen through the cracks of the private health care system. More recently, public systems have realized that ambulatory care is more humane and more effective in improving a population’s health, plus a more cost effective approach. Today, public systems include all of the elements and levels of ambulatory care from primary care through highly technical consultations and procedures, including surgery. Increasingly, these elements are organized into coordinated systems of care to increase their effectiveness and to use public funds more wisely. These ambulatory care systems are integrated with and complementary to their public health system’s acute care, inpatient and long term care programs. Parkland Health and Hospital System contains the full range of ambulatory care facilities, programs and practitioners required for a first rate ambulatory care system. Some of these programs are creative and nationally recognized. Other ambulatory programs at Parkland appear incorrectly sized to serve the population served by the system and are organized in outmoded models. The following reviews the elements of Parkland’s ambulatory care, its organization, functioning and integration in the Parkland system as well as the local healthcare community. It should be noted that HMA has completed a very thorough evaluation of the Parkland clinic system and most of the specific detail of this analysis is contained in the Appendices to this report. What follows are the key findings of this assessment. The COPC Model. Parkland was one of the first public hospitals in the country to establish a Community Oriented Primary Care (COPC) system of clinics in communities with high levels of unmet health need that had previously been addressed almost exclusively by the often inappropriate use of hospital Emergency Departments (EDs). Parkland understood that an integrated system of care must shift the emphasis in health care delivery toward primary and preventive care in order to provide the most cost-efficient and clinically effective model of care for its patients. Currently the COPC system consists of seven community-based clinics, the Ambulatory Care Center (ACC) providing urgent care on-site at Parkland, employee health, campus-based clinics for geriatrics and pediatric primary care, ten Youth and Family school-based clinics, and a

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homeless program (HOMES). Collectively, these facilities deliver 327,485 adult, geriatric, pediatric and behavioral health visits annually to approximately 121,872 patients. In addition to the COPC network, the Parkland system, in partnership with the University of Texas Southwestern School of Medicine, operates eight sites offering prenatal and other women’s health services through the WISH clinics, five of which are co-located with COPC clinics and three of which are independently housed. In 2003, these eight WISH sites provided 98,129 prenatal and women's health visits. Finally, two residency training primary care clinics (internal medicine and family practice) operate at Parkland hospital and provide another 22,297 and 10,971 visits respectively. While there are some differences between sites, these facilities generally function similarly and offer medical services, health education, social services, pharmacy, lab and x-ray services. For the most part, the COPC and WISH clinics are located in communities in which there are heavy concentrations of low-income people and from which there is a heavy utilization of the Parkland ED for primary care services that could be directed elsewhere. COPC Patients. Although there is no reliable income data on COPC patients, approximately 40 percent of those seen in the COPC clinics are uninsured and 39 percent qualify for Medicaid or the State’s SCHIP program, with the remainder of COPC patients covered by Medicare or other funding. The COPC patients are heavily Hispanic and African-American (46% and 36%, respectively). About half of the patients are children under the age of 14, 43 percent are between 15 and 64 years old, and 6 percent are over 65. Despite the different communities and populations that the COPC clinics serve, all sites report the top two diagnoses for their patients as hypertension and Type II diabetes, with asthma also in the top ten. These are all chronic illnesses requiring ongoing management to avoid preventable and expensive ED visits and hospitalizations. The patients who come to the ACC on-site at Parkland are predominately adult walk-in patients who suffer from long-standing chronic illnesses and are approximately 80 percent uninsured. These patients are often referred to the ACC when they are discharged from the hospital and need to be seen quickly or are triaged from the Parkland ED because they need primary, not emergent, care. There is then an attempt to refer these patients to a COPC clinic to be seen on an ongoing basis. The patients seen at the school-based clinics are predominately students of those

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schools but three sites also are open to adults from the surrounding communities. The HOMES program served about 5,000 homeless people during 2003 through a mobile program at 37 clinic sites. The patients seen at the WISH clinics are predominately Hispanic (80%) and uninsured (82%). However, it should be noted that once these prenatal patients deliver their babies at Parkland, their payor status changes and nearly 90 percent become eligible for Medicaid coverage. Thus, the investment in prenatal care results in paying patients for the hospital. COPC Productivity and Capacity. The federal government sets minimum productivity standards for the providers who practice in Federally Qualified Health Centers (FQHCs) and this standard serves as a rational benchmark for similar health care facilities. The COPC clinics, as a system, fell short of those minimum standards for physicians in 2003, although they met the standard for mid-level providers (nurse practitioners, for example). This doctor productivity level caused concern among the Parkland COPC administration and an effort has been underway, through an intensive team model, to improve this indicator. By the period of March through August of 2004, the annualized number of visits per physician had increased from the 2003 rate of 2,794 visits/doctor to 3,484, still under the minimum federal level of 4,200 but clearly significant progress has been made. Reaching greater productivity by COPC providers is critical to effectively meeting the increasing demand for services, particularly for chronically ill adults. If patients cannot get appointments in the COPC clinics, they will likely seek care in the ED. As the average cost per COPC visit is $90 and the average ED visit is $163, according to Parkland’s FY2003 Service Line Analysis figures, it is clearly valuable to the system to keep as many patients in the clinics as possible. In FY2003, the COPC clinics had the staff and physical space to provide 116,340 adult and geriatric visits yet they actually provided 92,413 visits in that category. The productivity efforts to date in 2004 have the clinics on target to come close to their filling their available capacity. In pediatric and adolescent services, there is also additional capacity in the current system. Across the seven COPC community clinics, the school-based centers and the pediatric clinic on campus, there is additional capacity, at current staffing levels, for approximately 2,300 visits per

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month, according to productivity benchmarks. There has been an improvement since 2003 when there was capacity to provide an additional 35,000 visits. As children are most likely to be covered by Medicaid or SCHIP, it should be—and is—a system priority to increase pediatric visits. It appears that most of the 16,000 babies do receive and keep their follow-up appointments at COPCs but it is unclear whether these children stay in the system after initial newborn visits. Further, the Parkland Community Health Plan, the system’s Medicaid/SCHIP managed care entity, assigns less that half of its children to COPC providers. This would be an additional opportunity to increase pediatric utilization. Finally, the utilization of the ED at Children’s Medical Center, which has increased precipitously over the past year, comes from communities in which COPC clinics are located. A formal arrangement to refer patients from the Children’s ED directly into COPC clinics would benefit both institutions and the patients as well. A common complaint from COPC Advisory Board members, the Parkland ED and staff in other community hospitals is that it is extremely difficult to get an appointment in the COPC clinics. There is clearly an ability to accommodate additional patients and the productivity efforts currently underway are increasing that capacity still further. The focus should now expand to administrative and policy barriers that may be impeding access. COPC Physicians. The physicians who work at the COPC clinics are employees of Parkland and are not included on the UTSW faculty contract, even though many of these physicians were trained at the University and hold clinical appointments there. When the COPC clinics opened, the University was not interested in providing physicians so Parkland recruited their own. There are several areas where these two different physician classifications, based solely on employment status, cause problems for continuity of care, for patient satisfaction and, ultimately for cost-effectiveness. When a patient needs to be referred from a COPC clinic to a specialty clinic at Parkland, the COPC doctor has to talk to a resident at Parkland. Most COPC physicians stress the frustration of trying to convince a physician-in-training that they, as seasoned physicians, are capable of determining whether their patient needs a referral and they often end up sending their patients to the ED to try to get into the care they need. Further, although there is a policy allowing for COPC doctors to directly admit their patients to Parkland Hospital, it does not function well.

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Usually patients are sent to the Parkland ED and they wait in line for admission with everyone else. Clearly, these scenarios represent problems for continuity of care but it is also the case that if there is an option for the patient to go to another hospital (i.e., if they have insurance) they will rather than have to endure the waits for admission or consults or diagnostic tests at Parkland. (Interestingly, this connection between COPC doctors and hospital-based doctors works much better for the pediatricians who want to send patients to the Children’s Medical Center as many of the COPC pediatricians are on Children’s medical staff, make rounds there and supervise Children’s residents in the COPC clinics). The need for strong physician leadership within individual clinics and as a system, is a clear priority for the COPC network. While there are Lead Physicians throughout the network, and the COPC Medical Director is charged with coordinating key quality improvement strategies, there is not a vehicle for coordinating patient care with physician counterparts at the specialty and inpatient tiers of the system. Addressing this physician-to-physician communication issue needs to take place at the level of senior leadership of the Parkland system. Further, in order to move the clinics to an aggressive management of chronic diseases, essential for the effective and cost-efficient management for a disproportionately large portion of the COPC patient population, there will need to be strong physician leadership empowered to guide the effort. (The issue of instituting a chronic disease management program is discussed at greater length later in this report). Operational and Policy Issues. The COPC clinic network is administered by a Parkland VicePresident who is supported by a team of twelve directors and associate directors. Each individual site is led by a Site Administrator and has a Lead Physician in each specialty and a Lead Nurse. Most clinics have Advisory Boards that provide input into the development of programs and bring the staff a perspective on patient satisfaction and community concerns. A major focus of COPC administration over the past several years, in addition to provider productivity, has been to improve the screening of its patients for all insurance coverage programs for which they may be eligible and to enforce the collections of cash co-payments, which are collected on a sliding fee scale according to income eligibility. Further, uninsured patients are required to enroll in Parkland Health Plus, the managed care plan for the uninsured, or they will be required to pay a greater co-payment. These efforts have

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demonstrably had an impact on revenue generation but there has been little assessment of the perhaps unintended consequence of patients seeking their primary care in the ED, where they cannot be turned away, rather than comply with the financial screening requirements at the COPCs. A policy has been enacted at COPC clinics that results in the refusal of care, except at full cost, to any person who works for a business that offers health insurance to its employees, regardless of the cost to the employee of securing that coverage. This policy should be re-examined. Most of the uninsured in Dallas, as in the rest of the nation, work full-time. Many businesses have either limited their insurance coverage to catastrophic medical expenditures or have made the premiums borne by the employee high enough that many opt out. The COPC policy, however well intentioned to minimize abuse of the system, may be sending more people to the ACC or EDs (either Parkland’s or others), resulting in a greater cost to the system. Access to COPC services is an issue with several components. First, most of the clinics are only open during weekdays, with no weekend or evening hours (although two sites do open for urgent care on one weekend day each). As a system, and building on efforts to increase productivity, it would make sense to explore the reallocation of staff from less busy clinics to those with greater demand, expanding hours in the process. This effort is already underway. In addition, there seems to be a variety of opinions on the effectiveness of the COPC appointment system. There is a widely held perception that it is very difficult to get an appointment to a COPC clinic in a timely manner, although most sites have available capacity. In an effort to understand the reality of this situation, HMA attempted to make appointments and did, indeed, have significant difficulty in gaining appointments. Addressing the appointment scheduling process should be seen as a priority for COPC administration. There are efforts underway to move toward a centralized appointment scheduling system. Finally, the COPCs need to be operationally integrated more effectively into the Parkland Hospital system. In addition to direct admission and specialty care referrals, discussed above, there is no organized and monitored process for patients in the Parkland ED to gain appointments for follow-up care in a COPC clinic near to their home, breaking the pattern of unnecessary ED utilization for primary care. The impact of COPC policies on other aspects of

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the Parkland system (i.e., financial policies that may send more patients to the ED) need to be understood and monitored and vice versa. Size and Location. As the pockets of medical indigency and poverty change in Dallas County, there may be less need for one COPC clinic and greater need for another, or there may be growing demand in a neighborhood where there had been no COPC clinic before. The monitoring of need should go hand-in-hand with productivity enhancement efforts. New clinics do not need to be built or existing ones expanded if they are not operating at full capacity. However, when existing facilities are at full capacity and there is still demand, additional COPCs will likely be needed. The growth in the number of uninsured in the County will mean that people will either utilize COPCs or EDs for their care. Clearly, it is financially more rational for Parkland to direct patients into clinic settings. Further, as community private hospitals are experiencing significant increases in the use of their EDs as a source of primary care for the uninsured, there are real opportunities to develop partnerships with these providers for either expansion of existing clinics or development of new ones. The proposal to develop a new COPC in Irving is a good example of a responsible way to approach COPC growth. Irving, as a community, is increasingly Hispanic and uninsured. Residents of that community already account for nearly 10,000 Parkland ED visits, 14,000 visits to other COPC clinics and 55,000 other outpatient service encounters. A plan was developed for Parkland to secure support from Baylor and government grants to help fund a new site of clear need. This model could well be pursued in other communities with documentable need. Parkland owns and is maintaining two empty clinic buildings previously owned by Kaiser, one in Oak Cliff and the other in Southeast Dallas. The evaluation of the potential use of these two clinics should commence. In particular, the current Oak West COPC clinic is small, cramped and operates at capacity. The potential relocation of that clinic into the Oak Cliff Kaiser facility (along with the WISH clinic) should be explored as a vehicle for increasing access in an area where there is high demand. The potential for a partnership in Southeast Dallas should also be evaluated, perhaps as a site for increasing specialty services. Finances. Few, if any, primary care networks—public or private—make money in and of themselves. Primary care systems focused on providing care for the medically indigent will

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clearly never break even, based on Medicaid reimbursement rates for outpatient services and the inability of many uninsured patients to cover the full cost of care. As the payor mix for COPC patients is essentially 90 percent dependent on federal, state or local government sources, the system will always need to be subsidized. However, it is also important to fully understand the true level of subsidy (as opposed to hospital overhead) and the impact for the rest of the system (i.e., allocation of costs, deflection of patients who otherwise would have utilized the ED for care). The best opportunity for the losses of the COPC system to be minimized is the conversion of the clinics to Federally Qualified Health Center (FQHC) status, a designation by the federal government that guarantees cost-based Medicaid and Medicare reimbursement. As the COPCs currently meet all of the requirements for populations served and scope of services provided, and because the governance requirements for public sector FQHCs are considerably less constrictive that those in the private sector, and because the revenue increase would be so substantial, HMA believes that this should be a major focus for the Parkland system. The financial implications are discussed fully in the Finance section of this Chapter. Conclusion. The Parkland COPC network should be viewed by the residents of Dallas County as a vital resource in their health care safety net and the continuing commitment to meeting the primary care needs of medically underserved populations and communities should be a priority for the Dallas County Hospital District. Attention to operational and policy issues which impact productivity and access, better integration into the entire Parkland continuum of care (specialties, ED, inpatient), fully developing a chronic disease management model for COPC patients, constantly monitoring the appropriateness of staffing and location, continuing to push for financial viability and new focus on building partnerships with other providers should all be priorities for Parkland and COPC leadership.

Specialty Care The Importance of Outpatient Specialty Services. Specialty outpatient medical services are essential to the Parkland system as well as to other providers caring for low-income residents of Dallas County. These specialty services are critical in addressing health disparities for poor and minority patients and in assuring the appropriate treatment of disease. There is growing

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pressure on Parkland, as there is on public hospitals in large urban areas across the country, to address the issue of access to specialty care. The growing population of the Parkland system is heavily made up of chronically ill adults who require access to specialty care to most effectively manage their illnesses. In addition, the broader safety net of private physicians, community hospitals, federally-supported health centers and public health departments have no other option for specialty care for their uninsured patients and either refer directly to Parkland’s specialty clinics or, more often, refer indirectly through the hospital ED. Finally, the demand on Parkland for specialty access is growing as other traditional providers of those services, private physicians or academic medical centers, are limiting access to Medicaid covered patients because of decreased reimbursement, or are leaving poor communities altogether. At first, the notion of allowing access to Parkland’s specialty services might elicit fears of uncontrolled spending and excessive use of expensive, marginally-beneficial technologies. It is responsible to attempt to avoid the runaway growth of technology and the specialty focus that characterizes the U.S. health care system and is a major cause of the cost crisis in health care that the nation faces today. However, there is a clear role for appropriate and cost-effective specialty care in public systems such as Parkland’s. Emerging research demonstrates that diminished access to some specialty services—for example, revascularization procedures—actually magnifies costs by greatly increasing hospitalization rates. In addition, limiting access to clinically effective and cost efficient specialty care has been identified as one of the reasons for the health disparities suffered by poor and minority populations. Outpatient specialty care is an essential adjunct to primary care prevention strategies. For example, screening breast exams and mammography are worthless without follow-up, ultrasound-guided biopsies. Colon cancer screening with fecal occult blood testing mandates access to colonoscopy, which allows removal of pre-cancerous polyps and early cancers and thereby reduces mortality and medical expenses. Another example involves special eye exams and laser treatments for patients with diabetic complications—proven to prevent blindness and save money. In addition, without efficient outpatient specialty care it is impossible to maintain sizable and efficient elective inpatient medical care. Many public hospitals maintain that they are too busy taking care of acute problems to focus on efficient elective care. However, what they are really abdicating is caring for elective health matter in anything other than an urgent,

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and often chaotic, manner. Elective patients, particularly those with insurance, that have been previously cared for at Parkland, are discouraged and driven away, leaving only those uninsured patients who have nowhere else to go. Access in the Current Parkland System. A clear problem exists in access to specialties at Parkland. The COPC clinic physicians report that they are often unable to successfully refer their patients to many of Parkland’s specialty clinics. New patient appointments, if obtained, are far in the future. If a patient does attend a specialty clinic, a report from the specialist consultant rarely returns to the referring primary care physician. As a result, a number of COPC patients who are insured find their way into the private system for outpatient specialty consultation and are more likely to be admitted into private hospitals for elective procedures and surgery. The Emergency Department also faces a similar situation. The conventional system of referral is not reliable and if physicians are concerned about a particular patient they directly call a physician working in the outpatient specialty clinic and obtain an appointment by going around the formal system. Community physicians who care for any indigent patients in their practices state that it is virtually impossible to refer to Parkland for specialty care. Community groups and Parkland community advisory groups complain vociferously about access to specialty services. It would be rational to conclude that a problem with access is a problem with capacity. However, with a dysfunctional referral system, the highest priority patients may not successfully be referred and no-shows and other inefficiencies are endemic. Further, the assignment of specialist clinical time within the system to meet the demands of the population is where much of the problem may exist. Cardiology is illustrative of this point. Heart disease is the major cause of death in Dallas and one of the major causes for admission to Parkland Hospital. Parkland contracts with UTSW for 11.5 FTE cardiologists. However, the Cardiology clinic, the portal of entry to elective cardiology care, sees what appears to be a number of patients that could be seen by 1.5 FTE attending cardiologists. The clinic meets only two half days a week and appoints patients only to Cardiology Fellows in training. After seeing the patient, the Cardiology Fellow does not usually provide directions to the primary care providers to follow recommendations that have been sent to them. This increases the amount of

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follow-up care Cardiology clinic must perform and decreases the number of new patients that can be seen. The Organizational Model. Price Waterhouse Cooper reviewed outpatient services at Parkland Hospital and stated that the Outpatient Specialty Center operations were designed to meet the training needs of the University of Texas Southwestern School of Medicine. Observation of the specialty clinics reveal that teaching needs and academic interests drive the services, staffing, hours and operations of the specialty clinics. To a varying degree in different clinics, patients may be seen by trainees and students who present the case to a faculty physician who personally never lays eyes or hands on the patient. All specialty services are centralized in one facility although Parkland’s outpatient specialty referral manual lists 162 separate clinics. Many of these separately designated clinics reflect current or past research or training interests rather than the contemporary organization of ambulatory care. The training model in Parkland is dated and does not absolutely need to persist. There are clear degrees of difference between clinics. The Gynecology Dysplasia clinic, for example, operates on a model that is driven by the perspective of providing sufficient levels of care to meet the needs of the population. Faculty gynecologists are directly involved with care and seem to believe it enhances the learning process for trainees. They have policies and procedures to assure that patients do not fall through the cracks in the system. This clinic may not be perfect but it’s a model that is built on a public health perspective, is more efficient, and is related to a primary care system of care. Other clinics also have developed around solid participation of faculty physicians in the care of patients. It provides encouragement that the teaching model can be restructured in the Parkland system. Redesign of Outpatient Specialty Care. Parkland should take measures to systematically determine the total predictable demand for each specialty from its ED, COPCs, inpatient followup and traditional referrers into the Parkland system. At the same time, unmet need within the Dallas community, particularly for populations that traditionally utilize Parkland, should be assessed as many people have simply quit trying to get into care and are just showing up at the ED when such visits could have been prevented. Present outpatient capacity at Parkland should be compared to this assessment of need and the gap quantified. The current assignment of specialist effort, purchased through the UTSW faculty contract, should then be evaluated and

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redirected to ambulatory care, if feasible. Parkland leadership should review the utilization of exam rooms dedicated to specialty care to assure that time is allocated effectively (which doesn’t appear to be the case currently). A collaborative effort should be undertaken between Parkland administration and UTSW medical staff leaders to make sure that clinic hours and space are allocated based on the clinical needs of the Parkland patient population, not solely assigned based on teaching priorities. After all of this analysis is completed, it may be necessary to invest in more specialists in order to meet the needs of the Parkland population, but that decision should not be made until a thorough review of the efficiency of the current system is completed. Further, a practical and accurate method of determining the appropriateness of specialty care referrals needs to be constructed. This determination may be able to be integrated into a mechanism that includes an electronic referral request and approval system that is able to track individual and clinic referrals. For example, every patient with a headache does not need to be referred to a neurologist but there needs to be a clear mechanism for assuring that the patients in greatest need of specialty care do receive appointments. This referral system may be part of Parkland’s current information system or could also be a stand-alone operation. An effort like this is currently underway in the Cook County system in Chicago and has been successful in reducing both backlogs and inappropriate utilization of specialist resources. Most patients referred into specialty care should have primary care practitioners and specialists should begin to act more like consultants, as they do in the private sector. Thus, specialists in the Parkland system need to be available to answer the questions of the referring provider, provide clear and concrete recommendations, and assure that the patient and the recommendations get returned to their primary care provider. New ways to increase access to specialty assistance within the constraints of the available resources should be explored by the hospital as support to the physicians (e.g. e-mail consultations, training primary care providers to deliver more specialty care, etc.). A process of redesigning the organization of the specialty clinics at Parkland should begin. Direct care and, if necessary, continuity with a faculty physician should be a core goal. Clinics should meet several times a week rather than in a single enormous session. Real connections with the rest of the Parkland system should be constructed. Teaching can and should be

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continued in such redesigned specialty services clinics but it should be layered over an efficient delivery system, not be the driving force. This is also a better training experience for future physicians. Finally, Parkland leadership should actively consider and pursue partnerships with other hospitals and their medical staffs to increase access to specialty outpatient care in communitybased settings, off of the main campus. For example, Parkland should explore whether hospitals and groups that are located near COPC centers might play a role in providing specialty care. The number of indigent in Parkland’s patient population makes this a complicated proposal, but in talking with these organizations and understanding the impact on private hospitals of inappropriate utilization of their EDs, it was clear that there is a definite willingness to discuss this option. Conclusion. Parkland has very competent and dedicated physicians who provide excellent quality of care to their patients. The reorganization and refocus of the specialty care outpatient clinics, however, must be a significant priority for Parkland’s administration and for its physicians in order to more effectively and efficiently meet the needs of its patients. Specialty outpatient care is, in many ways, the linchpin in assuring that patients can avoid unnecessary hospitalizations and ED visits, effectively manage their chronic diseases and even keep them in the system when they have insurance and other options. This area of the health care continuum should be viewed as a major priority for the health system.

Emergency Care The Parkland Hospital Emergency Department (ED) serves as the front door to the community. Typical of other public hospitals, most persons admitted to Parkland’s inpatient units enter through the ED, almost twice as many as are admitted through EDs at other large private urban teaching hospitals. The Parkland ED is crowded and waiting times are excessive, reflecting the experience at other public hospital EDS around the country. This growing phenomenon is ascribed to lack of access to primary care, enactment of EMTALA laws that mandate that the ED must not turn anyone away, increasing numbers of uninsured, and a change in the health seeking behavior of both the insured and uninsured. It has been said that the ED has become the “safety” of the safety net.

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There is one critical difference at Parkland. In the past several years, the number of persons seen and treated at Parkland’s ED has actually diminished unlike the experience of other urban hospitals. The decrease in numbers may be viewed as a success of Parkland’s ambulatory care expansion, or as a diversion of some of the traditional demand Parkland has borne now being shared by other Dallas hospitals. However, the patients who still use the Parkland ED and the staff that work there are dissatisfied with the effectiveness of its operation. This dysfunction can readily be witnessed in any visit to the ED waiting room and is reflected by such benchmarks as the average time it takes to complete a patient visit. The medical staff and nursing personnel are of high quality and committed to improving care in their Department. How can it be, then, with decreased volume and strong and knowledgeable staff that the current situation exists? The answer can be found in studies of emergencies services nationwide. The backlog in emergency rooms does not correlate so much with how many people arrive for care but, rather, with how readily and successfully the ED is able to admit patients to beds in the hospital. At Parkland, the average emergency room visit takes 7 1/2 hours. A patient who is admitted to the hospital, however, spends an average of 13 hours waiting in the ED for an inpatient bed. The result of these excessive delays is that almost 12 percent of patients leave the ED before they are treated by a doctor. When delays are excessive, the ED diverts ambulances away. ED Delays and the Inpatient Admissions Process. Patients waiting to be admitted to inpatient units continue to occupy space and resources in the ED and prevent other patients from being seen in a timely fashion. At all hospitals, and especially at Parkland, the ED is not really the master of its own fate. Emergency Departments’ delay problems and bottlenecks usually reflect malfunction downstream in admissions, bed control, and discharge practices, and not strictly the number of patients that present at their doors. Approximately 80 percent of all inpatients at Parkland have been admitted through the ED. Parkland has a glaring problem with inpatient admissions from the ED that has been identified previously in at least two independent consultant reports. Although the ED is staffed with highly trained Board-certified Emergency Medicine attending physicians, their decision to admit a patient with a medical condition--be it heart disease, a serious infection, or cancer—does not mean that the patient is promptly sent to an inpatient

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unit. Instead, the patient’s case is referred to a designated medical resident (the “A.O.D.”) who then begins another evaluation, ostensibly to decide if the admission is altogether appropriate and to determine to what kind of bed the patient should be assigned. On a recent visit to the ED, the AOD was a second year resident less than a year and half out of medical school. He had at that time eight patients awaiting this second evaluation. It was clear that he also was on the phone with residents upstairs on the medical floors negotiating the terms of the admissions. Further, medical residents insist on diagnostic tests being done while the patient is still in the ED, a workup that is actually part of the inpatient care, because they say that it is easier to obtain the tests in the ED. However, that operational detail is cause for hours of additional delay in the admission process. In the meantime, the spot in the ED is unavailable for use to assess other patients who are waiting. Once a patient is actually assigned to a bed, there are additional delays due to issues of bed control that are covered in the Inpatient Care section of this report The COPC clinics have great difficulty in admitting patients to Parkland. They are forced to send patients to the ED who could otherwise be directly admitted. The ED AOD again reassesses the patient. Specialty clinics within Parkland also admit their patients through the ED. It is stated that the AOD makes certain that the COPC and specialty patients do not displace a higher priority patient already in the ED. However, almost all of these patients are ultimately admitted but only after a prolonged and, from the perspective of the patient, unnecessary delay in a noisy and crowded area. Directors of private hospital EDs within Dallas County also experience the necessity to convince a relatively junior trainee of the appropriateness of transfers to Parkland. Admissions are simply not allowed to internal medicine wards between the hours of 4 a.m. and 7 a.m. Monday to Thursday, or between 2 a.m. and 7 a.m. on Friday through Sunday. This is meant to accommodate the intern and resident workloads. In the meantime, patients wait until morning. Since the early hours after 7a.m. are particularly hectic, patients may not actually be accepted until 10 a.m. There is clearly a need for some method of assessing and assigning admissions. However, the system in place at Parkland reflects organization and control that serves the teaching programs rather than a contemporary health care operation. The level of experience and the pressure felt

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by a resident often cause them to be myopic and blind to the needs of either a hospital organization or the population that the health system seeks to serve. Connections with Primary and Specialty Care. When patients registered in or referred from Parkland COPC clinics or patients from other Parkland ambulatory care sites have been treated in the ED, there is no consistent and effective method of sending results back to their original referring physician. Likewise, when patients have no primary care or need specialty consultation and follow up, the system for referral to get patients into ongoing care is unreliable. In fact. it is so unreliable that ED physicians worry that patients may fall through the cracks and they often work around the formal referral system and attempt to call a resident or fellow who is on the specialty rotation in order to gain an appointment. Even then, patients who need urgent outpatient visits may be turned away by the mechanics of the financial interview process and given an appointment to return to see a physician many months later. An effective system of specialty and primary care referrals could clearly reduce return visits to the ED, especially for patients with serious chronic illness. Accessible referrals are also likely to avoid expensive future hospital admissions. Other policies, such as the prohibition of providing inhaled steroids to asthmatics at the conclusion of acute exacerbations (because such a treatment would constitute “preventive care” not provided in the ED) are irrational and short sighted, as such a practice almost guarantees return visits in the near future. What Should Be Done? A critical assessment should be made of how Parkland’s ED can be reconfigured to meet the needs of the population it serves. Operational policies must be changed that do not achieve this or actually serve as obstacles. Changes that can and should be made include: • • Improve the ED waiting room space. Design a system and give authority to a single designated clinician that determines if a patient is to be admitted and to where within Parkland Hospital (i.e., eliminate the AOD system). • Allow and facilitate direct admissions to inpatient beds with rare delays for patients within the Parkland health system, including the COPCs.

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Stop requiring diagnostic tests, procedures, and workups in the ED as a requirement of admission that are more appropriate for inpatient units. If, for the same patient, tests are easy in the ED but difficult on the floor, reallocate and redesign policies and practices to remedy this situation.

Plan the construction of Observation Beds in or adjacent to the ED to avoid admissions that are inappropriate and will be served better and more quickly by using an approach that has succeeded in similar clinical facilities.

Improve bed control to meet accepted benchmarks and thereby provide more capacity and relieve waiting, backup, and diversion for the ED.

Redesign the process to allow referrals from the ED into primary care and specialty clinics, and referral back for follow up care to sites that provide ongoing care for patients.

Review and change clinical and administrative policies and practices that are likely to encourage unnecessary return visits to the ED.

Evaluate and implement interventions and policies that are consistent with using the ED as an element in a disease management approach to the patients with chronic illness and conditions cared for by Parkland. (see Disease Management section of this report).

Inpatient Care HMA’s assessment of the inpatient services at Parkland Hospital was based on discussions with Parkland’s medical and administrative staffs, independent observation on clinical physician rounds, data analysis and review of previous consultant reports on targeted operational areas. The following discussion is focused on the strategic areas that represent only the most immediate priorities for the system. Bed control. The ability of a hospital to discharge patients in a timely way, freeing up beds for new patients waiting to be admitted, is a major factor in the efficient operation of any hospital. For Parkland, the ramifications of an ineffective bed control system are profound. Not getting patients out of beds who can leave the hospital means that there are fewer beds available to move patients up onto inpatient units, causing massive backlogs in the ED. It means not

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admitting some paying patients who have options to go to other hospitals when there are long waits for admission to Parkland, depriving the hospital of the revenue that admission would bring. It means keeping patients in the hospital unnecessarily and, for those patients with no payer source, burdening the hospital with the cost of those unnecessary days. Finally, it means a distorted reporting of patient census (i.e., the average med/surg census may be 72 percent at midnight but 94 percent at 1:00 p.m.). Currently at Parkland, very few patients who will be discharged during the day get their discharge order written by the physician before noon, the industry benchmark. Further, there is a very long wait from the time that the discharge order is written and the time that the availability of the bed is entered into the hospital’s computer system (often 6-9 hours). Finally, there is still further delay in getting the empty beds cleaned and ready for additional patients. Over the past several years, there have been significant efforts by the administration of the hospital to address this problem. Several consultants have developed implementation plans for restructuring bed control at Parkland and attempts have been made to work with doctors to get orders written earlier and to have unit managers more accountable for getting the information about bed availability into the computer. Most Parkland administrators acknowledge, however, that bed control remains a significant problem. Rehabilitation Inpatient Capacity. Parkland Hospital currently operates 14 inpatient rehabilitation beds. In 2002, the hospital’s internal demand for those beds exceeded its capacity by 300 percent. Parkland admitted 279 patients into these beds and referred 485 patients to other institutions, simply because they had no available beds. The patients that Parkland kept were primarily uninsured (87%) and those that were transferred out were primarily insured (96%). This is a significant opportunity lost to keep paying patients in the institution who wanted to come there. With the aging of the population, this demand will only grow. Ultimately, the issue of additional rehabilitation inpatient capacity needs to be addressed in the planning for a replacement for Parkland Hospital. There are opportunities in the shorter term, however, to look at less drastic ways to increase Parkland’s ability to maintain these paying patients. There are two inpatient units (1S and 2S) that are currently not utilized for clinical services that could be retrofitted for additional rehab beds. In addition, there has been some interest expressed by UTSW to develop a partnership between Parkland and Zale-Lipshy to

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jointly expand rehab services at both institutions, with each institution perhaps concentrating on particular sub-specialty areas. The exploration of both short- and long-term strategies to increase inpatient rehabilitation capacity at Parkland should be a programmatic priority for the institution. Operating Rooms. The operating room (OR) capacity at Parkland and the efficient use of that capacity is having far-reaching impacts of the entire institution. Over the past two years, there has been a significant increase in the average length of stay (ALOS) for surgical inpatients, with a jump of nearly two full days to the current ALOS for 7.6 days. It is not uncommon for patients to be admitted to the hospital for a surgical procedure, wait in a bed for several days because their surgeries have gotten “bumped” by emergency trauma cases, sometimes leave the hospital to come back another day. This is poor patient care, unnecessary utilization of inpatient beds (for which services cannot be billed because no service was provided), and a guarantee that any patients who have other options to get their care elsewhere (i.e., are insured) will do just that. The lay-off of eleven surgical case managers as a result of the hospital’s “Transforming Care” initiative is widely believed to have crippled the effective management of the ORs. Operative cases are now scheduled almost entirely by residents. These doctors, who need to experience certain kinds of surgeries as part of their training, will often look for the most “interesting” cases, leaving general surgeries behind. It is very difficult, for example, to schedule a routine gall bladder or hernia operation in the Parkland ORs. The lack of OR capacity and effective management are also resulting in physicians scheduling patients at other hospitals if they have insurance, simply because they don’t have access to the OR time at Parkland. In order to address the operational, clinical and financial problems resulting from the current surgery situation at the hospital, several steps should be taken. First, the development of the Ambulatory Surgery Center, already endorsed by the Dallas County Hospital District, should proceed as rapidly as possible. Second, the hospital should explore the potential for leasing OR space in other institutions as an interim plan for moving outpatient surgeries out of the Parkland ORs. Apparently preliminary discussions are currently underway with St. Paul

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Hospital. Finally, the OR management needs to be taken away from residents, even if that means replacing the case managers who had previously administered the area. Labor and Delivery. Parkland has, by far, the single largest obstetrical program of any hospital in the United States. At around 16,000 births per year, it has about twice the number of the next busiest hospital in the nation. It also produces irrefutably positive results and has impacted the entire County’s infant mortality health status in a positive way. On the inpatient labor and delivery units, the services are operated under a protocol developed by the UTSW OB/Gyne Department. It is difficult to argue with the operation, given both the enormous challenges of managing the volume of patients and of the ultimate clinical results. Operationally, however, the inpatient practice model, utilizing four different inpatient units within the hospital, results in some units with census of over 90 percent and some at 50-60 percent. Some units have women delivering in hallways where other units have unoccupied beds. The reorganization of the labor and delivery units to assure greater consistency in census is important for both the institution (which needs to fully utilize all available beds) and for the care of the patients. Given the anticipated increase in obstetrical services at Parkland, this effort needs to take a priority within the institution. The UTSW Department has indicated a willingness to work with Parkland administration to develop a better use of bed capacity and the planning should be initiated as soon as possible. Direct Admission from COPC Clinics. As has been described elsewhere in this report, there is no effective way currently for physicians in the COPC clinics to directly admit their patients into Parkland Hospital. They must send them to the ED where they wait in line through the long triage process. The result is that most patients in the clinics who have any form of insurance, and there is a substantial number of them, will go to other hospitals. If one of the system-wide priorities is to keep those paying patients who already identify with Parkland in the system throughout the course of their care, resolving this issue should be of paramount importance. It will require, as will many of these operational restructuring recommendations, directly addressing the teaching model at the hospital as admissions are organized around resident services.

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Conclusion. There are enormous challenges inherent in running a hospital of the size and complexity of Parkland. There are also many highly qualified administrators who are addressing these challenges every day. Many of the operational priorities identified above will require a thorough restructuring of the current teaching model. Physician leadership and a strong operational focus, perhaps strengthened with the recruitment of a hospital Chief Operating Officer, will need to work in a collaborative way to take on these tasks.

Gaps in the Current System of Care The Parkland system does not—nor should it—directly provide all of the health and social services necessary to assure an effective use of medical resources. Without a formal way of assuring access to those services that it does not provide itself, Parkland will often bear the brunt of a gap in the continuum of care that will result in the inappropriate use of its own services. For example, patients are often kept in acute care beds in Parkland Hospital because of the difficulty in finding long term care (nursing home) beds for them in private institutions. This is a particular problem for patients who may have ongoing medical, substance abuse, mental health, social or a combination of these problems. Other patients may end up being admitted to the hospital who could have otherwise be cared for in less costly venues if the services that they required could be delivered in an outpatient setting. This is clearly the case with surgeries that could be provided in an outpatient setting if it existed within the system. Still others represent potential sources of new revenue for Parkland if the gaps in the system could be closed, like rehabilitation services discussed above. Parkland administration needs to review the potential for filling holes in its current system by: 1) assessing opportunities for mutually beneficial partnerships with other providers already delivering those services; and 2) creating business plans for potential new services to both generate new revenue and to allow it to utilize its current levels of care more effectively. In addition to developing ambulatory surgery and additional rehabilitation services described above, the key area of primary focus for Parkland should be the development of a formal arrangement for long-term care services for its patients. Public hospital systems around the country address the issue of long-term care quite differently. Some (Chicago, San Francisco, Memphis, New York, Indianapolis) have long-term care beds as

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part of their systems. Others, like Parkland, have relied on establishing relationships with longterm care institutions, whereby the nursing home agrees to take a certain number of unfunded patients along with the paying referrals. As the population ages and as the demands for acute care beds intensifies, having long-term care beds as part of the system allows for significant flexibility to move patients into less costly levels of care. In some systems, these beds have allowed the acute care hospital to transfer not only the elderly but also disabled trauma patients, those needing long-term IV antiobiotic therapy, “rule-out tuberculosis” patients and others who simply need to be confined to a bed for a period of time, though not necessarily in an acute care institution. This issue has not been a priority for Parkland, although front-line administrators agree that it is becoming more difficult to transfer patients needing continuing care out of the hospital and into a nursing home. The long-term care issue has many facets. Publicly-owned nursing home beds open up additional opportunity for federal match of local financial contributions to health care services. Further, there is the opportunity for establishing a partnership with either a current nursing home provider or with another hospital system to enter into a contractual arrangement. Finally, the planning for a replacement hospital for Parkland will provide the opportunity for further assessing the levels of care that need to be built in order to assure that all are operated most efficiently (if there are long-term care beds in the system, for example, it may decrease the need for some acute care med/surg beds). This planning is complex but is absolutely essential to assuring a cost-effective system of care. Similar comprehensive planning efforts, involving financial, clinical and partnership assessments should take place for psychiatric services, substance abuse treatment and home health care.

Disease Management “Disease management” may seem to be the latest buzz word in the effort to manage health care in the United States. It is an approach that is a180 degree departure from utilization management by which managed care organizations reviewed requests for health care services in an attempt to discover and eliminate inappropriate and excessive use. Disease management is a strategy designed to find the right clinical intervention for the right person at the right time.

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In spite of the many studies of disease management that have been done, the vigorous debates between academics about its merits, and the numerous vendors offering disease management packages that have appeared, the definition of disease management used has not always been consistent. For the ensuing discussion the definition used expresses an emerging consensus of disease management as the planned and systematic approach to caring for a population of patients with anticipatable needs and problems, typically defined by a chronic illness or condition. Importance for the Parkland System. Chronic illnesses, the usual subjects of disease management programs, make a particularly large contribution to poor health status in the United States and Dallas County. These conditions include diabetes, asthma, heart disease, depression, arthritis, and cancer. Increased prevalence and poor control of chronic illnesses are the causes of the worse health status that minorities and the poor suffer compared to the general population. Chronic illness accounts for 75 percent of national spending on healthcare. Chronic health conditions, on the other hand, are not strictly illnesses but are important health issues that are amenable to disease management and include reproductive health, child development and health practices such as immunizations. Review of Parkland’s diagnosis data and its exploding pharmacy program reveal that its patients have a very high burden of chronic illness. This is the case at all levels of the system, from the COPC clinics to specialty care, to the walk-in Ambulatory Care Center to the inpatient units. Most of the chronically ill in the Parkland system are uninsured and, thus, the costs of their care are ultimately the responsibility of the County subsidy. In addition, the system’s employees, who receive care in Parkland Health Plus managed care plan, have extraordinarily high levels of chronic disease. Managing the care of both patients and employees of the Parkland who have chronic illnesses needs to be viewed as a system priority. The core strategies in disease management enable clinicians to improve their care of chronic health conditions through population medicine principles as well as access to timely information. A population medicine principle, for example, is the identification of every diabetic in a physician’s practice to assure that each one of them receives an influenza vaccination at the appropriate time each year. Timely information for a health care provider might be a warning that the medicine they just prescribed should not be used if the female patient intends to become pregnant or is even at risk of pregnancy. The best clinical and

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population practices change constantly based on new clinical evidence from scientific studies and national consensus recommendations. In a disease management program, the system assumes responsibility to provide and advance best practices rather than leave it solely to the individual practitioner. Disease management is a particularly attractive approach in that it improves health and patient satisfaction and, at the same time, is associated with significant cost savings. Recent clinical trials and disease management programs sponsored by managed care organizations have demonstrated achievements in limiting complications, improving health measures, reducing costs, and enhancing the quality of life of the person with chronic diseases. (Disease Management
March 2004, Vol. 7, No. 1, Pages 47-60)

Components for Disease Management. Interviews, direct observation of Parkland operations, and review of organizational documents and policies reveal that Parkland has made abundant investment in the components necessary for disease management. Although Parkland Health and Hospital System currently performs only limited disease management activities, an appraisal of these management components for an effective disease management program reveals that Parkland is particularly well positioned and equipped to implement a such an approach. Disease management components include: • An identifiable patient population. Parkland has stable populations enrolled in their various managed care programs including Medicaid patients, employees and approximately 75,000 medically indigent patients who are enrolled Parkland Health Plus. Additional chronically ill patients are served in the COPC clinics. • Parkland’s management information systems should be sufficiently robust to identify patients and capture required clinical and utilization data as necessary in disease management. At the present time, Parkland facilities are not uniformly on the same information system. This is being actively addressed and should be resolved in the near future The departments of Strategic Planning, Quality Improvement and Decisions Support are all resources that possess strong data analysis and program improvement capacities to evaluate and manage data for disease management purposes.

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Evidence-based practice guidelines are protocols for clinical management of various stages and circumstances of a chronic illness that, when used effectively, improve the health of patients and limits more costly care. Parkland staff is familiar with and open to implementing these guidelines and, in fact, certain members of Parkland’s staff are actually involved in preparing national protocols.

Patient self-management education/support is a proven method to increase the patients’ ability to care for their own condition. It draws on modern behavioral and educational techniques to increase self-monitoring, the accurate assessment of the chronic condition, and assures effective responses by patients. The patient then changes their medication in response, if necessary. Staff at Parkland’s COPC clinics has begun training in how to increase self-management. Group sessions, written action plans for patients and goal setting methods are being introduced.

Collaborative practice models. Team based health care has been introduced in the COPC clinics and is in an early stage of development.

Care Management Services. Parkland employs care managers but the scope of their job is limited to inpatient care rather than the longitudinal care of a caseload of high-risk patients.

Process and outcomes measurement, evaluation, and management with routine feedback. Parkland has the ability to assess its patient population’s clinical status, physician compliance with evidence-based practice, patient success with self-management.

Disease Management at Parkland. Actually, Parkland Community Health Plan (PCHP) does offer disease management through a contract with a private vendor for its Medicaid/SCHIP enrolled children and the smaller number of adults with asthma in its Health First program. Although this represents an opportunity to improve the health of children, the resources within the Parkland system are not used in disease management since Parkland does not provide specialty or inpatient care for children nor does it provide most of the primary care for Health First enrollees. PCHP initially also sought to include Parkland employees and indigent Health Plus members with diabetes, coronary artery disease, and congestive heart failure in a disease management

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program. However, this effort was rejected by the plan’s employee benefits committee. There are a few less than robust efforts within Parkland Health and Hospitals that might be characterized as disease management. Several years ago, Parkland invested in what was called disease management. However, most of the resources were directed to departments that planned efforts that were isolated from the patients in Parkland’s managed care plans that are described above, and reflected departmental interests that were often academic in nature. For example, Parkland’s adult asthma clinic was designed and is operated in such a way that COPC or other primary care providers in the system have trouble accessing it and rarely refer patients who would benefit from the more intensive asthma care provided there. There is little interaction between the “front line” doctors and the specialist who could assist with patient care decisions. The ED doctors attempt to refer patients to the asthma clinic but new appointments are distant and asthmatics who are smokers, a high risk group, are excluded. It clearly is not an important factor in a disease management approach to the large number of persons with asthma for whom Parkland is the ongoing source of care. Although the components are present, Parkland does not perform disease management in a systematic way for several key reasons, including: • • Disease management programs have never been optimally integrated across the system. Recognition for health benefits and savings from disease management programs may or may not accrue to the entity that implements them. For example, COPC clinics could decrease ED use, but this not measured or considered in resource distribution within the system. • The care of indigent patients within Parkland Health Plus is no longer effectively managed. The indigent are the Parkland patients most appropriate for disease management. If they generate high costs from complications of chronic illness, Parkland incurs those costs fully. • There is no comprehensive commitment to implement disease management across Parkland Health System. No one person or department “owns” disease management at Parkland and no one has authority or responsibility for population outcomes.

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Implementing Disease Management. A commitment should be made at Parkland to focus on the management of chronically ill patients in its system, understanding that this effort will have a positive impact of the health of their patients and the cost of the services provided to them. This initiative will entail planning and resource allocation to: 1) build information system capacity dedicated to disease management; 2) redirect and integrate current care management and quality improvement activities under a comprehensive disease management strategy; 3) apply selected disease management strategies to the entire systems’ patients and physicians; 4) distribute the expense and return benefits under an explicit plan; 5) designate leadership and structure that has authority to implement a full disease management program for the entire Parkland system, giving priority to the indigent patients and employees who will have the greatest impact on cost-savings for the system. Initially, this effort should target the most prevalent and costly chronic medical conditions in the Parkland system, including diabetes, asthma, hypertension, chronic heart failure, depression, coronary heart disease, HIV, and reproductive health (including preconception care).

B. The Relationship of Parkland to the University of Texas Southwestern School of Medicine

History Parkland and the University of Texas Southwestern School of Medicine (UTSW) grew up together. Until 1943, Parkland was the primary teaching hospital for Baylor University. When Baylor left Dallas, a private medical school was formed that would, by 1949, become a public institution, UTSW. UTSW medical school students rotated through the old Parkland Memorial Hospital on Maple Avenue from their classrooms in prefabricated huts behind the hospital. The current Parkland Hospital opened on Harry Hines Avenue in 1954 and UTSW was close behind, relocating into their current buildings immediately adjacent to Parkland the year after. Parkland has been the primary teaching hospital for UTSW since its inception and Parkland has looked to UTSW as the source of its medical staff for over sixty years. Together, they have developed into one of the country’s preeminent medical schools and on all lists of the best public health and hospital systems in the nation.

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In the 1980s, UTSW was becoming increasingly concerned that its faculty had little or no opportunity to build a practice of privately insured patients because they had no hospital to which they could admit them. (The perception, right or wrong, was that these patients would not want to be admitted to Parkland). In 1989, the University opened Zale-Lipshy, a private hospital adjacent to Parkland to be used to admit patients seen in its physicians’ private practices. A decade later, they added St. Paul Hospital, also on the Parkland/UTSW campus, to further build their private referral practices. Most of the physicians who practice at Parkland also practice at Zale-Lipshy or St. Paul, depending upon their specialty.

The Faculty Contract Over the years, Parkland and UTSW have taken significant steps toward making the annual faculty contract more transparent. As with many public hospital/medical school contracts around the country, the old approach seemed to be to agree to give the school a set amount of money every year and assume that this payment would cover the costs of the clinical care provided in the hospital and its clinics. Also like most other similar relationships, the partnership between Parkland and UTSW was built almost totally on residents delivering the vast majority of the clinical service load, with faculty physicians providing nominal supervision. This arrangement satisfied UTSW’s need to have a training ground for their students and residents and Parkland’s need for clinical services provided most cost-effectively to their patients. Over the past decade, national attention has increasingly focused on assuring both the quality of resident physician training and the clinical care that they delivered by setting standards for direct, hands-on supervision by faculty physicians. As in other academic medical centers across the country, Parkland and UTSW have been struggling with meeting these standards, resulting in additional UTSW faculty time in both the inpatient and outpatient settings within the Parkland system. At the same time these structural changes were occurring, the efforts were starting to be made to assure that the faculty contract accurately reflected the services that were being provided as a protection for both sides. It should be noted that, unlike medical schools that have their own hospitals and operate their own resident continuity clinics, UTSW provides all of its indigent care at Parkland and gets

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reimbursed by Parkland for any care provided to the uninsured. In order to be clear about the clinical care being reimbursed, a decision was made to base clinical reimbursement on a nationally-recognized payment system, Relative Value Units (RVUs). Faculty would directly bill any third party coverage for which their patients may be eligible (Medicaid, Medicare, commercial insurance). Parkland would be billed directly by UTSW for care provided to patients without any form of coverage. It was also agreed, primarily because the Texas Medicaid reimbursement rate for physician services was so low, that Parkland would reimburse UTSW for indigent patients at Medicare rates. In addition, to help with the transition to this more accountable system, Parkland agreed to establish a “collar” around the predicted amount of payment to be made to the University for these RVUs. Thus, no matter how many RVUs were billed to Parkland, UTSW was guaranteed to never get more than 2 percent less—or more—than the projected amount. This agreement also protected Parkland from unanticipated budget demands. The guarantee, though, was meant to be temporary, allowing UTSW to gear up to start billing under this system. In addition, the faculty contract allowed for a number of departments (primarily, hospital-based services such as radiology, pathology and psychiatry) to be paid a negotiated rate outside of the RVU system. These payments were to be based on documentable services provided to Parkland’s patients. The contract also paid for “performance enhancements” to incentivize both quality and productivity. Some of these performance enhancements were used to encourage additional faculty presence in clinics, inpatient units and the operating rooms, behaviors that shouldn’t need additional payments to assure. Further, the contract provided funding for “medical director” payments to well over 100 faculty members who played leadership roles of some kind in the Parkland system, resulting in many physicians who have responsibility but no identified real authority. It also specifically provides financial support for “stand-by” coverage for services that require extensive call, and payments for technical services, which originally covered specific purchased services but now include an amalgam of payments, including those for staff that should better be included in another, more accountable, contract line. Despite the lack of any significant service volume increase over the past decade, the value of the faculty contract increased from $22.1 million in 1993 to $72 million in 2003. Much of this increase is due to the actual cost of assuring faculty supervision of residents in the Parkland

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system, which has significantly increased over the past decade. However, recently UTSW has not been able to fully document the level of RVUs and the contract “collar” assured that they remained at the negotiated payment level. For FY 2005, UTSW requested a major increase in the faculty contract of $26 million—to a total of $98 million. Again, there has been little or no increase in service volumes, even though part of the request is to increase the clinical service portion of the contract. A significant portion of the increase originally requested ($10.8 million) was due to pressures being felt by UTSW to comply with the requirements of Residency Review Committees (RRCs) to limit resident work schedule to 80 hours per week. This requirement had gone into place in July, 2003 and has been accommodated by hospitals and medical schools around the country by staggered scheduling, additional support staff, heavier reliance on provider “extenders” like nurse practitioners. Parkland must make the same staffing and scheduling adjustments. Other major increases are in the areas of non-RVU reimbursed departments and in stand-by coverage. HMA has participated in numerous sessions with the leadership of both UTSW and Parkland to review all aspects of the faculty contract. In addition, HMA has reviewed the data submitted by UTSW that documents what it has determined as its cost of doing business at Parkland Hospital. It is important to note that contracts in the past were negotiated without the available cost data and gaining this extra knowledge was extremely helpful in understanding why UTSW has stated that Parkland was not covering its cost (a loosely defined requirement contained in the May, 2003 state appropriations bill addressing the responsibility of “institutions of higher education providing indigent health care to contract with relevant counties in their service area to recover the costs associated with treating those counties’ indigent patients,” a provision whose definition of “cost “ has not been tested). The submitted cost data indicates an extremely high proportion of UTSW expenditures dedicated to administrative costs of one type or another (more than half of its total cost). The various overhead payments (departmental administration, residency program operations, institutional support, etc.) need to be thoroughly scrutinized. These may well represent the UTSW costs. However, this level of overhead on the provision of clinical services is of significant concern. Further, the data provides detail on the amount of time per physician spent caring for patients at Parkland. The hospital’s leadership should review this information

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carefully to validate that the amount of time attributed is actually provided, and provided for the services that Parkland needs and has contracted for. The fact that UTSW has provided this information is an enormous step toward creating an agreement that is transparent. The next step will be to assure that what Parkland pays for is appropriate. (See further discussion of the faculty contract for 2005 under the Finance Section in this Chapter). Conceptually, as the contract negotiation process moves forward, HMA recommends that the following issues be addressed: • UTSW costs that are directly and appropriately attributed to the expenses incurred by providing services at Parkland Hospital, should be reimbursed. • Clinical services should continue to be reimbursed on the RVU system (even those not currently supported that way). • There should be third party verification of clinical services reimbursed through the contract. • The “collar” guaranteeing payment should be based on the previous year’s actual numbers with a collar of 10 percent. • • Performance enhancements should be targeted to increasing productivity and quality. Payments for “medical directors” should be consolidated and targeted to fewer and fulltime physicians practicing at Parkland, with clear authority at the hospital for designated service areas (i.e., medicine, surgery, critical care, women’s services, ambulatory care) and at UTSW for faculty issues. • The contract should be transparent to all of the Departments that provide services in the hospital and clinics. If dollars are targeted to certain Departments, they should be assured to go to those Departments. In addition to these principles for renegotiating the annual faculty contract, Parkland and UTSW should begin the process of renegotiating the Master Affiliation Agreement, established in 1979, in recognition of the major systemic changes of both institutions.

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Medical Staff Leadership Parkland has clearly benefited from the affiliation with UTSW as its medical staff is made up of extremely competent and dedicated physicians. UTSW has also relied heavily on its relationship with Parkland to develop into a widely respected teaching and research institution. However, the structure of the clinical services provided at Parkland by UTSW physicians, dictated heavily by the teaching model where resident doctors and teaching needs of the University are the predominate concerns, has increasingly serious impacts on the ability of Parkland to effectively and efficiently respond to the health care needs of its patients. The impact is felt in areas throughout the system, from the capacity and productivity of the specialty clinics, to timely discharge from the hospital, to continuity between the COPCs and hospital-based services, to direct admission to the hospital without going through the Emergency Department. Significant changes have already taken place in the expectation for attending physician involvement in the direct supervision of residents; this same expectation needs to be translated into the delivery of clinical services. This focus is a responsibility of both Parkland and UTSW. The key issue is now to build upon the truly valuable and vital relationship between the hospital and the school to move into a different way of approaching the clinical delivery of care. A critical component of making this transition is having clear, strong, accountable medical leadership that is responsive to the needs of the physicians and the patient care they are providing, actively involved in both setting and implementing the strategic direction of the health system, and that is given authority and accountability at both the medical school and the hospital over budgets and personnel. It should be the charge of this leadership that the clinical, teaching and research priorities of the hospital are consistent with the needs of the patient population that it is charges with serving. In discussions with both Parkland and UTSW leadership, there was an agreement to move forward on establishing this new cohort of medical leaders. Despite the fact that there are many committed physicians at Parkland who view their primary allegiance to the hospital, they are nearly all on the payroll of UTSW. Most physicians work substantially in other venues and admit to other hospitals. The Chairs of Departments are UTSW Chairs, who have responsibilities at several different hospitals. They are faced with different and often competing missions and expectations from their roles with the hospital and

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the University. But the structure within the Parkland system is also discouraging of active physician involvement in leadership. It is a commonly heard complaint that physicians practicing at Parkland on both the front lines and in leadership positions don’t know who is in charge. Many physicians feel as though they don’t have a formal and recognized role in addressing operational issues in the hospital. HMA believes that a medical leadership structure needs to be developed with the following components: 1) a Chief Medical Officer for Parkland, directly reporting to the CEO, with clear authority over the physicians and medical care practiced in the institution, with a defined role at the University in addressing the teaching and research aspects of services provided at Parkland, and with control over budget and policy impacting the practice of medicine and patient care; 2) medical directors in key areas of the system (e.g., medical services, surgical services, women’s/infants’ services, ambulatory specialty and primary care/COPC) who are near full-time at Parkland and have authority over the clinical services in these designated areas, although it is clearly beneficial for these leaders to have an administrative and/or teaching role at the University as well; 3) movement toward a dedicated medical staff at the hospital and the system, better integrating the COPC clinics’ medical staff; and 4) a formal mechanism for involving medical staff leadership in the senior management of the system, both in day-to-day operations and in setting long term direction. It is vital that these positions are recruited by Parkland, with participation by the University, perhaps trading on the enormous reputation of Dr. Anderson in the medical community nationwide. These positions should include meaningful faculty appointments at UTSW and roles within the school, while the primary focus should be at Parkland. It would be preferable, though not absolutely necessary, that these physicians were on the payroll of Parkland.

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Long-Term Planning Issues UTSW has publicly and aggressively moved forward in the further development of its own clinical services on-site of the Parkland/UTSW/Children’s campus. The issue for this analysis focuses on the impact of this plan on Parkland, not on the University or on other institutions. There seem to be several key issues to consider as Parkland looks at its relationship with the University over the next decade. First, a clear understanding needs to be established of what constitutes a Parkland patient. Perhaps out of no ill will to Parkland, it is not uncommon for paying patients who are either patients in Parkland’s specialty clinics, its Emergency Department or even in its hospital beds to be admitted or transferred to the University’s Zale-Lipshy or St. Paul’s hospitals. This relocation out of Parkland is explained as due to patient preference, medical necessity, lack of bed capacity (documented above for rehabilitation patients), the perception that paying patients are really UTSW physician’s patients because they are not paid by Parkland to see them or other rationale. However, non-paying patients are almost never transferred out of Parkland for these reasons. It is critical for Parkland as it takes on an increasing load of uninsured patients to, at minimum, maintain the paying patients (particularly Medicare patients) that they have now. As the University further develops its clinical services at Zale-Lipshy and St. Paul and, ultimately, the planned new University hospital, the inclinations, however innocent, to transfer patients into these institutions, will intensify for UTSW physicians. A clear understanding of when transfers are appropriate needs to be agreed upon, monitored and enforced. The UTSW leadership has agreed that this could be accomplished. As the University builds clinical services in its own facilities, Parkland needs to be able to objectively assess the impact of the UTSW plans on the care of its own patients. If, for example, the University wishes to build its heart surgery program at St. Paul and all Parkland patients are transferred there for these procedures, Parkland needs to be able to assess, both currently and in the long-run, if such an arrangement is economically and clinically appropriate and beneficial. Or, as the University expands its neonatal intensive care units (NICUs) at one of its hospitals and at Children’s, Parkland needs to assess the impact on its own NICU, which is staffed and led by UTSW physicians who may now be stretched to cover other programs. These are clear long term issues that Parkland and UTSW need to have a formal mechanism to discuss

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and resolve, even if that means that Parkland needs to find other medical service arrangements for certain areas. The University has expressed a willingness to assure that Parkland will be able to look elsewhere if it cannot meet Parkland’s needs in particular areas, like they did when Parkland opened the COPC clinics. Optimally, there should be a commitment to enter into serious discussions about a rational and collaborative approach to the capital and service development on the campus. While there is currently a forum for sharing the master facilities planning initiatives between Parkland, Children’s and the University, there has been little serious discussion about the potential for collaborating on either building projects (ambulatory surgery, rehabilitation, etc.) or services (food services, labs, security, etc.). All three institutions are initiated major master facilities planning efforts and this is a critical time for such collaborations to be explored.

Conclusion It is without dispute that the UTSW partnership with Parkland is valuable, long-standing and must be preserved for the mutual benefit of Parkland, the University and the Dallas community. It must also, however, be remodeled to reflect the clinical, operational and financial needs of the Parkland system, while still providing the academic benefits for UTSW. This new approach will require new thinking and new structures from both the hospital and the school. While the current faculty contract needs to be executed fairly quickly, it is imperative that the University and Parkland begin the process of renegotiating the Master Affiliation Agreement to fully address the complex issues related to leadership, clinical service models, teaching and research priorities and interaction between two clinical enterprises. This is a very different time and these are all issues that didn’t exist substantially when the agreement was first negotiated twenty-five years ago. Failing to fully understand and confront them now would be a disservice to both institutions.

C. The Financing of the Parkland System
The financial health of a public hospital system should be evaluated based on its ability to accomplish its mission, maintain the viability of its plant, and accomplish this while

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maintaining a stable tax rate. The community should have an expectation that the public hospital system has a financial plan in place that allows for appropriate levels of service to be maintained in difficult economic times, that the physical facilities are replaced at regular intervals and updated appropriately between replacements, and that the tax rate is relatively constant unless extraordinary circumstances arise. Accomplishing this within the constraints of a patient mix like Parkland’s (49% government-sponsored, 37% charity/self-pay, and 14% commercial) is challenging. Within this context, HMA identified the following critical success factors for evaluation: • • • • • • adequate leveraging of local tax revenue; maintenance of adequate local tax revenue and taxpayer equity; operational effectiveness of the Parkland system; financial management and information technology; contract for medical staff; and additional service opportunities.

Each of these issues is discussed below, along with potential opportunities for stabilizing or increasing revenue, reducing cost and/or improving operations. (Additional information and supporting documentation is included in the Appendices.)

Adequate Leveraging of Local Tax Revenue Medicaid is a joint state and federally funded program targeting low-income families, those receiving cash benefits through other federal programs and low-income elderly and disabled individuals. In Texas, each dollar spent on Medicaid services consists of $0.61 from the federal government and $0.39 in state or other local funds. States are allowed to generate their share of Medicaid payments in a variety of ways, including the use of intergovernmental transfers (IGTs) from counties and other units of government. How states leverage local resources in their Medicaid programs is not only a financing issue, it is a taxpayer equity issue. By not leveraging all available local tax dollars, the burden of paying for indigent health care is disproportionately borne by the local taxpayer.
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Financing Medicaid poses significant problems for states during periods of economic downturns. Demand for assistance from qualified individuals increases at the same time state budgets are struggling due to lower tax revenues. Without a strong partnership between local and state governments, the state may constrict its Medicaid budget resulting in the loss of federal matching funds forcing the local unit of government to bear the entire burden of increased demand alone. This places a significant strain on local taxpayers, as people who previously qualified for assistance from state and federally supported programs must turn to resources financed solely from local taxes. A creative partnership between local and state governments works to maximize the leverage of the local financial contribution. In fact, anytime this partnership is not working, the burden of paying for indigent health care is disproportionately borne by the local taxpayer. This is the case in Dallas County and Texas today. Special Financing Opportunities. As discussed in Chapter One, Dallas County spends approximately $322 million on low-income health care services, of which $150 million is not matched. Despite the extensive efforts of the Parkland CEO and other health care leaders in the community, this money remains unleveraged. HMA believes the only way the County will receive an appropriate level of Federal participation in low income health care financing will be based on a strategy whereby political and business leaders address this issue as a taxpayer equity issue. This increased leveraging is critical if Parkland is to meet the growing needs of the community into the future at acceptable property tax levels. There are two issues related to increasing federal participation in low-income health care. The first is to have a source for the state match. Dallas County has that. Its $150 million of match will generate $225 million of new federal money. The second issue is to have a State Medicaid Plan that conforms to federal guidelines and allows for the expenditure of this money. HMA reviewed the current Texas Medicaid reimbursement system for both fee-for-service and managed care members and evaluated several options for generating additional Medicaid revenues. The following represent the most practical options in terms of potential implementation in Texas in a timeframe of one year or less. These strategies entail no new State money; they are based entirely on leveraging currently unmatched County tax dollars. Recently, State Medicaid Plans and related Amendments have come under the scrutiny of the federal

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government. HMA believes that the options described below, while requiring negotiations with Center for Medicaid and Medicare Services (CMS), would be approved. This conclusion is based on the experience that HMA has had in this area in other states around the country. • Additional Upper Payment Limit (UPL) Payments. Federal Medicaid regulations limit total Medicaid payments to what Medicare would pay for the same services for each class of provider (e.g., non state-owned public hospitals), which is commonly referred to as the Upper Payment Limit (UPL). Within each class of provider, each facility’s payments are limited to no more than total charges. Despite a recent increase, Parkland’s charge structure is still a limiting factor in maximizing UPL payments. Concurrent with an increase in Parkland’s charge structure, Medicaid UPL payments could be increased. The final reconciled data is not yet available. Based on current data the maximum is $16 million, but Parkland’s expectation is that this number may actually turn out to be lower. • Expanded Eligibility. The State Medicaid agency could take actions to expand Medicaid eligibility to undocumented immigrants that are pregnant to pay for prenatal care. This would require a Medicaid State Plan Amendment (SPA) from CMS. Rhode Island, Illinois, Minnesota, Arkansas, Washington, Massachusetts, and Michigan already have approved such waivers. This care is currently being provided by Parkland and other safety net hospitals and paid for entirely by local tax dollars. HMA estimates that this could yield additional revenue of approximately $7 to $9 million. • Physician Payments. Increasing Medicaid payments to physicians affiliated with public entities is a strategy being used in several other states to claim match for local funds and increase access for Medicaid patients. Texas is exploring this opportunity, but estimates of its impact on Parkland are not available. However, it is important for the community to ensure that the benefit accrues to Parkland for its employed physicians and to UTSW for its faculty. UTSW has indicated that if it received additional Medicaid funding through these enhanced payments its need for funding from Parkland would be reduced. • Medicaid HMO Rates. Federal regulation requires Medicaid HMO rates to be set based on principles of “actuarial soundness.” However, broad discretion exists in defining this

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term. Clearly, the Parkland HMO enrolls a different mix of patients than other Medicaid HMOs in Dallas. The State has explored adjustments in rates based upon the severity of patient needs. These criteria, along with arguments for expanded access to care, could easily justify increased capitation payments to Parkland’s HMO, which could be used to benefit the hospital and/or the physician groups affiliated with the hospital. Improving the Medicaid fee-for-service base payment rate (the basis on which Parkland’s HMO rates are set) would assist this process. HMA estimates the potential impact on Parkland to be approximately $5.6 million, assuming a 5 percent increase in premiums. • Charity Care Funding. The community could establish a 501 ( c)(3) entity to fund charity medical care in Dallas County. This entity could legally receive contributions from private hospitals that wish to alleviate pressure on their emergency room by promoting access to appropriate health care services for uninsured. The private hospital contributes to the not-for-profit entity that, in turn, funds health care for uninsured patients at Parkland and other entities in the community. • Private Providers. Dallas County can pay the state share of Medicaid UPL payments to the private DSH hospitals in Dallas County. HMA estimates that the available UPL capacity of these private DSH hospitals in Dallas County is approximately $412 million ($179 million if Children’s Medical Center is excluded). In fact, this strategy could absorb the entire $150 million of unmatched local tax dollars. Converting COPCs to Federally Qualified Health Centers (FQHC). Parkland can significantly improve the financial position of its COPC clinics by converting them to Federally Qualified Health Centers (FQHC). FQHCs receive cost-based reimbursement for Medicaid fee-for-service and managed care patients and are also eligible for other benefits, including drug pricing discounts, “first dollar” Medicare reimbursement, and, in the case of Section 330 grantees, federal grant funds to support the costs of providing uncompensated care. It has been determined that the Parkland COPCs already meet most of the requirements for FQHC designation and would only have to adjust to the governance guidelines for public sector FQHCs. HMA analyzed Parkland’s cost reports to estimate the net impact of cost-based reimbursement, assuming FQHC status. The analysis indicates that Parkland could receive an additional $9.3
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million in annual Medicaid reimbursement under an FQHC model for their current COPC clinic operations.
Table 8 COPC Under FQHC Reimbursement (Dollars in millions) FY 2003 COPC Medicaid FFS Payments $3.0 Medicaid Managed Care Payments $4.3 UPL Payments $2.7 Professional fees $0.6 Total Payments $10.6
*Source: HMA analysis of Parkland cost reports

FQHC $6.3 $13.6 $0.0 $0.0 $19.9

Maintenance of Adequate Local Tax Revenue and Taxpayer Equity HMA subcontracted with an independent economic analysis firm – Texas Perspectives, Inc. (TXP) – to assess the long-term financial health of Parkland given demographic and economic trends in the region (see Appendices for complete report). TXP’s analysis shows that, in the near term, Parkland’s local tax revenue is adequate to support its uncompensated care costs. Within the next three to seven years, however, uncompensated care costs will equal and eventually exceed tax revenue at the current rate of ($0.254 per $100 of assessed value). This timeline is accelerated when the Medicaid shortfall (Medicaid costs minus Medicaid base, DSH and UPL payments) is taken into account. Currently, Parkland’s tax revenue is supporting its uncompensated care and also compensating for poor Medicaid payment rates that fall far short of costs. The County will not be able to continue subsidizing Medicaid payments at the current tax rate. This supports the need to capitalize on existing opportunities to maximize available matching funds as detailed above, both as a means of protecting the long-term financial health of Parkland and as a matter of taxpayer equity. While a stable tax rate is a reflection of Parkland’s financial health, it also has a direct impact on its financial health. There will be years when revenues are particularly strong due to unforeseen changes in reimbursement, settlement of past cost reports or lawsuits, or other factors. These positive financial results do not by themselves justify lower tax rates or new responsibilities unless Parkland’s Board-approved capital plan shows this money is not needed for anticipated plant and/or equipment needs or to maintain a cushion for leaner years. By allowing the

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institution to develop reasonable reserves in accordance with a Board approved plan, management will be encouraged to act with long-term goals in mind, which further protects taxpayers from future tax rate increases.

Out-of-County Care Provided By Parkland Out of County care has been the subject of much recent media attention in Dallas County. While this is an important equity issue for the region, HMA’s analysis shows that the dollars involved are not of the scale of some of the other issues discussed in this chapter. Nevertheless, it is an issue that requires a sustainable, long-term solution. Table 9 presents a per capita comparison of indigent care expenditures in Dallas County and the surrounding counties and illustrates the inequities in the current system.
Table 9 Out-of-County Care – Per Capita Comparison Population (2000 Census) 491,675 2,218,899 432,976 111,360 126,811 71,313 43,080 Indigent Care Coverage Level (as % of FPL) 25% 200% 21% 21% 21% 21% 21% 2003 Indigent Care Expenditures $ 2,147,573 $285,236,000 $1,649,463 $703,172 $1,765,887 $45,966 $99,633 Indigent Care Expenditures Per Capita $4.37 $128.55 $3.81 $6.31 $13.93 $0.64 $2.31 Indigent Care Expenditures as % of General Revenue Tax Levy (GRTL) 2.60% NA 3.94% 4.19% 12.70% 0.46% 1.06%

County Collin* Dallas Denton Ellis Johnson Kaufman Rockwall

Source: 2003 County Indigent Health Care Program Summary, Texas Department of Health *Collin County finances indigent care through a foundation, not through tax revenue. Source: Collin County

Parkland provided approximately $81 million in care to out-of-county patients in FY 2003, including both funded and unfunded patients, as summarized in the following table. Approximately three-quarters of the costs incurred for unfunded patients came from patients who were admitted through the Emergency Department or were considered “unavoidable” by Parkland, meaning that they required a service that only Parkland could reasonably provide. Parkland lost $10.1 million in 2003 on unfunded out-of-county patients, but only $2.5 million of this was considered “unavoidable” by Parkland. The above calculations were based on full cost, which is comprised of the direct cost of the services provided and a proportional share of overhead (items such as building depreciation,

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utilities, administration). Contribution margin is another way of looking at the impact of this activity. It is based on direct cost only. The contribution margin for unfunded out-of-county care was a negative $3.8 million, but the overall contribution margin for all out-of-county care, including the care provided to funded patients, was a positive $17.1 million. Interestingly, Parkland also incurred significant losses on its out-of-county funded patients, particularly those covered by Medicaid. In fact, Parkland loses more on Medicaid-funded outof-county patients than on “avoidable” unfunded out-of-county patients ($4.7 million versus $2.5 million). The current Medicaid reimbursement situation in Texas, as well as opportunities for enhancing Medicaid revenue, is discussed elsewhere in this report.
Table 10 Parkland Hospital Out-of-County Care At Full Cost (FY 2003)
Total Payments (including allocation) $4,555,241 $3,495,727 $169,891 $3,665,618 $889,623 $58,895,057 $264,852 $24,458,217 $7,437,134 $26,734,854 $63,450,298 Contribution Margin ($3,811,734) ($2,580,662) ($173,235) ($2,753,897) ($1,057,838) $20,884,865 $60,187 $8,230,699 $1,988,050 $10,605,929 $17,073,131 Excess/ (Shortfall) ($10,107,046) ($7,152,536) ($431,403) ($7,583,939) ($2,523,107) ($7,730,233) ($92,534) ($4,667,097) ($1,957,148) ($1,013,454) ($17,837,279)

Out-of-County Unfunded Admitted Through ER Other Unavoidable Total Unavoidable Unfunded Remaining Unfunded (avoidable) Out-of-County Funded County Indigent Medicaid Medicare Other Total Out-of-County

Direct Cost $8,366,975 $6,076,389 $343,126 $6,419,515 $1,947,461 $38,010,192 $204,665 $16,227,518 $5,449,084 $16,128,925 $46,377,167

Total Cost $14,662,287 $10,648,263 $601,294 $11,249,557 $3,412,730 $66,625,290 $357,386 $29,125,314 $9,394,282 $27,748,308 $81,287,577

Source: HMA analysis of Parkland Hospital data

The imbalances of the current system require a long-term, equitable solution that is both politically and economically feasible. HMA discussed this issue with commissioners from each of the counties surrounding Dallas County to assess the readiness to move toward a regional system. Several counties expressed a willingness to consider contributing to a Regional Trauma Network to finance out-of-county trauma care. Several counties also expressed interest in using their current indigent care expenditures to leverage federal matching funds to finance indigent health care. The counties generally did not react favorably to mandates requiring a minimum expenditure (e.g., 8%) of their General Revenue Tax Levy (GRTL) on indigent care, as has been proposed in the past.

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Table 11 illustrates the potential impact of leveraging current county expenditures to generate federal matching funds, as well as the impact of matching county funds assuming an 8 percent GRTL mandate.
Table 11 Impact of Medicaid Leveraging of County Funds CIHCP 2003 CIHCP Spending if Matched at 60% Spending 8% GRTL $2,147,573 $5,368,933 $6,620,546 $1,649,463 $4,123,658 $3,349,935 $703,172 $1,757,930 $1,342,631 $1,765,887 $4,414,718 $1,112,588 $45,966 $114,915 $801,298 $99,633 $249,083 $636,582 $6,411,694 $16,029,237 $13,863,580

County Collin Denton Ellis Johnson Kaufman Rockwall TOTAL

8% GRTL if Matched $16,551,365 $8,374,838 $3,356,578 $2,781,470 $2,003,245 $1,591,455 $34,658,951

Operational Effectiveness of the Parkland System HMA devoted fewer resources to this topic relative to other issues under the scope of this report due to the large amount of work that has already been done in this area by other contractors. In addition to identifying areas for improvement, outside contractors are often brought in to serve as catalysts for change that would be difficult to affect from inside the organization alone. HMA’s limited review of Parkland’s financial performance indicates expenses have been controlled and lowered in some cases. It is important to note, however, that at least one of the initiatives identified has resulted in far less revenue than was reported. Parkland’s internal auditor reviewed the Denial Management initiative for purposes of validating the $8 million reported improvement over the baseline. The auditor found that the baseline appears to have been overstated and, as a result, the net reduction in denials was also overstated. In fact, their findings indicated there were no increases in net revenues. Parkland management and its Board are currently working through this issue with the contractor. The following discussion touches on additional areas of potential financial improvement in the Parkland system, beyond those described above. Operations/Revenue Cycle Improvements. HMA was asked to conduct its own revenue cycle analysis to identify additional opportunities for improving cash collections. ESI performed this work (see Appendices for complete report). The evaluation included the financial operations for

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inpatient services, the emergency department, outpatient specialty clinics and the COPC clinics. ESI interviewed more than 20 individuals with direct involvement in Parkland’s revenue cycle, including individuals in finance and administration, as well as in clinical areas. Both “frontend” admissions and registration and “back-end” billing and collections were observed. ESI also performed significant analysis of financial and receivables data. Table 12 summarizes the revenue cycle opportunities identified, which total $6 to $8 million in potential new revenue. The recommendations focus primarily on front-end process improvements to qualify more eligible individuals for coverage and build upon improvements already made in increasing collections at the time of service.
Table 12 Revenue Cycle Opportunities Process Goal Convert patients to funded sources by evaluating and implementing Convert approximately $20 technology to support the enrollment million more gross charges to a process into funded sources and to funded source support improved identification of patients, addresses, and eligibility. Implement a stronger denial management and collections strategy. 10% to 15% reduction in There is still room to improve approximately $10 million in FY collections by focusing resources 2004 write-offs toward the highest dollar accounts. Improve time of service collections through enhancing participation by Increase in clinic related timeclinical staff and fostering a sense of of-service cash by raising to responsibility toward the taxpayer internal best performing levels among all staff.

Opportunity

$4 - $5 million

$1 - $1.5 million

$1- $1.5 million

While revenue cycle operations are relatively strong, two areas were identified as a concern. First, certain co-pay policies would appear to be counter-productive to the overall goals and good of Parkland as a system. Relatively large co-pays and restrictive eligibility for reduced fee programs (including the policy that refuses reduced fees to those who work for employers who offer health insurance, no matter what the cost to the employee) at the COPCs may be driving patients to seek care at more expensive Parkland venues, such as the Emergency Department. We would recommend these policies be reviewed and a fiscal impact study be prepared for the Board for their action. The other area of concern is the significant number of accounts in the receivables of the hospital, especially the COPCs, many of which are over a year old. HMA/ESI was advised that the balances in these accounts were mainly comprised of adjustments and

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other write-offs never completed (some five years old). While the financial impact may be minimal, this is a poor business practice and should be corrected. As part of longer-term planning, Parkland should also begin to consider the mutual benefits of a combined revenue management entity that combines the hospital and the medical school revenue management processes, including medical records, billing and collections. Pharmacy Opportunities Under the Medicare Modernization Act (MMA). Parkland pharmacy represents approximately $80 million of Parkland’s overall $820 million budget (FY05 budget request). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides several opportunities for safety net providers like Parkland (see Appendices for a more detailed discussion). Members that currently receive drugs through Parkland Health Plus will either access their medications at Parkland or off site at a local pharmacy. Either scenario benefits Parkland in terms of reduced exposure to a cost pressure. The potential opportunities are summarized below: • Drug Discount Subsidies. From June, 2004 through December 2005, beneficiaries below 135 percent of FPL who do not have private or Medicaid drug coverage will have $600 per year for drug expenses. Parkland estimates the target population (Medicare recipients not enrolled in Medicaid) to be approximately 4,900 individuals. If 25 percent of the 4,900 eligibles are enrolled with a discount drug card, this will save Parkland up to $1.1 million. The impact of the subsidies could be as high as $5.9 million (through December 2005) depending upon federal enrollment provisions and how the Discount Card will be integrated into Parkland Health Plus (PHP) eligibility. • Low-Income Assistance. Medicare will provide additional low-income assistance beginning on January 1, 2006. Whereas the majority of beneficiaries will have substantial cost sharing responsibilities beneficiaries with incomes below 150 percent will have their premiums subsidized. The estimated maximum potential impact of the low-income assistance program on Parkland is $5.8 million, assuming a total eligible population of 5,800. • Mail Order –It is clear given the current mail order volume, the current refill level (57%) that mail order pharmacy, a central refill station, or a combination of the two are an

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important consideration when moving forward. As noted elsewhere in this chapter, the VA is widely respected across the country for its efficiency and quality assurance in the implementation of a pharmaceutical distribution system, particularly in the area of mail order prescription refills. Recently, the North Texas VA has doubled its capacity for taking on additional business and would be interested in collaborating with Parkland in more efficiently providing refill medications for its patients. Managed Care Opportunities. HMA conducted a review of the Parkland Community Health Plan (PCHP), Parkland’s Medicaid and SCHIP HMO, to determine whether opportunities exist for operational and financial improvement. Parkland has contracted with Aetna to provide administrative services for PCHP. Among the key findings from this review are: • PCHP generated a total loss of $4.0 million in 2003 ($6 million loss for Medicaid and a $2 million profit for SCHIP). • Administrative costs for both the Medicaid and SCHIP plans are increasing sharply and now stand at 15 percent versus the industry standard of 12 percent. • • PCHP pays non-participating providers 100 percent of billed charges. All participating primary care physicians are paid a $3 per member per month “gatekeeping fee” to manage care. The review also identified several data and systems limitations at PCHP: • Aetna provides comprehensive data files to PCHP, but extensive data analysis is required to obtain relevant, useful and actionable information. • Budgeting, financial and utilization reporting are performed at aggregate and gross levels with limited ability to drill down to cost, quality and utilization drivers or perform root cause analyses. • There is no provider profiling capability.

Based on these findings, HMA makes the following recommendations for improving PCHP’s operations:

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Reduce administrative costs to industry standard of 12 percent of revenue. This will generate approximately $3.7 million in savings. HMA understands that the U.S. Department of Health and Human Services Office of the Inspector General (OIG) will be conducting an audit of the administrative costs of all Medicaid managed care plans in the current fiscal year. PCHP’s current administrative cost structure will not be viewed favorably in this review.

Renegotiate provider contracts to pay Medicaid rates, generating approximately $1.5 million in savings.

Eliminate the current $3 primary care “gatekeeping” fee and replace it with an incentive pool for primary care physicians that see a large volume of PHCP patients and/or are effectively managing their patients’ care. The elimination of the current fee would save approximately $2 million, some of which would need to be used for the incentive pool.

Retain a contingency-based claims auditing organization to cover incorrectly paid claims. Estimated savings are approximately $500,000.

Reduce SCHIP payments to non-participating providers, yielding potential savings of $500,000.

In addition to the opportunities outlined above, PCHP should consider the development of a data warehouse and decision support system (including provider profiling capabilities) to help it identify cost, utilization and quality drivers.

Financial Management and Information Technology Over the past year, Parkland’s finance department has been largely rebuilt, both in terms of leadership and systems. Despite recent improvements, including the implementation of a powerful decision support system, some financial systems remain antiquated, particularly patient accounting. Outdated systems and a change in financial leadership have caused most of the effort and vision to be internally focused, leading to progress on internal problems. Nevertheless, there continues to be room for improvement. During this time of transition, it is extremely important that Parkland’s financial and operational leadership review all publicly released financial information for accuracy, consistency and reasonableness. This may increase

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the time required to get important information to the Board and ultimately to the Court, but it is imperative this extra time be taken to ensure decisions are based on the best available information. During HMA’s interviews and analysis, the lack of long-term business and financial planning was apparent. Parkland does not have a current capital plan, its IT plan ends in the current fiscal year, and there is no current long-term business or strategic plan for the health system. These factors make it extremely difficult for the Board to evaluate new opportunities or current progress in any meaningful way. These types of plans are needed to help the Board understand and set important policies and evaluate capital and cash needs. While the development of these plans is not the responsibility of the finance department alone, it is imperative that the financial leadership devote time and energy on collaborating with the medical and operational leadership to drive their development. Also of critical importance to Parkland’s financial future is its ability to look outward and develop and implement major revenue generation efforts through UPL, DSH and other mechanisms. It was apparent during HMA’s review that these issues were not getting the necessary attention from a finance team that is mired in day-to-day operations and systems overhauls. It was also apparent that the financial leadership is not always on the same page as the operational and clinical leadership with respect to these strategies as well other issues of critical importance to Parkland’s financial health. It is important that all members of the leadership team understand the financial and operational implications of decisions. More time spent in strategic discussions among this group is needed. The following sections provide a brief discussion of several key financial management issues examined by HMA. These include information technology, maintenance of plant viability, and cash balances and capital formation. Information Technology. As noted above, Parkland is in the final stages of implementing a new patient registration system that will standardize these functions across the hospital and clinics. Parkland also recently implemented a powerful decision support system known as T2. While some data refinements are needed to make T2 function at optimal capacity, the system

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has the potential to significantly enhance Parkland’s ability to analyze its operations and service lines. The major shortcoming identified in Parkland’s information technology efforts is a lack of a long-range strategic plan and a corresponding IT plan to support it. While Parkland has made significant IT improvements in recent years, much of that progress has been out of necessity, and there is still a considerable amount of work remaining. The Board needs to be given the opportunity to understand the ongoing IT needs and assist in prioritizing them based on Parkland’s business objectives. Maintenance of Plant Viability. The average age of the Parkland plant exceeds 10.5 years. This is significantly over optimal industry standards. Parkland should attempt to lower the average age of the plant to 8 years or below as soon as practical, an effort that will require a comprehensive capital plan. Older average age of plants often indicate that higher operating costs exist due to obsolete equipment or plant designs that do not optimize how medicine is currently practiced. It may also indicate significant future capital outlays that may be crippling from a cash flow perspective if not planned for. Cash Balances and Capital Formation. The availability of unrestricted cash is a concern at Parkland. Cash and short term investment balances at Parkland net of amounts for incurred but not reported claims from the managed care plan and those restricted for capital should be monitored and efforts made to rebuild them. This is the short-term concern. The long-term concern is the lack of a capital plan. Parkland should have a Board approved capital plan in place. This plan should be composed of sources and uses of cash over the next five years. This will assist the Board in decisions regarding when to pay cash for long-term assets and when to borrow. It will also provide important information in the decision making process and the impact of those decisions on capital planning and tax rate implications. Health care is a capital-intensive business. Parkland has little debt, which is normally positive. But when coupled with low cash reserves and an aging plant, a low debt burden loses some of its luster. A capital plan should highlight potential opportunities and risks well in advance to assist management and the Board in informing the Court and other appropriate parties of their position and needs.

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Contract for Medical Staff In all negotiations, the symbiotic relationship between Parkland and the medical school must be remembered. The quality and cost of care at Parkland are in large measure determined by the faculty of UTSW. Parkland needs to have a strong working relationship with these physicians based on mutual respect and fair treatment. Parkland should actively support the medical school’s efforts to enhance payments from third parties, including the State of Texas for medical education and the state Medicaid program for care of patients. Parkland’s Board has currently budgeted $77 million for this contract for 2005. Based on our analysis of the contract, as well as cost data provided by UTSW, this is not an unreasonable amount. However, if additional services are needed by Parkland, an increase may be warranted. As soon as possible, negotiations for the 2006 contract should be initiated. The focus of this effort should be to produce an easy-to-understand, transparent, and verifiable agreement. The completion of this negotiation by May 1 will allow the Board to thoroughly understand it and include it in the budget process from the beginning. This should allow the management, the Board, and the medical school to know the exact amount and its impact on the budget in early summer and come to an agreement. This will also assist the medical school in recruiting the best available physicians for Parkland in the number and specialties required. Cost of Services. UTSW approaches this contract from the perspective of their business need, which is to recover their costs for providing services at Parkland. In response to HMA’s request, the medical school shared its departmental cost data. Based on their internal calculations, total costs for services provided to Parkland are $93 million, not including an add-on for technical services. This figure includes approximately $48.3 million in total physician costs, net of collections (HMA imputed an amount for reasonable collection expenses), based on HMA analyses of the UTSW data. The remaining costs consist of residency administration, other departmental costs of the Medical School and administrative overhead. Specifically, they include: • $9.6 million for the costs of administering the residency program. The residency program is a UTSW residency based at Parkland for the majority but not all of the residents. According to UTSW, this figure represents the total costs of administering the

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residency program (excluding pediatrics at Children’s Medical Center), not just the portion directly attributable to Parkland. • $23.1 million in departmental costs, including billing and collections, other staff and supplies attributed by USTW to activities at Parkland. • $10 million in institutional overhead of the UTSW, which represents the school’s estimate of Parkland’s share of this cost. While it is certainly reasonable to expect that Parkland should contribute to departmental costs, as well as some institutional overhead and administrative costs of the residency program, the question is how much. For example, it does not appear reasonable for Parkland to bear the entire financial burden of the UTSW residency program when this program trains physicians for the benefit of the entire state of Texas. UTSW maintains they have no place else from which to recoup this cost. This is also true of departmental and institutional overhead costs. Parkland and UTSW should begin working together to find strategies to both reduce these costs and find appropriate alternative revenue sources. Analysis of Current Contract. In recent years, steps have been taken to make Parkland’s contract with UTSW more transparent and accountable. Under the contract, clinical services for uninsured patients are reimbursed on a relative value unit (RVU) basis, with a “collar” that effectively guarantees reimbursement at a specified level even if actual RVUs are much higher or lower than anticipated. Most services are reimbursed at the Medicare rate, commonly known as the conversion factor, though some (anesthesia and radiology) are reimbursed at much higher rates based on the rationale that the market rate for these services far exceeds Medicare rates. In addition, the contract includes reimbursement for some services that are not reimbursed on an RVU basis, as well as performance-based payments, payments to support administrative costs, and payments for stand-by coverage. Finally, the 2005 UTSW request includes an additional $10.8 million for additional staff to compensate for the effects of the 80hour rule. It is important to note that some of the medical school’s request and budget methodologies reflect a need to subsidize low payments for physicians from Texas Medicaid in addition to covering the costs of uninsured patients. The faculty treats a disproportionate number of these

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patients making a subsidy necessary. HMA’s recommendations do not fully reflect the subsidy necessary. As a point of reference, in another Midwestern community the state determined that to equitably compensate faculty physicians for their disproportionate Medicaid mix the payment rate had to be increased from 28 percent of charges to 64 percent of charges. The total faculty contract request from UTSW for FY2005 is $98 million. The following table outlines each component of the request and HMA’s recommendation. HMA’s recommendation in each area is based on what it views to be good business practice. In fairness, when HMA reviewed the document, each segment of the contract was reviewed in isolation and on its merits. The original contract, however, was based on the perception at the time of the whole cost of doing business and those costs were then delegated to certain categories. HMA’s recommendation for the RVU portion of the contract is based on 2003 volumes, which are the most recent actual, although not independently verified, figures. It is further recommended that a wide collar be applied to allow for any variations above or below this estimated number. To ensure that payment is based on actual volumes, and that all monies that can be collected from other payors are collected, it is critical that third-party verification of claims be reinstated. The vendor selected should assist the medical school in re-billing accounts that have third-party coverage. Despite the fact that HMA’s review of the components of the contract reaches a lower number, this transition year between the old and the new contract, justify the Board’s approved number of $77 million. During this year, Parkland and UTSW need to work together to try to reduce the administrative overhead costs documented by the University which HMA views as high.

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Long Range Planning Issues for the Dallas County Hospital District Table 13 Faculty Contract Analysis (Dollars in millions) Provision 80-hour rule 2004 $0 2005 Request $10.8
HMA Recommendation

Discussion
Support of this magnitude has not been seen in other venues; need for support and ancillary staff is more critical. HMA recommends a 33% “collar,” from $22 million to $44 million, which affords some level of protection to both parties while also reflecting actual utilization. No change recommended HMA concurs with Parkland’s analysis of this provision. Administrative fees should be more targeted and tied to specific job descriptions and performance criteria. HMA’s review of the contract revealed that many of the performance-based payments are for activities that could reasonably be considered basic job performance. Our recommendation eliminates these payments. HMA concurs with Parkland’s analysis of this provision. Removed new ED position, which should generate RVUs. Several components of this section were not “technical” in nature and reflect clinical staff or lab services that should be generating RVUs. These components were removed in HMA’s recommendation.

$0 Range of $22.0$44.0 ($4.4) $14.4 $10.0

RVUs Mid-level deduction and concurrency Non RVU Administration

$32.6

$46.0

($4.4) $12.9 $9.4

($4.4) $14.5 $11.0

Performance Standards Stand-by Coverage Program Enhancements Technical

$8.4

$8.8

$6.8

$2.2 $1.3

$5.7 $2.4

$3.1 $1.8

$3.6

$3.6

$2.8 Range of $56.0 to $78.0

TOTAL

$66.0

$98.4

Additional Service Opportunities HMA identified several service areas that warrant further research to determine operational feasibility and potential for revenue generation. These, listed from highest probability of success to lowest, include rehabilitation, long-term care, and psychiatry. These services have been successful at other public hospitals, and the chances of success are further enhanced if the public hospital can enter into a joint venture to build the service. Despite a strong potential for success, none of these opportunities should be pursued prior to the development of a comprehensive business plan that assesses the likelihood of success given Parkland’s payor mix, partnership opportunities, and the Dallas marketplace.

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Conclusion Parkland continues to achieve its mission of providing health care services to the underserved of Dallas County, but this mission may be in jeopardy if it fails to adequately plan for the future. Parkland’s current tax rate is adequate to support the provision of indigent care. However, its physical plant is aging, and the hospital lacks a strategic plan and a capital plan, which are needed to ensure the stability of future tax rates. Parkland has undergone substantial leadership changes within its management structure in recent years, which has led to some noticeable improvements, particularly in the area of cost reductions, but has also created a lack of cohesiveness at the very top of the organization – a problem that is exacerbated by the lack of a permanent Chief Operating Officer. Parkland’s relationship with the medical school continues to be a critical operational and financial issue. While this report contains specific recommendations for the 2005 contract, work should begin immediately on ensuring that the process for the 2006 contract produces an easy-

to-understand, transparent, and verifiable agreement in a timeframe that allows it to be incorporated into the budget process.
Financial stability could be greatly enhanced by maximizing opportunities to leverage local tax dollars to secure federal matching funds. Parkland currently has approximately $150 million in local tax dollars that are not being matched. This is not just a Parkland budget issue, it is a taxpayer equity issue, as Dallas County taxpayers shoulder a disproportionate share of the costs of treating uninsured patients. The unwavering support of the County Commissioners and the local business community will be needed to garner state cooperation in leveraging these local funds. Finally, there are several additional service opportunities that should be carefully evaluated both in terms of operational feasibility and likelihood of financial success. These services have been successful at other public hospitals, but no action should be taken without the completion of a comprehensive business plan.

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D. The Physical Facilities Challenges for the Parkland System
Over the past several years, there has been a significant amount of work done on the evaluation of current Parkland facilities and the development of a master plan for their replacement. There have been numerous reports prepared, some presented to the Dallas County Hospital District and shared with the Dallas County Court. Land has been purchased and schematics developed for replacement facilities for the services currently provided at Parkland Hospital, projecting into the future.

Moving Forward on a Capital Master Plan The discussion of the facilities Master Plan has been effectively tabled for the past year, except for a discussion about moving forward on the Ambulatory Surgery Center. HMA urges that a thorough evaluation of the facilities needs of the Parkland system be reopened and the development of a capital plan for the system become a priority for the following reasons: 1) There are capital projects for the current facility that should be reviewed now, regardless of the long-term plan for the replacement of the hospital, which could take a decade to complete. For example, there is the potential for renovating several units within the hospital (if an accommodation can be reached with Children’s Medical Center, which is currently leasing the space for storage) to expand rehabilitation capacity. Further, the potential renovation of some administrative space in the ED to allow for observation beds could significantly address some of the bed availability issues. Neither of these projects has an excessive price tag but both could result in significantly more efficient operations and/or revenue generation opportunities. 2) The longer that a replacement facility is put off, the more it will ultimately cost, both in actual replacement dollars and in expenditures on maintaining the current plant. For example, by the time that the replacement Cook County Hospital was built in Chicago, it was estimated that the new hospital would cost approximately $440 million less in the first five years than continuing to maintain—and meet code for—the existing facility. Parkland has significant facilities problems that, unless there is a commitment to a new facility in the next several years, will likely require significant investment to maintain its accreditation. If it was decided that a replacement facility or facilities would be built,

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there are some major capital projects that could be deferred. If no decision is made, large investments will need to be made in infrastructure simply to stay in compliance. Internal estimates by Parkland’s facilities management leadership indicate that $120 million would need to be spent over the next 5-10 years if there was no commitment to a new facility if the implication is that the current buildings will need to be maintained. If there is a plan to replace Parkland in the next decade, approximately $90-100 million of that investment could be eliminated, also according to Parkland’s internal estimates. 3) There are issues of size, location and scope of services that need to be re-explored and that cannot be accomplished until the discussion is reopened and sanctioned by the Board. There has already been internal work done on the projected size (for example, a reduction of about 125 beds now amends earlier projections for the women’s and infants services for the WISH facility, based on revisions in utilization estimates). In addition, other scenarios are being contemplated, including a smaller, tertiary hub hospital on the central campus supplemented by decentralized facilities providing different services in other areas of the County. Finally, the scope of the current operation may need to be amended to address the changing demographics and methods of providing care (i.e., more outpatient specialty, long-term care capacity) that could have an impact on the acute care inpatient needs of a replacement facility. These are issues that should be discussed and analyzed as soon as possible. 4) There should be a comprehensive approach to the financing of capital projects once there is a plan in place. Currently, financing strategies appear to be developed in a disjointed fashion and may actually result in more expensive building projects. For example, it is widely felt that the current thinking about building two replacement hospitals—an acute care hospital and the WISH hospital—will make better sense because it may be politically expedient to finance them separately, even though building and operating two different facilities may cost more to construct and to operate (estimates range from $20-40 million more in construction costs alone, and operating costs would be significantly greater). Decisions about financing (revenue bonds, cash, general obligation bonds, etc.) should follow the agreement on an overall master capital plan.

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5) The potential for partnerships with other providers for component parts of the overall system replacement plan should be thoroughly explored, whether those partners are on campus or elsewhere. Potential collaboration exists with UTSW, Children’s Medical Center, private hospitals and the Veteran’s Administration in such areas as rehabilitation services, long-term care, inpatient psychiatric care, low-risk deliveries, outpatient specialties, and other discrete service lines.

Next Step: A “Blue-Ribbon” Panel Part of the current impasse preventing forward movement in the development of a capital plan for Parkland appears to be a lack of trust between the Commissioners Court, the Dallas County Hospital District Board and the Parkland administration. There is a lot of money at stake and decisions about facilities replacement require firm and defensible information. In order to break the current logjam, HMA recommends that the Dallas County Commissioners Court and the Dallas County Hospital District jointly appoint a “blue-ribbon panel” made up of local hospital, civic, and business leadership, who are charged with working with Parkland administration to: • • assess the current facilities issues and prioritize current projects; come to a conclusion about the need for a replacement facility, building on information contained in existing consulting reports so as not to duplicate effort; • • request and review documentation on current and future demographic projections; explore the potential for provider partnerships on campus and with other entities in Dallas County; • • • make final recommendations on the elements of the capital plan; develop a financing strategy; and provide ongoing oversight to any resulting project as it moves forward.

This model of an independent oversight body was utilized in Chicago as the Cook County was anticipating the replacement of Cook County Hospital. The committee was chaired by a prominent businessman, and its membership included key private hospital CEOs, and other business leaders and civic representatives. The committee took it upon themselves to

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commission a major consulting firm to undertake a pro bono financial feasibility study of replacing the hospital. This process assured both credibility and buy-in from the larger community for acceptance of the ultimate recommendations. HMA recommends that this independent panel be appointed by the end of 2004, with a report anticipated by the end of 2005.

E. Potential Provider Partnerships for the Parkland System
It is clear that no matter how efficient Parkland is now or ultimately becomes, it will never be in the position to meet all of the health and medical needs of low-income people in Dallas County. Even its own projections for the replacement of its facilities are based on addressing only half of the projected indigent population health service demand for the county over the next decade. Across the country, public health and hospital systems are learning that they simply cannot do it all and need to enter into partnerships with other providers who are willing to be defined parts of a “virtual safety net” to care for the indigent population in a particular community. Most of these private health care providers understand that, given the growing number of patients without insurance, they will ultimately see more medically indigent patients at any rate, whether through their Emergency Departments (EDs) or their clinics. It makes much more sense to plan ahead in a rational way to build on each other’s strengths and weaknesses, whether clinical or geographic, and to spread out the responsibility over the entire health system. Throughout the course of this study, HMA interviewed the CEOs and other senior staff of private hospitals, community health centers, mental health agencies and other public health agencies. There was unanimous interest in both embarking on new collaborations with the Parkland system or expanding existing relationships. The following represents some, though clearly not all, of the potential areas for partnership development.

Private Hospitals Other than Children’s Medical Center described below, the key private hospitals that serve significant numbers of Medicaid/SCHIP and uninsured patients in the Dallas area appear to be

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institutions in the Baylor, Methodist and Texas Health Resource (THR) systems. For the most part, Medical City Dallas and Zale-Lipshy don’t serve substantive numbers of Medicaid and uninsured patients (although the other hospital operated by UTSW, St. Paul, does provide Medicaid and uninsured care in both its inpatient units and its ED). Several conclusions can be made about these hospitals. First, while the overall percentage of inpatient admissions hovers at a bit less than 20 percent Medicaid/SCHIP and 6 percent uninsured/self-pay for these hospitals, the percentages over the past three years have been inching up. Second, a significant number of Medicaid patients (between 13-16 percent) and uninsured patients (between 23-36 percent) utilize the EDs at these private hospitals, often seeking care that they could receive in non-emergent settings. Finally, these numbers appear to be relatively consistent and growing across all institutions. While private hospitals in Dallas are not in the same position as many private hospitals serving inner city populations in other metropolitan areas (where it is not uncommon to have more than a few private hospitals providing care to 50-70 percent Medicaid and uninsured), the trend is clearly worrisome to these hospitals. The projected growth of the uninsured in Dallas and the continuing low Medicaid reimbursement are certainly detrimental to the bottom lines of private hospitals, institutions that operate with no direct subsidy for care provided to the indigent. The continued stability of the Parkland system, including its COPC clinics that deflect some of the ED volume from these private hospitals, is of paramount concern to the Dallas private hospital industry. The willingness to look at expanded and formalized partnerships with Parkland to rationalize services to the low-income population was endorsed by every CEO interviewed. The key areas of potential collaboration to be explored should include, but not be limited to: financial support, clinical collaboration, capital investment and political engagement. Several private hospitals already provide support to specific Parkland COPCs. These commitments should be solidified and expanded, based on the need in the communities jointly served by the private hospital and the Parkland clinic. Support can include direct financial subsidy of clinic operations, capital development (space), and access to clinical support services. (specialty and diagnostic services for clinic patients). Further, as Parkland moves toward a replacement of its current hospital, intensive discussions should occur with private hospitals to determine opportunities for decentralizing some services,

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through contract or joint venture, to better serve a geographically changing low-income population. In addition, there are clinical service needs that are currently not being met at Parkland that could pose on opportunity for collaboration with other hospitals. Most notably partnerships in the development of specialty outpatient, rehabilitation and some tertiary service capacity should be actively pursued. Evaluation of the best partnerships should include economic realities as well as quality and responsiveness of services. Finally, efforts to increase the availability of federal dollars matching the local government contribution of Dallas County to the provision of health care services should be heavily supported and, in some cases, led by the private sector hospitals and their business-oriented Boards, whether or not they are directly benefited. It is clear that keeping Parkland a vital health care institution is of enormous indirect benefit to these institutions and to the entire community.

Children’s Medical Center An obvious partner to Parkland in the more formal creation of a health care system for the indigent is Children’s Medical Center (CMC), located adjacent to Parkland hospital. In the mid1990s, a mutual agreement was reached between CMC and Parkland for CMC to take on the responsibility of the pediatric patients, including the indigent, who previously had been cared for at Parkland. The hospital is now disproportionately dependent upon Medicaid and SCHIP and so, over the past few years, has been significantly impacted by the reductions in these programs by the State of Texas Parkland and CMC already interact on several different levels. The hospital provides the inpatient, emergent and subspecialty outpatient back-up to the pediatric primary care delivered at Parkland’s COPC clinics. Some of the COPC physicians, who are also UTSW faculty, rotate on the inpatient units at CMC and supervise pediatric residents in the COPC clinics. It is generally felt, by both COPC and CMC leadership, that this is a positive relationship that should be expanded. The CMC has established its own neighborhood health center in a community in which many patients who had been utilizing its ED reside and found that effort to have a profound effect on reducing unnecessary ED visits. As the COPCs currently are located in communities that make up the CMC ED primary service areas, the potential for collaboration is significant.

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New partnership areas of focus should include the following elements: 1) implementation of a formal appointment process from the CMC ED to COPC clinics for patients seeking primary care; 2) the exploration of co-location of CMC pediatricians into existing or new COPCs to increase pediatric primary care capacity and further encourage the redirection of patients out of the ED; and 3) collaboration on accessing specialty care outpatient visits for COPC children, a growing problem as the eligibility for SCHIP in Texas has been constrained. The partnership potential for the two institutions extends to joint facilities planning. Both CMC and Parkland are in the midst of Master Planning efforts for new and/or expansion facilities on the same campus. Discussions should be initiated to determine potential areas of collaboration, whether in facilities or services. The leadership of CMC has clearly stated its interest in being part of a coordinated approach to the care of low-income people in the County.

Veteran’s Administration/North Texas Region In recent years, Veteran’s Administration (VA) hospitals have been given a great deal more latitude in entering into partnerships with other non-VA health care providers. The VA in Dallas, which serves over 40 counties in north Texas and Oklahoma, is a major health care resource for the community, providing nearly 1 million primary and specialty ambulatory visits every year to veterans in its catchment area, as well as significant inpatient, mental health and long-term care capacity. There have been previous discussions about developing collaborative initiatives between Parkland and the VA and some efforts have been made in that direction. The two institutions share many of the same patient populations and collaboration could better assure that resources are used most appropriately. The VA is widely respected across the country for its efficiency and quality assurance in the implementation of a pharmaceutical distribution system, particularly in the area of mail order prescription refills. Recently, the North Texas VA has doubled its capacity for taking on additional business and would be interested in collaborating with Parkland in more efficiently providing refill medications for its patients. The VA has also developed formal contracts with a network of longterm care providers that allows the VA to more efficiently discharge patients out of its acute care institution. Many of their patients, as Parkland’s, have special needs that have to be accommodated. The VA would be interested in assessing the potential for

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collaborating with Parkland on this contracting effort. The VA also operates its own home health service, made up of nurses and nutritionists and therapists and home health aides. This service now provides care for several hundred VA patients in their homes, decreasing the likelihood of unnecessary hospitalizations. They would be interested in exploring the potential for extending that service to Parkland patients. Despite the extensive ambulatory capacity currently operated by or contracted with the VA, there is interest in exploring the potential with Parkland of contracting for primary care for veterans at the COPCs that serve particular neighborhoods and communities. In addition, there is interest in jointly assessing the opportunities for developing community-based mental health services, both inpatient and outpatient. This is an area in which Parkland is currently overwhelmed, particularly in inpatient psychiatric capacity, and the VA has committed to expand services. There appears to be a willingness to explore what seem to be significant partnership opportunities between the Parkland and VA systems. A process should be commenced at the highest levels to begin these discussions.

Community Primary Care Despite the substantial primary care load provided by Parkland’s COPCs, there are only two federally supported community health centers in Dallas County, Martin Luther King and Los Barrios. This is substantially less subsidized primary care than exists in other large metropolitan areas (Chicago, for example, has 25 community health centers with 90 sites). In an effort to address this disparity, the Dallas County Medical Society has established a program called Project Access and there are a number of free-clinics developed through faith-based groups and social service programs to attempt to meet the growing need of the uninsured. Several neighboring counties are also pursuing the development of primary care for the indigent. There appears to be relatively little formalized joint planning and collaborative thinking about where to locate facilities or how to resolve problems accessing services and pharmaceuticals for the patients served by these clinics and programs. It would benefit Parkland to take the lead in bringing these providers together to begin discussion about potential areas of coordination.

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Further, the common issue for most of these primary care providers is access to specialty and diagnostic services at Parkland for their indigent patients. Establishing a rational referral process will serve to decrease the number of unnecessary admissions into the Parkland ED or inappropriate specialty referrals from providers simply trying to get consultations for their patients, while potentially easing the current backlogs.

Other Health Care Agencies There are numerous other health care and social service agencies that could serve Parkland’s patients with greater coordination. Parkland clearly has well-established and ongoing relationships with many of these agencies but there may be the potential for increased collaboration. Key priorities to explore for more effective partnerships would include the County’s own public health department as well as that of the City of Dallas. The option for colocating public health services into COPCs should be explored to assess the potential for minimizing duplication and enhancing the effectiveness of services for those patient populations designated at risk by both the public health department and the COPCs. There is also the potential for increased grant funding for programs that combine the efforts of public health and medical providers to address the needs of vulnerable populations and communities. Discussions should also be held with Dallas MetroCare Services, the quasi-public organization that provides mental health care to approximately ¾ of the Medicaid and uninsured population in Dallas County. While there may be some constraints in the definition of populations served under this program, the need for enhanced mental health services by Parkland and a more formal partner for medical services by MetroCare is clear. A partnership has been established between MetroCare and the Parkland ED and seems to be successful. This model should be built upon and expanded. In order to assure the most effective and efficient use of the resources of the Parkland system, other partnerships should be developed and formalized with nursing homes, home health agencies, and substance abuse treatment centers. These partnerships should, whenever possible, be developed by meeting each other’s needs, providing value to each other. Many of these relationships already exist and the focus should be on building real systems of care for the future.

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F. Governance Effectiveness Issues for Dallas County, the Dallas County Hospital District and the Parkland Health and Hospital System

Background The conclusions that HMA has drawn related to the structure of governance over policymaking and operations of the Parkland Health and Hospital System are based on extensive interviews with all of the Commissioners of the Dallas County Court (the Court), the Members of the Board of the Dallas County Hospital District (the Board), senior administrators of the Parkland system and UTSW, and leadership from throughout the health care, business, civic and advocacy sectors of the Dallas community. The analysis was also influenced by the experience of other governance models of public hospital systems throughout the country, which include direct governance by the elected County administration (Cook County, Los Angeles County, San Francisco), separately incorporated public benefits corporation (New York), municipal corporation (Marion County/Indianapolis), public health authority (Denver, Boston), 501(c) (3) hospital (Memphis), to other models. The primary findings on the issue of governance are as follows: • the structure of governance utilized in Dallas is not, in and of itself, an impediment to efficient operations of the delivery system; • a dysfunctional situation has evolved over the past several years which has resulted in a culture of distrust between the Court, the Board and Parkland administration; • the Court has taken on some level of operational oversight (such as the approval of contracts over $200,000) which would otherwise have been beyond its purview in part in response to the lack of effective synergy between the Board and Parkland administration; • there has been vocal and public participation in the governance process by members of the business, civic and advocacy communities; and • the roles and responsibilities have become blurred and unclear between the Court and the Board and those expectations need to be redefined.

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HMA recommends the following areas of redefinition in order to assure competent, nonduplicative, accountable and efficient governance of the Parkland Health and Hospital System.

The Role of the Dallas County Commissioners Court The Court should reassume its role as the government body ultimately responsible for: 1) assuring maximum leveraging of County dollars to gain all available federal dollars, minimizing the need to rely solely on the County taxpayers to assume the costs of the uninsured and Medicaid patients not adequately funded by the State of Texas; 2) negotiating regional approaches to the financing and/or delivery of health care services for the indigent; 3) approving the acquisition or disposition of property and the issuance of debt by the Dallas County Hospital District; 4) approving the Dallas County Hospital District annual budget; 5) setting the tax rate; and 6) appointing the members of the Board of the Dallas County Hospital District. In this latter role, the Court should consider a new appointment process to assure that Board members have the skill and experience to provide effective oversight to a highly complex health care system. In much the same way that local communities have formed groups to review candidates for local judgeships (like the Committee for a Qualified Judiciary in Dallas), the Commissioners Court would establish a “nominating committee” to review candidates for members of the Board of the Dallas County Hospital District. This Committee would be comprised of representatives from key business, civic and health care organizations and would be charged with reviewing potential Board members based on a set of criteria for experience, skills, Board composition and other factors determined by the Court. The Committee would review resumes and interview all interested candidates and then present a list of “qualified” potential Board members to the Court. The Court would then vote among themselves for the seven people who would ultimately be named to the District Board.

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This process would emphasize the critical need for highly skilled people to be Board members, provide the Court some isolation and eliminate charges of politicizing the process, and involve the broader interests of the community in selecting those who are responsible to assure that the Parkland system is acting in the interests of the entirety of Dallas County.

The Role of the Dallas County Hospital District The Board of the District needs to function in the same manner as any other Board of Trustees of a large health care system. Its primary responsibilities and areas of focus should be: • establishing system-wide policies related to the clinical, administrative and financial performance of the Parkland system; • assuring the development and adoption of strategic operational plans, with clear goals and objectives, including plans for capital, partnerships with other providers, scope of services and other aspects of assuring the most effective health system possible; • reviewing and approving any issue (i.e., budget, land acquisition or disposition, issuance of debt) ultimately requiring County action prior to presentation to the Commissioner’s Court; and • appointing the Parkland system CEO and holding him/her accountable for performance objectives established on an annual basis and, in order to function most effectively, the Board needs to rely on its CEO to provide information to and be accountable for the performance of other senior staff.

Conclusion The governance model for Dallas County health care services can actually provide accountability and political strength if the roles for both the Court and the District--and the administration of the Parkland system--are clearly delineated and if there is a shared understanding of the institutional mission. It has been HMA’s experience during the course of this project that there is a desire by the principals at all levels of the system to reach a standard of trust and shared commitment to the maintenance of an effective health care delivery operation and to the assurance of the health of the public of Dallas County.

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CHAPTER 3: RECOMMENDATIONS FOR LONG-RANGE PLANNING PRIORITIES FOR THE DALLAS COUNTY HOSPITAL DISTRICT
The recommendations that follow are discussed in detail in Chapter 2 and additional documentation is also available in the Appendices of this report. It should be noted that these recommendations do not represent all of the areas that HMA has identified for further activity but, rather, constitute those priorities for long range planning attention by the Dallas County Commissioners Court, the Dallas County Hospital District and Parkland administration. Financial impact is given whenever a degree of certainty is available.

Priorities for Parkland System Clinical Operations

System-Wide Issues 1) Make the recruitment of a Chief Operating Officer for the Parkland system a priority and ensure that there is a more integrated approach to planning and operations for the system as a whole, avoiding “silos” of management within the system. 2) Begin, in partnership with the University of Texas Southwestern (UTSW), a process to reassess policies and procedures and allocation of clinical resources that were developed to facilitate teaching in Parkland but now may inhibit effective operation of the health system. 3) Establish an agenda of operational issues to be addressed to maintain current paying patients in the Parkland system, particularly Medicare patients, to increase revenue to be used to off-set the cost of the growing number of uninsured. 4) Initiate serious and specific discussions with other health care providers to identify areas of potential collaboration.

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Primary Care 5) Make the improvement of access to the COPC clinics as a primary focus of the Parkland system, addressing such issues as the ease of appointment scheduling (working with the Parkland and Children’s EDs, specialty clinics and inpatient services), hours of operation, the cash collection and financial screening policies that may result in disincentives to utilize the clinics and send people to more expensive EDs, and provider productivity efforts to assure the maximum utilization of capacity. 6) Better integrate the health services delivered at the COPCs with the needs of the communities that are served by: coordinating with the medical, public health and mental health services offered by other agencies; assessing the potential for expansion or contraction of clinics based on population growth or movement; and maintaining the ongoing role of community advisory boards in assuring that the services offered at the COPCs are meeting the specific needs of the communities that they serve. 7) Ensure that the COPCs are seen as an essential component of the continuum of care by the entire Parkland system, including the clinical leadership. Issues of referrals, admission procedures, policies, medical staff communication and resource allocation for the COPCs must be viewed for their impact on every aspect of the Parkland system.

Specialty Care 8) Initiate an immediate and thorough assessment of the clinical resources and space needed to provide accessible specialty outpatient services for the patients who depend upon the Parkland system for that care who otherwise will inappropriately utilize the Parkland ED or be admitted for services that could have been provided in specialty clinics. 9) Develop a plan to reallocate or, where necessary, expand resources dedicated to certain specialty areas where there is a current deficit. 10) Develop a referral system, based on sound clinical guidelines, that will assure ease of access to specialty services, the appropriateness of referrals to specialty care, and return to primary care after the specialty consult to avoid misuse of scarce resources.

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11) Explore the potential for partnering with other hospitals and/or physician groups to expand accessibility to specialty outpatient services, particularly in less expensive and more accessible community-based settings.

Emergency Services 12) Initiate a major overhaul of the Parkland admissions processes, addressing such issues that are contributing to the current backlog as: the resident-driven “AOD” system, the policy of requiring diagnostic work-ups before patients leave the ED, and the inability of other parts of the system (COPCs, specialty clinics) to directly admit patients into the hospital. 13) Develop an effective referral system to allow ED physicians to send patients needing ongoing care to COPC or specialty clinics. 14) Explore the potential for establishing Observation Bed capacity adjacent to the ED to minimize unnecessary admissions into the hospital. 15) Begin a review of clinical policies that may adversely impact efforts to prevent unnecessary return visits to the ED (i.e., asthma) and/or may assist in efforts to develop system-wide disease management protocols.

Inpatient Care 16) Establish bed control as an institutional priority, building on recommendations from previous consultant reports and involving clinical as well as administrative leadership. 17) Rationalize the current logjam in the operating rooms by reassessing the management structure (including reassigning case managers who had been replaced by residents), moving forward on the construction of the Ambulatory Surgery Center, and exploring the potential for an interim strategy for moving outpatient surgeries into a temporary location at another institution. 18) Initiate a process, with clinical leadership in OB/Gyne, to restructure the inpatient units assigned to Labor and Delivery to assure the most effective utilization of all inpatient

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beds while, at the same time, maintaining the protocols that have resulted in such impressive outcomes. 19) Investigate the potential for immediate conversion of unused space within Parkland to expand the capacity for rehabilitation services at Parkland, allowing for the retention of current paying patients who are now being sent to other institutions.

Gaps in the Current System 20) Develop a comprehensive plan, perhaps in connection with the VA or other providers, for access to long-term care for Parkland patients. While the areas of mental health, substance abuse and home health care services also need to be addressed, immediate priority should be given to the establishment of a vehicle for Parkland to more easily discharge patients into less costly nursing home beds. This part of the continuum of care will become increasingly important as the population continues to age and as the issue of the bed need for a replacement for Parkland Hospital is discussed.

Disease Management 21) Implement a disease management approach throughout the Parkland system, targeting those chronic conditions (i.e., diabetes, asthma, hypertension) that have the greatest impact on Parkland resources and its patients. This approach has been proven to save money and improve health outcomes and will require the cooperation of the medical and administrative leadership (primary, specialty, emergent, inpatient), the involvement of information systems and quality assurance personnel and the designation of clearly identified accountability and authority within the system.

Medical Staff Relationship 22) Resolve the current FY2005 faculty contract between Parkland and UTSW and view it as a transition agreement, beginning immediately to negotiate the contract for FY2006 based on covering appropriate costs, verifiability, and adequate payment for all clinical service expansions.

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23) Begin to develop a new Master Affiliation Agreement between the two institutions that will reconfirm the importance of the relationship and will address, at minimum: • job descriptions and the search process for new, dedicated medical staff leadership for Parkland, with clear authority/accountability at both the hospital and UTSW; • the process for annual assessment and negotiation of costs for the faculty contract; • operational areas of concern at Parkland related to the inherent tension between academic facilitation and clinical efficiency (i.e., admission policies, discharge procedures, specialty care allocation and connections); • the responsibility of Parkland to assure an agreed upon level of operational and administrative support to clinical services; and • the process for collaboration related to the long-term planning efforts of both Parkland and UTSW and procedures for resolving potential areas of conflict).

Physical Plant Issues 24) Initiate discussion now between Parkland and the Dallas County Hospital District about the development of a Master Capital Plan for the Parkland system. 25) Determine capital project priorities for the current system that will either assure greater efficiency or allow for the generation of increased revenue. Priority areas should include the construction of the Irving COPC and the Ambulatory Surgery Center, and the renovation of existing space for the establishment of increased rehabilitation capacity and observation beds adjacent to the ED. 26) Establish a “blue ribbon panel,” appointed by the Dallas County Court of Commissioners and the Dallas County Hospital District, made up of key health care, civic and business leaders. This panel would be charged with overseeing the development, with Parkland leadership, of a Master Capital Plan for the system, including the scope of and financing for a facilities replacement strategy for Parkland hospital.

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Priorities for Health Care Financing

System Financial Strategies 1) Leverage available Dallas County funds through a variety of special financing mechanisms, including the following. It is important to note that the leadership of the Court and the support of the local business community will be critical to garnering State support for these efforts. • Take advantage of additional Upper Payment Limit (UPL) payments by increasing Parkland’s charge structure. (Estimated impact = $ 16 million currently, although further data analysis may lower that figure) • Secure a federal waiver for Medicaid to cover the costs of prenatal care for undocumented immigrants. (Estimated impact = $5 to $7 million) • • Increase Medicaid payments to Parkland and UTSW physicians. Secure increased Medicaid managed care rates through risk adjustment and/or increasing the base rate on which the managed care rates are set. (Estimated impact = $5.6 million) • Utilize the Upper Payment Limit (UPL) capacity of other private hospitals in Dallas County that serve large numbers of Medicaid and uninsured patients. (Estimated potential= $225 million; $105 million if Children’s is excluded) 2) Explore the creation of a 501 (c) (3) charity care entity to help fund care at Parkland and other organizations in the community. 3) Work with the counties contiguous to Dallas and the State to establish a regional trauma network that would help finance trauma care provided by Parkland to out-of-county patients by leveraging current County Indigent Health Care Program (CIHCP) expenditures. (Estimated impact = $10 million) 4) Convert Parkland’s COPC clinics to Federally Qualified Health Centers (FQHCs). (Estimated impact = $9.3 million)

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5) Carefully evaluate new service opportunities for their potential to be successful given Parkland’s demographics and payor mix. These include rehabilitation, long-term care and psychiatry.

Financial Management 6) Ensure that Parkland has a long-term strategic business plan in place that reflects the collective input of the operational, financial and medical leadership. The strategic plan should be supported by a long-range capital plan and an information technology (IT) plan. All of these documents are needed to help the Board make decisions based on the best available information and the long-range goals of the organization. 7) Begin work immediately on negotiating the 2006 contract with UTSW to produce an

easy-to-understand, transparent, and verifiable agreement in a timeframe that allows it to be incorporated into the budget process.
8) Continue to build on revenue cycle improvements by increasing conversion of patients to funded sources, improving time-of-service collections and implementing a stronger denial management and collections strategy. (Estimated impact = $6 to $8 million). 9) Begin to consider the mutual benefits of a combined revenue management entity that combines the hospital and the medical school revenue management processes, including medical records, billing and collections. 10) Improve the position of the Parkland Community Health Plan by reducing administrative costs to the industry standard, reducing payment rates to the Medicaid rate, and reducing payments for non-participating providers. (Estimated impact = $8.2 million) 11) Ensure that Parkland is positioned to take advantage of pharmacy opportunities afforded by the Medicare Modernization Act (MMA), including the discount card program, low-income subsidies, and mail order, potentially through a partnership with the VA Hospital. (Estimated impact = up to $11.7 million, not including mail order).

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Priorities For Partnership Development and Expansion
1) Initiate discussions with the leadership of private hospitals in the Dallas community to determine the potential areas of collaboration for current and future health services provided for low-income residents of the County including, but certainly not limited to: support (financial or service) for existing or expanded COPCs, collaboration on the provision of community-based specialty outpatient services, joint development of service lines (i.e., rehabilitation services), and the delivery of tertiary services for Parkland patients. These partnerships should be approached as an opportunity to provide a mutually beneficial vehicle to minimize duplication and spread responsibility for meeting needs of indigent patients more equitably. 2) Develop expanded collaboration with Children’s Medical Center, particularly focusing on: enhancing access into the COPC clinics for patients coming to the Children’s ED for primary care; collaborating on expanded community-based pediatric specialty care access; exploring the potential of co-locating Children’s physicians in COPC facilities; and better coordinating facilities and support service planning on the medical center campus. 3) Enter into serious discussions with the Veteran’s Administration Hospital system in Dallas to explore potential partnerships in such areas as: participating in the VA’s mail order pharmaceutical program, one of the most effective in the country; connecting to the VA-affiliated network of nursing home providers and contracting with its home health services, both efforts to assure that patients do not stay in inpatient beds unnecessarily; entering into an agreement whereby the VA would contract with the COPCs for primary care for its veterans; and planning for a collaborative approach to mental health services.

Priorities for an Effective Health System Governance
1) Ensure that the roles and responsibilities of the Dallas County Commissioners Court and the Dallas County Hospital District be clearly defined and duplication should be eliminated whenever possible.

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2) Empower the Dallas County Commissioners Court to appoint a civic “nominating committee,” made up of health care, business, civic and community leaders, to screen potential candidates for the Dallas County Hospital District for skills and expertise outlined in a clear job description for Board membership. This committee would present a slate of a number of candidates that they have deemed to be “qualified” from which the Court would select the Board’s membership. This process would go far in assuring that the members of the District Board were committed, skilled and as unaffected as possible by political pressure, real or perceived.

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APPENDICES
A. Project Interview/Interaction Listing B. Maps C. Private Hospital Data Profiles D. Project Access, FQHCs, Free Clinics, and Public Health Departments E. Parkland Health & Hospital System, Uncompensated & Undocumented Health Care Analysis (Economic Projections) F. Medicaid Reimbursement Comparisons G. Pharmacy Issue Paper H. Parkland Community Health Plan Report I. Finance Deliverables J. Revenue Cycle Report K. COPC Assessment Report K-1. COPC Assessment K-2. COPC Maps K-3. Community Clinic Profiles K-4. Operations Plan performance COPC Service Standards Financial Management Tool Care Team Roles K-5. COPC Staffing Tool June 2004 MGMA 2002 Benchmarks K-6. EPIC Newborn Appointments COPC

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Project Interview/Interaction Listing
Chad Adams Judge Ellis County Kevin Alaggio Associate Director of Nursing Parkland Health & Hospital System COPC Joel Allison President & CEO Baylor Healthcare System Rita Alvarez Member COPC Advisory Board Ron J. Anderson, M.D. President & CEO Parkland Health & Hospital System Myra Austin Christ’s Family Clinic Arturo E. Aviles, M.D. Board Member Dallas County Medical Society Tim Bahe President & CEO Parkland Community Health Plan James G. Baker, M.D. CEO Dallas Metrocare MHMR Services Claudia Barner Dallas Area Interfaith (Wilshire Baptist Church) Pam Barnes Director of Reimbursement Baylor Healthcare System Paul M. Bass Chairman of the Board Southwestern Medical Foundation; Vice Chairman First Southwest Company Katrina Bassel, M.D. Board Member Dallas County Medical Society John Baumgartner Senior Vice President Methodist Health System Bruce Beaty Commissioner Rockwell County Louis A. Beecherl, III Board Member Dallas County Hospital District Syl Benenson Member COPC Advisory Board Mary Bergman, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Britt Berrett President & CEO Medical City Hospital Deaina Berry, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Bill Bilyeu County Administrator Collin County

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Appendix A

Jan Hart Black President Greater Dallas Chamber of Commerce Member Dallas Medical Resource Martha Blaine Board Member Community Council of Greater Dallas Jim Blasingame Finance Department Parkland Health & Hospital System Steve Bloom, M.D. Associate Chief of OB Service Parkland/UTSW Charlene Bonvissuto Project Manager, Parkland Project Capgemini Paul Boumbulian Former Stategic Planning Director Parkland Health & Hospital System Dorruth Boyd Coordinator Head Start of Greater Dallas Susan Briner, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Adeline Brown Member Texas Silver-Haired League Rick Brown Sr. Vice President (Facilities/Master Plan) Parkland Health & Hospital System

Ryan Brown Chief Financial Officer Dallas County Bing Burton Director of Public Health Denton County Craig Callewart, M.D. Board Member Dallas County Medical Society Linda Camin Member League of Women Voters Mike Cantrell Commissioner Dallas County Sister Pearl Ceasar Dallas Area Interfaith Lynn Cearley Dallas Area Interfaith Denise Chamberlain Vice President of Finance Parkland Health & Hospital System Howard Chase President & CEO Methodist Health System Juanita Chism Lead Nurse (Geriatrics) Parkland Health & Hospital System COPC Gretchen Claiborne Associated Director Texas Council of MHMR Centers Patti Clapp Member Greater Dallas Chamber of Commerce

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Appendix A

Allen Clemson Chief Operating Officer Dallas County Reed Click, M.D. Attending Physician, Internal Medicine Parkland/UTSW Phyllis Cole Commissioner Collin County Jennifer Coleman Sr. Vice President (Public Affairs) Baylor Health Care System Sheila Coleman Lead Nurse (Pediatrics) Parkland Health & Hospital System COPC Theresa Comstock Dallas Area Interfaith (Transfiguration Episcopal Church) Dia Copeland Site Administrator Parkland Health & Hospital System COPC Suzanne Corrigan, M.D. Board Member Dallas County Medical Society Vicki Crane Vice President (Pharmaceutical Services) Parkland Health & Hospital System Jennifer Cutrer Director, Legislative Affairs Parkland Health & Hospital System

Michael Darrouzet CEO Dallas County Medical Society Joe DaSilva Sr. Vice President (Advocacy & Education) Texas Hospital Association Sharon Davis, M.D. Lead Physician (Family Practice) Parkland Health & Hospital System COPC Albert de la Cruz Vice President (Business Services) Parkland Health & Hospital System Kay Dial Clinic Coordinator Agape Clinic Maurine Dickey Former Chairperson Dallas County Hospital District Keri Disney Director of Government Reimbursement Parkland Health & Hospital System Christopher Durovich President & CEO Children's Medical Center Bruce Fairbanks Vice President (Financial Affairs) UT Southwestern Medical School Gretchen Feinhals Member COPC Advisory Board Mike Fichtel Vice President/CFO Children's Medical Center

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Appendix A

Argentry Fields Site Administrator Parkland Health & Hospital System COPC Greg Fitz, M.D. Chairman of Internal Medicine Parkland/UTSW April Foran Corporate Communication Parkland Health & Hospital System Charlotte Forswall Finance Department Parkland Health & Hospital System Veletta Forsythe Lill Dallas City Councilwoman Dallas County Dan Foster, M.D. Former Chairman of Internal Medicine Parkland/UTSW Annie Franklin Sr. Vice President (Medicine Services) Parkland Health & Hospital System Silvia Gallegos Member COPC Advisory Board Gilbert Galvan Program Specialist V Health & Human Services Commission Trini Garza Executive Director La Voz Del Anciano John Gates CFO Parkland Health & Hospital System

John Gavras President & CEO Dallas Fort Worth Hospital Council Wayne Gent County Judge Kaufman County Artie Giles Member COPC Advisory Board Gary Godsey President & CEO United Way of Metropolitan Dallas Mary Greene KERA Charles L. Gummer Board Member Dallas Medical Resource (Comerica Bank) Robert Haley, M.D. Past President Dallas County Medical Society L.W. Hall Senior Citizens Council Donna Halstead President Dallas Citizens Council L. Levet Hamilton Lead Nurse (Pediatrics/Adult) Parkland Health & Hospital System COPC Shirlisa Hampton Associate Director of Business Services Parkland Health & Hospital System COPC

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Appendix A

Kathy Hanold Sr. Vice President, WISH (Womens & Infants) Parkland Health & Hospital System Walker Harman Chairman of the Board Baylor Health Care System Alan Harper President & CEO VA North Texas Health Care System John Harris Member COPC Advisory Board Adlene Harrison Former Mayor Dallas County Cathy Harrison Lead Nurse (Adult/Geriatrics) Parkland Health & Hospital System COPC Douglas Hawthorne President & CEO Texas Health Resources Jim Hayman Sr. Vice President (Pharmacy/Purchasing/Laboratory) Parkland Health & Hospital System Barry Henry Managing Director Crow Holdings Jessica Hernandez Site Administator Parkland Health & Hospital System – COPC

Maria L. Hernandez Policy Analyst Dallas County Paul Hoffman Executive Director Dental Health Programs of Dallas Bert Holmes Chairman Senior Citizens Board Janice Holmes WISH Parkland Health & Hospital System Cindy Hogan Director of Corporate Affairs Texas Health Resources Mary Horn Judge Denton County Jane Hunley Director (Geriatrics) Parkland Health & Hospital System COPC Ray L. Hunt Chairman of the Board Dallas Medical Resource (Hunt Consolidated) Emmanuel Inyang, M.D. Lead Physician (Adult/Geriatrics) Parkland Health & Hospital System COPC Laura Irvine Senior Vice President (Planning & Marketing) Methodist Health System

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Appendix A

Jim Jackson Commissioner Dallas County Lee Jackson Chancellor University of North Texas System Claudie Jimenz, M.D., M.S. Assistant Professor UT Southwestern Medical Center Reverend Peter Johnson Dallas NAACP Jim Johnson Manager (Benefits & Compensation) Parkland Health & Hospital System Denise Johnson, M.D. Lead Physician (Family Practice) Parkland Health & Hospital System COPC Larry Jones Commissioner Ellis County Walter Jones Facilities Planning & Development Parkland Health & Hospital System Margaret Jordan Executive Director Dallas Medical Resource; Executive Vice President Texas Health Resources Bethanne Keating Parkland Health Plus Margaret Keliher Judge Dallas County Commissioners Court

James Kennedy, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Rehan Khan, M.D. Lead Physician (Internal Medicine) Parkland Health & Hospital System COPC Renuka Khurana, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Kirk Kirksey Vice President (Information Resources) UT Southwestern Harold Kleinman Chairman of the Board Methodist Health System J. Peter Kline Board Member Dallas Medical Resource (Seneca Advisors) Richard Kneipper Board Member Dallas County Hospital District John Knutson Dallas Area Interfaith Mike Korpiel Sr. Vice President (Surgical Services) Parkland Health & Hospital System Jack Kowitt Senior Vice President & CIO Parkland Health & Hospital System Pauline Kress Friends of Senior Affairs of Dallas

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Appendix A

LeAnn Kridelbaugh, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Barry Lachman, M.D. Medical Director Parkland Community Health Plan Charlene Lawrence Clinic Director Dallas Life Foundation Jonathan Leffert, M.D. Board Member Dallas County Medical Society Kenneth Leveno, M.D. Chief of Service/OB/GYN Parkland/UTSW Warren Lichliter, M.D. President Dallas County Medical Society Amy Lindley Director of the Senate Committee on Health & Human Services Dalton Lott Board Member Dallas County Hospital District Ted Lyons Product Manager Parkland Community Health Plan Willis Maddrey, M.D. Sr. Vice President (Clinical Affairs) UT Southwestern Medical Center G.K. Maenius Administrator Tarrant County

Ann E. Margolin Former Chairperson Dallas County Hospital District Adriane Mahnken Associate Director Managed Care Contracts Mary E. Mancini, PhD, RN, CNA, FAAN Former Chief Nursing Officer Parkland Health & Hospital System Glenna Maples Director of Planning & Business Development Texas Health Resources Leonor Márquez Site Administrator Parkland Health & Hospital System COPC Kenneth Mayfield Commissioner Dallas County Susan McBride Vice President (Data Initiative) Dallas Fort Worth Hospital Council John McConnell, M.D. CEO University Medical Center, Inc. Pam McDonald Health & Human Services Commission Lauren McDonald, M.D. Chairman Dallas County Hospital District Darren McGuire, M.D. Assistant Professor of Internal Medicine Parkland/UTSW

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Appendix A

Nina McIntosh Vice President (Ambulatory Services) Parkland Health & Hospital System Pam McNutt Senior Vice President & CIO Methodist Health System Joe Minei, M.D. Chief of Trauma Parkland/UTSW Patsy Mitchell Manager, Community & Public Health Dallas County Presley Mock, M.D. Board Member Dallas County Medical Society Norman Moorehead Director Dallas Area Agency on Aging Community Council of Greater Dallas Joseph Murphy, M.D. Associate Professor of Surgery Parkland/UTSW Muhammad Nasir, M.D. Lead Physician (Internal Medicine) Parkland Health & Hospital System COPC LaVone Neal Vice President (Decision Support) Baylor Healthcare System James Oesterreicher Chairman of the Board Texas Health Resources Dighton Packard, M.D. Chief of Emergency Services Baylor University Medical Center

Bob Parkey, M.D. Chairman of Radiology Parkland/UTSW Tim Parris President & CEO Baylor University Medical Center Tena Patterson, M.D. Lead Physician (Family Practice) Parkland Health & Hospital System COPC Lisa Payne Lead Nurse (Pediatrics) Parkland Health & Hospital System COPC Pam Peiffer Assistant Vice President UT Southwestern Health Systems Patricia Peiser Temple Emanue Paul E. Pepe, M.D. Chair of Emergency Medicine Parkland/UTSW Donna Persaud, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System – COPC Rick Peters, Sr. Partner Health Data Partners, LLP Debbie Phillips, Sr. Partner Lead Nurse (Pediatrics/Adult/Geriatrics) Parkland Health & Hospital System COPC Frank Phillips Director of Administration Denton County

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Sharon Phillips Vice President (Operations) Parkland Health & Hospital System COPC Sue Pickens Director, Strategic Planning Parkland Health & Hospital System Carolyn Pratt Health & Human Services Commission John Wiley Price Commissioner Dallas County Joel Pugh Craig Purdue Director of Gov. Relations Dallas County Angelique Ramirez, M.D. Medical Director Parkland Health & Hospital System COPC Jaime Ramon Treasurer United Way of Metropolitan Dallas; Scott Reasonover Health & Human Services Commission Bob Rege, M.D. Chairman of Surgery Parkland/UTSW Doreen Reynolds Director of OR Parkland Health & Hospital System Yesenia Reyes White Rock United Methodist Church

John Roan, M.D. Executive Vice President (Business Affairs) UT Southwestern Medical Center Hortencia Rodriguez Executive Director Grand Prairie Wellness Center Robert D. Rogers Board Member Dallas Medical Resource (Texas Industries) Sharon Roland Member, COPC Advisory Board Jack Roper Senior Vice President (Finance) Texas Health Resources Samuel Ross, M.D. Interim COO/CMO Parkland Health & Hospital System

Marcene Royster Director of Community Services Parkland Health & Hospital System COPC Duke Samson, M.D. Chairman of Neurosurgery Parkland/UTSW Noel Santini, M.D. Lead Physician (Internal Medicine) Parkland Health & Hospital System COPC Horace Sarabia Executive Director Los Barrios Unidos Community Clinic

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Joseph Schaffer, M.D. Dept. of OB/Gyn Parkland/UTSW Richard Schirmer Texas Hospital Association Leslie Secrest, M.D. President-Elect Dallas County Medical Society Allan N. Shulkin, M.D. Board Member Dallas County Hospital District Kathy Shumaker Medical City Dallas Hospital Mike Sims Temple Emmanuel Danica Simmons Mission East Dallas Sandy Skelton CEO Texas Council of MHMR Centers Michelle Smith, M.D. Clinic Physician Central Dallas Ministries Trish Smith Associate Vice President (Health System Planning) University Medical Center, Inc. William T. Solomon Board Member Dallas Medical Resource (Austin Industries) Joel Sontag Interim President Oak Cliff Chamber of Commerce

Susan Spalding, M.D. Lead Physician (Pediatrics) Parkland Health & Hospital System COPC Ronald G. Steinhart Board Member Dallas Medical Resource (Bank One) Jacqui Stephens Director of Behavioral Health Parkland Health & Hospital System – COPC Andy Stern Chairman of the Board Medical City Dallas Hospital Member Dallas Medical Resource William L. Storms Member COPC Advisory Board Sandy Stuart Dallas Area Interfaith (King of Glory Lutheran Church) Steve Svadlenak, Interim Executive Director Texas Association of Public & NonProfit Hospitals Lisa Swanson, M.D. Board Member Dallas County Medical Society David J. Tesmer Vice President (Government & Community Affairs) Texas Health Resources Zachary Thompson Director Dallas County Department of Health and Human Services

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Beverly Tobian Health & Human Services Coalition Lee Vaness Assistant District Attorney Denton County Kim Vernon, M.D. Secretary/Treasurer Dallas County Medical Society Belinda Vicioso, M.D. Lead Physician (Geriatrics) Parkland Health & Hospital System COPC Joseph Viroslav, M.D. Board Member Dallas County Medical Society Nancy Volk North Dallas Shared Ministries Fran Wagnon Member COPC Advisory Board Michael P. Wainscott, M.D. Professor UT Southwestern Medical Center Eric Walker Site Administrator Parkland Health & Hospital System – COPC Thomas Wallace, M.D. Senior Medical Resident Parkland Health& Hospital System Alan Walne Board Member Dallas County Hospital District

William J. Walton, M.D. Board Member Dallas County Medical Society Elgin Ware, M.D. Medical Director Stew Pot Medical Clinic John L. Ware Board Member Dallas Medical Resource (21st Century Group) Karen Ware Member COPC Advisory Board Barbara Watkins President & CEO Parkland Foundation Kerrie Watterson Site Administrator Parkland Health & Hospital System COPC Connie Webster, M.D. Board Member Dallas County Medical Society Polly Weidenkopf Member COPC Advisory Board Henry Welles Health & Human Services Commission George Wendel, M.D. Dept. of OB/Gyn Parkland/UTSW Colette White Operations/Finance Manager Parkland Health & Hospital System – COPC

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Martin White, M.D. Dallas Area Interfaith Shelia White-Jackson, M.D. Lead Physician (Adolescent) Parkland Health & Hospital System COPC Kern Wildenthal, M.D. President UTSouthwestern Medical Center J. McDonald Williams Board Member Dallas Medical Resource (Trammell Crow) Jenny Williams Mission East Dallas County Health Ministries Lee Williams Member COPC Advisory Board Maggie Willis Member COPC Avisory Board Harold Wilson Member COPC Advisory Board Jerry Wimpee Commissioner Rockwell County Gary B. Wood, Ph.D. Board Member Dallas County Hospital District Donnie Woodkins Member COPC Advisory Board

David Young Former Executive Director Dallas Area NorthStar Authority Lori Zamora Lead Nurse (Adolescents) Parkland Health & Hospital System COPC

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Appendix A

Dallas County Hospitals & COPC Clinics

35E

635

75

Baylor - Irving Coppell

$

$

RHD Memorial Med City
$

Baylor - Garland
$$

Vista Presbyterian

Lake Pointe
$

$

$Las

Colinas

Garland
$ $
635

Vickery
Baylor - Irving
$

HealthSouth

$

Zale
$ Doctors $ $ $ $ $ $
30

PPCC/FMC
St. Paul Parkland Children's
30

$

Mary Shiels
$$ $

$ Mesquite Community

Scott Rite

East
Baylor U.
$

deHaro
80

$

Baylor Heart Methodist
$

Mesquite

175

$

Southeast
$

Oak West
20

$

?

Bluitt-Flowers
35E

Methodist Charlton$
67

$

Lancaster
$
45

$

COPC Clinic Hospital

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Appendix B

Medicaid Primary Care Providers by Service Area

High No. of Providers 300-400 Medium No. of Providers 200-250 Low No. of Providers 50-150 Extra Low No. of Providers 0-15 Stemmons Corridor

Northern Corridor Mesquite/ Garland/ Rowlett

Vickery

Irving

East Dallas

West Dallas Grand Prairie South Dallas

Northwest Oak Cliff

South Oak Cliff

Southeast Dallas

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Appendix B

COPC Locations & Distribution of Persons Under 200% of Poverty
Each blue dot equals 500 persons under 200% of poverty

$$ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $$$ $ $$ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $$$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$$ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $$ 75 $ $ $ $ $$ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $$$ $ $ $$ $ $ $ $ $$ $ $ $ $$ $$$ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $$ $$ $$ $ $ $ $$$ $$ $ $ $ $ $ $ $ $$$$ $ $ $ $$ $ $ $ $ $ $$ $$ $ $ $$ $ $ $$ $$ $ $ $ $ $ $$$ $ $ $$ $ $ $ $$ $ $$$ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $$ $ $ $ $ $$ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $ $$ $ $ $$ $ $ $ $$ $ $ $$$ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$$$ $$ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $$ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $$ $ $ $ $ $$ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $ $$ $ $ 80 $ $ $ $$$ $ $$ $ $$ $$ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ 30 $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $$ $$ $$ $ $ $$ $ $ $$ $ $$$ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $ $$ $ $$ $ $ $$ 80 $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $$ $ $ $ $ $$ $ $$ $ $$ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$$ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $$ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $$ $ $$ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $ $$ $ $ $$ $ $ $ $$ $ $ $$ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ 175 $ 20 $ $ $$ $ $ $ $ $ $$ $ $ 20 $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ 45 $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 35E $ $$ $ $ $ 67 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
35E

$$ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $

$ $

Garland

Vickery

PPCC/FMC

East

deHaro

Southeast

Oak West

Bluitt-Flowers

Heath Management Associates

Appendix B

$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $$$ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $$$$$ $ $$ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $$$ $$ $ $ $ $ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $$$ $$$ $$ $ $ $ $ $ $ $$ $ $ $$ $ $ $$$ $ $ $ $$$$ $ $ $ $ $ $$ $ $ $ $$ $$ $$ $$$$$ $ $$$$$ $ $ $$ $ $ $ $ $ $$$ $ $$ $$ $ $$ $$ $ $ $ $ $$$$$ $ $$$$ $ $ $ $ $$ $ $ $ $ $$$$ $ $$ $ $ $$$$ $ $$ $ $$$ $ $$ $$ $ $ $$ $ $ $ $$ $$ $ $ $ $$ $ $$$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $$ $ $$$ $$$ $ $ $$ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $$$$$ $ $ $ $$ $ $ $$ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $$ $$ $$ $ $ $ $$ $ $$$$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $$ $ $ $$ $ 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$ $ $ $ $ $$ $ $ $$ $$ $ $ $$$ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $$$$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $$$$ $ $$ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $ $$$ $ $ $ $$ $$ $ $$ $$ $ $ $ $ $ $ $$ $ $$ $ $$ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $$ $$ $$$ $$ $$ $ $ $$ $ $$ $ $$ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $$ $ $$$ $ $ $ $ $$ $$ $ $ $ $$ $ $ $ $ $$$$ $ $ $ $ $$$$$$ $ $$ $ $ $$ $$ $ $ $ $ $ $$ $ $ $ $ $ $$ $$ $$$$$ $ $$ $ $$$ $$ $ $ $ $ $ $ $ $ $ $ $$ $$$ $ $$$$ $ $$ $ $ $ $ $$$ $ $ $ $$ $ $ $ $ $$$ $$ $ $ $ $$ $ $ $ $ $$ $ $$ $ $$ $ $ $$ $$$ $$$ $ $$ $ $ $$$ $ $$$$$ $ $ $ $ $ $$ $$$$$$ $$$ $ $ $ $ $$$ $$ $ $$ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$$ $ $ $$ $ $ $$ $ $ $ $ $ $$$$ $ $ $ $ $$ $ $$$$$ $$ $ $ $ $ $$ $ $ $$ $ $ $ $$ $ $ $$ $$ $ $ $ $$ $$$$$ $$ $ $ $ $$ $ $$ $$ $ $ $ $ $$$ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ 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$ $ $ $$ $ $$ $ $ $ $$ $$ $ $ $ $ $ $ $ $$ $ $$ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Water Area $ $ $ $ $ $ $$ $ $ $ $ $ $ County Line $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ COPC Clinic $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ = 200 Persons of Hispanic Origin $ $ $$ $ $ $ $ $ $ $ $ WESTLAKE
$

2000 Census Distribution - Hispanic Population
SOUTHLAKE COPPELL ADDISON GRAPEVINE FARMERS BRANCH

$

$

$

$

$

$ $ $$ $ $

$

CARROLLTON

SACHSE

RICHARDSON

KELLER

FATE

Garland

! GARLAND

ROWLETT

MOBILE ROCKWALL CITY

COLLEYVILLE

Vickery

!

NORTH RICHLAND HILLS
HURST

BEDFORD EULESS

IRVING

UNIVERSITY PARK

HEATH

MCLENDON-CHIS

Parkland Memorial

RICHLAND HILLS

!

HIGHLAND PARK

East

! &

DALLAS

SUNNYVALE

deHaro

!

MESQUITE

FORNEY

COCKRELL HILL

Southeast

PANTEGO

ARLINGTON DALWORTHINGTON GARDENS

Bluitt-Flowers Oak West !

!

BALCH SPRINGS

GRAND PRAIRIE

!

TALTY

SEAGOVILLE

KENNEDALE

DUNCANVILLE

HUTCHINS

CRANDALL

DESOTO

LANCASTER

WILMER

RENDON

CEDAR HILL

MANSFIELD

!

GLENN HEIGHTS

Dot-Density

OVILLA

FERRIS

Heath Management Associates

Appendix B

$
$

$

$ $

$ $ $$ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $$$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $$ $$ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $$ $ $$ $$ $ $ $$ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $$ $ $ $$$ $ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $$ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $$ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $$ $$$$ $$$ $ $ $$ $ $$ $ $ $$ $ $$ $ $$$ $ $ $$$ $ $ $$ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $$$ $ $ $ $ $$ $ $ $ $$ $ $ $ $$ $$ $ $ $ $ $ $ $ $$ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $$ $$ $$ $ $ $ $ $$ $ $$ $ $ $$ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $$ $ $ $ $$ $ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $$ $ $ $$$$ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $$ $$ $ $ $ $ $ $ $$ $ $ $$ $ $$ $ $ $$ $$ $ $ $ $ $$ $$ $ $ $$ $ $ $ $ $ $ $ $ $$ $$ $ $ $$ $ $ $ $ $ $$$ $ $ $ $ $$$ $ $ $$ $ $$$ $$$ $ $ $ $$ $ $$ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$$$ $ $$ $ $ $ $$ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $$$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $$ $$ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $$ $ $ $$ $ $ $$ $ $ $ $$$ $$ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $$ $ DALLAS$$ $$$$ $ $ $ $ $$ $ $$ $ $ $ $ $$ $ $ $ $$$ $ $$ $ $ $ $$$ $ $ $ $ $ $ $ $ $$ $ $ $ $$$$$$$ $ $$ $ $$ $$$ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $$$ $$ $ $$$$ $ $ $ $ $ $ $ $$ $ $$ $ $$ $ $ $$$ $ $$ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $$ $ $$ $ $ $ $ $$ $ $ $ $ $$$ $ $ $ $ $$ $ $ $$ $$$$ $ $ $$ $ $ $ $ $ $ $ $$ $$ $ $$$$$ $$ $ $ $$ $$ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $$ $$ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $$ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $$ $$ $ $$ $ $$$ $ $$ $ $ $ $ $$$$ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$$ $ $ $ $ $$ $ $$ $ $$$$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $$ $ $$$$$$ $ $ $ $$ $$ $ $$ $$ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $$ $ $$ $$ $ $ $$ $ $$ $ $$ $ $$$ $$ $$ $ $ $ $ $ $$ $ $$$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $$$$ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $ $$ $ $$ $ $$ $$ $ $$ $ $ $$ $ $ $ $ $ $$ $ $ $$ $$ $$ $ $$ $ $ $ $$$ $$ $ $ $ $ $ $ $ $ $$ $$$ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $$ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $$$ $$$$$ $ $$ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $$$ $ $$$$ $$$ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $$ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $$ $ $$ $$$$ $$$ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$$ $ $ $ $ $$ $ $$ $ $ $ $$ $ $ $ $$ $ $$$ $ $ $$ $ $ $$ $$$ $ $$$$ $$ $$ $$ $ $ $ $ $ $ $ $$ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $$$ $$ $ $$ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $$$ $ $$ $ $ $ $$ $ $ $ $ $$$ $$$ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $$$ $ $ $ $$ $ $ $ $ $ $$ $ $ $$$ $ $ $ $ $ $ $ $$ $ $$ $$ $ $$$$ $ $ $ $$ $$ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $$ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $$ $ $$ $ $ $ $$ $ $ $ $ $$$ $ $ $$ $ $ $ $ $$$ $ $ $ $ $ $ $$ $ $ $ $ $$ $$ $ $ $ $ $ $ $$$ $ $ $$ $ $ $ $$$ $ $$$ $ $ $$ $ $ $$ $ $$$ $ $ $ $$ $ $ $ $$$ $ $ $ $$ $ $ $ $$$$ $$$$ $$ $ $ $ $ $ $$ $ $$ $ $ $ $$$$$$$ $$ $ $ $ $ $ $ $ $ $ $$ $$$ $$ $$ $$ $ $ $ $$ $ $ $$ $ $ $ $ $ $$ $$$ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $$$$ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $$$ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $$ $$$ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $$ $$ $$ $ $ $ $ $ $ $ $ $ $ $$ $$$$ $$$ $ $ $ $ $$ $ $ $ $ $ $$$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $ $ $ $ $ $ $ $
$

WESTLAKE

$ $ $ $ $

$

2000 Census Distribution - African American Population RICHARDSON
$ $

$ $$ $ $ $ $$ $ $$ $ $ $$ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $

$ $

$ $

$

$ CARROLLTON $$ $$

$ $

$

$

$ $

$

COPPELL

SACHSE

$

SOUTHLAKE

ADDISON

$

KELLER

GRAPEVINE

FATE

FARMERS BRANCH

Garland

! GARLAND

ROWLETT $
$ $ $

$

MOBILE ROCKWALL CITY
$

$

COLLEYVILLE

ROC KWALL

Vickery

!

NORTH RICHLAND HILLS
HURST

BEDFORD EULESS

IRVING

UNIVERSITY PARK

$

HEATH

$

MCLENDON-CHIS

Parkland Memorial

RICHLAND HILLS

!

HIGHLAND PARK

East

$ $

! &

DALLAS

SUNNYVALE

deHaro

$ $
$

!

MESQUITE

FORNEY
$ $
$

COCKRELL HILL

Southeast

$ $$ $

PANTEGO

ARLINGTON DALWORTHINGTON GARDENS

Bluitt-Flowers Oak West !

!

BALCH SPRINGS

$ $ $ $ $

GRAND PRAIRIE

!

$

TALTY

SEAGOVILLE
$

KENNEDALE

DUNCANVILLE

HUTCHINS

CRANDALL
$

$

DESOTO

LANCASTER

WILMER

COMBINE

Map layers
Water Area County Line COPC Clinic

RENDON

CEDAR HILL

MANSFIELD

!
$

GLENN HEIGHTS

Dot-Density
= 200 African American Persons

OVILLA

FERRIS

Heath Management Associates

Appendix B

Baylor University Medical Center
3500 Gaston Dallas, TX 75246

PATIENT DEMOGRAPHICS (2003) Inpatient Emergency Visits
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 4,472 8 563 4,723 5,074 5,437 8,964 12,177 17,056 24,362 0 0 8,714 27,196 5,507 3,992 37,426 41,418 Percent 10.80% 0.02% 1.36% 11.40% 12.25% 13.13% 21.64% 29.40% 41.18% 58.82% 0.00% 0.00% 21.04% 65.66% 13.30% 9.64% 90.36% 100.00% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency Visits 1,214 2,821 5,733 13,447 10,579 9,814 8,440 6,590 26,451 32,179 0 0 28,522 18,944 11,170 10,312 48,326 58,638 Percent 2.07% 4.81% 9.78% 22.93% 18.04% 16.74% 14.39% 11.24% 45.11% 54.88% 0.00% 0.00% 48.64% 32.31% 19.05% 17.59% 82.41% 100.00%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $403,877,400 $122,215,805 $58,115,034 $416,944,923 $86,933,196 $1,088,086,360 Percent 37.12% 11.23% 5.34% 38.32% 7.99% 100.00% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Emergency Visits
Charges $3,073,487 $2,614,159 $6,983,314 $4,979,427 $1,243,785 $18,894,172 Percent 16.27% 13.84% 36.96% 26.35% 6.58% 100.00%

Inpatient
DRG 391 373 209 371 127 359 14 89 500 390 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 78650 78900 490 7840 462 7242 V583 8470 3829 4659 Description
CHEST PAIN NOS ABDMNAL PAIN UNSPCF SITE BRONCHITIS NOS OTH BONE REPAIR/PLAST OP ACUTE PHARYNGITIS LUMBAGO ATTEN-SURG DRESSNG/SUTUR SPRAIN OF NECK OTITIS MEDIA NOS ACUTE URI NOS

NORMAL NEWBORN VAGINAL DELIVERY W/O CC MJR JOINT/LIMB REATTACH, LWR EXTREM CESAREAN W/O CC HEART FAILURE & SHOCK UTER/ADNEXA , NON-MAL W/O CC INTRACRANIAL HEMORAGE & STROKE PNEUMONIA & PLEURISY >17 W CC BACK & NECK PROCED W/O CC NEONATE W OTHER SIGN PROBLEMS

Health Management Associates

Appendix C

Nearest Parkland Clinics
(COPC, WISH, and School based Clinics) *East Dallas Health Center & Women’s Clinic (.35 miles) Woodrow Youth & Family Center (2.5 miles) *Indicates a relationship between Clinic & Hospital

CENSUS (AHA 2001 survey)
Census #: 589 Staffed Beds: 907

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Patients whose household income is ≤ 200% of the Federal Poverty Level qualify for a specific level of charity care outlined by a schedule (schedule not provided). Medically Indigent Qualifications: For patients whose household income is > 200% FPL, amount owed to the hospital after third-party payment has been made must be above 50% of annual income; or for patients whose household income is between 200 – 500% FPL, amount owed to the hospital after the third-party payment has been made must exceed a percent of annual income outlined in an income schedule (not provided).

RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Currently have 16 ACGME, 11 TSBME, & 1 ADA approved programs. In addition, 5 program affiliations w/ UTSW: Anesthesiology, Nephrology, Orthopaedic Surgery, Plastic Surgery, Urology Which departments have residency programs? 33 residencies & fellowships in total How many residents are in each program? 195 Residents & Fellows in total Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. Yes, see below

o o o

Payor Mix for 2003 Resident Clinic Visits:
Payor Medicaid Managed Care/Other Self-Pay Medicare Total Visits 3,329 681 5,373 3,709 13,093 Percent of Visits 25.4% 5.2% 41.0% 28.3% 100.0%

Health Management Associates

Appendix C

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? The Baylor system operates: 8 Senior Health Centers, located at: Brookhaven, Casa Linda, Fairpark, Garland, Hillside, Irving, Mesquite, and Dallas. Plus 1 Tiny Tots NeoNatal clinic (serves “graduates” of the BHCS NICUs) o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. Informal relationship between Baylor ED and East Dallas COPC for primary care referrals and some inpatient admissions. o Do you operate any hospital-supported indigent care clinics? No o

TOTAL BED AVAILABILITY (2003)
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 682 4 79(a) 94 23 72 Staffed Available to be staffed* 576 4 72 86 15 72 8

12(b) 16

12 24

9

9

(a) Includes 5 LDRP beds. (b) Separated from 15 Roberts at the request of Dr. Wilson Weatherford. Reported separately on the TDH/AHA Annual Survey in FY 2002.

38 1,029

38 916

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) Percent (2002) Percent (2003) Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges:

Emergency Visits
Percent (2001) Percent (2002) Percent (2003)

38.13% 8.61% 4.49% 39.40% 9.37%
$948,597,800

37.80% 10.06% 5.49% 38.11% 8.55%

37.12% 11.23% 5.34% 38.32% 7.99%

15.65% 10.00% 35.52% 30.81% 8.01%
$14,515,758

15.69% 12.42% 36.21% 28.76% 6.92%
$16,994,553

16.27% 13.84% 36.96% 26.35% 6.58%
$18,894,172

$987,916,762 $1,088,086,360

Health Management Associates

Appendix C

Baylor Medical Center at Garland
2300 Marie Curie Garland, TX 75042

PATIENT DEMOGRAPHICS (2003) Inpatient
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 1,736 8 227 1,675 1,411 1,278 2,154 3,615 4,483 7,619 57 439 1,337 8,067 2,179 1,589 10,515 12,104 Percent 14.34% 0.07% 1.88% 13.84% 11.66% 10.56% 17.80% 29.87% 37.04% 62.95% 0.47% 3.63% 11.05% 66.65% 18.00% 13.13% 86.87% 100.00% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency

Emergency Visits
Visits 2,824 6,824 8,795 10,696 8,098 6,230 4,902 4,502 23,321 29,544 143 1,500 10,988 25,044 15,062 14,316 38,555 52,871 Percent 5.34% 12.91% 16.63% 20.23% 15.32% 11.78% 9.27% 8.52% 44.11% 55.88% 0.27% 2.84% 20.78% 47.37% 28.49% 27.08% 72.92% 100.00%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $67,637,609 $15,457,625 $10,467,268 $65,142,379 $4,163,099 $162,867,982 Percent 41.53% 9.49% 6.43% 40.00% 2.56% 100.00% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Emergency Visits
Charges $1,941,999 $2,504,254 $4,817,798 $4,938,643 $549,512 $14,752,206 Percent 13.16% 16.98% 32.66% 33.48% 3.72% 100.00%

Inpatient
DRG 391 373 462 371 359 127 89 390 88 209 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 78900 7806 3829 V643 78650 4660 5990 V583 4659 462 Description
ABDMNAL PAIN UNSPCF SITE FEVER OTITIS MEDIA NOS NO PROC FOR REASONS NEC CHEST PAIN NOS INTESTINAL FIXATION NOS URIN TRACT INFECTION NOS ATTEN-SURG DRESSNG/SUTUR ACUTE URI NOS ACUTE PHARYNGITIS

NORMAL NEWBORN VAGINAL DELIVERY W/O CC REHABILITATION CESAREAN W/O CC UTER/ADNEXA, NON-MALIG W/O CC HEART FAILURE & SHOCK PNEUMONIA & PLEURISY >17 W CC NEONATE W OTHER SIGN PROBS CRONIC OBSTUCTIVE PULMINARY DISEASE MJR JOINT/LIMB REATTCH OF LWR EXTREM

Health Management Associates

Appendix C

Nearest Parkland Clinics
(COPC, WISH, and School based Clinics) Garland Health Center & Women’s Clinic (2.75 mi) Vickery Family Health Center & Women’s Clinic (8.19 mi) White Rock Youth & Family Center (6.98 mi)

CENSUS (AHA 2001 survey)
Census: 130 Staffed Beds: 188

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Patients whose household income is ≤ 200% of the Federal Poverty Level qualify for a specific level of charity care outlined by a schedule (schedule not provided). Medically Indigent Qualifications: For patients whose household income is > 200% FPL, amount owed to the hospital after third-party payment has been made must be above 50% of annual income; or for patients whose household income is between 200 – 500% FPL, amount owed to the hospital after the third-party payment has been made must exceed a percent of annual income outlined in an income schedule (not provided).

RESIDENCY PROGRAM
o o o o Are your residency programs free-standing or affiliated? If affiliated, with whom? Which departments have residency programs? Family Practice How many residents are in each program? 18 Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. Yes, see below

Payor Mix for 2003 Resident Clinic Visits:
Payor Medicaid/CHIP Managed Care/Other Self-Pay Medicare Total Visits 3,087 2,394 378 441 6,300 Percent of Visits 49.0% 38.0% 6.0% 7.0% 100.0%

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? The Baylor system operates: 8 Senior Health Centers, located at: Brookhaven, Casa Linda, Fairpark, Garland, Hillside, Irving, Mesquite, and Dallas. Plus 1 Tiny Tots NeoNatal clinic (serves “graduates” of the BHCS NICUs) o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No o Do you operate any hospital-supported indigent care clinics? No

Health Management Associates

Appendix C

TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 135 28 19 14 Staffed Available to be staffed 100 28 19 14

24

24

*Source: self reported data

220

185

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Ttl Charges: Percent (2001) Percent (2002) Percent (2003) Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges:

Emergency Visits
Percent (2001) Percent (2002) Percent (2003)

40.90% 7.83% 4.66% 42.57% 4.05%

42.24% 8.17% 5.57% 41.62% 2.40%

41.53% 9.49% 6.43% 40.00% 2.56%

12.58% 8.73% 27.91% 43.55% 7.22%
$8,827,212

14.53% 12.94% 28.57% 39.78% 4.18%
$10,388,733

13.16% 16.98% 32.66% 33.48% 3.72%
$14,752,206

$145,832,518 $147,116,781 $162,867,982

Health Management Associates

Appendix C

Baylor Medical Center at Irving
1901 North MacArthur

Irving, TX 75061 PATIENT DEMOGRAPHICS (2003) Inpatient Emergency Visits
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 2,048 0 171 2,059 1,577 1,519 2,550 4,035 5,188 8,771 26 386 1,550 8,963 3,013 2,658 11,301 13,959 Percent 14.67% 0.00% 1.23% 14.75% 11.30% 10.88% 18.27% 28.91% 37.17% 62.83% 0.19% 2.77% 11.10% 64.21% 21.58% 19.04% 80.96% 100.00% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency Visits 2,168 4,508 5,874 9,689 6,607 5,111 3,779 3,300 18,328 22,708 71 671 6,426 18,815 15,010 14,208 26,828 41,036 Percent 5.28% 10.99% 14.31% 23.61% 16.10% 12.45% 9.21% 8.04% 44.66% 55.34% 0.17% 1.64% 15.66% 45.85% 36.58% 34.62% 65.38% 100.00%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $86,065,898 $19,664,128 $13,030,843 $91,313,307 $7,341,028 $217,415,204 Percent 39.59% 9.04% 5.99% 42.00% 3.38% 100.00% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Emergency Visits
Charges $1,655,497 $2,354,238 $4,009,517 $4,941,555 $584,027 $13,544,833 Percent 12.22% 17.38% 29.60% 36.48% 4.31% 100.00%

Inpatient
DRG 391 373 462 371 127 143 209 359 520 89 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 V655 V583 3829 462 8470 78900 4660 486 8472 7840 Description
PERSN W FEARED COMPLAINT ATTEN-SURG DRESSNG/SUTUR OTITIS MEDIA NOS ACUTE PHARYNGITIS SPRAIN OF NECK ABDMNAL PAIN UNSPCF SITE INTESTINAL FIXATION NOS PNEUMONIA ORGANISM NOS SPRIAN LUMBAR REGION OTH BONE REPAIR/PLAST OP

NORMAL NEWBORN VAGINAL DELIVERY W/O CC REHABILITATION CESAREAN W/O CC HEART FAILURE & SHOCK CHEST PAIN MJR JOINT/LIMB REATTCH OF LWR EXTREM UTER/ADNEXA, NON-MALIG W/O CC CERVICAL SPINAL FUSION W/O CC PNEUMONIA & PLEURISY >17 W CC

Health Management Associates

Appendix C

Nearest Parkland Clinics
(COPC, WISH, and School based Clinics)

- Family Medicine Clinic (7.23 mi) - Pediatric Primary Care Center (7.23 mi)

- Maple Women’s Health Center (7.23 mi)

CENSUS (AHA 2001 Survey)
Census #: 138 Staffed Beds: 226

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Patients whose household income is ≤ 200% of the Federal Poverty Level qualify for a specific level of charity care outlined by a schedule (schedule not provided). Medically Indigent Qualifications: For patients whose household income is > 200% FPL, amount owed to the hospital after third-party payment has been made must be above 50% of annual income; or for patients whose household income is between 200 – 500% FPL, amount owed to the hospital after the third-party payment has been made must exceed a percent of annual income outlined in an income schedule (not provided).

RESIDENCY PROGRAM
There is no residency program at this hospital.

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? The Baylor system operates: 8 Senior Health Centers, located at: Brookhaven, Casa Linda, Fairpark, Garland, Hillside, Irving, Mesquite, and Dallas. Plus 1 Tiny Tots NeoNatal clinic (serves “graduates” of the BHCS NICUs) o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No. However, Baylor has proposed to contribute funds to establish a new COPC site in Irving. o Do you operate any hospital-supported indigent care clinics? No o

Health Management Associates

Appendix C

TOTAL BED AVAILABILITY (2003)*
Bed type Coronary Care Unit Day Surgery Unit Holdover Unit Intensive Care Unit Labor and Delivery MS2 Neurology Ortho Neuro Med/Surg Med/Surg Oncology Neuro ICU Neonatal/Special Care Dept. Patient Care Unit Post Partum Rehab Telemetry Newborns (bassinets) Total Beds: Licensed Staffed 12 Available to be staffed 14

14 13 12 26 24 21 10 14 11 18 33 30 238

18

*Source: self reported data

288

14 13 12 26 24 21 12 10 22 11 18 33 30 260

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Ttl Charges: Percent (2001) Percent (2002) Percent (2003) Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges:

Emergency Visits
Percent (2001) Percent (2002) Percent (2003)

36.89% 6.90% 5.56% 44.73% 5.93%

38.84% 7.75% 5.27% 43.77% 4.36%

39.59% 9.04% 5.99% 42.00% 3.38%

10.12% 10.36% 27.56% 41.87% 10.09%
$9,622,172

10.77% 14.45% 29.82% 38.20% 6.77%
$10,941,819

12.22% 17.38% 29.60% 36.48% 4.31%
$13,544,833

$174,721,083 $203,634,914 $217,415,204

Health Management Associates

Appendix C

Children’s Medical Center Dallas
1935 Motor St Dallas, TX 75235

PATIENT DEMOGRAPHICS (2003) Inpatient Emergency Visits
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 4,428 4,335 6,461 194 2 0 0 1 8,657 6,764 3,036 161 5,812 5,676 19 5,676 9,745 15,421 Percent 29% 28% 42% 1% 0% 0% 0% 0% 56% 44% 20% 1% 38% 37% 0% 37% 63% 100% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency Visits 25,405 37,394 35,341 540 121 75 53 13 53,817 45,125 24,795 781 16,949 52,880 94 52,880 46,062 98,942 Percent 26% 38% 36% 1% 0% 0% 0% 0% 54% 46% 25% 1% 17% 53% 0% 53% 47% 100%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $4,079,528 $348,415,924 $6,056,868 $193,522,117 $28,867,223 $580,941,660 Percent 1% 60% 1% 33% 5% 100% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Emergency Visits
Charges $53,131 $33,580,583 $6,892,930 $13,731,272 $1,426,277 $55,669,948 Percent 0.10% 60% 12% 25% 3% 100%

Inpatient
DRG 98 389 26 91 184 396 21 298 3 279 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 382.9 465.9 79.99 780.6 558.9 493.9 466.19 486 462 464.4 Description
OTITIS MEDIA NOS ACUTE URI NOS VIRAL INFECTION NOS FEVER NONINF GASTROENTERIT NE Asthma – unspecified ACU BRNCHL TS D/T OTH OR PNEUMONIA ORGANISM NOS ACUTE PHARYNGITIS CROUP

BRONCHITIS & ASTHMA AGE 0 – 17 FULL TERM NEONATE W/ MJR PRB SEIZURE & HEADACHE AGE 0 – 17 SIMPLE PNEUMONIA & PLEURISY ESOPH, GASTR & DIGEST DISORDERS RED BLOOD CELL DISORDERS AGE 0 – 17 VIRAL MENINGITIS NUTRIT & METABOLIC DISORDERS CRANIOTOMY AGE 0 – 17 CELLULITIS 0 – 17

Health Management Associates

Appendix C

Nearest Parkland COPC Clinics
- Pediatric Primary Care Center, On Campus - Family Medicine Clinic, On Campus - East Dallas Health Center 5.22 Miles

CENSUS & LENGTH OF STAY Average Occupancy* (2003): 70.64% Average Length of Stay (2003): 4.83 days *Excludes Obs. INDIGENT/CHARITY CARE POLICY Financially Indigent Qualifications: Patient’s total gross family income must fall below 200%
of the Federal Poverty level, must reside within Children’s service area, and have “exhausted all reasonable efforts to obtain third party assistance”.

Medically Indigent Qualifications: A monthly payment schedule no longer than sixty (60) months in length will be set up between the patient’s parent/guardian that reflects a reasonable monthly burden (general guidelines are 10% to 20% of monthly income on a graduated scale). RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Yes, Children’s Medical Center is affiliated with the University of Texas Southwestern Medical Center at Dallas Which departments have residency programs? Not available. How many residents are in each program? Children’s Medical Center currently has 82 residents and 3 chief residents.

o o o

Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. Payor Mix for 2003 Resident Clinic Visits:
Payor Medicaid/CHIP Managed Care Self-Pay/Charity All Other Medicare Total Visits 7,922 717 614 89 6 9,348 Percent of Visits 84.7% 7.7% 6.6% 1.0% 0.1% 100.0%

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? Outpatient clinics encompass 59 specialties o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. COPC pediatricians supervise CMC residents at the clinics, attend on inpatient units at CMC, and refer their patients to CMC for emergencies, specialties, and inpatient care. o Do you operate any hospital-supported indigent care clinics? No. o

Health Management Associates

Appendix C

TOTAL BED AVAILABILITY (2003)^
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Licensed Staffed 137 33 13 Available to be staffed* 150 44 17

46* 63 68

12

12

*reflects beds already counted in the Med-surg & Cardiac IUCs, not additional beds. ^Self reported data

Total: 348

Total: 258

Total: 291

THREE-YEAR TRENDS Inpatient
Inpatient Payor Mix Percent (2001) Percent (2002)
0.42% 56.71% 1.21% 32.76% 8.90%

Emergency Visits
Percent (2003)
0.70% 59.97% 1.04% 33.31% 4.97%

Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Percent (2001)
0.02% 50.10% 20.00% 26.26% 3.62%

Percent (2002)
0.07% 59.28% 13.47% 23.86% 3.33%

Percent (2003)
0.07% 60.32% 12.38% 24.67% 2.56%

Medicare 0.77% Medicaid/SCHIP 53.65% Self-pay/Charity 1.81% Managed Care 35.40% All Other 8.36% Total $402,153,583

$460,069,775 $580,941,660

$42,007,516 $49,034,184 $55,669,948

Health Management Associates

Appendix C

Medical City Hospital
7777 Forest Lane Dallas, TX 75230

PATIENT DEMOGRAPHICS (2003) Emergency Visits Inpatient
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 4,131 959 1,806 2,530 3,221 2,681 4,047 5,838 10,051 15,162 19 583 3,897 16,331 4,383 2,145 23,068 25,213 Percent 16.3% 4.6% 6.4% 9.9% 12.9% 10.7% 16.0% 23.2% 39.9% 60.1% 0.1% 2.3% 15.5% 64.8% 17.4% 8.5% 91.5% 100.0% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency Visits 2,600 4,883 6,571 7,972 6,040 4,441 3,416 2,512 16,983 21,452 13 606 12,588 16,294 8,934 6,946 31,489 38,435 Percent 6.8% 12.7% 17.1% 20.7% 15.7% 11.6% 8.9% 6.5% 44.2% 55.8% 0.0% 1.6% 32.8% 42.4% 23.2% 18.1% 81.9% 100.0%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $295,509,849 $62,641,778 $19,877,587 $518,699,615 $19,898,331 $916,627,160 Percent 32.2% 6.8% 2.2% 56.6% 2.2% 100.0% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Emergency Visits
Charges*** $131,696,404 $24,944,833 $25,718,824 $154,068,038 $5,718,100 $342,146,199 Percent 38.5% 7.3% 7.5% 45.0% 1.7% 100.0%

*** Total ER IP & OP account charges (not just ER charges)

Inpatient
DRG 391 373 371 359 098 462 390 517 209 127 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 382.9 465.9 079.99 789.00 558.9 462 466.0 784.0 786.50 847.0 Description
UNSPECIFIED OTITIS MEDIA ACUTE URI NOS VIRAL INFECTION NOS ABDMNAL PAIN UNSPCF SITE NONINF GASTROENTERIT NEC ACUTE PHARYNGITIS ACUTE BRONCHITIS HEADACHE UNSPECIFIED CHEST PAIN NECK SPRAIN

NORMAL NEWBORN VAGINAL DELIVERY W/O CC CESAREAN W/O CC UTER/ADNEXA, NON-MAL W/O CC BRONCHITIS & ASTHMA AGE 0-17 REHABILITATION NEONATE W OTHER SIGN PROBLEMS PERC CARDIO W NON-DRUG ELUTNG W/O AMI MJR JOINT/LIMB REATTACH, LWR EXTREM HEART FAILURE & SHOCK

Health Management Associates

Appendix C

CENSUS (AHA 2001 survey)
Census #: 329 Staffed Beds: 530

INDIGENT/CHARITY CARE POLICY
No policy currently exists, but one is in the process of being drafted.

RESIDENCY PROGRAM o Are your residency programs free-standing or affiliated? If affiliated, with whom? Affiliated with UTSW for OB/Gyn only o Which departments have residency programs? OB/GYN Only – limited scope o How many residents are in each program? 1-3 per year
o Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. No

OUTPATIENT CLINIC
o o How many clinics do you operate and where are they located? None Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. NA

o Do you operate any hospital-supported indigent care clinics? NA TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 223 64 47 32 18 38 10 14 0 61 10 17 0 0 0 0 0 0 9 + 38 NBN 581 Staffed 123 64 47 32 18 38 8 14 0 61 10 17 0 0 0 0 0 0 432 Available to be staffed 123 due to construction

10

*Source: self reported data

Health Management Associates

Appendix C

THREE-YEAR TRENDS
Inpatient *^
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) Percent (2002) Percent (2003) Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges:

Emergency Visits *^
Percent (2001) Percent (2002) Percent (2003)

19.8% 4.6% 2.5% 70.7% 2.4%
$632,488,759

21.8% 5.1% 2.4% 68.0% 2.8%
$799,723,026

23.0% 5.6% 2.8% 66.5% 2.2%
$916,627,160

11.6% 5.5% 20.3% 57.6% 5.0%
$285,604,730

11.9% 7.1% 20.1% 57.2% 3.8
$342,146,199

*^ Percentages based from Admit/Visit Volumes (not charges)

Health Management Associates

Appendix C

Methodist Charlton Medical Center
350 W Wheatland Rd Dallas, TX 75237

PATIENT DEMOGRAPHICS (2003) Emergency Visits Inpatient
Category < 1 year 1-17 years 18-24 years 25-39 years 40-54 years 55-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 2,334 326 1,413 2,425 2,425 1,615 4,203 5,018 9,723 4 77 6,231 6,890 1,539 1,454 13,287 14,741 Percent 15.83% 2.21% 9.59% 16.45% 16.45% 10.96% 28.51% 34.04% 65.96% 0.02% 0.52% 42.26% 46.74% 10.44% 9.86% 90.14% 100.00% Category < 1 year 1-17 years 18-24 years 25-39 years 40-54 years 55-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency Visits 2,103 12,100 7,346 11,706 8,291 2,869 3,752 19,695 28,472 15 148 30,533 12,832 4,639 4,707 43,460 48,167 Percent 4.37% 25.12% 15.25% 24.30% 17.21% 5.96% 7.79% 40.89% 59.11% 0.03% 0.31% 63.39% 26.64% 9.63% 9.77% 90.23% 100.00%

Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges
$75,895,544 $16,887,658 $9,649,060 $45,099,947 $5,818,418 $153,335,510

PAYOR MIX (2003)
Percent
49.50% 11.01% 6.29% 29.41% 3.79% 100.00%

Emergency Visits
Charges
$6,993,561 $7,466,073 $10,487,359 $15,998,900 $3,528,431 $44,474,324

Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Percent
15.72% 16.79% 23.58% 35.97% 7.93% 100.00%

Inpatient
DRG 391 373 371 143 127 89 390 359 88 209 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 78900 3829 4660 49390 4659 78659 07999 8470 462 5990 Description
ABDMNAL PAIN UNSPCF SIT OTITIS MEDIA NOS ACUTE BRONCHITIS ASTHMA W/O STATUS ASTHM ACUTE URI NOS CHEST PAIN NEC VIRAL INFECTION NOS SPRAIN OF NECK ACUTE PHARYNGITIS URIN TRACT INFECTION NO

NORMAL NEWBORN VAGINAL DELIVERY W/O CC CESAREAN W/O CC CHEST PAIN HEART FAILURE & SHOCK PNEUMONIA & PLEURISY >17 W CC NEONATE W OTHER SIGN PROBS UTER/ADNEXA, NON-MALIG W/O CC CRONIC OBSTUCTIVE PULMINARY DISEASE MJR JOINT/LIMB REATTCH OF LWR EXTREM

Health Management Associates

Appendix C

Nearest Parkland Clinics
(COPC, WISH, and School based Clinics) - Oak West Health Center & Women’s Clinic (3.9 mi) - Red Bird Youth Family Health Center (5.43 mi) - Old Kaiser clinic (5.17 mil)

CENSUS (AHA 2001 Survey)
Census #: 121 Staffed Beds: 163

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Uninsured/underinsured patients w/ income ≤ the Federal Poverty Level & a demonstrated inability to pay. Medically Indigent Qualifications: Patients whose medical bills, after third-party payment, would require use of income/assets critical to living or earning a living. Other Factors: No Charity care determinations will be made until the patient has received at least one balance due statement that gives no indication of possible charity care status. The patient will continue to receive balance due statements until charity status is determined & it is clear that further statements will not result in payment. The hospital may notify a patient that they are under consideration for charity care if “doing so will enhance the public’s understanding of the hospital’s charity care or assist in the collection of a portion of the account”.

RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Freestanding with the exception of the Family Practice residency which is affiliated with UT Southwestern Medical School Which departments have residency programs? Family Practice & Sports Medicine How many residents are in each program? Family Practice 18; Sports Medicine 2 Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. Yes, see below

o o o

Payor Mix for 2003 Resident Clinic Visits:
Payor Medicaid Managed Care Self-Pay All Other Medicare Total Visits 4,961 2,631 1,345 904 2,616 12,457 Percent of Visits 39.8% 21.1% 10.8% 7.3% 21.0% 100.0%

Health Management Associates

Appendix C

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? 3 Family Health Centers: i. Cedar Hill – 326 B. Cooper St, Cedar Hill, TX 75104 ii. Central Grand Prairie – 820 S Carrier Parkway, Grand Prairie, TX 75051 iii. South Grand Prairie – Westchester Market Shopping Center, 4116 S Carrier Parkway, Suite 250, Grand Prairie, TX 75052 o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No o Do you operate any hospital-supported indigent care clinics? No o

TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 191 Staffed 148 35 24 Available to be staffed

24

*Source: self reported data

215

207

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) 50.48% 8.79% 6.00% 31.03% 3.70% 96,803,501 Percent (2002) 49.44% 10.75% 6.49% 30.17% 3.18% Percent (2003) 49.50% 11.01% 6.29% 29.41% 3.79% Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other

Emergency Visits
Percent (2001) 14.77% 10.79% 24.21% 42.02% 8.22% Percent (2002) 15.50% 14.48% 23.40% 39.67% 6.94% $37,312,451 Percent (2003) 15.72% 16.79% 23.58% 35.97% 7.93% $44,474,324

127,199,649 $153,335,510

Total Charges: $28,712,984

Health Management Associates

Appendix C

Methodist Dallas Medical Center
1441 N Beckley Ave Dallas, TX 75203

PATIENT DEMOGRAPHICS (2003) Emergency Visits Inpatient
Category < 1 year 1-17 years 18-24 years 25-39 years 40-54 years 55-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges
3,309 439 2,016 3,512 3,246 2,255 5,170

Percent
16.59% 2.20% 10.11% 17.61% 16.27% 11.30% 25.92%

Category < 1 year 1-17 years 18-24 years 25-39 years 40-54 years 55-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Emergency

Visits
1,948 9,399 6,724 11,503 8,899 3,170 4,634

Percent
4.21% 20.31% 14.53% 24.86% 19.23% 6.85% 10.01%

7,814 12,133 21 106 6,386 6,157 7,277 7,195 12,752 19,947

39.17% 60.83% 0.11% 0.53% 32.01% 30.87% 36.48% 36.07% 63.93% 100.00%

19,659 26,618 33 100 21,111 7,272 17,761 17,781 28,496 46,277

42.48% 57.52% 0.07% 0.22% 45.62% 15.71% 38.38% 38.42% 61.58% 100.00%

Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges
131,826,177 54,505,389 28,473,294 85,696,253 19,729,017 320,230,130

PAYOR MIX (2003)
Percent
41.17% 17.02% 8.89% 26.76% 6.16% 100.00%

Emergency Visits
Charges
10,616,042 7,423,476 16,268,349 11,683,094 4,221,574 50,212,535

Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Percent
21.14% 14.78% 32.40% 23.27% 8.41% 100.00%

Inpatient
DRG 391 373 462 371 372 127 89 296 14 359 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 3829 4659 78659 4660 5990 78900 462 8470 7840 5589 Description
OTITIS MEDIA NOS ACUTE URI NOS CHEST PAIN NEC ACUTE BRONCHITIS URIN TRACT INFECTION NO ABDMNAL PAIN UNSPCF SIT ACUTE PHARYNGITIS SPRAIN OF NECK HEADACHE NONINF GASTROENTERIT NE

NORMAL NEWBORN VAGINAL DELIVERY W/O CC REHABILITATION CESAREAN W/O CC VAGINAL DELIVERY W CC DIAGNOSES HEART FAILURE & SHOCK PNEUMONIA & PLEURISY > 17 W CC NUTRI & METABOLIC DISORDERS >17 W CC INTERCRANIAL HEMORAGE & STROKE UTER/ADNEXA, NON-MALIG W/O CC

Health Management Associates

Appendix C

Nearest Parkland/Community Clinics
(COPC, WISH, and School based Clinics) De Haro-Saldivar Health Center (4.07 mi) Bluitt-Flowers Health Center (4.65 mi) Lakewest Women’s Health Center (4.18 mi) North Oak Cliff Youth & Family Center (2.55 mi) - West Dallas Youth & Family Clinic (2.91 mi) - *Los Barrios Unidos Comm. Clinic (FQHC) (2.14 mi)

-

*Indicates a relationship between Clinic & Hospital

CENSUS (AHA 2001 Survey)
Census #: 275 Staffed Beds: 360

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: Uninsured/underinsured patients w/ income ≤ the Federal Poverty Level & a demonstrated inability to pay. Medically Indigent Qualifications: Patients whose medical bills, after third-party payment, would require use of income/assets critical to living or earning a living. Other Factors: No Charity care determinations will be made until the patient has received at least one balance due statement that gives no indication of possible charity care status. The patient will continue to receive balance due statements until charity status is determined & it is clear that further statements will not result in payment. The hospital may notify a patient that they are under consideration for charity care if “doing so will enhance the public’s understanding of the hospital’s charity care or assist in the collection of a portion of the account”.

RESIDENCY PROGRAM
o Are your residency programs free-standing or affiliated? If affiliated, with whom? Freestanding with the exception of the Family Pratice residency which is affiliated with UT Southwestern Medical School Which departments have residency programs? Internal Medicine, OB/GYN, Gen Surgery, Anesthesia How many residents are in each program? IM = 21, OB/GYN = 11, Gen Surg = 12, Anesthesia = 3 Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. Yes, see below

o o o

Payor Mix for 2003 Resident Clinic Visits:
Payor Medicaid Managed Care Self-Pay All Other Medicare Total Visits 4,334 1,053 3,573 488 1,616 11,064 Percent of Visits 39.1% 9.5% 32.3% 4.4% 14.6% 100.0%

Health Management Associates

Appendix C

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? 3 Family Health Centers: i. Cedar Hill – 326 B. Cooper St, Cedar Hill, TX 75104 ii. Central Grand Prairie – 820 S Carrier Parkway, Grand Prairie, TX 75051 iii. South Grand Prairie – Westchester Market Shopping Center, 4116 S Carrier Parkway, Suite 250, Grand Prairie, TX 75052 o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No o Do you operate any hospital-supported indigent care clinics? No o

TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 357 Staffed 225 41 32 16 50 Available to be staffed

35 16 50

15

15

20

20

*Source: self reported data

493

399

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) 43.37% 14.87% 8.04% 26.65% 7.06% 215,253,579 Percent (2002) 42.52% 16.92% 7.38% 27.39% 5.80% 265,152,683 Percent (2003) 41.17% 17.02% 8.89% 26.76% 6.16% 320,230,130 Emergency Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges:

Emergency Visits
Percent (2001) 22.15% 10.41% 30.25% 28.10% 9.08%
27,108,779

Percent (2002) 21.57% 12.46% 30.17% 27.36% 8.44%
38,329,849

Percent (2003) 21.14% 14.78% 32.40% 23.27% 8.41%
50,212,535

Health Management Associates

Appendix C

Presbyterian Hospital of Dallas
8200 Walnut Hill Lane Dallas, TX 75231

PATIENT DEMOGRAPHICS (2003) Inpatient
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Hispanic Other Total Inpatient Discharges 1,120 86 342 4,454 4,768 3,421 5,424 10,979 9,957 20,637 372 18 3,512 21,693 2,181 2,818 30,594 Percent 3.66% 0.28% 1.12% 14.56% 15.58% 11.18% 17.73% 35.89% 32.55% 67.45% 1.22% 0.06% 11.48% 70.91% 7.13% 9.21% 100.00% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Hispanic Other Total Emergency

Emergency Visits
Visits 3,669 7,244 6,748 15,673 9,801 7,041 5,440 5,940 25,050 36,506 31 305 18,370 22,810 10,980 9,060 61,556 Percent 5.96% 11.77% 10.96% 25.46% 15.92% 11.44% 8.84% 9.65% 40.69% 59.31% 0.05% 0.50% 29.84% 37.06% 17.84% 14.72% 100.00%

Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $313,866,484 $70,043,478 $25,872,090 $310,867,218 $10,947,527 $731,596,797

PAYOR MIX (2003)
Percent 42.90% 9.57% 3.54% 42.49% 1.50% 100.00% Payor

Emergency Visits
Charges $11,930,276 $7,401,480 $13,542,508 $20,919,651 $1,305,578 $55,099,493 Percent 21.65% 13.43% 24.58% 37.97% 2.37% 100.00%

Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Inpatient
DRG 373 371 462 209 359 127 517 430 25 14 Description

DRG & ICD-9 TOP 10 (2003) Emergency Visits
ICD-9 382.9 465.9 780.6 466.0 462 784.0 786.50 920 599.0 789.00 Description
OTITIS MEDIA NOS ACUTE URI NOS FEVER INTESTINAL FIXATION NOS ACUTE PHARYNGITIS OTHER BONE REPAIR/PLAST OP CHEST PAIN NOS CONTUSION FACE/SCALP/NECK URIN TRACT INFECTION NOS ABDOMINAL PAIN UNSPCF SITE

VAGINAL DELIVERY W/O COMPLICATIONS CESAREAN W/O COMMPLICATIONS REHABILITATION MJR JOINT/LIMB REATTCH OF LWR EXTREMITY UTER/ADNEXA, NON-MALIG W/O CC HEART FAILURE & SHOCK PERC CARDIO W NN-DRG ELUT STENT WO AMI PSYCHOSES SEIZURE & HEADACHE AGE >17 W/O CC INTRACRANIAL HEMRRGE & SROKE W INFRCTN

Health Management Associates

Appendix C

(COPC, WISH, and School based Clinics) *Vickery Family Health Center & Women’s Clinic (1.24 mi) East Dallas Health Center & Women’s Clinic (7.76 mi) Kiosco Youth & Family Center (5.12 mi) Woodrow Youth & Family Center (6.84 mi) *Indicates a relationship between Clinic & Hospital

Nearest Parkland Clinics

CENSUS (2004) Census #: 460 Staffed Beds: 695 INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: If the patient’s gross annual income is ≤ 100% of the Federal Poverty level and they lack sufficient funds/assets to pay without incurring a financial hardship, they qualify for a charity adjustment of 100% unpaid charges If the patient’s gross annual income is 100% - 200% of the Federal Poverty level and they lack sufficient funds/assets they qualify for a charity adjustment to be determined by the Charity committee Medically Indigent Qualifications: Qualifying patients have unpaid medical bills that exceed 3% - 15% of income (determined on a sliding scale by income bracket) & have insufficient funds/assets to pay remaining charges. Eligibility for full or partial adjustment determined by Charity committee. Other Circumstances: Charity committee has authority to grant full or partial charity to any patient otherwise deemed to be unable to pay their medical bill rather than unwilling to pay. Charity committee must reach majority consensus in these cases.

RESIDENCY PROGRAM
o o o Are your residency programs free-standing or affiliated? If affiliated, with whom? One freestanding, One affiliated with UT Southwestern & Parkland Which departments have residency programs? Internal Medicine & Colon Rectal Surgery (Parkland & UTSW) How many residents are in each program? IM – 24, Colon – 1 Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. No

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? SW Diagnostic Imaging Center – 8230 Walnut Hill Ln – Dallas, TX 75231 Surgery Center Southwest – 8230 Walnut Hill Ln – Dallas, TX 75231 Westmoreland Clinic – 1350 N Westmoreland Rd – Dallas, TX 75211 o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. Yes. Presbyterian provides rent and operating support to Vickery COPC. o Do you operate any hospital-supported indigent care clinics? No.

Health Management Associates

Appendix C

TOTAL BED AVAILABILITY
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 559 31 Med/Surg 30 10 68 NA NA NA NA NA 52 NA 89 27 NA NA NA NA 866 Staffed 378 20 86 30 10 68 Available to be staffed* 378 20 86 30 10 68

52

52

24 27

24 27

695

695

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix (As % of Charges) Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) Percent (2002) Percent (2003) Emergency Visit Payor Mix (As % of Charges) Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other

Emergency Visits
Percent (2001) Percent (2002) Percent (2003)

41.87% 8.24% 3.35% 43.28% 3.26%

41.69% 10.67% 3.59% 41.55% 2.50%

42.90% 9.57% 3.54% 42.49% 1.50%

20.70% 9.45% 22.65% 43.10% 4.10%

21.60% 11.71% 23.14% 40.55% 3.00%
$47,993,625

21.65% 13.43% 24.58% 37.97% 2.37%
$55,099,494

$543,190,555 $622,950,070 $731,596,797

Total Charges: $47,643,620

Health Management Associates

Appendix C

St. Paul University Hospital
5909 Harry Hines Blvd Dallas, TX 75235

PATIENT DEMOGRAPHICS (2003) Outpatient Inpatient
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 3,268 255 3,080 2,171 2,047 2,878 3,663 6,051 11,311 10 193 4,058 7,679 5,422 5,902 11,460 17,362 Percent 18.8% 0.0% 1.5% 17.7% 12.5% 11.8% 16.6% 21.1% 34.9% 65.1% 0.1% 1.1% 23.4% 44.2% 31.2% 34.0% 66.0% 100.0% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Outpatient Visits 1,220 1,328 2,714 13,202 10,370 12,286 16,379 16,428 50,385 23,542 96 546 20,707 28,086 24,492 18,264 55,663 73,927 Percent 1.7% 1.8% 3.7% 17.9% 14.0% 16.6% 22.2% 22.2% 68.2% 31.8% 0.1% 0.7% 28.0% 38.0% 33.1% 24.7% 75.3% 100.0%

Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $127,563,501 $40,973,121 $10,909,948 $107,051,556 $16,921,563 $303,419,689

PAYOR MIX (2003)
Percent 42.0% 13.5% 3.6% 35.3% 5.6% 100.0% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Outpatient
Charges $29,137,643 $5,824,882 $10,559,559 $40,201,022 $5,480,069 $91,203,175 Percent 31.9% 6.4% 11.6% 44.1% 6.0% 100.0%

Inpatient
DRG 391 373 390 430 127 371 370 209 462 372 Description

DRG & ICD-9 TOP 10 (2003)
ICD-9 V76.12 401.9 V58.49 V22.1 250.00 789.00 V57.1 789.09 786.2 786.50

Outpatient

Description
SCREENING MAMMOGRAM HYPERTENSION NOS POST-OP AFTERCARE NEC SUPERVIS OTH NORMAL PREG DIABETES UNCOMPL TYPE II ABDOM PAIN NOS SITE PHYSICAL THERAPY NEC ABD PAIN NEC/MULTI SITE COUGH CHEST PAIN NOS

NORMAL NEWBORN VAGINAL DELIVERY X/COMPLICATIONS NEONATE W/SIGNIFICANT PRO PSYCHOSES HEART FAILURE & SHOCK CESAREAN SECTION X/CC CESAREAN SECTION W/CC MAJOR JOINT LIMB REATTACH REHABILITATION VAGINAL DELIVERY COMPLICATIONS

Health Management Associates

Appendix C

CENSUS (AHA 2001 survey)
Census #: 193 Staffed Beds: 145

INDIGENT/CHARITY CARE POLICY
Financially Indigent: An uninsured or underinsured person who qualifies for charity care under the hospital eligibility system will be accepted for care with no obligation or a discounted obligation to pay for services rendered. The income eligibility portion shall not be set lower than the legal limit or higher than 200% of the Federal Poverty level. Medically Indigent: “A person whose medical or hospital bills, after payment by third-party payers, exceed a specified percentage of the patient’s annual gross income, determined in accordance with St. Paul Medical Center’s eligibility system, and the person is financially unable to pay the remaining bill.” A combined Charity Policy for St. Paul and Zale is being finalized and should be in effect by the end of year.

RESIDENCY PROGRAM o Are your residency programs free-standing or affiliated? If affiliated, with whom? Our residency programs are affiliated with the University of Texas Southwestern Medical School in Dallas.
o Which departments have residency programs? During the 2003-2004 academic year (07/01/03 to 06/30/04), St. Paul sponsored residency programs in the following departments: ♦ Family Practice ♦ Internal Medicine ♦ Obstetrics and Gynecology How many residents are in each program? During the 2003-04 academic year (07/01/03 to 06/30/04), the number of residents in each of the residency training programs was: ♦ Family Practice – Number of Approved Positions = 12, Number filled = 11 ♦ Internal Medicine – Number of Approved Positions = 19, Number filled = 19 ♦ Ob/Gyn – Number of Approved Positions = 12, Number filled = 12 Do you operate any resident clinics? If so, please provide the total number of visits and the payor mix for the clinics. For 2003: IM 4,505, Surg 203, Gyn 1,924, OB 9,723

o

o

Payor Mix for 2003 Resident Clinic Visits: For St. Paul Clinic Only
Payor Medicaid Managed Care/Other Self-Pay Medicare Total Visits* Percent of Visits 60.16% 7.13% 28.55% 4.16% 100.0%

*unable to provide due to systems constraints

Health Management Associates

Appendix C

OUTPATIENT CLINIC
How many clinics do you operate and where are they located? 5909 Harry Hines Blvd: St. Paul Clinic 5550 Harvest Hill Road: Family Practice Clinic o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. No o Do you operate any hospital-supported indigent care clinics? o

No; only clinics are for the residency programs.

TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 377 Staffed 229 Available to be staffed 148

24 23 34

18 18 24

6 5 10

14 14 64

14 0 0

0 14 64

*Source: Self reported data

550

303

247

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Percent (2001) Percent (2002) Percent (2003) Outpatient Payor Mix

Outpatient
Percent (2001) Percent (2002) Percent (2003)

37% 40.9% 42.0% Medicare 7% 11.0% 13.5% Medicaid/SCHIP 5% 3.3% 3.6% Self-pay/Charity 38% 34.9% 35.3% Managed Care 13% 9.9% 5.6% All Other Total Charges: $241,886,915 $271,005,560 $303,419,689

28.5% Medicare 4.4% Medicaid/SCHIP 9.8% Self-pay/Charity 45.7% Managed Care 11.7% All Other Total Charges: $74,759,493

31.3% 5.9% 8.0% 43.7% 11.1%
$72,739,784

31.9% 6.4% 11.6% 44.1% 6.0%
$91,203,175

Health Management Associates

Appendix C

Zale Lipshy University Hospital
5151 Harry Hines Blvd Dallas, TX 75235

PATIENT DEMOGRAPHICS (2003) Inpatient Outpatient*
Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Inpatient Discharges 0 0 52 378 605 1,152 1,961 2,057 2,754 3,451 5 67 607 5,151 375 302 5,903 6,205 Percent 0.0% 0.0% 0.8% 6.1% 9.8% 18.6% 31.6% 33.2% 44.4% 55.6% 0.1% 1.1% 9.8% 83.0% 6.0% 4.9% 95.1% 100.0% Category < 1 year 1-4 years 5-17 years 18-29 years 30-39 years 40-49 years 50-64 years 65+ years Male Female American Indian Asian/Pacific Black White Other Hispanic Not Hispanic Total Outpatient Visits 13 2 164 982 1,704 2,722 4,324 4,181 6,366 7,726 4 219 1,329 11,587 953 640 13,452 14,092 Percent 0.1% 0.0% 1.2% 7.0% 12.1% 19.3% 30.7% 29.7% 45.2% 54.8% 0.0% 1.6% 9.4% 82.2% 6.8% 4.5% 95.5% 100.0%

PAYOR MIX (2003) Inpatient
Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges $67,015,427 $3,899,854 $2,011,439 $50,462,223 $43,467,956 $166,856,899 Percent 40.2% 2.3% 1.2% 30.2% 26.1% 100.0% Payor Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total

Outpatient*
Charges $14,617,475 $604,829 $848,136 $14,999,870 $13,809,335 $44,879,646 Percent 32.6% 1.3% 1.9% 33.4% 30.8% 100.0%

DRG & ICD-9 TOP 10 (2003) Inpatient
DRG 462 430 002 001 288 209 303 500 148 520 Description
REHABILITATION PSYCHOSES CRAINOTOMY AGE >17 W/O CC CRAINOTOMY AGE >17 W CC MJR THUMB/JOINT OR HAND/WRIST PROC W CC MJR JOINT/LIMB REATTACH, LWR EXTREMITY KIDNY/URTR & MJR BLADDR PROC FOR NEOPLAS BACK & NECK PROCEDURE W/O CC MAJR SM & LR BOWEL PROC W CC CERVICAL SPINAL FUSION W CC

Outpatient*
ICD-9 366.9 No Code 592 174.9 188.9 189 296.3 437.3 185 174.8 Description
CATARACT NOS CALCULUS OF KIDNEY MALIGN NEOPL BREAST NOS MALIG NEO BLADDER NOS MALIG NEOPL KIDNEY RECURR DEPR PSYCHOS-UNSP NONRUPT CEREBRAL ANEURYM MALIGN NEOPL PROSTATE MALIGN BEOPL BREAST NOS

Health Management Associates

Appendix C

CENSUS (AHA 2001 survey)
Census #: 114 Staffed Beds: 145

INDIGENT/CHARITY CARE POLICY
Financially Indigent Qualifications: If the patient’s family income is less than or equal to 200% of the Federal Poverty Level for the family’s size, the patient qualifies for charity care equaling 100% of patient’s balance. Medically Indigent Qualifications: If amount owed after third party payment exceeds percentage of family income specified by hospital then the patient would qualify for a portion of bill to be written off as charity care. (table describing income/payment breakdown not provided) A combined Charity Policy for St. Paul and Zale is being finalized and should be in effect by the end of year.

RESIDENCY PROGRAM
Are your residency programs free-standing or affiliated? Affiliated. If affiliated, with whom? Our residency programs are affiliated with the University of Texas Southwestern Medical School in Dallas. Which departments have residency programs? o Oral Surgery: 1 o Anesthesiology: 8 o Orthopedics: 2 o Internal Medicine: 6 o Otolaryngology: 2 o General Surgery: 6 o Pathology: 1 o Neurology: 2 o Plastic Surgery: 2 o Physical Medicine: 2 o Psychiatry: 3 o Neurosurgery: 4 o Urology: o OB/Gyn: 0.25 o Ophthalmology: 2 How many residents are in each program? See above Do you operate any resident clinics? No If so, please provide the total number of visits and the payor mix for the clinics.

o

o

o o

OUTPATIENT CLINIC
o How many clinics do you operate and where are they located? N/A

o Do the clinics have any affiliation with the Parkland COPC clinics? Please describe. N/A o Do you operate any hospital-supported indigent care clinics? N/A

Health Management Associates

Appendix C

TOTAL BED AVAILABILITY (2003)*
Bed type General med-surg Pediatric med-surg Obstetrics Med-surg ICU Cardiac ICU Neonatal intensive care Neonatal intermediate care Pediatric intensive care Burn care Other special care Other intensive care Physical rehab Alcohol/Drug Abuse or Dependency care Psychiatric Skilled Nursing care Intermediate Nursing care Acute long term care Other long term care Other care Total Beds: Licensed 91 Staffed 91 Available to be staffed 0

20

20

0

20 21

20 21

0 0

*Source: self reported data

152

152

0

THREE-YEAR TRENDS
Inpatient
Inpatient Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other Total Charges: Percent (2001) Percent (2002) Percent (2003) Outpatient Visit Payor Mix Medicare Medicaid/SCHIP Self-pay/Charity Managed Care All Other

Outpatient*
Percent (2001) Percent (2002) Percent (2003)

36.1% 2.8% 1.9% 35.7% 23.5%

38.5% 2.5% 1.2% 32.2% 25.7%

40.2% 2.3% 1.2% 30.2% 26.1%

26.5% 1.6% 8.6% 41.9% 21.4%

29.3% 1.3% 3.3% 34.6% 31.6%
$40,496,462

32.6% 1.3% 1.9% 33.4% 30.8%
$44,879,646

$152,264,710 $147,513,930 $166,856,899

Total Charges: $37,260,333

*Includes Health Center and Day Surgery.
Laser Eye Center was moved under UT in July 2003

Health Management Associates

Appendix C

Project Access Project Access is a physician-led community effort to provide health care to low-income, employed but uninsured residents of Dallas County. It is managed by the Dallas County Medical Society and operates through a network of volunteer physicians and hospitals. Project Access provides both primary and specialty care, as well as access to pharmaceuticals, lab tests and other ancillary services (see summary below). Project Access is funded through grants and donations to the Medical Society’s charitable foundation and just completed its third and final year of funding under the Community Access Program (CAP) from the U.S. Department of Health and Human Services. In addition, Dallas County recently approved a $125,000 contribution to help support growing pharmacy costs in the program.
Project Access – Summary 2001 - 2004 Performance Measure Year 1 Year 2 Unduplicated patients 62 475 Prescriptions filled 143 1,954 Average prescription cost $35.81 $33.71 New physician appointments 48 370 Primary care physician appointments 9 321 Specialty care physician appointments 31 167 Hospital contacts 4 18 Ancillary/radiological contacts 10 92 Patients contacted by community health workers 612 1,825 Value of donated care $26,026 $307,096 Value of donated care per enrollee $420 $646 Average Monthly Enrollment 43 172 * Annualized 9 month Year 3 Average (Sept. 03-May 04) ** Estimates based on Year 3 Rate/Enrollee/Mo. Year 3* 971 5,480 $27.08 568 503 407 65 273 4,812 $627,396 $646 408 Year 4** 1,463 6,156 $23.97 626 555 449 72 301 5,307 $945,098 $646 450

Federally Qualified Health Centers (FQHC) There are two Federally Qualified Health Centers (FQHCs) located in Dallas County. FQHCs are required to provide care to all individuals regardless of ability to pay in exchange for receiving cash-based reimbursement from Medicare and Medicaid and access to other federal grants and programs. FQHCs are governed by community boards. MLK Family Center 2922-B Martin Luther King Jr. Blvd. Dallas, TX 75215 The Martin Luther King Jr. Family Center is located in the Fair Park area of Dallas and provides primary care and dental care to the underserved of Dallas. In 2002, the clinic saw more than 20,000 patients and provided immunizations for 8,000 children. The clinic has three physicians, two dentists and two nurse practitioners and sees an average of 200 patients per day.

Health Management Associates

Appendix D

Martin Luther King has an in-house laboratory and pharmacy and also provides transportation services to appointments for patients who do not have access to their own transportation.

Los Barrios Unidos 809 Singleton Blvd. Dallas, TX 75212 Los Barrios Unidos is located in the West Dallas neighborhood and has been operating for thirty-two years. Los Barrios provides prenatal, well-baby, adolescent health, immunizations, dental for children 5 to 17, some x-rays, pharmacy, some optometry, adult and geriatric services, WIC and other services. Each year, Los Barrios provides 60,000 medical encounters and an additional 40,000 other clinical encounters. Twelve to 15 percent of the clinics patients have Medicaid; the rest are self-pay. Los Barrios has 7 FTE pediatricians, 7 FTE internal medicine physicians, 6 FTE ob/gyns affiliated with Methodist Hospital, 2 nurse practitioners devoted to prenatal care, and 1 FTE dentist. The clinic sees 1,500 obstetrical patients each year. Approximately half of these women deliver at Parkland Hospital, while most of the remaining deliver at Methodist. Dallas County Free Clinics A number of free primary and urgent care clinics operate within Dallas County to help meet the needs of the uninsured. Many are sponsored by faith-based groups and most have limited hours and volunteer providers. Following is a list of the Dallas County clinics that participate in the Dallas County Medical Society Health Clinics Forum, including 2003 visits, where available (note: this is not an inclusive list of all clinics in Dallas County that provide free or low-cost care).
Dallas County Medical Society Health Clinics Forum Clinic 2003 Visits Agape Clinic at Grace United Methodist Church 7,722 Central Dallas Ministries Community Health Services 3,753 Christ’s Family Clinic Christian Community Action Adult Health Center Cornerstone Ministries Life Medical Clinic Dallas Life Foundation 5,426 Friendship House Health Ministries 560 (2002 visits) Grand Prarie Wellness Center 2,020 Islamic Association of North Texas Clinic Metrocrest Family Medical Clinic Mission East Dallas 1,286 (medical and dental) North Dallas Shared Ministries Medical Clinic 3,400 North Texas Indian Physicians Charitable Clinic The Stewpot Clinic 1,881 Urban Inter-Tribal Center of Texas *Source: Dallas County Medical Society and Parkland Strategic Planning & Population Medicine

Health Management Associates

Appendix D

Dallas County Department of Health and Human Services In 2002, the Dallas County Department of Health and Human Services expended approximately $7.2 million of general fund dollars to health administration, public health and disease prevention efforts and administered an additional $4.3 million in grant funding for disease prevention, training and immunization efforts. The following table summarizes utilization of the department’s immunization and clinic services over the last three years.
Indicator FY 2001 Childhood Immunizations 54,703 STD Clinic Visits 18,147 TB Clinic Visits 53,230 Source: Dallas County Management Report FY 2002 43,582 17,189 58,742 FY 2003 47,711 15,948 53,684

Dallas Department of Environmental and Health Services. The city of Dallas spent slightly more than $5 million on low-income health care services in 2002. The majority of this spending came from the city’s general fund to finance neighborhood clinics providing health screening and immunization services. The city also received about $725,000 in grant funding from the Texas Department of Health (TDH) for disease screening, immunization and lead abatement initiatives. The Dallas Department of Environmental and Health Services provides approximately 5,000 office visits for children at its four neighborhood clinics, approximately 1,000 visits to its low birth weight clinic, and provides 150,000 immunizations each year.

Health Management Associates

Appendix D

Parkland Health & Hospital System Uncompensated & Undocumented Health Care Analysis
Prepared for

October 7, 2004

1310 South First St. #105 Austin, Texas 78704 512-328-8300 www.txp.com

Parkland Uncompensated & Undocumented Health Care Analysis

Table of Contents
Introduction ...................................................................................................................................1 1. Assess Parkland’s Role in the Dallas Regional Economy ....................................................1 2. Identify the Current Level of Uncompensated and Undocumented Care ............................2 3. Analyze and Forecast Tax Revenues Used to Fund Uncompensated Care ......................10 4. Determine the Drivers of Parkland Uncompensated Care ..................................................12 5. Develop a 10-year Forecast for Parkland Uncompensated Health Care Costs .................15

Parkland Uncompensated & Undocumented Health Care Analysis
Introduction In light of shifting patterns of demand and changing demographics, an assessment was undertaken to analyze the key factors affecting the Parkland Health & Hospital System’s (Parkland) future uncompensated care costs. Five tasks were required for this analysis: 1) Assess Parkland’s Role in the Dallas Regional Economy; 2) Identify the Current Level of Uncompensated and Undocumented Care for the Dallas Region; 3) Analyze and Forecast Tax Revenues Used to Fund Uncompensated Care; 4) Determine the Drivers of Parkland Uncompensated Care; and 5) Develop a 10-year Forecast for Parkland Uncompensated Health Care. 1. Assess Parkland’s Role in the Dallas Regional Economy As a starting point for this analysis, it is important to understand Parkland’s role in the overall Dallas MSA. Public hospitals typically attract a disproportionately larger share of regional uncompensated health care, commensurately lowering the amount of uncompensated care provided by private hospitals. Since less uncompensated care is provided, private hospitals may be able to charge lower fees for overall health services. Beyond this “cost-containment” function, access to high quality public health care is crucial to the general well-being of a region for a number of additional reasons. First, health care is an oftentimes listed as a critical “site selection factor” for expanding and relocating businesses. Even if a business offers private heath insurance, the quality and existence of a public medical institution servers as an indicator of the region’s overall health care infrastructure. Second, a hospital’s affiliation with a medical school increases the region’s ability to attract doctors, nurses, and other medical support staff as well as creating an environment that can lead to spin-off economic developments. Third, hospitals are an important driver of economic activity in a region. Medical institutions typically pay above average wages, employ a large number of workers, and partake in a significant level of R&D. Annual Economic Impact of Parkland In 2003, Parkland employed approximately 7,800 part and full-time workers and paid salaries and benefits in excess of $410.5 million. The benefits of Parkland to the entire Dallas MSA economy consist of the day-to-day operation of the hospital, normal operating expenditures, purchases from local vendors, and spending of people employed by these businesses. In the final analysis, the economic benefits of this spending materialize in the form of increased Dallas MSA employment and income. The annual economic impact of Parkland has been calculated based on 2003 wage, salary, and total hospital charges. Specifically, this section of the analysis measures the economic impacts of Parkland’s normal operating activity on the Dallas MSA. Economic Impact Methodology In an input-output analysis of new economic activity, it is useful to distinguish three types of expenditure effects: Direct, Indirect, and Induced. Direct effects are production changes associated with the immediate effects or final demand changes. The payment made by an out-of-town visitor to a hotel operator is an example of a direct effect, as would be the taxi fare that visitor paid to be transported into town from the airport. Indirect effects are production changes in backward-linked industries caused by the changing input needs of directly affected industries – typically, additional purchases to produce additional output. Satisfying the demand for an overnight stay will require the hotel operator to purchase additional cleaning supplies and services, for example, and the taxi driver will have to replace the gasoline consumed during the trip from the airport. These downstream purchases affect the economic status of other local merchants and workers.

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Parkland Uncompensated & Undocumented Health Care Analysis
Induced effects are the changes in regional household spending patterns caused by changes in household income generated from the direct and indirect effects. Both the hotel operator and taxi driver experience increased income from the visitor’s stay, for example, as do the cleaning supplies outlet and the gas station proprietor. Induced effects capture the way in which this increased income is in turn spent by these people in the local economy. Figure 1: The Effects of an Initial Change in Economic Activity

Direct

+

Indirect

+

Induced

=

Total Impact

An economy can be measured in a number of ways. Three of the most common are “Output,” which describes total economic activity, and is equivalent to a firm’s gross sales; “Value Added,” which equals payments made by industry to workers, interest, profits, and indirect business taxes; and “Employment,” which refers to full and part-time jobs that have been created in the local economy. In order to provide an accurate basis of comparison, all dollar-denominated results are expressed in constant 2003 figures. The interdependence between different sectors of the economy is reflected in the concept of a “multiplier.” An output multiplier, for example, divides the total (direct, indirect and induced) effects of an initial spending injection by the value of that injection – i.e., the direct effect. The higher the multiplier, the greater the interdependence among different sectors of the economy. An output multiplier of 1.4, for example, means that for every $1,000 injected into the economy, another $400 in output is produced in all sectors.
Annual Economic Impact of Parkland’s Normal Operating Activity On the Dallas Metropolitan Statistical Area Economy Output (millions) Direct Indirect & Induced Total $709.1* $581.5 $1,290.6 Labor Income (millions) $410.5 $225.1 $635.6 Employment (Part & Full-time) 7,810 5,393 13,203

Source: TXP * Parkland Health & Hospital System FY2003 Payments & Allocations

The value of Parkland’s annual economic activity to the region is clear. The hospital system’s direct operations will generate an annual increase of $1.3 billion in total output, $635.6 million in employee wages, while supporting a total of 13,200 full and part-time local jobs. 2. Identify the Current Level of Uncompensated and Undocumented Care As Dallas County’s only public and tax-supported hospital, Parkland is the leading provider of uncompensated care for the community. In 2002, Parkland provided over $410 million in uncompensated care (charges based on charity care and bad debt). This represents nearly 50 percent of all uncompensated care provided by Dallas County acute care hospitals. From 19982002, Parkland’s total uncompensated care charges increased 33 percent or a compound annual growth rate of 7.3 percent.

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland Hospital Uncompensated Care Charges 1995 - 2002

$500 $410.1 $358.5 $351.6

$400.7 $400 $353.4 $290.0 $300.6 $301.5

$300
(Millions)

$200

$100

$0 1995 1996 1997 1998 1999 2000 2001 2002

Source: Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database

Dallas MSA Uncompensated Care Charges 1995 - 2002

$1,200
Dallas MSA Dallas County Parkland

$1,000

$800
(Millions)

$600

$400

$200

$0 1995 1996 1997 1998 1999 2000 2001 2002

Source: Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database

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Parkland Uncompensated & Undocumented Health Care Analysis
The Parkland HEALTHplus program is the mechanism used to meet a significant portion of the medical needs of Dallas County’s low income citizens. The following highlights of the Parkland HEALTHplus program was obtained from the Annual Report of Charity and Community Benefits for Fiscal Year 2001 And Plans for Fiscal Year 2002: Parkland HEALTHplus is designed to meet the health care needs of the medically and financially needy residents of Dallas County. Because of their inability to pay, many lowerincome Americans have had limited, and in many cases, no access to arguably the finest medical care the world has to offer. Parkland HEALTHplus focuses on preventive health care in Dallas County through more than a dozen of its neighborhood and school-based health centers. Parkland HEALTHplus is a sliding scale payment program for Dallas County self pay patients. This program is designed to foster increased patient responsibility while providing access to and continuity of care. The bottom line for Parkland; better allocation of health care resources, allows Parkland to provide more patients with quality care for the same health care dollar. Parkland HEALTHplus also serves as a crossover program for patients no longer eligible for Medicaid. Many residents of Dallas County, while earning too much money to qualify for Medicaid, still cannot afford traditional health care coverage. Rather than let this population continue to go unserved, Parkland HEALTHplus will allow them access to quality health care, at a cost determined on a sliding income scale.

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland HEALTHplus Encounters 2001 - 2003

500,000
Inpatients Outpatients

413,555 354,293 372,878

400,000

300,000

200,000

100,000

3,721 0 2001
Source: Parkland Health & Hospital System

3,712 2002

4,009 2003

Parkland HEALTHplus Charges 2001 - 2003

$200
Inpatients Outpatients

$150 $126.8 $117.8
(Millions)

$100

$94.8

$64.9 $52.2 $50 $49.5

$0 2001
Source: Parkland Health & Hospital System

2002

2003

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland HEALTHplus Costs 2001 - 2003

$200
Inpatients Outpatients

$150

(Millions)

$100 $76.1

$89.8 $78.5

$50 $29.4 $31.1

$34.5

$0 2001
Source: Parkland Health & Hospital System

2002

2003

Parkland HEALTHplus Encounters by Sliding Scale Category 2001 - 2003

500,000
Parkland HEALTHPlus Level 2 All Other

400,000 312,390 300,000 280,388

303,925

200,000

104,877 100,000 77,626 72,962

0 2001
Source: Parkland Health & Hospital System

2002

2003

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland HEALTHplus Charges by Sliding Scale Category 2001 - 2003

$200
Parkland HEALTHPlus Level 2 All Other

$156.8 $135.2

$150 $118.2
(Millions)

$100

$50 $28.8 $32.1

$34.9

$0 2001
Source: Parkland Health & Hospital System

2002

2003

Parkland HEALTHplus Costs by Sliding Scale Category 2001 - 2003

$200
Parkland HEALTHPlus Level 2 All Other

$150

(Millions)

$100

$96.7 $83.9

$92.6

$50 $21.5 $24.1 $20.4

$0 2001
Source: Parkland Health & Hospital System

2002

2003

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Parkland Uncompensated & Undocumented Health Care Analysis
A review of Parkland HEALTHplus activities over the past three years reveal a number of important considerations that influenced the forecasting of total Parkland uncompensated care: • Based on historical data provided by the Texas Department of Health and information provided by Parkland on the HEALTHplus program, the HEALTHplus program represents 40-50 percent of total Parkland uncompensated care charges. From 2001-2003, 78 percent of HEALTHplus patients were eligible to receive services under the Level 2 category. To qualify for Level 2 coverage, the Dallas County resident must have income less than 133 percent of the federal poverty level and have no other primary coverage (i.e., Medicare, Medicaid, or commercial insurance). The sliding scale used for the HEALTHplus program is divided into three main categories and is based on income relative to the federal poverty level (FPL) and family size: 0-133 percent of FPL, 133-200 percent of FPL, and 200-250 percent of FPL. Given the overwhelming utilization of the HEALTHplus by residents in the 0-133 percent of FPL bracket, most attempts to reduce costs would be minimal unless changes were made to this category. The cost-to-charge ratio for the HEALTHplus program during fiscal year 2003 was 59 percent. This is down significantly from the 72 percent cost-to-charge ratio experienced in fiscal years 2001 and 2002. The change in the cost-to-charge ratio was a result of Parkland’s response to Medicaid reimbursement rules that provide funding based on hospital charges. By increasing the charges for uncompensated care, Parkland was able to receive additional federal funds. This policy change had the indirect effect of lowering the cost-to-charge ratio. The cost-to-charge ratio for the entire Parkland system was 46 percent for fiscal year 2003. This is below the 1999-2002 cost-to-charge ratio of 54 percent.

Uncompensated care provided by Parkland is not limited to the HEALTHplus program and medical treatment for undocumented residents. Parkland also provides the community free and reduced services through unreimbursed costs of subsidized health services, educational programs, and unreimbursed research costs. In addition, health care provided to patients who do not qualify for the Healthplus program and/or do not have the ability to pay is also defined as uncompensated care. These other uncompensated costs represent approximately 50 percent of total Parkland annual uncompensated care charges. As part of this analysis, it is also important to understand the level of care provided to undocumented residents. While most hospitals, including Parkland, do not verify legal status prior to emergency room treatment, many states along the U.S.-Mexico border are experiencing financial burdens in providing this care. A recent study by MGT of America, Medical Emergency: Costs of Uncompensated Care in Southwest Border Counties, identifies the challenges in providing care to undocumented persons1: • The Emergency Medical and Treatment and Active Labor Act (EMTALA) requires hospitals and emergency personnel to screen, treat and stabilize anyone who seeks emergency medical care regardless of income or immigration status. Under

TXP served as subcontractors to MGT on this study, with Jon Hockenyos and Chandler Stolp of TXP responsible for developing the estimating methodology that produced these figures.

1

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Parkland Uncompensated & Undocumented Health Care Analysis
Emergency Medicaid, the federal government pays for some emergency medical care delivered to undocumented immigrants who, except for their immigration status, would be eligible for Medicaid. EMTALA mandates conflict with Emergency Medicaid reimbursement policies to the extent that EMTALA requires screening and treatment beyond those covered under the Medicaid “emergency condition” definition. • No standard method to track the amount of uncompensated care provided to undocumented immigrants currently exists. The absence of Social Security Numbers (SSN), in combination with other factors, may provide the federal government with an adequate proxy to enable tracking of aggregate amounts of uncompensated emergency care delivered to undocumented immigrants. State and local governments and local health care providers absorb a large portion of the costs of providing uncompensated emergency medical care to undocumented immigrants. These costs impose a significant financial burden on southwest border hospitals’ and emergency medical services (EMS) providers, and account for an estimated 23 percent of hospitals uncompensated costs.

While Dallas County is not located on the Texas-Mexico border, anecdotal evidence from a central Texas hospital that is currently tracking undocumented health care confirms these findings would also apply to non-border counties. For the purposes of this study, it is estimated that approximately 20 percent of uncompensated Parkland health care is provided to undocumented persons (emergency and non-emergency treatment), a figure consistent with the MGT study and the additional reported estimates in the region. This percentage is likely to remain fairly static over the next ten years, as there are a number of countervailing forces at work. For example, the ongoing overall disparity between the Mexican and U.S. economies suggests that the U.S. will continue to be viewed as the land of economic opportunity, especially in light of domestic trends such as greater female labor force participation, a shortage of blue-collar workers in the trades, and the general aging of the population. All of these factors would suggest greater in-migration. On the other hand, Border security has been heightened in the wake of 9/11 (both in terms of policy and enforcement), which will tend to dampen movement of undocumented persons northward. As a result, the percentage of uncompensated care attributable to undocumented persons is held constant over the forecast horizon.

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Parkland Uncompensated & Undocumented Health Care Analysis
Estimated Parkland Uncompensated Care: U.S. and Undocumented Persons 1995 - 2002

$500
U.S. Citizens Undocumented

$400

(Millions)

$300

$200

$100

$0 1995 1996 1997 1998 1999 2000 2001 2002

Source: TXP, Cooperative TDH/AHA/THA Annual Survey of Hospitals and Hospital Tracking Database

3. Analyze and Forecast Tax Revenues Used to Fund Uncompensated Care To help offset these uncompensated health care costs, Parkland receives public funds from the Dallas County Hospital District. Note, the ad valorem tax rate increased from $0.196 per $100 valuation in 1999 to $0.254 per $100 valuation in 2000. To assess the long-term implications of uncompensated care, a 10-year forecast of Dallas County Hospital District tax revenue was created by extrapolating recent growth trends in the total appraised value of the District’s tax base. After peaking at 9.1 percent growth during 1999, the value of the District’s tax base grew only 0.2 percent during 2003 before rebounding to a 4.1 percent growth rate this year. A fouryear moving-average of annual growth was used to project the value of the tax base through 2015. By using a fairly short-term extrapolation base, greater emphasis is put on recent performance, which is consistent with expectations that overall economic growth in the Dallas area will be slower over the forecast horizon that it was during 1994-2004. As a result, the District’s tax base is expected to grow at a compound annual rate of 3.1 percent for the next ten years, in contrast to the 5.7 compound annual rate for the past ten.

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Parkland Uncompensated & Undocumented Health Care Analysis
Estimated Parkland Hospital District Tax Revenue 1995 - 2002

$400

$300

(Millions)

$200

$100

$0 1995 1996 1997 1998 1999 2000 2001 2002

Source: Dallas Central Appraisal District

Parkland Hospital District Tax Revenue Forecast
1995 - 2015

$600
Start of forecast values

$500

$400
(Millions)

$300

$200

$100

$0 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Source: TXP, Dallas Central Appraisal District

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Parkland Uncompensated & Undocumented Health Care Analysis
4. Determine the Drivers of Parkland Uncompensated Care The fluctuation in uncompensated health care costs for Dallas County and Parkland is consistent with the economic highs and lows witnessed over the past five years. The Dallas MSA was disproportionately impacted by the downturn in the technology sector. Tens of thousands of high paying jobs that provided health insurance were lost. Part of the explanation also lies in the “jobless” nature of the current recovery – without significantly higher levels of job creation, it will be challenging for many citizens to afford individual health insurance, private physician care, and hospital health care costs. The demand for public sector health care services is largely a function of access to private health insurance. As a result, changes in local economic activity, overall employment, and benefits provided by local business to a large extent determine changes in demand for public health care. This relationship is especially true over an extended period of time. There are two broad approaches to time series forecasting: extrapolation techniques, which use past observations of a given series to predict its future values, and structural or econometric methods, where changes in an explanatory variable or variables are used to forecast the series in question. Each has its relative strengths. Extrapolation methods are normally considered to be most effective when the number of observations in the series is high (ideally at least twenty), when any underlying trends are fairly evident, and when the forecast horizon is short (usually no more than six periods). In terms of uncompensated health care forecasting, actual elapsed time is also relevant; using extrapolation techniques to forecast annual data is generally only appropriate when the time series is “stationary,” which means it tends to revert to a constant long-term value. Since measures of the economy (and, by extension, uncompensated health care) are not stationary, extrapolation techniques, on a stand-alone basis, ideally should be used for very short-term forecasts. As mentioned above, structural forecasts involve using changes in an explanatory variable or variables to forecast change in the series under analysis. Uncompensated health care costs are generally highly correlated with changes in the overall economy, and, in particular, tend to reflect shifts in personal income, access to employer sponsored health insurance, and overall regional population and employment growth. In other words, uncompensated health care costs are based on a combination of regional forces that may appear to be unrelated. Ideally, an uncompensated health care cost equation would include all of the elements listed above. However, limitations on data availability and timeliness make that approach less than optimal at the local level. There is no credible Dallas-specific data on health insurance costs, and information on undocumented residents is Dallas County is either not publicly available or does not provide enough data points for analysis. As a result, alternative measures are used. Dallas MSA and Parkland Per Capita Uncompensated Care Costs – Regression Model Located in a major metropolitan area, Parkland is greatly influenced by regional economic trends, which in turn are determined by national and international factors. Iterative regression modeling suggests that regional employment data provides insight into the percentage of residents that may have employer sponsored medical insurance (the Dallas County unemployment rate), statistics on the percentage of non-U.S. residents without health insurance, and state data on health insurance costs do an excellent job of explaining changes in Dallas MSA uncompensated per capita health care costs. This data is then integrated with three alternative regional population forecast scenarios (the driver determining the theoretical number of residents that may need to be served) to generate overall levels of projected uncompensated care. The following graphics depict data used in the regression model.

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Parkland Uncompensated & Undocumented Health Care Analysis
Percentage of Uninsured Non-Citizens Residing in the U.S. 1996 - 2002

80%

60%

42.4% 40%

43.6%

42.9%

42.1%

41.7%

42.9%

43.3%

20%

0% 1996 1997 1998 1999 2000 2001 2002

Source: TXP, U.S. Census Bureau

Texas Average Total Family Premium Per Enrolled Employee at Private-Sector Establishments that Offer Health Insurance 1996 - 2002
$10,000 $8,837 $8,000 $6,638 $6,209 $6,000 $4,899 $4,000 $5,693 $5,588 $7,486

$2,000

$0 1996 1997 1998 1999 2000 2001 2002

Source: Medical Expenditure Panel Survey

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Parkland Uncompensated & Undocumented Health Care Analysis
Dallas County Unemployment Rate 1996 - 2002

10% 9% 8.0% 8% 7% 6% 5% 4% 3% 2% 1% 0% 1996 1997 1998 1999 2000 2001 2002 4.5% 4.2% 3.7% 3.5% 3.5% 5.4%

Source: Texas Workforce Commission

The end result of the first regression analysis was the identification of per capita cost of uncompensated health care for the entire Dallas MSA. The logic is that the dynamic nature of the Dallas MSA creates linkages between each county, with some non-Dallas County citizens traveling to Parkland to receive medical treatment. Therefore, it is important that the model take this interaction into account. An analysis limited to Dallas County or Parkland would fail to capture these important components. The findings indicate that the equation is statistically significant at the highest confidence level, with 95.5 percent of the change in uncompensated health care costs being explained by changes in the independent variables. The following table presents the results of the regression.
Table 1: Summary Regression Statistics R Square .9550
Source: TXP

Adjusted R Square .9099

Standard Error 8.7316

F – Statistic 21.2091

Once the explanatory relationship between per capita uncompensated health care costs and the independent variables is delineated, actual values and projections of each variable can be used to generate a specific forecast of Parkland uncompensated health care over the next ten years. The projection for each of explanatory variable was based on 3rd order polynomial trend extension, a process that yielded overall results reasonably consistent with extrapolation of the dependent variable (per capita uncompensated care) itself.

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Parkland Uncompensated & Undocumented Health Care Analysis
Dallas MSA Per Capita Uncompensated Health Care Costs Forecast 1995-2015

$800

Start of forecast values

$600

$400

$200

$0 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Source: TXP

5. Develop a 10-year Forecast for Parkland Uncompensated Health Care Costs Upon completion of developing the projections, Dallas County and Parkland’s share of regional uncompensated health care costs were estimated based on the widely accepted county population forecasts produced by the Texas State Data Center. Three population forecasts were used to create low, medium, and high scenarios: Low - The One-Half 1990-2000 Migration (0.5) Scenario - This scenario has been prepared as an approximate average of the zero (0.0) and 1990-2000 (1.0) scenarios. It assumes rates of net migration one-half of those of the 1990s. The reason for including this scenario is that many counties in the State are unlikely to continue to experience the overall levels of relative extensive growth of the 1990s. A scenario which projects rates of population growth that are approximately an average of the zero and the 1990-2000 scenarios is one that suggests slower than 1990-2000 but steady growth. Medium - The 1990-2000 Migration (1.0) Scenario - The 1990-2000 scenario assumes that the trends in the age, sex and race/ethnicity net migration rates of the 1990s will characterize those occurring in the future of Texas. The 1990s was a period characterized by rapid growth. It is seen here as the high growth alternative because its overall total decade pattern is one of substantial growth (i.e., 22.8 percent for the 1990-2000 decade for the State). Because growth was so extensive during the 1990s it is likely to be unsustainable over time and thus this scenario is presented here as a high growth alternative. For counties that experienced net outmigration during the 1990s, this scenario produces continued decline.

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Parkland Uncompensated & Undocumented Health Care Analysis
High - The 2000-2002 Migration Scenario - The 2000-2002 projection scenario provides a scenario that takes into account post-2000 population trends. In the State overall and in some counties the post-2000 period has resulted in reduced levels of net migration. In other counties post-2000 net migration rates have been greater than those of the 1990s. Under this scenario the 2000-2002 age, sex and race/ethnicity specific migration rates are assumed to prevail from 2000 through 2040. This scenario allows those users who believe that the 2000-2002 period has produced fundamental long-term changes in population patterns to ascertain the likely future size and characteristics of the population.

Dallas Metropolitan Statistical Area Population Forecast 1995-2005
6.0
Low Start of forecast values

5.5

Medium High

5.0
(Millions)

4.5

4.0

3.5

3.0

2.5 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015

Source: Texas State Data Center

The result of Task 2 yielded a per capita uncompensated health care cost for the Dallas MSA. The following graphics depict the uncompensated health care cost scenarios based on varying levels of population growth. The cost-to-charge ratio used was 55 percent, consistent with the cost-to-charge ratio for Parkland over the past few years. Projected Parkland Hospital District tax revenue estimates have been incorporated into the charts to highlight potential shortfalls in revenue and assist in long-term planning. Medicaid Reimbursement Shortfall and Other Parkland Uncompensated Costs The uncompensated costs scenarios do not include any shortfall due to insufficient Medicaid reimbursement or other hospital losses offset by Parkland Hospital District tax revenues. In 2003, for example, Parkland experienced a Medicaid shortfall of $63.4 million. Since Medicaid reimbursement rates can fluctuate substantially over time and are determined by public policy at the national level, these costs have been excluded. Therefore, any graphic or data that depicts Parkland tax revenues in excess of uncompensated costs does not assume these funds are not required to support and sustain other important hospital operations and activities.

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland Uncompensated Costs Scenarios 1995 - 2015
$800
Low Medium Start of forecast values

$600

High

(Millions)

$400

$200

$0 1995
Source: TXP

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Parkland Uncompensated Costs Low Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue Uncompensated Costs

$600

(Millions)

$400

$200

$0 1995
Source: TXP

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

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Parkland Uncompensated & Undocumented Health Care Analysis
Parkland Uncompensated Costs Medium Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue Uncompensated Costs

$600

(Millions)

$400

$200

$0 1995
Source: TXP

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

Parkland Uncompensated Costs High Growth Scenario vs. Parkland Hospital District Tax Revenue
$800
Tax Revenue Uncompensated Costs

$600

(Millions)

$400

$200

$0 1995
Source: TXP

1997

1999

2001

2003

2005

2007

2009

2011

2013

2015

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Parkland Uncompensated & Undocumented Health Care Analysis
Dallas MSA Population Estimates & Per Capita Uncompensated Charges 1995 - 2015
Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Dallas MSA Population Low Medium 2,958,809 2,958,809 3,032,906 3,032,906 3,117,245 3,117,245 3,202,721 3,202,721 3,280,310 3,280,310 3,519,176 3,519,176 3,560,750 3,592,060 3,602,766 3,667,611 3,642,929 3,743,993 3,681,986 3,820,773 3,719,867 3,898,970 3,755,989 3,977,406 3,790,439 4,056,798 3,823,287 4,135,858 3,854,937 4,215,645 3,885,472 4,296,902 3,915,001 4,377,878 3,943,221 4,460,569 3,970,770 4,544,027 3,996,917 4,628,444 4,022,783 4,713,133 High 2,958,809 3,032,906 3,117,245 3,202,721 3,280,310 3,519,176 3,611,665 3,709,756 3,812,413 3,918,475 4,028,336 4,142,271 4,259,042 4,380,320 4,504,945 4,633,516 4,766,790 4,904,636 5,046,817 5,194,257 5,345,840 Dallas County Population Low Medium 1,961,007 1,961,007 1,986,996 1,986,996 2,016,929 2,016,929 2,045,309 2,045,309 2,062,100 2,062,100 2,218,899 2,218,899 2,245,639 2,251,775 2,270,794 2,284,143 2,296,507 2,318,646 2,321,572 2,352,877 2,346,180 2,388,186 2,369,565 2,423,428 2,391,945 2,459,162 2,413,366 2,494,168 2,433,817 2,529,553 2,453,675 2,565,731 2,472,908 2,601,214 2,491,295 2,638,001 2,509,214 2,674,973 2,526,262 2,712,368 2,542,977 2,749,375 High 1,961,007 1,986,996 2,016,929 2,045,309 2,062,100 2,218,899 2,257,306 2,298,091 2,341,937 2,387,537 2,434,946 2,484,686 2,535,923 2,589,165 2,644,450 2,702,237 2,762,094 2,824,527 2,889,021 2,956,289 3,025,283 Est. Charges Per Capita (MSA) $194 $211 $217 $235 $257 $255 $267 $294 $308 $326 $345 $365 $386 $407 $428 $450 $472 $494 $515 $537 $558

Source: U.S. Census Bureau, Texas State Data Center, TXP

Parkland Uncompensated Charge & Cost Estimates 1995 - 2015
Year 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Source: TXP Charges (Millions) Low Medium $290.0 $290.0 $300.6 $300.6 $301.5 $301.5 $353.4 $353.4 $400.7 $400.7 $358.5 $358.5 $351.6 $351.6 $410.1 $410.1 $432.4 $444.4 $457.3 $474.6 $494.1 $517.9 $526.4 $557.5 $560.2 $599.6 $597.0 $645.8 $633.2 $692.4 $670.4 $741.4 $708.5 $792.3 $746.5 $844.5 $784.9 $898.2 $823.1 $953.2 $861.2 $1,008.9 High $290.0 $300.6 $301.5 $353.4 $400.7 $358.5 $351.6 $410.1 $452.5 $486.7 $535.0 $580.6 $629.5 $684.0 $740.0 $799.5 $862.7 $928.5 $997.6 $1,069.7 $1,144.4 Low $159.5 $165.3 $165.8 $194.4 $220.4 $197.2 $193.4 $225.5 $237.8 $251.5 $271.7 $289.5 $308.1 $328.4 $348.3 $368.7 $389.7 $410.6 $431.7 $452.7 $473.6 Cost (Millions) Medium $159.5 $165.3 $165.8 $194.4 $220.4 $197.2 $193.4 $225.5 $244.4 $261.0 $284.8 $306.6 $329.8 $355.2 $380.8 $407.8 $435.7 $464.5 $494.0 $524.2 $554.9 High $159.5 $165.3 $165.8 $194.4 $220.4 $197.2 $193.4 $225.5 $248.9 $267.7 $294.3 $319.3 $346.2 $376.2 $407.0 $439.7 $474.5 $510.7 $548.7 $588.3 $629.4 Estimated Tax Revenue $159.6 $162.9 $167.6 $176.8 $210.1 $292.8 $317.6 $327.4 $328.0 $341.4 $354.9 $364.9 $375.0 $387.8 $400.3 $412.6 $425.5 $439.1 $452.9 $467.1 $481.9

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Parkland Uncompensated & Undocumented Health Care Analysis
Legal Disclaimer
Every attempt has been made to ensure the information contained herein is valid at the time of publication. Texas Perspectives Inc. (TXP), however, reserves the right to make changes, corrections and/or improvements at any time and without notice. In addition, Texas Perspectives Inc. disclaims any and all liability for damages incurred directly or indirectly as a result of errors, omissions or discrepancies. Any statements involving matters of opinion or estimates, whether or not so expressly stated, are set forth as such and not as representations of fact, and no representation is made that such opinions or estimates will be realized. The information and expressions of opinion contained herein are subject to change without notice, and shall not, under any circumstances, create any implications that there has been no change or updates.

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Medicaid Reimbursement Comparisons
The following table presents a comparison of Medicaid payments to large public hospitals on an adjusted Medicaid patient day basis. It is important to note that hospitals report their Medicaid payments differently. The payments in the table include base Medicaid payments, net DSH payments and, in some cases, net UPL payments. Because of differences in reporting, these figures are not exact, but they do illustrate the magnitude of the Medicaid reimbursement issue at Parkland.
Medicaid Payment Comparison -- Selected Hospitals (2002)
Estimated Medicaid Payments/ Adjusted Medicaid Patient Day $1,091 $2,073 $2,217 $2,436 $2,672 $3,956 $2,107

Hospital Parkland Jackson Memorial Cook County Wishard LA County – USC Denver Health Total/Average

Estimated Adjusted Medicaid Patient Days 196,593 133,133 103,588 70,140 164,974 41,525 709,953

Medicaid Payments $214,434,922 $276,035,801 $229,648,946 $170,859,154 $440,755,042 $164,279,991 $1,496,013,856

Source: NAPH 2002 Member Survey

Health Management Associates

Appendix F

Parkland Pharmacy Issue Paper I. Pharmacy Overview Parkland pharmacy represents approximately $80 million of Parkland’s overall $820 million budget (FY05 budget request). Approximately 300 staff including pharmacists, pharmacist technicians, and support staff cover operations for all campus and off-campus locations. Some observations about Parkland’s pharmacy program: • Systems and Automation Capacity Appear to be Progressive – automated ambulatory prescription filling at all clinics, PPC, and OPC, access to patient profiles on the intranet for prescribing physicians and pharmacists, and the T2 cost accounting system appear to provide a strong system infrastructure. • Pharmacy and Therapeutics Committee and Preferred Drug List Appear to be Aggressive. Parkland works closely with Southwestern physicians and COPC physicians to coordinate the P&T’s Committee work. Looking at access in some of the highly prescribed classes indicates that the PDL is being carefully managed (e.g. 1 statin and 1 SSRI on the PDL). 99% of prescriptions filled are filled from the PDL. • Drug Manufacturer Supplemental Rebates and Product Donation Appear to be Aggressive –Additional rebates from drug manufacturers and product donation are one variables taken into consideration (in addition to patient safety, efficacy) as the preferred drug list is constructed. Parkland obtained $22.7 million in product through the Texas Department of Health, various drug manufacturers, and investigational drug services. II. Opportunities under MMA The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) provides several opportunities for safety net providers like Parkland. Members that currently receive drugs through PHP will either access their medications at Parkland or off site at a local pharmacy. Either scenario benefits Parkland in terms of reduced exposure to a cost pressure. • Drug Discount Subsidies – From June, 2004 through December 2005, beneficiaries below 135% of FPL ($12,569/single;$16,862/couple in 2004) who do not have private or Medicaid drug coverage will have $600 per year for drug expenses. Parkland estimates the target population (Medicare recipients not enrolled in Medicaid) to be approximately 4,900 individuals. • Drug Discount Subsidies Impact - If 25% of the 4,900 eligibles are enrolled with a discount drug card, this will save Parkland up to $1.1 million. The impact of the subsidies could be as high as $5.9 million (through December 2005) depending upon federal enrollment provisions, how the Discount Card will be integrated into PHP eligibility, and how much of the subsidy is spent by the member. Every effort should be made to coordinate PHP members and prospective members with the Drug Discount Card. • Low-Income Assistance – Medicare will provide additional assistance on January 1, 2006. Outpatient prescription drugs will be covered through private plans. Whereas the majority of beneficiaries will have substantial cost sharing responsibilities: o Beneficiaries with incomes below 135% of FPL will receive a subsidy to cover the average premium cost and will have no deductible and no cost-sharing above the out of pocket threshold. They will pay $2 and $5 copays.

Health Management Associates

Appendix G

o Beneficiaries with incomes below 150% of FPL will receive premium subsides on a sliding scale. They will pay a $50 deductible, 15% coinsurance up to the out of pocket threshold, and $2 to $5 copays above the threshold. Low-Income Assistance Impact – The 4,900 individuals were responsible for approximately $4.9 million for the past 4 quarters. Since the Low-Income population is covered at slightly higher income levels than the Discount Card (150% FPL vs. 135% FPL), a larger population will be covered. Given the limitations of the T2 and the eligibility system, the 0%-150% cohort is prorated to be approximately 5,800 individuals and $5.8 million. This is maximum estimated number. It is recommended that this be looked into in greater detail considering MMA cost-sharing requirements and participation rates. Enrollment in MMA is Voluntary and Seamless Coordination with PHP is Imperative to Maximize MMA’s Value. It will be important to enroll as many PHP members and prospective PHP members into a Medicare Drug Plan as possible. The details associated with late enrollment are yet to be established by the Secretary of HHS, but it is important to note that late enrollments may potentially adversely affect Parkland.

III. Capacity Issues There will be several issues associated with the pharmacy cost and system capabilities over time. The following data will lay out some of the key indicators that reflect some of the compelling pharmacy issues: Table 1:
2000 Number of Prescriptions Mail Order Prescriptions Refill Percentage Turn Around Time (min)
Source: Parkland Pharmacy, 2004

2001
1,482,517 7,267 51% 73

2002
1,697,267 7,814 53% 38

2003
1,881,189 11,344 50% 46

2004
1,823,308 17,266 57% 62

1,399,203 0 47% 56

Chart 1:
Prescription Volume Over Time (in millions)

2.0 1.5 1.0 0.5 0.0 2000 Prescriptions Refills

2001

2002

2003

2004

Source: Parkland Pharmacy, 2004

Health Management Associates

Appendix G

Chart 2:
2004 Prescription Volume by Payor
30% PHP Non-indigent

Chart 3:
2004 Prescriptions by Type
Refills

43%

New Presciptions

70%

57%

Source: Parkland Pharmacy, 2004

Source: Parkland Pharmacy, 2004

Parkland Health & Hospital System Department of Pharmacy Services Annualized Pharmacy Statistics by Store Cost Center
COPC Facilities deHaro Saldivar Fiscal Year 2000 Total Rx Volume Average Rx TAT (min) Mail Order Rx's Fiscal Year 2001 Total Rx Volume Average Rx TAT (min) Mail Order Rx's Fiscal Year 2002 Total Rx Volume Average Rx TAT (min) Mail Order Rx's Fiscal Year 2003 Total Rx Volume Average Rx TAT (min) Mail Order Rx's Fiscal Year 2004 * Total Rx Volume Average Rx TAT (min) Mail Order Rx's 176,954 19 156,841 18 129,773 31 176,751 47 246,548 59 119,205 35 358,421 141 458,815 142 17,266 1,823,308 62 17,266 167,091 16 152,477 20 123,872 18 192,710 40 233,929 53 196,685 27 363,835 103 450,590 88 11,344 1,881,189 46 11,344 140,138 11 127,442 25 121,749 13 176,206 31 193,930 36 202,366 21 338,045 85 397,391 82 7,814 1,697,267 38 7,814 118,043 14 108,308 50 99,699 31 147,783 163 152,159 100 204,276 18 289,008 116 363,241 91 7,267 1,482,517 73 7,267 94,817 19 92,687 75 83,515 25 142,111 54 139,114 75 217,369 23 315,277 109 314,313 68 1,399,203 56 0 East Dallas Garland Bluitt Flowers Southeast Dallas On Campus Facilities Discharge / ER Pharmacy OPC Pharmacy PPC Pharmacy Grand Totals

* Annualized based on 11 months YTD Source: Parkland Pharmacy

Health Management Associates

Appendix G

Compelling Issues • Opportunity for Mail Order Pharmacy is Strong – Infrastructure issues will need to be addressed as drug volumes will increase over time. It is clear given the current mail order volume, the current refill level (57%) that mail order pharmacy, a central refill station, or a combination of the two are an important consideration when moving forward. Substantial operational savings opportunities are available for the present and opportunities to deal with outyear pricing and infrastructure pressures add layers of options. • Central Refill Station - If implemented as a package with mail order, there will be a significant reduction in labor costs, increased patient safety and reduced turnaround times. Implementing any part of the automation by itself will help, but it will not provide the potential returns as package will. • PHP Dominates Drug Use – PHP represented 70% of the prescription volume as indicated in Chart 2. Opportunities for care management with PHP may pay dividends in the pharmacy budget. • Careful Monitoring of Prescription Volumes and Unintended Impacts – Parkland changed its discharge policy which has had an effect upon prescription volume. Table 2 indicates that prescription volume is likely to decrease in 2004 for the first time in many years. This is likely a combination of the discharge policy and stations at PPC and OPC operating at full capacity. It will be important to monitor if a suppressed demands creates unintended consequences at other points in the system • Prescription Turn-Around Times – Turn-Around times for filling prescriptions substantially increased from 2002 to 2004 (decrease from 01 to 02 was due to automation adjustments and redesign). OPC and PPC are at capacity with waits over 2.5 hours while clinic times remain relatively reasonable.

Health Management Associates

Appendix G

PARKLAND COMMUNITY HEALTH PLAN
KEY FINDINGS AND RECOMMENDATIONS Isadore J. King, MBA, CPA October 6, 2004 SCOPE This review was limited to the Medicaid and CHIP HMO operations of Parkland Community Health Plan (PCHP) and included an in depth interview with Timothy Bahe, Executive Director. None of the findings and recommendations applies to the indigent health plan or the employee health plan. DOCUMENT REVIEW The following documents were reviewed and serve as the basis for the contents of this report. A. B. C. D. E. PCHP Meeting Summary May 24, 2004 PCHP Board Overview February 11, 2004 PCHP Executive Summary April 2004 AETNA (NYLCare Southwest) ASO Contract PCHP Board Orientation July 2004

KEY FINDINGS • • • • • • • • In 2003 PCHP generated a total loss of $4.0 million ($6.0 million loss for Medicaid, $2.0 million profit for CHIP) For the first quarter of 2004 PCHP operated at breakeven (approximate $1.0 million loss for Medicaid, $1.0 million profit for CHIP) Medicaid revenue pmpm for first quarter of 2004 increased by 6% ($155.36 vs. $146.91), medical costs increased slightly ($135.32 vs. $134.16) and administrative costs increased by 19% ($23.59 vs. $19.84) Improved Medicaid results for first quarter of 2004 attributed to 9/03 Medicaid rate increase and renegotiation of provider contracts to lower rates CHIP revenue pmpm for first quarter of 2004 was flat ($78.94 vs. $78.89), medical costs decreased by 13% ($56.65 vs. $64.99) and administrative costs increased by 54% ($11.96 vs. $7.79) AETNA ASO fees pmpm for both products increased by 2.5% (Medicaid $16.40 vs. 16.00, CHIP $8.95 vs. $8.73) Overall administrative costs are 15% for both products PCHP has acquired staffing and other resources to provide leadership, oversight, direction and communications in the areas of Marketing, Community Relations,

1

• • • • • • • •

Member Services, Provider Relations and Medical Management; AETNA remains responsible for program implementation and day to day operations PCHP pays Children’s Medical Center 105% of Medicaid rates PCHP pays non-participating CHIP providers 100% of billed charges All PCPs are paid a $3 pmpm gatekeeping fee No detailed actuarial analysis has been conducted for Medicaid or CHIP revenue rates AETNA provides comprehensive data files to PCHP but PCHP has to perform extensive data analysis to obtain relevant, useful and actionable information Budgeting, financial and utilization reporting are performed at aggregate and gross levels with limited ability to drill down to cost, quality and utilization drivers or perform root cause analyses Data received from behavioral health and PBM providers (services are carvedout) is not useful or actionable There is no provider profiling capability

RECOMMENDATIONS • Reduce administrative costs to industry standard of 12 % of revenue; ASO services and internal administrative operations should be reviewed to delineate responsibilities, clarify deliverables, eliminate redundancies, and identify and take advantage of any opportunities for synergy. We understand that the U.S. Department of Health and Human Services Office of the Inspector General (OIG) will be conducting an audit of the administrative costs of all Medicaid managed care plans in the current fiscal year. PCHP’s current administrative cost structure will not be viewed favorably in this review. Renegotiate ASO contract to provide for fee reductions at higher membership levels Renegotiate provider contracts (as applicable) to pay Medicaid rates (especially Children’s) Pay all CHIP non-participating providers at reasonable and customary rates Eliminate $3 gatekeeping fee for PCPs; establish an incentive pool (for ex: $1.0 million) to reward PCPs who achieve certain utilization and quality targets Conduct detailed actuarial analyses of Medicaid and CHIP rates to facilitate negotiations with state (possibly pursue risk adjusted rates) and improve financial forecasting and budgeting Retain a claims auditing organization on a contingency fee basis to identify and recover claims paid incorrectly Develop a data warehouse and acquire a decision support solution (including provider profiling) to identify cost, utilization and quality drivers

• • • • • • •

2

POTENTIAL SAVINGS Reduce administrative costs to 12 % of revenue Pay Medicaid rates to Children’s Medical Center Eliminate $3 PCP gatekeeping fee (establish incentive pool) Recover claims paid incorrectly Reduce CHIP payments to non-participating providers TOTAL $3,700,000 1,500,000 2,000,000 500,000 500,000 $8,200,000

3

Deliverable: Identify the total resources by source (i.e., Medicare, Medicaid, taxes, other public and private sources) that are dedicated to low income care. Table 1 identifies the resources, by source, that are dedicated to low-income care in Dallas County. All data is from 2002, the most recent year for which complete data is available. In 2002, more than $1.6 billion was expended for low-income health care in Dallas County. Medicaid/SCHIP Medicaid accounted for the vast majority of available funding for low-income health care in Dallas County at a little over $1.2 billion in 2002. Medicaid is a joint state and federally funded program targeting low-income families, those receiving cash benefits through other federal programs and low-income elderly and disabled individuals. In the state of Texas in 2002, Medicaid benefits are available, depending upon eligibility category and family composition, to individuals earning between 0% and 185% of the federal poverty level (FPL). The $1.2 billion figure includes payments for services received by individuals enrolled in Medicaid managed care plans and those enrolled in fee-for-service Medicaid. It also includes direct payments to hospitals that serve a disproportionate number of individuals who are either uninsured or covered by Medicaid, through Texas’ Medicaid Disproportionate Share Hospital (DSH) program. Approximately $220 million, about 18% of total Dallas Medicaid spending, of the $1.2 billion was spent for nursing home services. State of Texas State Children’s Health Insurance Program (SCHIP) funds accounted for about $55 million in fiscal year 2002. SCHIP is another joint state and federally funded health insurance program. This program provides health insurance coverage for children up to age 19 ineligible for Medicaid with family income below 200% FPL. Substantial changes were made to Medicaid and SCHIP eligibility during the 2003 legislative session for the final FY2004-2005 biennium budget. HHSC and state officials projected children’s Medicaid and SCHIP enrollments to be 577,981 less in FY2005 and that total savings for the biennium budget at more than $1.6 billion.1 Based upon spending and enrollment assumptions, it is projected that this will reduce spending for the biennium by approximately $140 million and enrollments by approximately 50,000 members in Dallas County2. The cuts were driven primarily by reducing continuous eligibility, establishing a 90-day waiting period, higher cost sharing requirements, eliminating a number of optional medical services, and provider rate cuts. Medicare Medicare is not a means-tested program, and reliable data on Medicare spending on lowincome beneficiaries is not readily available. Therefore, this analysis includes only those Medicare resources expended in Dallas County through the Medicare Disproportionate Share Hospital (DSH) program, which funds hospitals that serve a large proportion of Medicaid patients and low-income Medicare patients. Dallas County hospitals received
1

“Children’s Medicaid and SCHIP in Texas: Tracking the Impact of the Budget Cuts”. Kaiser Commission. July, 2004. 2 Impact prorated from HHSC Reports

Health Management Associates

Appendix I

Medicare Disproportionate Share (DSH) payments from the federal government in excess of $34 million in fiscal year 2002. Tax Support The Dallas County Hospital District (Parkland Hospital and Health System) received $311 million in tax support in 2002 for indigent health care. This is based on the current rate of $0.254 per $100 of assessed value. Other Public The city of Dallas spent slightly more than $5 million on low-income health care services. The majority of this spending came from the city’s general fund to finance neighborhood clinics providing health screening and immunization services. The city also received about $725,000 in grant funding from the Texas Department of Health (TDH) for disease screening, immunization and lead abatement initiatives. The Dallas County Health Department accounted for about $11.5 million of the total resources dedicated to low-income health care in the county. The department expended about $7.2 million of general fund dollars to health administration, public health and disease prevention efforts and administered an additional $4.3 million in grant funding for disease prevention, training and immunization efforts. The Dallas County Hospital District received $3.4 million in 2002 from tobacco settlement proceeds, pursuant to the settlement agreement dated July 18, 1998. Under the agreement, "all hospital districts, other local political subdivisions owning and maintaining public hospitals, and counties of the State of Texas responsible for providing indigent care to the general public” are eligible to receive funds. Parkland Foundation The Parkland Foundation is a nonprofit corporation organized in Texas in 1985 to support and benefit Parkland exclusively. The Foundation’s mission is to provide resources and promote community involvement to embrace the mission and vision of Parkland. Expenditures represented in the table are the support for low-income patients channeled directly or through the Parkland Foundation to Parkland Health and Hospital System in 2002. 2002 Expenditures for Low-Income Healthcare in Dallas County, By Source
2002 Expenditures $1,202,119,500 $54,962,100 $34,454,800 $310,763,000 $20,153,800 $3,380,300 $5,241,800 $11,531,700 $8,163,600 $1,630,616,800 2002 Dallas County Enrollment 190,000 47,800 NA NA NA NA NA NA NA 237,800

Program Medicaid SCHIP Medicare DSH Tax Support Other Public Tobacco Settlement Dallas City Dallas County Health Dept. Parkland Foundation Total

Source HHSC HHSC Centers for Medicare and Medicaid Svcs. 2002 Dallas County Budget Texas Department of Health 2002 Dallas City Budget 2002 Dallas County Budget Parkland Foundation

Health Management Associates

Appendix I

Deliverable: Identify the standard of indigence used by the Hospital District, what standard is used by adjacent counties and what are the options that may or should be considered as a reasonable standard for eligibility for indigent care.

Deliverable: Identify the surrounding counties’ standard of indigency for medical services, the amount of healthcare funding set aside and dollars expended by counties for low income citizens. This analysis should include the level and scope of publicly and privately funded health care including non-facility based resources available in the surrounding counties and their funding source.

STATE LAW REQUIREMENTS – INDIGENT HEALTH CARE In Texas, indigent care is primarily provided by hospital districts, public hospitals and county run programs operated under the umbrella of the County Indigent Health Care Program (CIHCP). Counties that are not fully served by a public hospital or hospital district are responsible for administering a CIHCP for indigent residents of all or any portion of the county not served by a public hospital or hospital district. With the recently created hospital district in Travis County, almost all urban counties currently operate hospital districts. Most public hospitals are located in hospital districts and, therefore, fall under the hospital district guidelines. The following table provides a summary of the indigent care delivery mechanism in Texas counties: Indigent Care Delivery Mechanism County Run Programs (CIHCP) Hospital Districts Public Hospitals Number of Counties 142 120 25

State Law Standards of Indigence – County Indigent Health Care Programs State law establishes minimum requirements for counties in establishing eligibility and service standards for indigent care. The eligibility standard for indigence includes four factors: Income level – as measured against the federal poverty level Asset/resource test – the level of resources owned, for example, the value of a car Household composition – whose income is counted toward the standard Residency – where a person must live to be eligible for services These factors are detailed below (addition detail is contained in Attachment 2): Income Requirements. State law eligibility standards for CIHCP classify income as exempt or non-exempt for purposes of counting towards income eligibility limits. Exempt income is not counted towards determining whether a person meets the standard. Health Management Associates Appendix I

Exempt income includes income such as child support up to a certain amount; educational assistance such as Pell Grants; government programs such as SSI, TANF, Food Stamps, and Foster Care; and cash contributions from exempt persons for common household expenses such as rent or food. Examples of income that does count towards eligibility limits includes military pay, pensions, disability insurance benefits, dividends and royalties, interest, self-employment income minus business expenses, worker’s compensation, unemployment compensation, and VA benefits. The countable eligibility level for the CIHCP program is gross monthly income, minus standard work related expense deductions from earned income. The minimum required eligibility level for CIHCP programs is 21% of the Federal Poverty Level, but counties may choose to use higher income limits up to 125% FPL and be eligible for State matching funds (see below). However, most CIHCPs set their standard at the minimum – 21% FPL. Asset/Resource Requirements. State law standards for CIHCP also apply an assets test, comparing a person’s resources against a maximum amount for purposes of eligibility. A CIHCP household is not eligible if the total countable household resources exceed $2,000 on or after the first application date. If the applicant or a relative living in the home is aged or disabled, the household resources cannot exceed $3,000 on or after the first application date. As with income, certain resources are considered exempt for purposes of the eligibility standard, including 401K, burial plot, homestead, life insurance, personal possessions, vested retirement accounts, and vehicles with a fair market value of less than or equal to $4,650. Non-exempt resources include IRAs; insurance or lawsuit settlements; liquid resources such as cash or a checking or savings account; and the fair market value of vehicles in excess of $4,650. Household Composition Requirements. State laws for CIHCP eligibility also consider household composition in apply income eligibility standards. CIHCP household composition consists of those persons living together who are legally responsible for each other, such as parents and minor children and spouses. Medicaid recipients are disqualified household members and not considered in determining household income. Residency Requirements. Under the CIHCP, state law requires that applicants must live in the Texas County in which they apply. There are no durational requirements for residency and intent is a major factor in determining residency. People who have access to services from other counties are not considered residents, for example minor students supported by their parents, inmates or residents of a state school, and persons living in areas served by a public hospital or hospital district.

Required Services – County Indigent Health Care Programs State law requires CIHCP counties to provide basic health care services, including primary and preventive services such as immunizations, inpatient and outpatient hospital services, physician services, prescription drugs, skilled nursing facility care, rural health care clinic services, family planning, and lab and x-ray. Texas Health and Safety Code Section 61.028 (See Attachment 1 for a complete listing).

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The Health and Safety Code also provides state matching funds for certain optional services provided by CIHCP counties, including emergency services, ambulatory surgical center services, diabetic supplies, durable medical equipment, home and community health care services, counseling, dental care, vision care, FQHC services, and services by certain health care practitioners such as certified nurse midwives and physician assistants. Texas Health and Safety Code Section 61.0285 (See Attachment 1 for a complete listing)

Other Requirements – County Indigent Health Care Programs Matching Funds. A CIHCP county may qualify for state assistance funds if they expend 8% of their General Revenue Tax Levy (GRTL) on TDH-established basic services or TDH-approved optional services for qualified individuals. Eligible CIHCP counties receive a 90/10 match for services above the 8% GRTL. TDH administers this state assistance fund. Enforcement. Texas Department of Health (TDH) has no enforcement authority but does handle eligibility dispute request resolutions between providers and counties, public hospitals, and hospital districts. Program administration is solely the responsibility of the county government, hospital district, or public hospital. Payment Standards for Services. State law also establishes standards related to how counties pay providers for services. The TDH-established payment standards for CIHCP services are based on the Medicaid rates and are updated periodically. Counties are not legally liable for more than the TDH-established payment standards. At the beginning of each calendar year counties must choose to pay for inpatient hospital services by either the Medicaid inpatient percentage rate or the Medicaid DRG (Diagnostic Related Group) prospective payment amount. A county using DRGs for inpatient hospital payment must pay the DRG amount regardless of the amount billed. However, a county may negotiate a contract with a provider to pay an amount below the established payment standard. Limitation of County Liability. In addition to income eligibility limits, state law also imposes a cap on a county’s responsibility for health care. The maximum county liability for each state fiscal year for health care services provided by all assistance providers, including hospital and a skilled nursing facility, to each eligible county resident is: 1. $30,000; or 2. The payment of 30 days of hospitalization and/or treatment in a skilled nursing facility, or $30,000, whichever occurs first. Payor of Last Resort. CIHCP counties are the payor of last resort, but they can pay for services at state hospitals or clinics. Counties may also rely on other health care sources that might reduce costs, including the Texas Department of Human Services, Texas Rehabilitation Commission, Texas Department of Health, Social Security Administration, Veteran's Administration, or Attorney General's Office (Victims of Violent Crimes).

State Law Standards of Indigence – Hospital Districts

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In Texas, hospital districts in major urban areas are established under Article IX, Section 4 of the Texas Constitution and Chapter 281 of the Texas Health and Safety Code. They are political subdivisions of the State of Texas, created to provide medical and hospital care to the needy and indigent county residents. As hospital districts under state law, they qualify as governmental entities. As taxing entities, hospital districts can only be created pursuant to an election by the county residents. The election sets the authority of the entity to collect taxes and establishes a maximum tax rate. Under the law, hospital districts are payors in the sense that they collect taxes and pay for services. Hospital districts have the authority and the option to operate hospital systems or to contract for hospital and other medical services, and have the authority to create affiliated entities such as managed care organizations. That is, a hospital district’s delivery system is not mandated by state law. Hospital Districts cannot establish income, household composition, and resource eligibility standards that are more restrictive than the legal minimum standards for CIHCP counties, and they must “endeavor to provide” the basic services that CIHCP counties must provide. Texas Health and Safety Code Sections 61.055(a), 61.006(b), 61.052. Most hospital districts significantly exceed the minimum income requirement specified in State law, setting their standard at 100% of the FPL or above. State Law Requirements Related to Residency. The Texas Health and Safety Code includes requirements for residency for purposes of eligibility for services from a hospital district. These provisions include:

“a person is presumed to be a resident of the governmental entity in which the person's home or fixed place of habitation to which the person intends to return after a temporary absence is located.” Texas Health & Safety Code § 61.003(a) “If a person does not have a residence, the person is a resident of the governmental entity or hospital district in which the person intends to reside.” Texas Health & Safety Code § 61.003(b) “The burden of proving intent to reside is on the person requesting assistance.” Texas Health & Safety Code § 61.003(e) “A person is not considered a resident of a hospital district if the person attempted to establish residence solely to obtain health care assistance.” Texas Health & Safety Code § 61.003(d)

STANDARD OF INDIGENCE – DALLAS COUNTY HOSPITAL DISTRICT
Eligibility Requirements, Parkland Health and Hospital System Parkland cites Chapter 281 of the Texas Health and Safety Code as establishing primary responsibility with the Hospital District for providing medical care to the indigent citizens of Dallas County, Texas. Parkland also cites the provision which authorizes the Health Management Associates Appendix I

hospital district to apply eligibility criteria to applicants and their legally responsible relatives to determine whether an applicant is required to pay for part of the care provided. See Texas Health ad Safety Code Section 281.071(a). Parkland Health and Hospital System, the Dallas County Hospital District, considers five elements when determining eligibility for the Parkland HealthPlus program – residency, existence of 3rd party coverage, identification, household composition, and income: Residency. Applicant must have an established residence in Dallas County at time of treatment. Residents of the City of Dallas where the city limits have crossed into Collin or Denton counties are excluded. Applicants who come to Dallas County for the sole purpose of obtaining medical care are also excluded, a requirement reflected in state law. The Texas Health and Safety Code also recognizes that residency can be established based on the intent of the person, though the burden of proving intent falls on that person. Parkland’s requirements do not address “intent” to reside in the county. Third Party Coverage. Applicants who have access to health insurance are not eligible for PHP even when they may not be covered. Applicants who are not able to access employer provided health insurance due to a preexisting condition or a probationary period are not eligible for PHP. Further, applicants who have missed the enrollment period or who have elected not to participate in employer provided health insurance are also not eligible. Identification. Parkland requires proof of an applicant’s identification, such as a passport or a driver’s license. A picture identification is not required, however, and wage stubs, voter registration cards, and church referral letters for example are acceptable forms of identification. Household Identification. Parkland considers a household to be a person living alone or persons living together where one or more individuals have a legal responsibility for the support of the others. Individuals receiving TANF or SSI are excluded. Income. Parkland HealthPlus enrollees must have income below 200% of the federal poverty level (FPL). Prior to April 1, 2004, PHP covered individuals up to 250% FPL, but new enrollment for the 200-250% FPL group has since been eliminated (coverage continues for those already enrolled in the plan). Parkland considers income as any type of payment or recurring benefits received that is of gain to a household, including earned and unearned income. Monthly household income is verified and compared to the “Qualified Income Levels Chart” included in the Appendices of the Parkland HealthPlus Eligibility Manual.

Comparison with Selected Texas Hospital Districts JPS Health Network, the Tarrant County Hospital District, considers similar elements when determining eligibility for its indigent care program, JPS Connection. Eligibility is based on household size and gross monthly income according the current federal poverty level and proof of current residence in Tarrant County. The program is available for Health Management Associates Appendix I

persons who do not have Medicaid, Medicare with prescription benefits or any medical coverage that covers all or part of medical services or pharmaceutical costs. JPS Connection covers individuals with income up to 200% of the federal poverty level, with graduated co-pay requirements at two levels (0 to 133% FPL; 134% to 200% FPL). The hospital district also provides a program for the Medically Indigent, which offers some coverage for patients who are uninsured or underinsured with high medical bills. The Harris County Hospital District. considers residency, third party coverage, identification, household composition, and income levels to determine eligibility for coverage. Citizenship is not required to qualify for financial assistance, though documentation from INS is required to determine eligibility for assistance (i.e., to determine legal status). Harris County covers individuals up to 250% FPL. Individuals below 100% FPL have no co-pay. Individuals between 100 and 200% FPL pay graduated co-pays. Individuals above 200% FPL must pay half of total charges. University Health Systems, the Bexar County Hospital District considers residency, and income levels as criteria for participation in the CareLink program, which is a managed care program for eligible patients. The Hospital District also provides financial assistance for patients who do not fit the participation requirements for the CareLink program. A person is considered a resident if the person’s home or fixed place of habitation to which the person intends to return after a temporary absence is located in Bexar County. A person’s citizenship status is not considered in determining residency. Residents are consider indigent and eligible for assistance if they fall at or below 75% of FPL based on gross family income and family size. Residents are considered needy and eligible for assistance if they fall between 76% and 185% of FPL based on gross family income and family size.

STANDARD OF INDIGENCE – ADJACENT COUNTIES
Eligibility Requirements for all Counties Adjacent to Dallas County With the exception of Tarrant County, the counties adjacent to Dallas County (Collin, Ellis, Denton, Kaufman, Johnson, Rockwall and Tarrant) are covered by the County Indigent Health Care Act. Denton and Johnson counties, though adjacent to Dallas County, are also adjacent to another large urban center with a hospital district – Tarrant County. As with most of the CIHCP counties in Texas, none of the counties adjacent to Dallas County established income eligibility standards higher than the minimum, 25% of FPL, nor do any of the counties identified by Parkland as major “feeder” counties for indigent patients (Grayson, Navarro, Lamar). With the exception of Collin County, all of the counties contiguous to Dallas County requested funding for optional services in 2003. However, Johnson County was the adjacent county that spent sufficient funds to qualify for state matching assistance. All other adjacent counties provided less than 8% of their General Tax Levy towards health care services under their CIHCP programs. Health Management Associates Appendix I

Comparison with Adjacent Counties and Other Selected CIHCP Counties (2003)
County Program Type % FPL % of County General Tax Levy* 2.6% 3.94% 4.19% 12.70% 0.46% 1.06% State Matching Funds Optional Services Provided**

Counties Adjacent to Dallas County Collin CIHCP 25% Denton CIHCP 21% Ellis CIHCP 21% Johnson CIHCP 21% Kaufman Rockwall CIHCP CIHCP 21% 21%

$588,868

Tarrant Hospital District Other Selected Counties Bexar Hospital District Grayson CIHCP

200%*** 185% 21%

NA NA 9.57%

NA NA $226,673

None Diabetic Supplies Diabetic Supplies Ambulatory Surgical Center, FQHC Diabetic Supplies Certified Registered Nurse Anesthetist Diabetic Supplies (Syringes, lancets, and test strips only) NA NA Advance Practice Nurse Ambulatory Surgical Center Cert. Reg. Nurse Anesthetist Colostomy Medical Supplies Dental Care Diabetic Supplies FQHC Physician Assistant NA Ambulatory Surgical Center Cert. Reg. Nurse Anesthetist Diabetic Supplies NA

Harris Lamar

Hospital District CIHCP

250%**** 21%

NA 9.49%

NA $107,929

Navarro Potter Randle

CIHCP Hospital District CIHCP

21% 150% 21%

4.33% NA 4.08%

NA

Source: County Indigent Heatlhcare Spending for FY 2003, County Spending Compared to GRTL.
*Note: Only twenty counties received state matching funds for FY 2003. Those counties are: Aransas, Atascosa, Callahan, Cameron, Coryell, Dewitt, Eastland, Fannin, Grayson, Guadalupe, Hidalgo, Johnson, Kinney, Kleberg, Lamar, Medina, Montague, Morris, San Patricio, and Somervell **Note that 65 counties requested funding for optional services. Those are: Aransas, Archer, Atascosa, Austin, Bandera, Bastrop, Bell, Brown, Burnet, Callahan, Cass, Chambers, Cherokee, Colorado, Comal, Coryell, Crosby, Delta, Denton, DeWitt, Duval, Eastland, Ellis, Erath, Fannin, Fayette, Galveston, Grayson, Hale, Hamilton, Hardin, Harrison, Hays, Hidalgo, Hill, Howard, Irion, Jasper, Jim Hogg, Jim Wells, Johnson, Kaufman, Kerr, Kleberg, Lamar, La Salle, Lee, Liberty, McLennan, Medina, Milam, Mills, Newton, Orange, Polk, Rockwall, San Patricio, Smith, Somervell, Taylor, Tom Green, Uvalde, Waller, Webb, Wise. *** Tarrant requires graduated co-pays, in two levels (0 to 133% FPL and 134% to 200% FPL). **** Harris County’s Gold Card program has no co-pays up to 100% FPL and graduated co-payments up to 200% FPL. Patients between 200 and 250% FPL are asked to pay half of charges (source: Morningside Research, “Comparison of Texas Hospital District Costs” August 29, 2002.)

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ADDITIONAL INDIGENT CARE RESOURCES IN SURROUNDING COUNTIES
In addition to care financed through the County Indigent Care Programs, some private foundations offer grant programs that direct resources toward low-income care. Examples include the Harris Methodist Health Foundation and the Collin County Health Care Foundation. Hospitals located in the surrounding counties also provide some level of uncompensated care. The following table provides an estimate of the uncompensated care provided:

2002 Uncompensated Care Provided by Hospitals in Surrounding Counties (000s)
Total Uncompensated Charity Total Care as Percent Care Uncompensated Uncompensated Care Cost* of Total Charges Charges Care Charges Collin $38.2 $10.4 $48.6 $19.5 4% Denton $47.3 $4.0 $51.3 $20.5 4% Ellis $6.2 $4.6 $10.8 $4.3 10% Henderson $18.6 $13.8 $32.4 $12.9 23% Kaufman $10.0 $2.9 $12.9 $5.2 11% Rockwall $6.6 $0.7 $7.3 $2.9 6% TOTAL $127.0 $36.4 $163.4 $65.3 5% Source: 2002 TDH/AHA/THA Annual Survey. *Cost information was not available; HMA estimated costs off of the charges provided in the report (costto-charge ratio = 0.40) Bad Debt Charges

OPTIONS FOR REASONABLE DALLAS COUNTY HOSPITAL DISTRICT INDIGENCE STANDARD
An analysis of 2003 data on utilization by Parkland Health Plus patients reveals that the vast majority of utilization is by PHP enrollees in the lowest income group (0% to 133% FPL). Therefore, even a large change in the income standard in Dallas County would appear to have little impact. Data on PHP utilization also show that a sizable portion of PHP inpatients (62%) are admitted through the emergency department, indicating a serious medical condition and likely care that Parkland would provide regardless of PHP eligibility. Less than 5% of PHP outpatient utilization comes through the emergency department, which is an indicator that PHP coverage may effectively divert individuals from using the emergency room as a source of primary care. PHP’s apparent effectiveness in diverting primary care from the emergency room may warrant further analysis of the current PHP policy that denies eligibility to individuals who are offered employer-sponsored insurance, regardless of its affordability. Parkland may want to consider a less restrictive policy that imposes an affordability test before denying PHP eligibility on this basis.

2003 Parkland Health Plus Utilization
Inpatient Though ED Inpatient Other Outpatient Through ED Outpatient Other

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PHP Level 2 PHP Level 3 PHP Level 4 Total

0% to 133% FPL 133% to 200% FPL 200% to 250% FPL

2,089 371 21 2,481

1,241 253 34 1,528

15,749 2,534 192 18,475

284,846 63,743 5,735 354,324

Efforts should be focused instead on means for stabilizing the existing safety net in Dallas County by accessing appropriate levels of Federal matching funds, and evaluating more equitable methods for financing care provided to non Dallas residents, particularly for trauma services. These issues are discussed in detail in Chapter 2 of this report.

*Sources: County Indigent Health Care Program Provider Manual and Indigent Health Care Program Handbook Revision 04-03

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Deliverable: Identify the policy the Hospital District uses for providing care to undocumented immigrants, what is the legally required care that must be provided and what options may or should be considered for providing care to undocumented immigrants and international visitors and the estimated cost of such care

BACKGROUND STATISTICS As of 2000, Dallas County had approximately 2.2 million residents. The U.S. Census Bureau estimates about 21 percent of Dallas County’s residents were foreign born. Of these foreign born residents over 75 percent of them, or over 360,000, were not U.S. citizens.3 Non-citizens are more likely to live in poverty and less likely to have health insurance than Dallas County residents who are U.S. citizens. Counties contiguous to Dallas County include Kaufman and Rockwall counties to the east, Tarrant County to the west, Denton and Collin counties to the north, and Ellis County to the south.4 The surrounding counties have much smaller populations of noncitizen, foreign born than Dallas County. For instance, in Tarrant County, the county with the next highest percentage of non-citizens, less than 9 percent of the county’s residents fall in this category while more than 16 percent of Dallas County’s foreign born residents are non-citizens.
Foreign Born by Selected Texas Counties (2000) Tarrant Dallas County, County, Texas Texas Total Population 2,218,899 1,446,219 Foreign born: 463,574 183,223 Naturalized citizen 102,201 56,074 Not a citizen 361,373 127,149 U.S. Census Bureau, Census 2000 Collin County, Texas 491,675 65,279 22,237 43,042 Denton County, Texas 432,976 40,591 14,061 26,530 Ellis County, Texas 111,360 7,907 2,031 5,876 Kaufman County, Texas 71,313 4,039 1,303 2,736 Rockwall County, Texas 43,080 3,364 1,312 2,052

LAWS AND REGULATIONS AFFECTING UNDOCUMENTED IMMIGRANTS There are numerous federal and state laws, regulations and policies that impact undocumented immigrants’ access to healthcare and a provider’s ability to offer treatment. The provisions detailed in this document vary. EMTALA is a federal provision that requires hospitals to provide care. Other provisions provide funding for hospitals to seek reimbursement. Federal Laws That Affect Undocumented Immigrants EMTALA. In 1986, Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA), which requires hospitals and emergency personnel to screen, treat
3 4

U.S. Census Bureau, Census 2000 The Handbook of Texas Online http://www.tsha.utexas.edu/handbook/online/articles/view/DD/hcd2.html

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and stabilize anyone who seeks emergency medical care regardless of income or immigration status. This federal statute imposes an obligation on any facility providing emergency medical services. EMTALA defines an emergency as a condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health in serious jeopardy.
Penalties related to a failure to comply with EMTALA include: A civil penalty of $50,000 per violation for a hospital with more than 100 beds. A maximum civil penalty of $25,000 per violation for facility with less than 100 beds. A maximum civil penalty of $50,000 per violation for physicians. However, if a violation is found to be gross, flagrant, or repeated, physicians and hospitals may be excluded from participating in Medicare, Medicaid or state health programs. Further, individuals harmed by an EMTALA violation may file civil suits against both physicians and the emergency facility.

Emergency Medicaid. As discussed above, EMTALA creates an obligation to treat patients who present with an emergent condition. “Emergency Medicaid” reimburses providers for emergency medical services and childbirth related care rendered to undocumented immigrants who, except for their immigration status, would otherwise qualify for the Medicaid program. In fiscal 2003, Dallas County served approximately 17,000 unique individuals under Emergency Medicaid for a cost of $99.5 million5 While Emergency Medicaid has provided reimbursement for some emergency services delivered to the undocumented immigrant population, many patients do not qualify for coverage because they do not meet state Medicaid eligibility criteria (for example low-income adults without children). In addition, certain medical expenditures that occur after a patient has been stabilized and an emergency no longer exists do not typically qualify for reimbursement from the federal government. PRWORA. While the federal government authorized Medicaid reimbursement for emergency services for undocumented immigrants that would have qualified for a Medicaid program had they been US citizens, Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limited immigrants access to Medicaid benefits. PWORA allows access only to emergency health services and nonMedicaid funded public health assistance (e.g., immunizations, communicable disease treatment) and delays eligibility for non-emergency benefits for legal immigrants until five years after citizenship is granted.6 In addition, PRWORA requires states that want to provide non-emergency medical assistance to "non-qualified" immigrants to pass affirmative legislation before providing such services, even if the state already had such a law in place prior to the federal Act’s passage.7

Texas Health and Human Services Commission --- 9/3/04 e.mail correspondence. Eldridge, Jennifer, Health Care Access for Immigrants in Texas, Working Paper from the Policy Research Project on Expanding Health Care Coverage for the Uninsured , The Lyndon B. Johnson School of Public Affairs, The University of Texas at Austin, May 2002. 7 U.S. Public Law 104-193, Sec. 431, 104th Cong., 2d Sess. Personal Responsibility and Work Opportunity Reconciliation Act of 1996. August 22, 1996
6

5

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In 2003 Texas passed legislation affirmatively authorizing the provision of nonemergency services to undocumented. Medicaid and SCHIP Exclusion. Federal law further impacts funding for services to undocumented immigrants by excluding undocumented children from Medicaid and State-Children’s Health Insurance Program (SCHIP) enrollments. There are minor provisions in SCHIP that allow for some funding to effectively be permitted for undocumented immigrants. USCIS Statutes and Policies. Although less visible than the federal statutes already noted, a number of provisions within the US Citizenship and Immigration Services (USCIS) Bureau (formerly Immigration and Naturalization Service (INS)) directly affect the level of uncompensated care experienced by hospitals and emergency medical services (EMS) providers in border states. Prosecutorial discretion and Parole Authority are key policies that often dictate how immigration issues are handled. Unfortunately while they permit authorized status in the U.S., no funding has been appropriated to support these admissions for health care services. State Laws That Affect Medical Care for Undocumented Immigrants Indigent Health Care and Treatment Act. Chapter 61 of the Texas Health and Safety Code, “Texas’ Indigent Health Care and Treatment Act”, gives Texas hospital districts discretion to set eligibility standards for health services with the provision that the district does not set income eligibility below 21 percent of the federal poverty level (FPL).8 The act specifically provides that a hospital district shall provide health care assistance to each eligible resident in its service area who meets the basic income and resources requirements established by the state and the district. Chapter 281 of the Texas Health and Safety Code requires hospital districts to provide “medical aid and hospital care to indigent and needy persons residing in the district” The district may define “resident.” The Health and Safety contains no provisions or exclusions related to citizenship and eligibility for hospital district provided services. Interpretation of PRWORA. In July 2001, Texas Attorney General John Cornyn issued a written opinion in response to an inquiry from the Harris County Hospital District maintaining federal law prohibited county hospitals from using public money to provide non-emergency services to undocumented immigrants. The Attorney General’s opinion stated that the federal Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 prohibits the use of public funds to provide non-emergency services to undocumented residents unless a state law passed after PRWORA’s passage affirmatively grants authority to do so. The opinion further stated that recent Texas laws were not sufficiently explicit in reauthorizing such spending and that provision of this care was illegal. The opinion is nonbinding, and does not carry the weight of law, but it opened public hospitals to legal challenges.

8Texas

Health & Safety Code, Subtitle C. Indigent Health Care Chapter 61. Indigent Health Care And Treatment Act

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Act Clarified. This opinion generated legislation to correct this oversight. In the 2003 Legislative Session language was incorporated into HB2292, 78th Regular Session. Section 285.201”Provision of Medical and Hospital Care”: “As authorized by 8 U.S.C. Section 1621(d), this chapter affirmatively establishes eligibility for a person who would otherwise be ineligible under 8 U.S.C. Section 1621(a), provided that only local funds are utilized for the provision of non-emergency public health benefits. A person is not considered a resident of a governmental entity or hospital district if the person attempted to establish residence solely to obtain health care assistance.” This provision clarifies that public entities, including hospital districts, may provide nonemergency services to undocumented or non-citizen immigrants as long as they did not enter the U.S. solely for the purpose of obtaining health care. New Funding for Emergency Treatment of Undocumented MMA. Although much federal legislation has limited federal reimbursement for medical services provided to undocumented immigrants, recent passage of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 offers some financial relief. Section 1011 of this Act appropriates $250 million per year nationwide.9 Allocations to states will be based on the number of US Citizenship and Immigration Services Bureau apprehensions in each state. Reimbursement for emergency medical treatment provided to undocumented immigrants will be made directly to eligible providers which include hospitals, physicians, and ambulance service providers. This section of law takes affect October 1, 2004. CMS published initial guidance on implementation of Section 1011 in August 2004. The initial guidance indicated that hospitals would need to do the following in order to qualify for funds under Section 1011: 1. Determine the person does not have and does not qualify for another payment source. 2. Determine the patient is undocumented or a “non-qualified” alien 3. Collect personal information of the patient including name, address and date of birth. 4. Maintain documentation on the services provided and cost of the emergency services provided for audit purposes. A number of providers and advocacy organizations expressed concerns about CMS’ requirement that patient names and other identifying information be collected because they fear it may discourage undocumented immigrants from getting needed care. However, information regarding citizenship status is necessary to make an accurate determination regarding eligibility for Medicaid and SCHIP. Most health facilities

9

U.S. H.R. 1. Medicare Prescription Drug, Improvement, and Modernization Act of 2003, January 7, 2003.

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routinely conduct some medical assistance program eligibility screening. Many hospitals are using software to screen for Section 1011 eligibility. Table 1 shows CMS’ preliminary funding estimates per state under Section 1011 based on 2000 apprehension data. Final allocations will be based on 2003 alien apprehension data. Texas will receive about $48 million per year over the next four years.

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Table 1: Section 1011 Preliminary State Allocations
State Estimated Unauthorized Resident Population (1/2000) in 000s 24 5 283 27 2209 144 39 10 7 337 228 2 19 432 45 24 47 15 5 5 56 87 70 60 8 22 .5 24 101 2 221 39 489 206 .5 40 46 90 49 16 36 2 46 1041 65 .5 103 136 1 41 2 7,003 Preliminary State Allocations Based on % of Undocumented Aliens $572.326 $119,236 $6,748,679 $643,867 $52,677,852 $3,433,957 $930,030 $238,469 $166,928 $8,036,413 $5,437,098 $47,694 $453,092 $10,301,871 $1,073,112 $572,326 $1,120,805 $357,704 $119,235 $11,923 $1,335,428 $2,074,682 $1,669,285 $1,430,815 $190,775 $524,632 $11,923 $572,326 $2,408,539 $47,694 $5,270,170 $930,030 $11,661,145 $4,912,466 $11,923 $953,877 $1,096,958 $2,146,223 $1,168,499 $381,551 $858,489 $47,694 $1,096,958 $24,824,647 $1,550,050 $11,923 $2,456,233 $3,243,181 $23,847 $977,724 $47,694 $167,000,000 Number of Apprehensions by State in FY 2003 757 278 410,105 1,288 231,523 7,207 460 0 1,139 9,510 1,788 508 1.131 2,721 605 486 0 656 4,110 380 1,135 1,532 3,577 2,138 861 4,099 1,063 2,683 1,213 470 1,963 49,421 9,612 1,398 663 1,320 681 2,306 3,374 736 342 395 1,415 267,081 2,503 1,158 408 4,564 169 491 0 1,043,421 Projected State Allocation (Total) $572.326 $119,236 $41,579,731 $643,867 $72,341,572 $3,433,957 $930,030 $238,469 $166,928 $8,036,413 $5,437,098 $47,694 $453,092 $10,301,871 $1,073,112 $572,326 $1,120,805 $357,704 $119,235 $11,923 $1,335,428 $2,074,682 $1,669,285 $1,430,815 $190,775 $524,632 $11,923 $572,326 $2,408,539 $47,694 $5,270,170 $6,127,458 $12,477,512 $4,912,466 $11,923 $953,877 $1,096,958 $2,146,223 $1,168,499 $381,551 $858,489 $47,694 $1,096,958 $47,508,379 $1,550,050 $11,923 $2,456,233 $3,243,181 $23,847 $977,724 $47,694 $250,000,000

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Total Source: Department of Homeland Security, Office of Immigration Statistics

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Dallas County Hospital District Policy on Serving Undocumented Immigrants Public hospitals typically have written policies governing who qualifies for their indigent health care programs. Public hospitals and clinics throughout Texas have traditionally provided care to undocumented immigrants on the same basis as other uninsured residents. Generally, public hospitals and clinics do not require that patients be U.S. citizens to receive non-emergency services, however, hospitals may inquire about INS documentation to determine charity program eligibility. Parkland HEALTHplus (PHP) is the program through which the Dallas County Hospital District provides medical services to indigent residents of Dallas County. This plan operates under the provisions of Chapter 61 of the Health and Safety Code of the State of Texas. In 2004, this program has about 82,000 enrollees. Eligibility for participation in PHP is dependent upon residency, income, household composition and insured status requirements. Adherence to these requirements must be documented to a representative of PHP prior to receiving services. There is no specific provision in the PHP Eligibility Manual that states a person must be a citizen to qualify for benefits. Parkland employees are required to ask applicants for a Social Security number. It is not clear in written policy whether the lack of a Social Security number is used to deny benefits to otherwise qualified individuals. On a practical level, if a patient (emergency or non-emergency) does not share a Social Security, this does not preclude the patient from eligibility in PHP. Once a person has been found eligible to participate in PHP, this designation can remain in effect for up to 12 months and can be retroactively applied for 12 months. Eligibility for PHP coverage is calculated using a sliding scale based upon family size and income. Patients who have a monthly gross income equivalent to 100% of FPL or below are not required to participate in cost sharing, but PHP members with monthly gross income between 133% and 200% of FPL are required to provide co-pays for health services they receive. PHP coverage can also be used to supplement health benefits offered through other government health programs like Medicare, Medicaid, Title V, VA Health coverage and the Ryan White program. The table below compares PHP’s indigent health care program eligibility criteria to the policies of five hospital districts in Texas’ most populous counties. With the exception of counties contiguous to the Texas/Mexico border these large, urban counties are likely to have the largest indigent and immigrant populations.

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Eligibility Criteria for Indigent Health Care Programs for Selected Texas Counties Eligibility Criteria Proof Program of Verification Household Name County Identity Residency Income of Income Composition 100% 200% FPL. 133200% Parkland Resident FPL with Dallas HealthPlus Yes of County co-pay Yes Yes 75 % to 185 Resident % with Bexar Carelink Yes of County co-pay Yes Yes Thomason Resident 50 % Yes Cares of County FPIG El Paso Yes Yes Resident of County Up to 200 % FPIG with co-pay

Citizenship Considered

Asset Limits

Other

No

Yes

No No No

Annual recertification None INS documentation required

Harris

Gold Card

Yes

Yes

Yes

Yes

Yes

JPS Resident Last 4 pay Tarrant Connection Yes Yes No Yes of County stubs Medical Income for $5,000 Assistance Resident 100 % the past 30 Program days $10,000 Travis* Yes of County FPIG Yes No Note: Travis County has only recently formed a Hospital District. Prior to that the City of Austin funded and operated the Public Hospital. RH2 Consulting, June 2004

SSN for all members of household Over 67 up to 200 % FPIG

Cost of Serving Undocumented Immigrants The cost of serving undocumented immigrants who create uncompensated care has not been definitely measured. Model based estimates are available for counties bordering Mexico and some communities are beginning put methods in place to track actual levels of uncompensated care attributable to undocumented immigrants. The economic analysis prepared by Texas Perspectives Inc. for this report indicates that the 2004 cost for uncompensated care at Parkland is approximately $260 million. Approximately 360,000 non-citizens reside in Dallas County and another 208,000 reside in the counties contiguous to Dallas County. Studies vary regarding the extent to which uninsured affect health care premiums. A significant amount of published literature has pointed out that bad debt and charity care typically between 16% - 30% to health care premiums. Other works have pointed out that the cost-shifting is not significant since

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because the majority of the uninsured receive care from safety net providers that do not have a large enough base of private payers to support cost-shifting.10

OPTIONS FOR SERVING UNDOCUMENTED IMMIGRANTS AND COST OF SUCH OPTIONS As indicated previously, Parkland provides approximately $260 million in care for 2004 to undocumented immigrants. Given the federal EMTALA provision, the overwhelming majority of this care must be provided as prescribed in federal law. The follow options are important to consider as health care pressures continue for undocumented immigrants in Dallas County: • Primary Care Infrastructure Deflects More Costly Emergency Care. EMTALA and other provisions essentially require that undocumented immigrants are covered. Unfortunately, the federal provisions effectively funnel undocumented immigrants into higher-cost settings, namely the emergency room. The literature shows that using the emergency room for non-urgent care results in charges that are two- to three times more than a visit to another setting.11 The financial and clinical benefits of timely are especially well-documented for pregnant women. Several studies show a positive relationship between comprehensive prenatal care and reduction in low birth weight and infant mortality. Inappropriate or no prenatal care can increase the risk of premature delivery and/or low birth-weight infants. 12 The estimated average cost of postnatal care for women without prenatal care was $3,930 compared to $1,589 for a woman who had prenatal care.13 Support for an undocumented immigrants primary care infrastructure mitigates the high-cost loss in the emergency room. CMS Match. On November 11, 2002, CMS issued guidance to states to allow states to use enhanced match SCHIP funds for unborn children and uninsured low-income women. Labor and delivery costs are covered under Emergency Medicaid but prenatal and potentially post-partum services could be covered under this state plan amendment. This state plan amendment could impact health status and positively affect revenues for Dallas County. The state has not filed a state plan amendment to access federal funds. It is certainly worthy of consideration to access matching funds for services that are currently being provided and contribute towards cost-effective services (i.e. a healthy delivery). Rhode Island, Illinois, Minnesota, Arkansas, Washington, Massachusetts, and

10 11

Holahan and Hadley, http://books.nap.edu/books/030908931X/html/55.html. Baker LC and Baker LS, Excess Cost of Emergency Department Visits for Nonurgent Care, Health Affairs; Winter 1994. 12 See for example, Howell EM, The Impact of the Medicaid expansions for pregnant women: a synthesis of the evidence. Medical Care Research and Review. 2001 Mar; 58(1):3-30, and Lu MC, Lin YG, Prietto NM and Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California: A cost/benefit analysis. American Journal of Obstetrics and Gynecology. 2000 Jan; 181(1 part 1): 233-239. 13 Lu MC, Lin YG, Prietto NM and Garite TJ. Elimination of public funding of prenatal care for undocumented immigrants in California: A cost/benefit analysis. American Journal of Obstetrics and Gynecology. 2000 Jan; 181(1 part 1): 233-239.

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Michigan already have approved state plan amendments. This care is currently being provided by Parkland and other safety net hospitals and is paid for entirely by local tax dollars. HMA estimates that this could yield additional revenue of approximately $7 to $9 million. • Develop 3 Share Option. Ineligible non-citizens have a positive impact on the economy. Low-cost labor helps to fuel the economy nationally. Employers have a great interest in this population. Exploring the opportunity of the 3 Share Health Care Model that does not exclude ineligible non-citizens is a natural staring point. A 3 Share Model that has funding support from the County (already responsible for picking up the cost so this would not be additional money), an employer (incentive to keep reliable employees), and the employee (several potential incentives for employee participation if social is not required). o The key design components for a 3 Share program are employer eligibility criteria, employee eligibility criteria, dependent eligibility criteria, scope of covered benefits and program administration. These programs have typically been aimed at low-wage businesses that have been unable to afford the cost of health insurance as an employee benefit. Despite this commonality, the program elements vary greatly from community to community, illustrating the range of options that are available. o Each plan reflects a slightly different market approach, scope of services, eligibility/membership options and participation requirements. An highacuity benefit package could be designed and or a primary care benefit package. While programs have been designed with traditional workers in mind, a model that does not include a social security number as a required field for eligibility should be examined. • MMA Funding. Monitor and access funding that has been made available for the federal MMA impact as discussed previously.

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Deliverable: Using a common, agreed to and articulated definition of costs, identify the cost of charity, non-insured and non-compensated health care provided by the Dallas County Hospital District to residents of Dallas County.

Deliverable: Using a common, agreed to and articulated definition of costs, identify the costs of charity, non-insured and non-compensated health care provided by the Dallas County Hospital District to non-residents of Dallas County.

The following table details the cost of unfunded (self-pay and charity care) care provided by Parkland to Dallas County residents and non-residents in 2003.

Parkland Self-Pay and Charity Care at Cost (FY 2003) Before Tax and Tobacco Allocations
Charges Dallas County Unfunded Out-of-County Unfunded Through ER Other Unavoidable* Avoidable* All Unfunded $415.8 Direct Cost $132.4 Total Cost $230.3 Payment $9.4 Allocations** $25.7 Contr. Margin ($97.3) Excess/ (Shortfall) ($195.2)

$29.2 $22.9 $1.0 $5.3 $445.0

$8.3 $6.1 $0.3 $1.9 $140.8

$14.7 $10.6 $0.6 $3.4 $244.9

$1.1 $0.6 $0.0 $0.5 $10.5

$3.1 $2.7 $0.2 $0.3 $28.8

($4.1) ($2.8) ($0.1) ($1.1) ($101.5)

($10.5) ($7.3) ($0.4) ($2.6) ($205.6)

Unfunded as % 37.1% 35.5% 35.2% 4.0% 24.4% of Total *As classified by Parkland; includes primarily transfer cases. ** Includes UPL, DSH, Other Patient revenue, and timing variances (to tie to G/L).

Deliverable: Using a common, agreed to and articulated definition of costs, identify the cost of charity, non-insured and non-compensated healthcare provided in Dallas County by other Dallas County Community Hospitals (both for-profit and nonprofit) to residents and non-residents of Dallas County. The following table summarizes data provided to HMA by the members of the Dallas Medical Resource (DMR) group, which includes some of the largest hospitals in Dallas County. It is important to note that, due to data limitations, the table includes only inpatient and emergency room activity, which constitute most, but not all of the unfunded care provided by these hospitals. While Parkland is clearly the largest provider of

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unfunded care in Dallas County, many of these hospitals also serve significant numbers of the uninsured.

DMR Hospital Self-Pay and Charity Care (CY 2003) for Inpatient and Emergency Department (000s)
Unfunded as % of Total Hospital Charges Cost Charges Cost Charges Cost Payment Charges $6.7 Childrens $2.8 $2.6 $1.1 $9.3 $3.8 $0.6 1.5% Presbyterian $30.0 $11.2 $9.4 $3.5 $39.4 $14.8 $1.5 5.0% Methodist Char $17.4 $7.8 $2.8 $1.2 $20.1 49.0 $0.7 10.2% Methodist Dal. $36.8 $17.6 $7.9 $3.8 $44.7 $21.4 $2.2 12.1% BUMC $44.0 $16.1 $21.0 $7.7 $65.1 $23.7 $2.1 5.9% Baylor Irving $15.0 $6.2 $2.0 $0.8 $17.0 $7.0 $0.5 7.4% Baylor Gar. $13.3 $5.1 $2.0 $0.8 $15.3 $5.9 $0.4 8.6% Medical City* $23.6 $5.9 47.8 $1.9 $31.4 $7.8 $1.6 NA St. Paul $17.7 $7.5 $3.8 $1.6 $21.5 $9.1 $1.5 5.4% Zale Lipshy** $2.9 $1.3 $1.0 5.1% TOTAL $204.5 $80.2 $59.4 $22.5 $263.9 $102.7 $11.3 5.7% Note that totals and percentages in this table vary from other presentations in this report. This table is limited to Inpatient and ED data and, due to data limitations, does not include outpatient data. *Medical City is excluded from totals due to insufficient information. **Due to systems limitations, Zale Lipshy was unable to report data by County Dallas Out-of-County Total Unfunded

Deliverable: Analyze the potential of creating an expanded hospital district which includes surrounding counties whose citizens derive benefits from these services.
Introduction

The high percentage of uninsured persons in Dallas County has placed a significant amount of pressure on the regional health care system. This factor coupled with the changing composition of the population of counties contiguous to Dallas County and the evolution of state and federal law in how indigent individuals are cared for have placed a high financial burden upon Texas counties. This environment has made the concept of expanding the Dallas County Hospital District to include surrounding counties worthy of exploration. HMA has examined current efforts aimed at regionalizing health services in Texas and conducted interviews with political and administrative figures in surrounding counties to determine the feasibility of expanding the hospital district beyond Dallas County.
Landscape

The Texas Senate Health and Human Services Commission is currently exploring the concept of multi-county efforts to provide health services to the indigent. The commission is studying ways to improve Texas’ county and local indigent health care

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system. An element of this study is to examine “…whether the system should be regionalized to reflect usage and gain efficiencies, so that one or more counties are not paying for regional health care.”The report will be due in November 2004.
Contiguous Counties

Health Management Associates conducted a series of interviews with Judges, Commissioners, and Administrators from counties contiguous to Dallas County. The focus of the interviews was to understand contiguous counties indigency programs in greater detail their views of Parkland Hospital. Several major themes became apparent from discussions with representatives of these communities. These themes are discussed below.
Counties More Open-Minded with Extra Funding - The idea of seeking additional or enhanced federal funding garnered nearly universal support. Some individuals expressed frustration with the role the state has played in not allowing federal funding to pass through to counties. The view of many county representatives was that finding additional funding sources for providing these services would reduce the tax burden upon county residents used to fund indigent care.

Little Support for Raising Indigency Standard - The majority of counties bordering Dallas County have set their standard for indigency at 21%, the minimum required by state law. This level is far below the 200% set by Dallas County. Officials expressed concern that raising the standard would provide an incentive for low-income individuals to move to their county to take advantage of this service; that the state does not provide financial support to make this change feasible; and that increasing this standard has created financial difficulty in other counties. Strong Criticism for the Out-of-County Billing Process and Press Coverage - County officials expressed frustration that Parkland does a poor job screening patients and billing for services rendered. One official reported that over a six-month period Parkland sent hundreds of notifications to the county indigency office while only one resulted in a person added to the county program. County officials felt that the media coverage of outof-county billings did not provide enough details to get accurate messages to readers. Population Shifts Driving Change - Officials referred to population growth in their counties and attributed it to flight from Dallas. Many expressed the belief that many of their residents moved to their county to get away from the social and regulatory climate of Dallas County. Some Regional Activities Have Created Positive Past Experiences - Nearly all county representatives referred to positive experiences working with other counties on regional efforts. Many referred specifically to transportation and actions in response to the clean air act as especially positive.
Regional Health Care Opportunities

One opportunity of regional health collaboration would be the creation of a Regional Trauma Network. This network would allow Dallas and bordering counties to contribute

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to a limited number of trauma facilities. This would allow the expertise in trauma care gained by Parkland to be shared by bordering counties that often do not have the health resources to effectively treat trauma cases. Depending upon how this would be structured and worked out with Texas Medicaid, regional trauma an opportunity may be a platform to draw down federal monies. In discussions with county officials outside of Dallas, there was some interest in exploring whether a trauma services could be shared across counties. These interviews also revealed a generally positive history of inter-county efforts in this region.
Issues for Potential Development • Regionalization of Trauma Network consideration • Working with other counties to improve the billing process among counties • Continue to explore opportunities for matching state and county services with federal dollars

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Parkland Health and Hospital System ESI’s Assessment of the Revenue Cycle October 2004

Objective ESI’s objective was to evaluate the current state of the revenue cycle and determine if additional opportunities existed to improve. Since Parkland has worked with a number of consultants in the past few years in the revenue cycle area, our focus was to highlight issues of substance that had not been exhausted. We did not see the largest gains coming from highlighting the day to day detail challenges. Our focus took us outside of PFS in some cases to highlight issues that we felt would drive more significant change over time.We did spend some time validating the status of several current improvement initiatives. Scope The scope of our engagement included Patient Financial Services (PFS), COPC, and the outpatient clinics. PFS includes the emergency department. Primarily, this includes the processes of registration, financial counseling, verification of benefits, billing, collections, and certain other processes and areas that impact the revenue cycle such as medical records or charge capture. Approach Our approach was to interview key stakeholders, observe processes, and analyze data to support our findings and recommendations. We conducted more than 20 individual interviews of people throughout the clinical, PFS, and administrative areas. This was supplemented by many more in-depth conversations with key stakeholders in PFS. The analysis of data was extensive in order to help drive where we looked for opportunity and to substantiate those conclusions which were made. Overall Observations There are several issues that cannot be categorized as revenue cycle operational issues but may have the most significant positive impact on Parkland’s ability to collect more cash from operations. • Parkland must embrace a single vision of how to deal with the financial obligation of the patient. From interviews and observations, it is apparent that management is not aligned in their message of how the financial mission of Parkland is to be executed on a daily basis.

1

• •

Parkland should communicate the value of the services provided to each patient. A statement of value that is relevant to the individual patient is more tangible to that patient and may begin to change the behavioral expectation of the participant. Parkland has a number of initiatives in place and planned. Our process revealed a need to become focused on a few initiatives and ensure success. Distraction was a concept that was mentioned on more than one occasion. With a technology implementation underway, Parkland must be focused in choosing efforts with defined outcomes and allowing appropriate resources to attack the issues. Consultants should be used when the scope is clear, the benefits are well-defined and internal resources are supportive of the process. As a future vision, Parkland should begin to consider the possibility of a combined revenue cycle process with the Medical School. Parkland and the UT have a joint and vested interest in a single medical chart and are billing for the same patient. Economically, the shared function would reduce the overall costs to both organizations and ultimately ease the operational issues regarding access to the medical chart and sharing of eligibility information of the patient population.

Overall Opportunity The financial benefit to the issues discussed in this assessment should exceed $6 million and would likely approach a range of $7 - $10 million. Additional benefits exist within the system but may not have been included due to an inability to support the issue with a valid quantification. • • • Process Impacted Convert patients to funded source Collections area including denials Time of service collections Self-pay collections via vendor • • • Goal Convert approximately $20M additional gross charges 10% - 15% reduction in approximately $10M in FY04 denial write-offs Increase clinic related TOS collections by raising performance to internal best performers Goal in place is to double current collections, this goal is more conservative Opportunity • $4 - $5 Million Net • • $1 - $1.5 Million $1 - $1.5 Million $.5 – $1 Million

Other improvements that would lead to gains include the collecting better information during the registration process. This responsibility is shared by staff from outpatient services, COPC, and PFS. This process would assist in Parkland managing the out of county care issue. An opportunity exists to improve Pharmacy billing for patients that are given Medicaid retrospectively.

2

Convert More Patients to Funded Sources Parkland attacked this issue in FY 01 when collections equaled $196,000,000. Today, collections exceed $300,000,000. This gain was the result of significant focus on the eligibility process and financial counseling. Seventy-plus percent of inpatients have funding from a third party. Approximately fortyeight percent of outpatients are similarly funded. Part of the difference is because deliveries on the inpatient side are eligible for Medicaid. Outpatient benefits are not as generous. Investment in the Front-End Processes
$350,000,000 $300,000,000 $250,000,000 $200,000,000 $150,000,000 $100,000,000 $50,000,000 $2000 2001 2002 Cash Collections 2003 2004

Medicaid increases due to eligibility amounted to half of this increase. Other improvements have led to other payer increases.

The question becomes whether or not Parkland has hit the ceiling regarding converting more patients to a funded source. Consensus is no. In order to improve on current levels, additional process and technology changes must occur. In addition, PHP must not be viewed as a funded source. It is not for reporting purposes; however, observations and interviews outside of PFS suggested a perception that PHP somehow generated cash. PHP patients do account for a large portion of time of service collections, but the remaining bill is written off. PHP must be a last resort. • Parkland needs the ability to better manage the enrollment process in Medicaid and PHP. Currently, a system is in place to handle eligibility screening; however, it is not used all the time and it is not utilized to manage the eligibility case. The change relates to using the existing or similar application on the market in all the enrollment occurrences. As a result, Parkland would have more control over the process, hold the eligibility vendors to a stated performance, possibly reduce reliance on the vendors, and have a repository of information to help make better decisions regarding that patient population.

3

• •

Parkland currently has address verification software but needs something to improve their ability to match names and addresses to verify residency. An investment in this area is necessary and may be available first quarter of 2005. Parkland should create a policy that promotes community awareness of the patient’s obligation to participate in the financial funding process. All patients have the ability to participate in Parkland’s eligibility process regardless of their ability to pay. This does not mean Parkland would turn away patients that cannot pay, but rather might delay or defer non-emergent visits for patients that have not participated in the process. Parkland has considered in the past and should consider again a change to the PHP eligibility criteria. Currently, if a patient declines coverage of any kind at an employer, the patient is turned down for PHP coverage and is classified as a selfpay patient. A test related to the percentage of insurance cost to income should be incorporated into the PHP eligibility process. Rising medical premiums have made the choice of coverage that is available to some employees a non-choice. This recommendation is made under the assumption that today’s patient cannot pay for care regardless of financial classification. PHP allows that patient to define a level of contribution. There could be significant cost implications to this type of policy and should not be considered without further economic study. Parkland should work with Federal authorities to bring SSI resources to the main campus. Some patients that could qualify under SSI criteria may not be making to the SSI offices for completion of the process. The easier the process, the more participation Parkland should expect. The eligibility process cannot be performed without the patient and information from the patient. Parkland must take advantage of the opportunities when the patient is engaged in the process such as the scheduling process. Combining the scheduling process with other data collection would significantly streamline the verification of insurance process. At a minimum, this could be done for those patients that do not require clinical intervention in the scheduling process. Parkland will not know when the eligibility ceiling is met until they work more closely with other public facilities and understand their experiences. Currently, Parkland compares favorably in third-party funding percentages. This comparison was made with publicly available information. Parkland and the other healthcare districts could benefit from working together more closely. Parkland must begin to set behavioral expectations for the patient related to their financial obligation. One way to begin is to create consequences for any patient that is misrepresenting information to gain access to the tax-supported program. This effort should be directed by legal. Policy should be adopted that directs a front-line person on how to respond when they believe fraud has occurred. Parkland might even consider a person whose sole function in to review accounts for information that is misrepresented.

4

Conversion of Original Financial Classification of Self-Pay to Others on a Monthly Basis
$30,000,000

$20,000,000

$10,000,000

$0
October November December January February March April May June July

($10,000,000)

($20,000,000)

For example, June 04 efforts transferred nearly $27M from self pay into the following: $16.8M into Medicaid, $6.8M into charity, and $3M into commercial.

($30,000,000)

($40,000,000)
Self Pay Charity Medicaid-Traditional Medicaid Managed Care Commercial Insurance

Laser Focus on Collections The collections process is not broken. The recommendations are focused and do not require a wholesale change in the process. The largest opportunities in the back office collections area relate to denial management, collection strategies, and outsourcing the low dollar accounts. • The proactive management of denials should be a priority in the short-term even before the new technology advances. Although denials are received in the PFS area and write-offs are ultimately processed in PFS, the reasons for denials are most often generated upstream in the revenue cycle. Denials must be an organizational issue and not only an issue identified with PFS. Top Reasons for Medicaid Write-offs from Denials (October 2003 – July 2004)
$1,200 No Precert $1,000 Past filing/Not updated $800 Missing coding element $600 $400 $200 $0 Past filing/No Followup Past Filing/Medical Records Past filing/Never Billed

5

One significant denial reason that is not reflected on the chart above is medical necessity denials. This chart only included the largest Medicaid denials, but more than $500,000 of write-offs have been recognized for unsupported medical services based on admission criteria. • The cumulative amount of write-offs for the prior twelve months exceeds $10 million. PFS, as the “owner” of denial information, must implement an improved method for involving other key stakeholders that impact denial levels. Once way to accomplish this would involve communicating more concurrent denial information. Currently, write-off information is shared across the organization. Denials need to be shared as they are received. The collectors are divided by payer, by account age, and by balance. We recommend a different stratification of accounts first by balance, with some collectors working the highest dollar accounts across all payers. Second, accounts within certain dollar limits would be distributed by payer and then by age. Third, some collectors would be dedicated to resolving denials within certain payers. Accounts under a certain dollar value should be outsourced regardless of payer. This would likely include a significant volume of outpatient accounts since they tend to be lower charges. This would likely include all of COPC since virtually all of their accounts are lower dollar balances. Parkland should accelerate this process. Billed A/R Trial Balance
$0 - $250 $251 - $1,000 $1,001 - $2,500 $2,501 - $5,000 $5,001 - $10,000 Over $10,000 $ $ $ $ $ $ $ Dollars 10,195,195 32,907,248 41,406,850 31,130,103 43,614,045 194,990,977 354,244,418 2.9% 9.3% 11.7% 8.8% 12.3% 55.0% 100.0% Volume 205,952 63,068 26,158 8,849 6,068 6,339 316,434 65.1% 19.9% 8.3% 2.8% 1.9% 2.0% 100.0%

If you exclude self pay from these totals, you would subtract approximately $211,000,000 and 27,000 accounts from the accounts over $1,000. Self-pay accounts are not collected internally by Parkland staff. Additional analytics should be developed to determine the appropriate dollar value for cutoff of outsourcing. An outsourcing partner should not cost Parkland more for the same or less performance. • In addition to outsourcing the low dollar/high volume accounts, a concerted effort to clear the trial balance for both PMAS and COPC/EPIC of old and less viable accounts should be undertaken. This can mean giving the accounts to someone else to provide a last attempt at collection. The intangible gains from cleaning up the trial balance and outsourcing the low dollar accounts that are not prioritized anyway should lead to greater focus on the remaining accounts and more ability to focus on impacting issues upstream in the revenue cycle.

6

Clinical Involvement Perhaps the greatest gain to the revenue cycle exists in enlisting the physician and clinical staff in a broader participation in the financial processes at Parkland. The clinical staff can be the best collector. The patient responds well to direction from clinical staff. Patients must understand the value of services they receive. Today, a patient that drives to Parkland and parks must pay for parking. If they eat on the campus, they must pay for food. However, a patient that participates in PHP cannot be denied care or pharmaceuticals if they cannot pay. The competition for the same wallet dollars is a real issue and Parkland must get their share of those dollars. This is another issue that would be impacted by a single voice relative to how Parkland should deal with the financial obligations of the patient. A registration clerk must expect to be supported throughout the administrative organization when a patient complains about a legitimate co-payment or contribution that is requested at the time of service. • • Parkland, physicians and the clinical staff must mutually embrace the fiduciary responsibility Parkland has to the local taxpayer to maximize the possible revenue stream while recognizing the sensitivity of the mission of public healthcare As mentioned, medical records is a vital function along the revenue cycle. Parkland must own and control the medical record. This means that Parkland should use the Medical Record for coding before it is used by others. If other demands on the chart are required, the chart should be checked out from Medical Records. Tracking software should be implemented to be successful.

Build Single Accountability Organizational challenges facing Parkland are significant. We did not observe an overall belief by clinical service lines that functional process owners could provide adequate service levels. For example, traditional parts of the revenue cycle, such as access/registration personnel are not entirely part of the revenue cycle organization. Financial counseling is not entirely part of the revenue cycle. In fact, Patient Financial Services registers only about one-third of the patients across the organization. There are reasons other than the service level issues; however, it appeared as a central theme throughout conversations. For example, over time, the specialty clinics have integrated the registration process with so many other support functions within the clinic that it would be very difficult to carve out registration from the other responsibilities. For the patient, there are more touches and referrals than necessary with a fully integrated registration and admission process. The Patient Support Center would have lessened this issue. This initiative should continue with full attention and should consider incremental steps towards the end goal. There are points of integration possible without the full complement of technology and space the entire plan was designed to require.

7

Example of Funded Patient Access Experience
Initial Point of Entry

#1 # #3 #4

Patient gets appointment at COPC and is screened by the Financial Counselors and registered by COPC (TOS collections by COPC) Patient is referred to OPC for follow up visit. A PFS and then upon arrival will be registered by funded patient should be pre-registered by OPC staff.

Patient has emergent situation and goes to emergency department for care and is registered by PFS. Patient is admitted for inpatient stay and may be specialists from Care Management. seen by financial counselors from PFS and payer

Patient could easily been seen or called by 8 different people from 4 different departments for just the revenue cycle related processes
COPC OPC PFS Care Management

One possible process of integration relates to patients that do not require clinical intervention when scheduling a specialty clinic appointment. For those patients, perhaps the appointment and funding verification process can occur at the same time. Parkland has already identified the 21 data points that should be gathered at the time of scheduling. This would significantly streamline the process of trying to get the information from the patient after an appointment is made. Registrations by Area Area Number of Registrations Specialty Clinics ≈ 240,000 COPC ≈ 385,000 PFS (ER, Main, Women’s) ≈ 380,000

Quality of the registration is difficult to compare without significant chart auditing which was not performed for this assessment. However, there are some indicators such as time of service collections, available information at the time of registration and the environment of the registration that can be noted. Total Time of Service Collections by Area (Across all Payers)
(FY 2004 annualized after 9 months)

Area Specialty Clinics COPC PFS
Note: These numbers exclude pharmacy collections.

Total Collections ≈ $1.5 Million ≈ $2.0 Million ≈ $6.8 Million Additional Observations 8

PFS
• Large collections from repeat patients with prior balances or previous bad debt (approx. $3.0 million) • ER is difficult environment in which to collect given EMTALA, plus the competition for the wallet is high, focus less on speed and more on data validation

COPC
• High degree of focus on time of service collections • Integrated into site performance metrics which is good • Medicaid cash is tremendously higher evidencing improved eligibility and collection processes • •

Specialty Clinics
Higher clinic visit prices may lead to higher averages in self pay category Most often patients are referrals for COPC or other campus experience, they should already have a basis for registration

Ultimately, to attempt a reorganization of registration would be too disruptive to the organization. However, if Parkland were to consider adding FTE’s to the front-end process, the campus outpatient clinics would be a good place to implement a dedicated registration position. In addition, continued focus on always improving the ER process of registration with appropriate technology to support the registration is always an area of focus. Despite the lack of overall ownership, PFS should provide a standard expectation for the registration. Today, PFS meets with COPC and OPC to discuss issues and communicate any regulatory changes to the process. • Since the clinical areas own their own registration process, they must be open to participate in any initiatives raised by PFS as crucial to the other parts of the revenue cycle. Particularly, this should include denial management related initiatives since many of the issues that lead to denials can be caught in the initial registration process. Other organizational issues include the integration of the payer specialist position into financial counseling. This is overlap in the goal of this position and the financial counseling role. Discussion should occur regarding financial counseling to oversee this process. Also, Medical Records, a key component of the revenue cycle should reside in the same chief leadership structure as PFS. Experience suggests that when two areas share considerable parts of the same overall process, one single and accountable leader can affect change better. Finally, Parkland contracting for reimbursement by third-party payers should be consolidated within one office. In addition, the approval process should be streamlined so revenue generating changes to contracts can be approved without administrative delay.

Other Issues 9

Although only a brief conversation occurred, Medical Records appears to need a focused review that will bring sustaining improvement to the processing of charts. Recent involvement by third parties have only addressed backlogs and achieved one-time benefits that have not sustained themselves. There are significant challenges with calculating an accurate patient services net revenue amount on a monthly basis. Despite the difficulties, the accounting department must work diligently towards recognizing net revenue based on a consistent methodology rather than booking cash as net revenue. It is impossible to measure success of cash collections versus net revenue using the current method. This issue is linked to reserving methodology as well. Parkland has access to a tremendous amount of data. This can be good and bad. We found it difficult to decipher all the different data even when two different reports were covering the same issue. For example, days in receivables are calculated differently across the organization. There should be a consistent methodology for each data point, service line, etc. that is agreed upon and communicated consistently throughout Parkland. There is a commitment to the T2 system by decision support and accounting and everyone across the campus should work with the same data and define reports the same way. There has been progress during the past year to achieve these objectives. Accounting must work closely with PFS, particularly since cash has such a significant impact on how revenue is booked. Work with new technology to implement a process for deployment of software to generate ABN’s. Parkland must address this issue to better inform their Medicare patients.

Prioritization One of the recommendations we have made is for Parkland to focus on a few things to completion. There are many constituents internal and external to Parkland that help set priorities. Senior management must help staff to stay focused on a well-defined plan of attack. Complete the technology implementation Define, agree and publish next years goals Low dollar outsourcing of accounts (COPC/other) Assistance for Medical Records (not PFS decision) Trial balance clean up for EPIC/COPC and PMAS More proactive approach to denial management Research and implement technology to support demographic validation of patient information 8. Work with physicians and clinical staff on participation in eligibility and funding process 9. Integration solution to enrollment software 10. Research the annual contribution for PHP concept Summary 1. 2. 3. 4. 5. 6. 7. June 2005 30 days 60 – 90 Days ASAP 12/31 solution Ongoing Q1 2005 ongoing 12/31 solution TBD

10

PFS has experienced tremendous growth in cash collections over the past four years. During that time, PFS has gone from collecting $196 million to over $300 million. For the first year since FY 2000, cash collections are relatively flat. Some of the issues are quantifiable. It is estimated that the Medicaid changes alone to rates and coverage levels have led to at least $20 million less cash for FY 2004. Combined with the shifting patient population from inpatient to outpatient, Parkland has experienced a significant cash drain from just two sources. Increases in COPC and Medicare collections helped cut into those reductions. We found PFS management to have a firm understanding of the issues that need attention. We have discussed the recommendations, quantifiable opportunities, and thoughts regarding prioritization. There is acceptance by PFS management of the issues discussed. There are other opportunities that will produce financial wins that are not easily quantified and were not included in the opportunity schedule. For example, an opportunity for pharmacy to bill Medicaid when eligibility occurs after the script has been written or an opportunity to interface a part of the lab system that may have dollars that can be re-billed retrospectively. Perhaps a charge capture program that appropriately captures charges would result in a true reflection of the cost structure supporting the services provided and raise the UPL opportunity. These opportunities should not be left behind while planning continues for 2005. Since many of our recommendations do not focus entirely on PFS’ internal operations, the revenue cycle will need significant senior management support to achieve the gains. For example, the single voice of how to deal with the patient’s financial obligation and the physician staff assisting in the financial counseling/eligibility process by encouraging the patient’s participation are issues that PFS cannot attack without support. The best approach to all these initiatives is to define the objectives well, the performance measures for success, and resource the initiative appropriately with the right stakeholders involved. If this is done, Parkland has a better chance at success to achieve the goals set forth in this document.

11

COPC Assessment Report
Health Management Associates
Primary Care Parkland was one of the first public hospitals in the country to establish a Community Oriented Primary Care (COPC) system of clinics in communities with high, unmet healthcare needs. These needs were inappropriately utilizing the emergency department for health care that could be more effectively provided in a decentralized primary care system. Parkland understood that an integrated system of care must shift the emphasis in healthcare delivery toward primary and preventive care to provide the most appropriate level of care for its patients. The COPC system currently consists of: seven community-based clinics, the Ambulatory Care Center (ACC) providing urgent care on-site at Parkland, employee health, campusbased clinics for geriatrics and pediatric primary care, ten Youth and Family schoolbased clinics, and a homeless program (HOMES). Collectively, these facilities deliver 327,485 adult, geriatric, pediatric, and behavioral health visits to approximately 121,872 patients annually.1 In addition to the COPC network, the Parkland system operates eight sites offering prenatal and other women’s health services through the WISH clinics in partnership with the University of Texas Southwestern School of Medicine. Five WISH clinics are located within the COPC clinics and three are independently housed. In 2003, these eight WISH sites provided 98,129 prenatal and women's health visits. Finally, two residency training primary care clinics (internal medicine and family practice) operate at Parkland hospital and provide another 22,297 and 10,971 visits respectively. 2 The COPC sites offer the full range of primary care services for children, adolescents, adults, and geriatric patients. These services include well child checkups, routine physicals, treatment of acute and chronic health problems, immunizations, behavioral health, nutrition counseling, cancer screenings, HIV/AIDs testing and counseling, health education (smoking cessation, diabetes management, etc.) pharmacy, lab and x-ray services. Although there is no reliable income data on COPC patients, approximately 40% of those seen in the COPC clinics are uninsured and 39% qualify for Medicaid or the State’s SCHIP program, with the remainder of COPC patients covered by Medicare or other funding. The COPC patients are heavily Hispanic and African-American (46% and 36%, respectively). About half of the patients are children under the age of 14, 43% are between 15 and 64 years old, and 6% are over 65.

1 2

Does not include EPO (Parkland employees). FY2003 Service Line Analysis with fully allocated costs. PHHS

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Appendix K-1

Southwestern Obstetricians and Parkland midlevel providers staff the WISH clinics. The WISH clinics offer prenatal care in addition to women's health visits. The medical records of all prenatal patients are located at Parkland Hospital to enable efficient access for labor and delivery. After delivery, discharge appointments for the women and newborns are made electronically at COPC and WISH sites. There are also Family Planning clinics located within COPC and WISH at five sites. The patients seen at the WISH clinics are predominately Hispanic (80%) and uninsured (82%). However, it should be noted that once these prenatal patients deliver their babies at Parkland, their payor status changes and nearly 90% become eligible for Medicaid coverage. Thus, an investment in prenatal care results in paying patients for the hospital. Youth & Families and Dallas Independent School District recently received a presidential recognition for its integration of mental health and medical services. The Youth & Family school based sites are located on public school grounds, and are accessible throughout the year. Hours are generally Monday through Friday 8am-5pm, plus evening hours at three locations. The school district provides mental health services and Parkland offers medical services and a Class D pharmacy. Three sites also see adults from the surrounding community. Each school-based site is linked with a COPC clinic for referrals for lab, x-ray, and other services not offered on site. Pregnant students are referred to a Parkland WISH clinic for prenatal care. ACC (urgent care) serves adult walk-in patients who are sick and/or have long-term chronic illness and 80.3% of the patients are uninsured (charity and self-pay patients). Some patients are referred to ACC when they are discharged from Parkland (and other hospitals) and 12,153 visits (25% of total) were directly referred from the Parkland Emergency Department in 2003.3 The HOMES program is a Federally Qualified Health Center (FQHC); a federally funded Section 330(h) Healthcare for the Homeless grant program operated by COPC. In 2003 HOMES received $1,018,872 in grant funds (baseline award that is annually dispersed) to support and staff three customized mobile vans, that provide services at 37 clinic sites around Dallas County each week and provided services to 5,009 homeless patients in 2003. The COPC, WISH, and Youth and Family clinic sites are located in areas that have significant pockets of low income people (below 200% federal poverty), in neighborhoods that do not have enough primary care providers, and in zip codes with the heaviest utilization of the Parkland Emergency Department and Children's Emergency Department. (For detailed documentation, see Appendix K-2.) Detailed COPC clinic profiles for the seven community based sites are provided in appendix K-3. Each profile contains current COPC patient data and the demographics and health status of the community it serves.

3

Department of Emergency Services Monthly Statistical Report, 2003-2004

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Appendix K-1

COPC Providers and Programs COPC is involved with community-based organizations, churches, youth programs, and other local institutions, relationships that are sustained by COPC's community workers. As the most visible face of Parkland in the local communities, they work closely with ministers and local leaders to organize COPC Advisory Boards, immunization drives, and back to school health fairs. Such a high level of community involvement visibly demonstrates to local taxpayers that COPC and Parkland are attempting to address the health needs of their neighborhoods. Over the years, COPC has expanded its services to include more health education and prevention, behavioral health, child development, and more referrals to social service agencies. The federal government requires these "wrap around" services before designating FQHC status (cost based reimbursement) or providing section 330 grant funds, a HMA recommendation for the COPC sites. After 35 years of operating the community health center program, the government has documented that these services are essential, and would otherwise be inaccessible to vulnerable populations. Historically, COPC has implemented innovative clinical programming, most recently by becoming one of the first public institutions to test the Shared Medical Appointment (SMA). A SMA involves a group of similar patients (newborns, adults, etc.) agreeing to a 90 minutes group session with a physician, social worker, RN, and pharmacist. Patients arrive early to have their vital signs taken and the doctor interacts with each patient in the group setting, exposing everyone to the interaction/education. A patient may also request to speak privately with the doctor, social worker, or nurse at the end of the session. COPC was interested in this type of clinical session to reduce wait times and increase access to its sites. Patient surveys reveal very high levels of satisfaction. COPC and Parkland will undoubtedly continue to offer innovative clinical programming. All COPC services, (including Youth & Family, HOMES, ACC, support staff for COPC based pharmacies) were provided by 143 FTE medical providers, 25.65 FTE mental health workers, 196 FTE nurses and medical assistants, 256 FTE business and clerical staff, 18 FTE language assistants and 5 FTE community workers. COPC physicians are directly employed by Parkland. The pediatricians are on faculty at Children’s Medical Center and pediatric residents rotate through three COPC community based sites, supervised by COPC employed physicians. (For breakdown by site and provider type, see Appendix K-5: COPC Staffing Tool June 2004)

Staffing & Productivity The federal government sets minimum productivity standards for the providers who practice in Federally Qualified Health Centers (FQHCs) and this standard serves as a rational benchmark for similar health care facilities. The COPC clinics, as a system, fell short of those minimum standards for physicians in 2003, although they met the standard for mid-level providers (nurse practitioners, for example). This doctor productivity level caused concern among the Parkland COPC administration and an effort has been Health Management Associates Appendix K-1

underway, through an intensive team model, to improve this indicator. By the period of March through August of 2004, the annualized number of visits per physician had increased from the 2003 rate of 2,794 visits/doctor to 3,484, still under the minimum federal level of 4,200 but clearly significant progress has been made. Providers Physicians Mid-level providers BPHC benchmark 4,200 2,100 FY 2003 COPC baseline visits 2,794 2,568 March-Aug 2004 Annualized Visits 3,484 3,125

Source: BPHC and COPC Administration (See Appendix K-4: Operations Plan Performance, for monthly provider targets and average visits March August 2004.)

A team of administrators and clinicians established the Care Team model in March 2004 to accomplish this improvement. These Care Teams were comprised of a clinical provider, nurse and business support person. Clinical visits and financial goals were established for each Care Team based upon the type of provider (pediatrician, internist, nurse practitioner, etc.) and his/her administrative responsibilities, paid time off, and continuing medical educational requirements. Each individual team had quantifiable visit and cash collection goals established. The Care Team success will be taken into account for each COPC staff member's annual evaluation (worth 50% total) beginning this year. The clinical providers and business office staff are attempting to maximize clinical productivity, without compromising the quality of care. A group of physicians will be evaluating whether the quality of care has been maintained as productivity starts to increase. Greater productivity by COPC providers is critical in meeting the increasing demand for services, particularly for chronically ill adults. If patients cannot get appointments in the COPC clinics, they will likely seek care in the Emergency Department (ED). According to FY2003 Service Line Analysis figures, the average cost per COPC visit is $90 while the average ED visit is $163. It is clearly valuable to the system to keep as many patients in the clinics as possible. In FY2003, the COPC clinics had the staff and physical space capacity to provide 116,340 adult and geriatric visits yet they actually provided only 92,413 visits in that category. The productivity efforts to date in 2004 have them on target to come closer to their available capacity.

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Appendix K-1

Adult and Geriatric Capacity
Site Bluitt DeHaro East Dallas Garland Oak West Southeast TOTAL Annualized
Source: COPC Administration

FY 03 Monthly Average Visits 1,615 1,272 1,660 1,066 220 1,868 7,701 92,412

COPC Monthly Visit Target 2004 1,904 1,537 2,002 1,672 216 2,364 9,695 116,340

March-Aug 04 Monthly Average 1,952 1,518 1,884 1,514 447 2,124 9,439 113,268

Available Capacity (48) 19 118 158 (231) 240

Across the seven COPC community clinics, the school-based centers and the pediatric clinic on campus, there is additional capacity at current staffing levels, for approximately 2,300 visits per month, according to the COPC productivity benchmarks listed in the table below. There has been an improvement since 2003 when there was capacity to provide additional 35,000 visits. As children are most likely to be covered by Medicaid or SCHIP it is a system priority to increase pediatric visits.
Pediatric and Adolescent Capacity FY 03 Monthly Site Average Visits Bluitt DeHaro East Dallas Garland Oak West PPCC Southeast Vickery * Y& Family TOTAL Annualized 1,256 2,271 1,893 1,210 932 892 1,289 608 1,491 11,841 142,092 COPC Monthly Visit Target 2004 1,545 2,717 1,950 1,248 1,014 1,139 1,572 1,010 2,628 14,823 177,876 March-Aug 04 Monthly Average 1,158 2,096 1,907 1,442 864 936 1,313 901 1,972 12,588 151,056 Available Capacity 387 621 43 (194) 150 203 259 109 658**

Source: COPC Administration * Family Practice ** school was not in session 3.5 months

Most of the 16,000 babies born at Parkland do seem to keep their follow-up appointments at COPCs but it is unclear whether these children stay in the system. Further, the Parkland Community Health Plan, its Medicaid/SCHIP managed care entity, could be assigning larger numbers of children to the COPC sites. In August 2004, there were a total of 37,042 Parkland Community Health Plan members assigned to COPC sites, less than half the total health plan enrollment. This would be an additional opportunity to increase pediatric utilization.

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Appendix K-1

COPC administrators have already utilized the data above to make decisions about shifting Care Teams between the sites. Recently, to fill vacancies at Garland and Vickery, two pediatric Care Teams were relocated from Bluitt Flowers where demand for pediatrics had fallen. We encourage the additional reallocation of resource by taking a closer look at DeHaro pediatrics, which has tremendous excess capacity. COPC takes accountability very seriously and has not ruled out staff reductions in under-performing sites and/or Care Teams. (For the Care Team Roles and Financial Management Tool, see Appendix K-4.) The COPC leadership is to be commended for launching this effort and its success will rely on constantly monitoring the data and making difficult decisions. It is also important to evaluate other potential factors that may be adversely affecting a site's productivity beyond individual provider benchmarks and community demand. When we evaluated the number of exam rooms per provider at each COPC site, the sites with the highest ratios (Southeast at 2.66, DeHaro at 2.67, PPCC at 2.67 and Bluitt at 3.25) also had the lowest productivity. This is interesting because large public systems are traditionally unable to maintain a ratio of 2 exam rooms to 1 clinical provider, thus limiting a provider's capacity to maximize his/her time seeing patients. Since this is not a problem at some of the COPC sites, we must look elsewhere to evaluate productivity levels. Across all COPC sites, we evaluated staffing ratios by making a comparison to a commonly utilized benchmark established by Medical Group Management Association (MGMA) an organization representing over 237,000 physicians. Ratio Support staff FTE per physician RNs & Medical Assistants per physician Business and clerical staff
Medical Group Management Association, 2002

MGMA Mean 5.29 1.34 2.09

COPC 6.48 1.37 1.79

On average, the COPC provider to support staff model is in line with MGMA. However, COPC is higher when total support staff is compared. Business and clerical staff in a private physician office may be higher because COPC does not do its own billing, staff that are not included in table above. (Appendix K-5: COPC Staffing Tool June 04, MGMA 2002 Benchmarks.) We encourage COPC to continue to assess its staffing ratios as they carefully evaluate their cost structure. Recently, COPC discontinued its reliance on a nursing registry for coverage during vacations and other paid time off. They have also decreased float staff and are implementing the seasonal paid time off option at selected sites offered by Parkland Human Resources. As previously mentioned, the average COPC cost per visit is $90 (ACC urgent care $110) while the average Parkland ED cost per visit is $163. The best way to lower these costs even further is by increasing provider productivity. As the low income and uninsured population continues to increase in Dallas County, the long term sustainability of the COPC system becomes critical to maintaining the health status of this population, and

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Appendix K-1

maintain the ability to operate a cost effective delivery system for Parkland and Dallas County as a whole. Patients In 2003, COPC sites (excluding ACC urgent care and Parkland employees) provided services to 121,872 patients (58% female/42%male). There were slightly more children than adults, with very few adults over the age of 65. COPC Patients by Age* Unduplicated Patients Under age 5 38,968 Ages 5 - 14 22,789 Ages 15 - 44 28,311 Ages 45 - 64 24,089 Ages 65 and over 7,715 TOTAL 121,872 % Total 32% 19% 23% 20% 6% 100% % Female 51% 51% 66% 69% 71% 58%

(*Does not include ACC or Parkland employee site. See Appendix K-3: Community Clinic Profiles)

COPC does not keep income data on its patients. Yet when reviewing patient payor sources, we note that approximately 40% are uninsured and 39% qualify for Medicaid and KidsFirst (state/federal funded program for low income families) for a total of 79% participating in programs designed for low-income families. By analyzing charges and volume by revenue code at the largest COPC sites for the month of March 2004, we were able to document that 62.7% of all COPC pharmacy usage was by Charity patients or those in Parkland Health Plus (PHP) program for the low-income uninsured patient. Additionally, this same group utilized 57% of all clinic appointments. This is interesting because there are 41,701 COPC patients (49% of total) between the ages of 15-64, and the typical profile of a PHP patient is the uninsured adult. This leads us to speculate that it is the PHP patients that are utilizing COPC resources disproportionately, especially pharmacy, an indication that this population suffers from chronic illnesses. According to a National Research Corporation annual Dallas County survey of healthcare utilization and prevalence of chronic conditions conducted in 2001, the top diagnoses at the COPC clinics are consistent with prevalence rates for Dallas County. Hypertension is the number one adult diagnosis at every COPC site followed by type II diabetes and urinary tract infections. Others in the top ten include asthma, allergies, ear infections, flu, viral infections, and depression/psychological stress. These conditions are similar to other health status measures in Dallas County. Dallas County residents reported that 28.6% of them suffered from hypertension, 25.3% high cholesterol, 15.5% asthma, and 11.1% diabetes. It is this older age group that tends to have chronic diseases and utilize more health care. A disease management program designed to improve the health of persons with chronic conditions will, ultimately, result in cost savings. It is the Parkland Health Plus

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Appendix K-1

population that may benefit the most from a disease management approach, and we would recommend utilizing COPC as the platform for implementation.

Operations and Policies COPC has a Vice President of Operations, who is responsible for the oversight of the COPC clinics. A Resource Team comprised of twelve director and associate director level positions, including the Medical Director, Behavioral Health Director, Operations/Finance Director, among others, report directly to her. However, she also directly supervises the nine site administrators that oversee clinical services and operations at each site. In addition, each site has a Lead Physician and Lead RN. The COPC Medical Director does not have any direct supervising authority over the Lead Physicians. Most of the community based COPC sites have Community Advisory Boards. These were established when Parkland recognized the importance of community involvement and input into its clinic system. Historically, the Advisory Boards have brought community needs to the attention of COPC. For example, it was the Advisory Boards that raised a community concern regarding the injury rate of children in automobile accidents that resulted in the development of a COPC car seat distribution and car safety education program. Recently the Advisory Boards have felt some frustration with the COPC administrative focus on improving the point of service cash collections. They worry about this policy’s adverse impact on obtaining access by deterring uninsured selfpay patients from returning for services. The WISH clinics, for example, do not charge a co-payment for prenatal services to encourage early access to prenatal care. COPC's finance and eligibility staff report to the COPC leadership (instead of Parkland's financial operation). Approximately two years ago, a concerted effort was organized to improve eligibility screening for COPC patients to enroll them in Medicaid and other benefits for which they may qualify. Uninsured patients seeking care are required to enroll in Parkland Health Plus before obtaining services. At the same time, collection of co-payments for self-pay patients is now more strictly enforced. This has resulted in increased cash collections at COPC sites and some believe it has the perverse incentive of motivating some patients to go to the Emergency Department and ACC (where collecting co-payments in an emergency prior to providing a health service is illegal) instead of seeking primary care to avoid acute episodes. COPC and Parkland may want to review the impact this policy has had on the health seeking behavior of its patients. The COPC appointment function is moving towards a centralized system. HMA heard conflicting reports on appointment availability and accessibility. According to COPC, a new pediatric patient can receive same day or next day appointment. For adults, they indicated it might take 6 to 8 weeks to obtain an appointment as a new patient. The COPC Advisory Board focus group insisted that it is very difficult to obtain an appointment. To document the experience firsthand, we attempted to obtain appointments for both an uninsured new pediatric and new adult patient. It proved difficult for us to obtain any appointments at the clinics. In short, we were only able to Health Management Associates Appendix K-1

obtain an appointment for the child and the appointment clerk stressed the importance of being screened for Medicaid eligibility. At one site, the new adult patient was told to go to the unemployment office to get letter documenting employment status (if unemployed) and come in to the clinic and enroll in Parkland Health Plus prior to receiving an actual appointment, after which an appointment was not be available for 2-3 months. Another COPC clinic said they would mail the patient an appointment when one became available, and that all appointments were taken that month. Access to care is also affected by the hours a site is open. Most COPC sites are open Monday through Friday opening at 7:30am or 8:00am and close at 5:00am or 6:00pm. ACC (urgent care) is open seven days a week from 8:00am - 8:30 pm. DeHaro is opened on Saturdays from 8:00am - 6:00pm and Vickery operates urgent care hours on Sunday from 8:00am - 6:00pm.

Relationships Another barrier that interferes with continuity of care for Parkland patients involves the use of two information systems, one for on campus and one off campus for COPC sites. This becomes problematic when COPC patients go to the Emergency Department because the ED is unable to establish whether the patient receives their primary care within the Parkland system, both to obtain data on the patient and also to make a followup appointment upon discharge. The same is true for ACC (urgent care) even though is part of the COPC system. The COPC physicians are directly employed by Parkland and are not responsible for any inpatient activity. They have difficulty directly admitting a patient through the established protocol and often send the patient to the Emergency Department as the most efficient mechanism to get a patient admitted to the hospital. Unless the patient notifies the physician, the COPC site is unaware when their patients are admitted and/or discharged from Parkland. COPC providers confront long wait times in obtaining specialty and diagnostic appointments for their patients. There is tremendous demand at Parkland for cardiology, pain clinic, gastroentrology, dermotology, neurology, and opthamology clinic appointments. However, we were able to confirm that COPC newborn appointments are occurring upon discharge from the Parkland newborn nursery. The chart below summarizes a report generated by the EPIC electronic appointment system in use by COPC. EPIC Report Newborn Appointments to COPC: January 2004- August 2004 Regular Follow-up Regular High Risk FollowHigh Risk Appts (6-14 days) Appt's Kept up (within 6 days) Appts Kept COPC sites 9,000 7,619 325 293
(For newborn appointments made and kept by COPC individual sites, see Appendix K-6.)

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Appendix K-1

Children’s Medical Center relies on the COPC system of clinics, particularly for children covered by Medicaid and the uninsured. COPC pediatricians believe they have a better relationship with Children’s Medical Center than COPC physicians have with Parkland. Most of the pediatricians rotate through Children's inpatient service for two weeks a year. This appears to have a positive impact on their connection to Children's and on knowledge about how the systems work. Also, most of the COPC pediatricians were trained at Children's, so they know many of the physicians there. However, it is often difficult to obtain timely appointments for specialty and diagnostic services, particularly immunology, dermatology, MRIs, neurology, developmental assessments, and orthopedics. COPC has connections with several other hospitals, most notably, Baylor, and Presbyterian. Baylor is a contributing partner to the planning and operations of the new Irving site and Presbyterian provides ongoing financial support to the Vickery site. Finances There are inherent limitations on the overall potential of COPC to ever achieve a balanced budget. In fact, the reimbursement policies of Medicaid and Medicare are insufficient to achieve such a goal. Moreover, as the number of uninsured adults and children rises, so does the population Parkland exists to serve. The payor mix of COPC essentially is 90% dependent upon government reimbursement.4 Overall, the financial position of the COPC sites result in an annual loss of ($15,594,655) before allocations and ($29,124,805) after indirect costs and tax/tobacco dollars are applied. It is quite common for primary care to experience such losses, particularly in public systems with high numbers of uninsured patients. Nevertheless, primary care is the most effective and cost efficient level of care to offer. 2003 COPC Financials (in 000s)
Total Gross Charges Total Payments Cost Report Settlement Net Timing Variance Tied to G/L UPL Total Net Patient Revenue incl. Allocated Patient Revenue Direct Cost Contribution Margin Before Allocations Indirect Cost Excess (Shortfall) Before Allocations Tobacco Dollars Excess (Shortfall) After Tobacco Allocation Tax Dollars Excess (Shortfall) After Tax Allocation
4

COPC (Excluding Employee Clinic) $40.5 $10.1 $2.0 $0.7 $2.7 $15.6 $31.1 ($15.5) $27.5 ($43.0) $0.2 ($42.8) $13.6 ($29.1)

Self-Pay/Charity 37.58%; Medicaid Managed Care 26.60%; FFS Medicaid/KidsFirst 12.65%; Medicare 10.24%; and Other 12.93

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Appendix K-1

It is only by taking advantage of Medicaid and Medicare enhanced reimbursement, hence, by becoming an FQHC, that COPC may achieve a significantly improved financial position along with keeping provider productivity improvements on target. Key Issues Locations and Size The location, size, and staffing of clinics does not always align with community need. Monitoring provider productivity by Care Team, module, site, and community is essential in achieving alignment between supply and demand. A continuous process of assessing demand and reallocating resources should be instituted before expansion is considered. By utilizing the criteria outlined below, COPC can successfully evaluate if and where to expand. • Is there a sufficient portion of the population under 200% of the federal poverty level in the service area to support existing or new clinic, now and in the future?5 • Where is the population accessing care now? Is this an area of high, medium or low density of Medicaid physicians? Document Emergency Department usage at PHHS, Children's, and other hospitals. • Are there potential partners to contribute financially to the capital investment and ongoing operations? • To determine the type of providers and services to offer, COPC should document: o The age distribution trends of the surrounding community. o Health status of the surrounding population, particularly mortality and morbidity indicators. o Analyze the Emergency Department discharge diagnoses of local hospitals as well as the ambulatory sensitive and preventable conditions These are questions that should be asked on a regular basis. At the moment, we have several recommendations to make regarding the need for potential expansion into new communities and/or relocating or reducing services at existing sites. Expand into Irving Irving residents currently rely on COPC for 13,899 visits last year and utilized Parkland emergency department (9,621 visits), and other outpatient services for 54,497 visits. Additionally, Irving residents relied on WISH services at two sites, deHaro and Maple, for a total of 4,615 prenatal visits. The Irving population is increasingly Hispanic and poor. Characteristics of the segment of the population living below 200% federal poverty are: • 55% Hispanic, 25% White, and 11% African American • 36% age 0-18, 60% age 19-64, and only 4% over 65 years

Currently Parkland defines low income as families earning $25,000 or less per year. The federal government utilizes federal poverty level standards, a methodology we encourage Parkland to utilize.

5

Health Management Associates

Appendix K-1

Hence, Irving has a low-income, aging, and predominately Hispanic population that access Parkland services already. There have been other partners involved in the establishment of an Irving site and federal grants and local resources are already secured. The majority of PPCC's patients live in the northwest quadrant of Dallas County (about half in Irving) an area that lacks a COPC site. PPCC was started as a newborn discharge overflow clinic when appointments were unavailable in outlying COPC clinics. The idea was for initial newborn appointments to occur at PPCC and then transfer the patient’s care to their local COPC. Last year PPCC had 9,855 visits. Once a COPC site is built in Irving, it may be possible to significantly downsize PPCC. Evaluate feasibility of utilizing Parkland owned Kaiser buildings Parkland owns two empty buildings that are each between 35,000-38,000 square feet and were previously owned by Kaiser and used as medical office buildings. One is located in South Oak Cliff and another in Southeast Dallas. The current Oak West COPC site is small, cramped and operates at capacity. We recommend COPC and Parkland explore the feasibility of relocating Oak West (with the WISH clinic) to the South Oak Cliff empty Kaiser building and consider providing specialty and diagnostic services that are in high demand. The Southeast Dallas Kaiser building is located in a community that is one of the top ten zip codes utilizing both Parkland and Children's Emergency Departments. An assessment of demand for primary care should be conducted to evaluate the worth of opening this empty site as well. However, the assessment should include a thorough evaluation of the poorly utilized and underperforming Southeast COPC site. There are plans to locate a WISH clinic at Southeast and that may help generate pediatric visits, but there may be a more fundamental underlying problem. One possibility worth noting is the current building configuration may contribute to lower productivity. The Youth & Family school based sites have increased the number of students and community members they see since new leadership was installed two years ago. The Kiosco site is located in the affluent north Dallas area and serves a population that lives primarily in low-income apartment complexes, sometimes with multiple families sharing cramped quarters. This site offers evening hours one day a week and its services are in high demand. In addition, the Vivian Field site is located in north Dallas near a densely populated series of additional apartment complexes. COPC does not have a clinic in north Dallas and these sites have become points of access for the underserved population in these communities. The Kiosco site could easily offer more evening hours throughout the week to decrease reliance on the Parkland ED (Kiosco zip code is one of the top 10 highest utilizers of Parkland ED). The closest COPC clinic, Vickery, is also operating near capacity. Again, the northwest quadrant of Dallas County residing near I 35-E needs a coordinated PHHS plan to increase access by expanding capacity for this growing population in need.

Health Management Associates

Appendix K-1

Pediatric Patients One potential source of additional pediatric patients is the Parkland Community Health Plan, Inc. With almost 70,000 children enrolled in the plan, only 37,042 of these children selected COPC as the medical home for their primary care, as of August 2004. The documented need for more paying patients within COPC, particularly children, should motivate the health plan and COPC administration to work together for the benefit of the Parkland system. Furthermore, if COPC receives FQHC designation, all of the Parkland pediatric Medicaid patients, whether fee for service or managed care, will receive cost based reimbursement, a major incentive to redirect these pediatric patients into COPC sites. Enhanced reimbursement will also benefit the Parkland Community Health Plan, but only for those patients assigned to Parkland primary care sites. Hours A common strategy to increase access is to expand hours of operation. We recommend COPC explore the feasibility of expanding hours at the sites most in need of additional appointment slots. Examples are: • The Vickery site is one of the busiest sites and operates as an urgent care clinic on Sundays from 8am-6pm, yet their hours during the week extend only to 5pm. • Oak West is one of the smallest and most productive sites yet it does not have evening hours beyond 6pm (and 5pm 2 days a week) or weekend hours. Productivity vs Staffing COPC has implemented a major productivity initiative and we encourage COPC to put equal emphasis on continually reviewing its staffing model and staffing ratios. This will further refine its operations, help to achieve maximum capacity, and improve access for the population of Dallas County. Given the patient population's payor mix it is essential that COPC monitor its cost structure, which is predominately staff, in a primary care setting. Medical Leadership The role of the Medical Director should be reconsidered and expanded within the overall organizational structure to strengthen clinical leadership and accountability at the top of the organization, in addition to providing a more direct voice for COPC physicians. Physician leadership will also be required to implement an effective disease management program. The physicians will be required to directly report to a Medical Director when COPC applies for FQHC status. Operations and Policies COPC and Parkland should evaluate their cash collection and billing policies and try to remove any incentives that may motivate patients to seek inappropriate levels of care in order to avoid co-payments. Currently, the collection practice differs from one type of clinic to the next. COPC, residency clinics, specialty clinics, and the pharmacy clinics on campus all differ in their collection practices. The Emergency Department and ACC urgent care are required to meet Emtala regulations, however, we encourage COPC to reevaluate their Emtala interpretation for ACC. Working more closely with the ED to

Health Management Associates

Appendix K-1

encourage patient follow-up appointments in their community (rather than ACC) should be improved. However for this to occur, COPC must improve access to timely appointments for adult patients. Further refinement of the centralized appointment system for COPC should be a priority. Continued collaboration with WISH, and better communication at the local site level is encouraged. The goal should be to have policies and procedures that encourage the health seeking behavior that COPC and Parkland desire. Pediatric Partnerships Expanding the relationship between Children’s Medical Center and COPC is warranted. Both to improve referral processes between organizations, but also to coordinate and conduct strategic planning around the primary care needs of low-income Dallas County children. The same type of discussions must occur with other hospitals and COPC sites, including Presbyterian, Baylor, Methodist, and Medical City. Conclusion The Parkland COPC system has shown real improvement in productivity. We believe COPC can meet the future demands on its system with modest expansion efforts over the next few years. By implementing a formal disease management program, making a serious effort to improve connections both within Parkland and with external partners, applying for FQHC status and by modifying financial and appointment policies to improve patient access, COPC can remain a strong asset to the PHHS system.

Health Management Associates

Appendix K-1

COPC Locations & 10 Zip Codes with Highest Parkland ED Use

63 5 635 635 635 635 635 635

Garland$ Vickery$75231
75220
75
635 635 635 63 635

PPCC/FMC$

75235

75228

East$
75212
30

30 30 30

deHaro$
75215 75211

75227

Southeast$ Bluitt-Flowers$ Oak West$
?

75216

75217

20

35E

45

175

67

Health Management Associates

Appendix K-2

COPC Locations & 10 Zip Codes with Highest Children Medical Center’s Use

75

35E

635

Garland Vickery 75231 75220 75061
$

$

635

30

PPCC/FMC

$

75228 East
$
80

75212 deHaro
30

$

75227 75208

80

75211 Bluitt-Flowers $ Oak West
$
?

Southeast 75216

$

75217

20 175

67 35E

Health Management Associates

Appendix K-2

COPC & Unused Site Locations
35E 35E

635 75

Garland
$

Vickery
$
30
635 635 635 635 635 635

PPCC/FMC
$

East
$

30 30 30 30

80

$
30
80

?

deHaro

Empty Kaiser Bld Southeast

Empty Hospital ?
$

$

Bluitt-Flowers
20 175

Oak West $
20

?
?

Empty Kaiser Bld
35E

45

67

Health Management Associates

Appendix K-2

Appendix K – 3: Community Clinic Profiles

BLUITT FLOWERS EAST DALLAS dEHARO-SALDIVAR GREATER VICKERY GARLAND OAK WEST SOUTHEAST DALLAS

Health Management Associates

Appendix K-3

BLUITT FLOWERS FY 2003 Total visits = 46,048 Visits per exam room 1,180 2.17 clerical staff per provider Visits per provider FY 2003 = 3,837 1.33 Nurses/MAs per provider

Bluitt Flowers is located in South Oak Cliff, a community that is 62% African American and 27% Hispanic and the patients reflect the same racial mix. South Oak Cliff is one of three corridors that have "extra low" numbers of primary care physicians contracted to see Medicaid patients. South Oak Cliff also has some of the worst health status indicators in Dallas County. On a monthly basis Bluitt Flowers has the capacity to see 1,904 adult and geriatric patients and 1,545 pediatric and adolescent patients. Bluitt has exceeded its adult capacity for the past several months, particularly with geriatric patients. However, there isn't a plan to increase adult capacity despite long waiting times to get an appointment. Meanwhile, there have been 387 unused pediatric/adolescent appointments. This is particularly troubling because Bluitt is located in a zip code that generates a lot of visits to Children's ED. There is no WISH clinic located onsite. Recently, two pediatric modules were moved elsewhere in an attempt to match resources with demand. Bluitt should work more closely with Children's ED to ease access to follow-up appointments at its site. Bluitt is located near the empty Kaiser facility and could benefit tremendously if specialty and diagnostic services were offered there. Bluitt reports a backlog to obtain access to Parkland for cardiology, GI and pain clinic. Bluitt also says it receives referrals from Parkland ED and ACC, which other COPC sites felt was problematic. Bluitt is located in a zip code which is a top utilizer of Parkland's ED. The sexually transmitted disease rate in the South Oak Cliff is higher than any other part of Dallas County. The Chlamydia rate is 1,056 per 100,000 persons compared to a Dallas rate of 449.6 (Texas 327.9). Additionally, Gonorrhea is 871 per 100,000 compared to Dallas rate of 271 and Syphillis is 90 per 100,000 compared to Dallas rate of 29. Screenings for STDs start immediately in all COPC clinics that serve this geographic area. We noted the teen birth rate is twice Dallas County, 10% of all births are low birth weight and 14.6% of births occur without or unknown prenatal care yet the WISH clinic moved out of Bluitt some time ago. The Age adjusted death rates per 100,000 for South Oak Cliff exceed Dallas County for many indicators: Stroke (88 S Oak Cliff /57 Dallas County), Flu (25/19), homicides (33/12), Heart (330/231), Cancer (246/177), Diabetes (30/20), Kidney disease (23/11). When Ambulatory Sensitive and Preventable Conditions are analyzed, the following conditions are notable: Congestive heart failure (980 S Oak Cliff /620 Dallas County), second drug abuse (940/445), second alcohol abuse (920/569), Diabetes (400/255), Asthma (340/218), pneumonia (335/281). These indicators identify a community with high levels of chronic illness in need of an ambulatory chronic disease management approach.

Health Management Associates

Appendix K-3

Bluitt Flowers
Address 303 N. Overton Rd. Dallas, 75216 Phone (214) 266-4200 Service Area S Oak Cliff Site Administrator Kerrie Watterson Lead Physician Donna Persaud - Peds FY03 Clinician Visits 46,048

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours: Adolescent, Adult, Pediatrics, Geriatrics MHFP, Lab, Radiology, Pharmacy, Dental, Epilepsy, HIV, Mammography, Nutrition, Optometry, Podiatry, Psychology/Psychiatry,Social Work Red Bird (3 miles west), N. Oak Cliff (3 miles northwest), South (6 miles northeast) Parkland, Children's, WISH, some Methodist & Baylor None M-Th 7:30 am - 6:00 pm, Fri 8:00 am - 5:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland Methodist 44.2% 18.2% 42.4% 13.8% 12.6% 28.3% 22.9% 21.4% 22.1% 20.4% Charlton Children's 13.6% 0.0% 13.1% 10.8% 10.3% 12.8% 10.7% 11.9% 13.3% 8.8% Baylor St. Paul 5.1% 6.8% 4.2% 5.7% 5.9% 5.2% 7.7% 5.2% 8.2% 5.9% Other 12.0% 10.1% 24.8% 20.1% 21.4%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
S Oak Cliff 02 Pop. 114,267 49,259 17,030 2,564 183,120 S Oak Cliff 02 Pop. 14,495 31,188 79,387 39,641 18,409 183,120 Clinic 62% 27% 9% 1% Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

13,403 5,602 946 243 20,194 Clinic
CY'03 undup pts

66% 28% 5% 1% Clinic
62% female

n/a n/a n/a n/a

S Oak Cliff 00 Pop. 38,774 25,366 22,830 94,217 181,187 Clinic

21% 14% 13% 52%

PHHS Community Health

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

5,429 3,228 4,065 5,256 2,208 20,186

27% 16% 20% 26% 11%

49% 49% 68% 72% 75%

8% 17% 43% 22% 10%

Self-Pay Medicaid Medicare Other Total

18,439 17,040 9,649 1,839 46,967

39% Plan Members Aug 2003 36% 21% Health First 4,858 4% Kids First 671 Total 5,529

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001
S Oak Cliff Dallas Co. U.S.

Clinic - Top Diagnoses
With CY2003 number and percentage of encounters 8,337 ROUTIN CHILD HEALTH EXAM 6,655 HYPERTENSION NOS 2,883 DMII WO CMP NT ST UNCNTR 1,217 BENIGN HYPERTENSION 920 DMII WO CMP UNCNTRLD 899 ACUTE URI NOS 866 SCREEN MAMMOGRAM NEC 682 OTITIS MEDIA NOS ASTHMA W/O STATUS ASTHM 672 670 ROUTINE MEDICAL EXAM 608 HYPERMATURE CATARACT 596 DERMATOPHYTOSIS OF NAIL 544 Influenza 535 VIRAL INFECTION NOS 475 GYNECOLOGIC EXAMINATION 468 ASYMP HIV INFECTN STATUS 457 VAC-DIS COMBINATIONS NOS 433 ALLERGIC RHINITIS NOS 17.8% 14.2% 6.1% 2.6% 2.0% 1.9% 1.8% 1.5% 1.4% 1.4% 1.3% 1.3% 1.2% 1.1% 1.0% 1.0% 1.0% 0.9%

High Cholesterol High Blood Pressure Asthma Diabetes Stroke

n=106 16.8% 42.5% 28.6% 15.9% 3.7%

n=1,165 n=148,758 25.3% 26.5% 28.6% 32.3% 15.5% 16.0% 11.1% 13.5% 2.6% 2.8%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 12.0 (2.5 Ped, 4 Internist, 17.0 .7 podiatrist, 2 lead, 26.0 2.8 physician assts) 36.7 49,381 39.0

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
S Oak Cliff CONGESTIVE HEART FAILURE SECONDARY DRUG DEPENDENCY AND ABUSE SECONDARY ALCOHOL DEPENDENCY AND ABUSE DIABETES CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACTERIAL PNEUMONIA ASTHMA KIDNEY AND URINARY TRACT INFECTIONS INJURIES CELLULITIS Dallas Co. S Oak Cliff DEHYDRATION, VOLUME DEPLETION HYPERTENSION ALCOHOL DEPENDENCY AND ABUSE DRUG DEPENDENCY AND ABUSE CONVULSIONS NUTRITIONAL DEFICIENCIES Grand Mal Status and Other Epileptic Convulsions PELVIC INFLAMMATORY DISEASE ANGINA GASTROENTERITIS Dallas Co.

948.2 909.1 859.3 357.6 350.2 338.6 334.2 281.1 278.4 244.0

620.1 445.4 569.8 255.1 429.1 281.6 218.4 259.9 233.7 231.2

192.7 183.4 169.9 96.7 95.7 55.8 55.2 50.8 44.4 33.6

176.6 89.3 146.8 96.5 63.5 3.0 36.8 22.5 62.0 45.9

2001 Reported Incidence of Infectious Conditions & Injuries
per 100,000 Chlamydia Gonorrhea Syphillis Esherichia coli Samonellosis Shigellosis Hepatitis B carrier Hepatitis C Submersion injury Streptococcal invasive disease Meningococcal infection Tuberculosis Bacterial meningitis
S Oak Cliff Dallas Co. U.S.

1056.2 871.6 90.1 1.1 8.2 10.9 18.1 211.0 1.1 8.2 4.4 45.8 4.4

449.6 271.4 29.1 0.6 6.0 8.4 13.9 114.4 0.1 4.8 1.7 11.9 4.2

278.3 128.5 11.5 14.4 7.2 12.0

0.8 5.7

(Conditions listed are those with higher rates than county in 2001)

Maternal and Child Health
S Oak Cliff Dallas Co. U.S. Per 100,000

2001 Age Adjusted Death Rates
S Oak Cliff Dallas Co. U.S.

Fertility Rate - Births per 1,000 Females Age 15-44 2001 84.7 83.9 2000 82.8 80.2 1999 79.0 84.5 % Births to Teens Ages Less Than 18 2001 9.5% 5.3% 2000 9.7% 5.8% 1999 9.3% 5.7% % of Births That Are Low Birth Weight 2001 10.0% 7.7% 2000 10.0% 7.8% 1999 10.6% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 7.8 6.3 2000 6.6 5.5 1999 8.8 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 14.6% 10.2% 2000 12.2% 8.2% 1990 16.0% 11.4%

65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8

Stroke - 2001 2000 1999 Alzheimer's - 2001 2000 1999 Flu 2001 2000 1999 Accidents - 2001 2000 1999 Suicides - 2001 2000 1999 Homicides - 2001 2000 1999 Heart - 2001 2000 1999 Cancer - 2001 2000 1999 Kidney Disease - 2001 2000 1999 HIV/AIDS - 2001 2000 1999 Septicemia - 2001 2000 1999

88.4 80.0 78.7 22.3 25.4 16.4 25.3 19.4 19.2 18.3 16.1 18.7 10.5 5.0 8.0 33.8 14.5 26.0 330.7 339.0 334.7 246.2 246.0 240.4 23.7 26.0 17.7 20.5 23.9 25.4 15.6 12.0 15.3

57.2 66.2 64.1 21.2 23.7 19.3 19.1 23.1 17.1 16.2 14.9 15.2 10.3 8.4 10.7 12.9 10.6 9.8 231.7 275.7 269.3 177.4 202.7 194.5 11.6 11.9 9.2 7.8 8.1 9.0 10.0 12.5 11.5

57.9 60.8 61.8 19.1 18.0 16.5 22.0 23.7 23.6 35.7 35.5 35.9 10.7 10.6 10.7 7.1 6.1 6.2 247.8 257.9 267.8 196.0 201.0 202.7 14.0 13.5 13.1 5.0 5.3 5.3 11.4 11.4 11.3

2001 Age Adjusted Death Rates
Per 100,000 S Oak Cliff Dallas Co. U.S.

Diabetes - 2001 2000 1999 Respiratory - 2001 2000 1999 Cirrhosis - 2001 2000 1999

30.2 37.9 39.7 50.3 34.0 35.0 16.9 8.6 8.5

20.0 26.5 23.5 39.2 42.9 46.0 8.5 9.2 8.7

25.3 25.2 25.2 43.7 44.3 45.8 9.5 9.6 9.7

(Causes listed are those with higher rates than county for one, more years.)

Bluitt-Flowers Health Center
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

C

C

C
$

$

$

$ $ $ $

$ C $$ $

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$ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $$ $ $ $$ $$$$ $ $ $ $ $ $ $ $ $$$$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$$ $ $ $ $ $ $ $$ $$$ $ $ $ $$$ $ $$$ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $$ $ $ $ $ $$ $ $ $$$ $$ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $$ $ $ $ $ $ $$ $ $ $ $$$$ $ $$ $ $ $$ Bluitt-Flowers $ $ $ $ $$ $ $ $ $ $$ $ $ $$ $ $ $ $$ $ $ $ $ $ $$$$ $ $ $ $ $$ $ $ $$ $ $$$$ $$ $ $ $ $ $$ $ $ $ $ $$ $ $ $ $$ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $$$ $$ $ $ $ $ $$ $ $$ $ $ $ $$ $ $ $ $ $ $ $$ $ $$ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $$ $ $

C $

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$

Bluitt Encounters by Zip Code
Water A rea County Line Zip Code Boundary

$ $

$ $ $ $ $

$ $ $ $ $ $ $ $

C COPC Clinic
Dot-Density
$ = 100 Bluitt Encounters

dEHARO-SALDIVAR FY 2003 Total visits = 52,051 Visits per exam room 1,487 2.06 clerical staff per provider Visits per provider FY 2003 = 4,003 1.07 Nurses/MAs per provider

Seventy six percent (76%) of deHaro's patients are Hispanic and patients travel long distances to access services - 13,679 patients (27% of all patients)) travel from Irving and Grand Prairie and 4,637 patients live in South Oak Cliff. deHaro is across the street from West Dallas which has very few primary care physicians, similar to South Oak Cliff. This is a large clinic with 35 exam rooms, and it is open on Saturdays from 8am-6pm. Despite de-Haro's apparent efficiency, reflected in the numbers above, it has experienced a significant pediatric decline. The monthly capacity for pediatric appointments is 2,717 (the most of any COPC site) yet it has been averaging only 2,096 appointments per month or 621 unused appointments. The Lead pediatrician wants to eliminate pediatric appointments and become strictly a walk-in clinic with expanded hours. In fact, she is experimenting with the model herself. There have been discussions of relocating the adolescent module to a nearby school-based site (Red Bird). There is not a WISH site at deHaro; instead one is located very nearby, at the Lakewest location. Meanwhile, the monthly adult capacity (1,537) has been fully utilized. Hypertension and Diabetes II are frequent diagnoses along with asthma. The ambulatory sensitive discharge rates in NW Oak Cliff for congestive heart failure is higher than Dallas (680.7 vs. 620 per 100,000) as is chronic obstructive pulmonary disease, pneumonia, and injuries, all preventable conditions. The discharge rate for secondary nutrition deficiency in NW Oak Cliff is 1.5 times the discharges for Dallas (51 versus 36 per 100,000). The only age adjusted death rate that is higher than Dallas County is Cirrhosis at 12.1 per 100,000 population versus 8.5 for Dallas an a US rate of 9.5. The 2001 Prevalence of Chronic Conditions Survey in NW Oak Cliff reported 45.5% have high blood pressure and 36% high cholesterol. This profile, combined with the high demand for adult and geriatric services, points out the need for a focused chronic disease management program.

Health Management Associates

Appendix K-3

deHaro-Saldivar Health Center
Address 1400 N. Westmoreland Dallas, 75211 Phone (214) 266-0500 Service Area NW Oak Cliff (border with W. Dallas) Site Administrator Jessica Hernandez Lead Physician Emmanuel Inyang - Adult/Geri Susan Briner - Peds, Sheila White-Jackson - adolescents FT04 Clinician Visits 52,051

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours: Adult, Pediatrics, Geriatrics, Adolescents MHFP, Lab, Radiology, Pharmacy, Dental, Mammography, Nutrition, Psychology/Psychiatry, Social Work, Adolescent Medicine West (1.5 miles NE), North Oak Cliff (2 miles SE), Red Bird (5 miles south) Parkland, Children's, WISH WISH, WIC M-Th 7:30am-6:00 pm, Fri 8:00 am - 5:00 pm, Saturdays (urgent care) 8:00 am to 6:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland 34.8% 31.6% 7.5% 16.3% 17.1% Charlton Methodist Methodist Children's 19.5% 19.1% 0.0% 13.1% 19.2% 12.7% 33.6% 18.8% 14.0% 21.3% 18.2% 15.3% 21.8% 21.6% 9.4% Baylor 4.7% 4.0% 2.9% 5.8% 5.6% Dallas SW 4.9% 3.4% 5.3% 6.8% 5.5% St. Paul 7.8% 7.3% 3.3% 3.6% 5.2% other 9.2% 8.7% 14.7% 12.7% 13.8%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
NW Oak Cliff 02 Pop. 76,068 110,718 76,880 7,038 270,704 NW Oak Cliff 02 Pop. 23,850 47,340 127,789 53,316 18,408 270,703 Clinic 28% 41% 28% 3% Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

2,758 14,665 1,576 284 19,283 Clinic 6,661 3,308 4,454 3,525 1,312 19,260

14% 76% 8% 1% Clinic
59% female

n/a n/a n/a n/a

NW Oak Cliff 00 Pop. 36,152 28,974 27,559 169,285 261,970 Clinic

14% 11% 11% 65%

CY'03 undup pts

PHHS Community Health

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

35% 17% 23% 18% 7%

49% 49% 71% 70% 66%

9% 17% 47% 20% 7%

Self-Pay Medicaid Medicare Other Total

18,364 24,721 5,061 3,472 51,618

36% Plan Members Aug 2003 48% 10% Health First 5,099 7% Kids First 1,037 Total 6,136

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001 NW Oak Cliff Dallas Co. U.S. n=93 n=1,165 n=148,758 High Blood Pressure 45.5% 28.6% 32.3% High Cholesterol 36.0% 25.3% 26.5% Diabetes 13.2% 11.1% 13.5% Asthma 9.1% 15.5% 16.0% Stroke 2.4% 2.6% 2.8%

Clinic - Top Diagnoses
18.7% 7.3% 4.8% 3.8% 2.0% 2.0% 1.8% 1.5% 1.5% 1.5% 1.4% 1.3% 1.2% 1.1% 1.1% 1.0% 1.0% 1.0%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 13.1 20.0 28.0 59.3 36,297 35.0

With 2003 number and percentage of encounters ROUTIN CHILD HEALTH EXAM 9,635 ACUTE URI NOS 3,753 DMII WO CMP NT ST UNCNTR 2,466 HYPERTENSION NOS 1,983 AC SUPP OTITIS MEDIA NOS 1,034 DMII WO CMP UNCNTRLD 1,028 ALLERGIC RHINITIS NOS 946 ASTHMA W/O STATUS ASTHM 789 ROUTINE MEDICAL EXAM 765 (3.1 Ped, 4 Internist, LONG-TERM USE ANTICOAGUL 753 3 lead, 2 physician OTITIS MEDIA NOS 717 asst, 1 nurse pract.) CONTRACEPT SURVEILL NEC 668 DEPRESSIVE DISORDER NEC 596 FEVER 581 ACUTE PHARYNGITIS 551 NEED PRPHYL VC VRL HEPAT 514 SCREEN MAMMOGRAM NEC 507 URIN TRACT INFECTION NOS 496

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001 NW Oak Cliff Dallas Co. 680.7 620.1 CELLULITIS 537.2 569.8 ALCOHOL DEPENDENCY AND ABUSE 394.8 445.4 HYPERTENSION 348.9 429.1 DRUG DEPENDENCY AND ABUSE 333.9 281.6 CONVULSIONS 258.3 218.4 SECONDARY NUTRITIONAL DEFICIENCIES 253.5 233.7 ANGINA 232.6 259.9 GRAND MALL STATUS & OTHER EPILEPTIC 221.8 255.1 GASTROENTERITIS 212.0 176.6 VACCINE
NW Oak Cliff

CONGESTIVE HEART FAILURE SECONDARY ALCOHOL DEPENDENCY AND ABUSE SECONDARY DRUG DEPENDENCY AND ABUSE CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACTERIAL PNEUMONIA ASTHMA INJURIES KIDNEY AND URINARY TRACT INFECTIONS DIABETES DEHYDRATION, VOLUME DEPLETION

211.0 128.4 82.2 79.2 68.5 51.0 47.9 37.9 30.7 28.3

Dallas Co. 231.2 146.8 89.3 96.5 63.5 36.2 62.0 36.8 45.9 20.7

2001 Reported Incidence of Infections Conditions & Injuries
per 100,000 Pertussis Chlamydia Gonorrhea Syphilis Tuberculosis Amebiasis Salmonellosis Shigellosis Botulism, foodborne Streptococcal invasive disease Memingococcal infection Malaria
NW Oak Cliff

10.5 376.0 16.9 1.5 10.1 0.7 6.7 10.9 0.4 4.9 2.9 1.1

Dallas Co. 4.2 449.6 271.4 29.1 11.9 0.7 6.0 8.4 na 4.8 1.7 1.1

U.S. 278.3 128.5 11.5 5.7 14.4 7.2 0.8 5.7

(Conditions listed are those with higher rates than county in 2001)

Maternal and Child Health
Dallas Co. Fertility Rate - Births per 1,000 Females Age 15-44 2001 87.7 83.9 2000 79.3 80.2 1999 89.0 84.5 % Births to Teens Ages Less Than 18 2001 6.0% 5.3% 2000 6.8% 5.8% 1999 7.3% 5.7% % of Births That Are Low Birth Weight 2001 7.8% 7.7% 2000 8.2% 7.8% 1999 7.3% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 7.5 6.3 2000 5.0 5.5 1999 6.1 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 11.0% 10.2% 2000 8.9% 8.2% 1990 11.9% 11.4%
NW Oak Cliff

2001 Age Adjusted Death Rates
U.S. 65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8 Per 100,000 Heart - 2001 2000 1999 Stroke - 2001 2000 1999 Respiratory - 2001 2000 1999 Diabetes - 2001 2000 1999 Flu 2001 2000 1999 Accidents - 2001 2000 1999 Kidney Disease-2001 2000 1999 Homicides - 2001 2000 1999 Cirrhosis - 2001 2000 1999 HIV/AIDS - 2001 2000 1999 Septicemia - 2001 2000 1999 NW Oak Cliff 230.7 288.8 240.0 64.6 67.1 44.9 43.0 40.1 43.1 26.4 27.9 24.5 19.6 27.3 14.1 16.6 12.5 13.7 15.8 11.8 8.7 7.1 10.9 9.4 12.1 7.8 12.3 6.1 10.3 7.3 10.9 16.6 15.0 Dallas Co. 231.7 275.7 269.3 57.2 66.2 64.1 39.2 42.9 46.0 20.0 26.5 23.5 19.1 23.1 17.1 16.2 14.9 15.2 11.6 11.9 9.2 12.9 10.6 9.8 8.5 9.2 8.7 7.8 8.1 9.0 10.0 12.5 11.5 U.S. 247.8 257.9 267.8 57.9 60.8 61.8 43.7 44.3 45.8 25.3 25.2 25.2 22.0 23.7 23.6 35.7 35.5 35.9 14.0 13.5 13.1 7.1 6.1 6.2 9.5 9.6 9.7 5.0 5.3 5.3 11.4 11.4 11.3

(Causes listed are those with higher rates than county for one, more years.)

deHaro-Saldivar Health Center
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deHaro Encounters by Zip Code
Water A rea County Line Zip Code Boundary

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EAST DALLAS FY 2003 Total visits = 51,398 Visits per exam room 1,713 2.28 clerical staff per provider Visits per provider FY 2003 = 3,586 1.71 Nurses/MAs per provider

East Dallas is located in an office type building that requires use of a slow elevator to access clinical and other services. Despite this, over the past few months East has improved its productivity and had reduced underutilized capacity. As of August, there has been additional capacity for 118 adult appointments and 43 pediatric appointments per month at East. (Total pediatric monthly capacity is 1,950 appointments; for adults 2,002.) Approximately 70% of East patients come from East, Southeast Dallas and Vickery corridors. Over 1,000 patients come from Irving and 3,200 (6%) come from South Oak Cliff. Parkland owns the building next door that contains an empty floor that is available to East for non-patient activities. East Dallas is located down the street from Baylor, which refers uninsured patients to East from its ED. Baylor also operates a Medicaid clinic, Agape, that refers its high acuity patients to East. This relationship could be expanded to include some needs and issues that may be mutually beneficial. East also provides services in an assisted living facility, an adult day care provider, and operates a grant funded refugee program. The service area, East Dallas, is 36.5% Hispanic with an aging population, while East's patients are 69.6% Hispanic, 17.8% African American and 9% White and evenly divided between children and adults. Self-pay and Medicaid patients both comprise 47% of the patient population. Age Adjusted Death rates for East Dallas report that in 2001 the following causes of death were higher than for Dallas County per 100,000 of population: Flu (22.4 East/19.1 Dallas), HIV/AIDS (11.5 East/7.8 Dallas), and Homicides (13.7 East/12.9Dallas). Flu was the sixth highest clinical diagnosis at East in 2003. Ambulatory Sensitive and Preventable Condition discharge rates from East Dallas show Secondary Alcohol Abuse at 738.7 per 100,000 compared to 569.8 for Dallas County an indicator that is often related to high Homicide rates. Congestive heart failure was second with a rate of 712.9 per 100,000 compared to Dallas 620.1 with Secondary Drug Abuse leading as third with 516.9 discharges per 100,000 compared to Dallas 445.4. The East Dallas clinic site has a part time psychologist and psychiatrist, and 3 full time social workers. It may be appropriate for East to consider increasing its access to drug and alcohol abuse services as well as offering targeted programming on site, including a brief screening tool for clinical providers to increase identification of alcohol and drug abuse.

Health Management Associates

Appendix K-3

East Dallas Health Center
Address 3320 Live Oak Dallas, 75204 Phone (214) 266-1000 Service Area E Dallas Svc Area Site Administrator Eric Walker Lead Physician Noel Santini - Adult/Geri LeAnn Kridelbaugh - Peds FY03 Encounters 51,398

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours: Adult, Pediatrics, Geriatrics MHFP, Lab, Radiology, Pharmacy, Dental, Mammography, Nutrition, Psychology/Psychiatry, Refugee Program, Social Work Woodrow (2 miles northeast), West (3 miles west), South (3 miles southeast) Parkland, Children's, WISH, Lancaster Comm., some Methodist & Baylor WISH M-Th 7:30 am - 6:00 pm, Fri 8:00 am - 5:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland 43.4% 45.7% 7.5% 17.2% 19.4% Baylor 17.8% 14.3% 19.8% 27.7% 23.4% Doctors' 3.5% 1.8% 15.5% 15.2% 15.1% Presby Children's 12.5% 0.0% 8.5% 9.3% 16.3% 10.6% 8.9% 11.0% 11.2% 7.2% Other 22.8% 20.4% 30.4% 20.0% 23.6%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
E Dallas Svc Area 02 Pop. 28,144 13% 77,236 36% 96,281 46% 9,945 5% 211,606 E Dallas Svc Area 02 Pop. 16,040 8% 25,163 12% 112,294 53% 37,003 17% 21,106 10% 211,606 Clinic Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

2,947 11,523 1,500 591 16,561 Clinic 5,724 2,267 3,993 3,506 1,049 16,539

18% 70% 9% 4% Clinic
57% female

n/a n/a n/a n/a

E Dallas Svc Area 00 Pop. 33,506 16% 24,873 12% 20,761 10% 126,419 62% 205,559 Clinic
PHHS Community Health

CY'03 undup pts

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

35% 14% 24% 21% 6%

49% 49% 71% 70% 66%

Self-Pay Medicaid Medicare Other Total

21,876 21,777 6,420 2,407 52,480

42% Plan Members Aug 2003 41% 12% Health First 4,535 5% Kids First 686 Total 5,221

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001 E Dallas Svc Area Dallas Co. U.S. n=101 n=1,165 n=148,758 High Cholesterol 30.2% 25.3% 26.5% High Blood Pressure 26.3% 28.6% 32.3% Asthma 15.8% 15.5% 16.0% Diabetes 8.8% 11.1% 13.5% Stroke 0.0% 2.6% 2.8%

Clinic - Top Diagnoses
19.0% 8.0% 6.8% 3.0% 2.3% 1.9% 1.8% 1.5% 1.4% 1.3% 1.2% 1.1% 1.1% 1.0% 0.9% 0.9% 0.8% 0.8%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 14.3 24.0 30.0 54.5 43,154 30.0

With 2003 number and percentage of encounters ROUTIN CHILD HEALTH EXAM 9,949 HYPERTENSION NOS 4,212 DMII WO CMP NT ST UNCNTR 3,557 ACUTE URI NOS 1,564 DIETARY SURVEIL/COUNSEL 1,223 Influenza 984 VIRAL INFECTION NOS 942 ASTHMA W/O STATUS ASTHM 808 OTITIS MEDIA NOS 739 (5.7 Ped, 5.6 Internist, AC SUPP OTITIS MEDIA NOS 684 2 lead, 1 nurse pract.) DMII WO CMP UNCNTRLD 642 ALLERGIC RHINITIS NOS 595 LONG-TERM USE ANTICOAGUL 570 DEPRESSIVE DISORDER NEC 538 URIN TRACT INFECTION NOS 496 PSYCHOLOGICAL STRESS NEC 496 HYPERLIPIDEMIA NEC/NOS 429 FEVER 413

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
E Dallas Svc Area SECONDARY ALCOHOL DEPENDENCY AND ABUSE CONGESTIVE HEART FAILURE SECONDARY DRUG DEPENDENCY AND ABUSE CHRONIC OBSTRUCTIVE PULMONARY DISEASE KIDNEY AND URINARY TRACT INFECTIONS INJURIES BACTERIAL PNEUMONIA DEHYDRATION, VOLUME DEPLETION ALCOHOL DEPENDENCY AND ABUSE DIABETES Dallas Co. E Dallas Svc Area CELLULITIS ASTHMA DRUG DEPENDENCY AND ABUSE HYPERTENSION CONVULSIONS GASTROENTERITIS ANGINA SECONDARY NUTRITIONAL DEFICIENCIES Grand Mal Status and Other Epileptic Convulsions VACCINE Dallas Co.

738.7 712.9 516.9 440.7 343.9 302.6 273.7 245.8 238.3 235.1

569.8 620.1 445.4 429.1 259.9 233.7 281.6 176.6 146.8 255.1

228.8 170.4 116.1 85.6 62.4 52.9 43.0 32.2 25.6 24.9

231.2 218.4 86.5 89.3 88.5 45.9 62.0 36.2 36.8 20.7

2001 Reported Incidence of Infectious Conditions & Injuries
per 100,000 Chlamydia Gonorrhea Syphilis Tuberculosis Amebiasis Hepatitis A Hepatitis B carrier Hepatitis C Lead exposure, adult Legionellosis Streptococcal invasive disease Pertussis
E Dallas Svc Ar Dallas Co. U.S.

431.9 264.1 28.9 10.6 1.4 6.3 13.9 140.3 0.5 0.5 5.3 4.8

449.6 271.4 29.1 11.9 0.7 4.4 13.9 114.4 0.1 0.1 4.8 4.2

278.3 128.5 11.5 5.7 3.7 12.0

(Conditions listed are those with higher rates than county in 2001)

Maternal and Child Health
E Dallas Svc Area Dallas Co. U.S. Per 100,000

2001 Age Adjusted Death Rates
E Dallas Svc Area Dallas Co. U.S.

Fertility Rate - Births per 1,000 Females Age 15-44 2001 86.8 83.9 2000 77.0 80.2 1999 89.3 84.5 % Births to Teens Ages Less Than 18 2001 4.7% 5.3% 2000 5.5% 5.8% 1999 5.7% 5.7% % of Births That Are Low Birth Weight 2001 7.8% 7.7% 2000 7.0% 7.8% 1999 8.1% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 7.8 6.3 2000 7.0 5.5 1999 5.4 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 10.5% 10.2% 2000 8.4% 8.2% 1990 12.6% 11.4%

65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8

Alzheimer's - 2001 2000 1999 Flu - 2001 2000 1999 HIV/AIDS - 2001 2000 1999 Septicemia - 2001 2000 1999 Accidents - 2001 2000 1999 Suicides - 2001 2000 1999 Homicides - 2001 2000 1999

12.8 21.1 16.4 22.4 22.9 19.2 11.5 5.9 6.7 9.8 12.9 8.5 15.2 13.1 13.0 8.4 8.8 11.5 13.7 12.7 7.6

21.2 23.7 19.3 19.1 23.1 17.1 7.8 8.1 9.0 10.0 12.5 11.5 16.2 14.9 15.2 10.3 8.4 10.7 12.9 10.6 9.8

19.1 18.0 16.5 22.0 23.7 23.6 5.0 5.3 5.3 11.4 11.4 11.3 35.7 35.5 35.9 10.7 10.6 10.7 7.1 6.1 6.2

(Causes listed are those with higher rates than county for one, more years.)

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Water Area County Line Zip Code Boundary

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GARLAND FY 2003 Total visits = 31,796 Visits per exam room 1,271 1.86 clerical staff per provider Visits per provider FY 2003 = 3,312 1.63 Nurses/MAs per provider

The Garland COPC clinic was opened when the community of Garland mobilized and successfully lobbied for its opening. Garland pediatric capacity is 1,248 appointments per month and over the past few months the clinicians have exceeded the expected number of pediatric visits. A pediatric module from Bluitt Flowers was recently relocated to Garland to fill a vacancy. Adult capacity is 1,672 appointments per month and Garland has averaged 158 unused appointments per month for adults. Garland has only daytime appointments, Monday through Friday. Garland is the first site within COPC to conduct newborn Shared Medical Appointments. Although pediatrics is flattening across the COPC network, Garland is not experiencing the same pediatric decline despite a lower fertility rate than Dallas County. The Garland service area percentage of births with no or unknown prenatal care is about half that of the other COPC clinic service areas (4.7% versus 14% South Oak Cliff, 11% Northwest Oak Cliff, 9% Vickery, 10.1% Southeast Dallas, 10.5% East Dallas). Hypertension and Diabetes II are the top diagnoses at the Garland site. When the service area was surveyed on the prevalence of chronic conditions in 2001, 31% reported to have high blood pressure and high cholesterol, a slightly higher rate than Dallas County. An additional 15% reported having asthma. Overall, the service area's health status is better than Dallas County when analyzing age adjusted death rates and ambulatory sensitive conditions.

Health Management Associates

Appendix K-3

Garland Health Center
Address 802 Hopkins Garland, 75040 Phone (214) 266-0700 M/G/R Svc Area (Mesquite/Garland/Rowlett) Service Area Site Administrator Dia Copeland Lead Physician Mary Bergman - Peds, Tena Patterson - Family Practice FY003 Clinician Visits 31,796

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours: Adolescent, Adult, Pediatrics, Geriatrics MHFP, Lab, Radiology, Pharmacy, Dental, Epilepsy, Mammography, Nutrition, Psychology/Psychiatry, Social Work White Rock (6 miles SW) Parkland, Children's, WISH WISH, TDHS, WIC, Dental, Garland Health Dept. M-Th 7:00 am - 6:00 pm, Fri 8:00 am - 5:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland 24.3% 25.0% 2.3% 8.8% 10.2% Baylor Baylor Garland University 18.3% 7.4% 11.1% 9.9% 30.0% 3.6% 22.9% 10.1% 23.8% 9.4% PresbyMedical Mesquite terian City Children's Comm. 12.6% 7.2% 0.0% 9.0% 11.4% 7.2% 7.9% 5.2% 8.6% 7.2% 10.8% 5.0% 7.1% 9.8% 10.6% 4.3% 8.6% 7.8% 6.6% 5.7% Others 21.2% 22.3% 32.5% 26.4% 27.9%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
M/G/R Svc Area 02 Pop. 37,498 11% 75,660 23% 190,477 57% 28,206 8% 331,841 M/G/R Svc Area 02 Pop. 26,256 8% 56,248 17% 155,680 47% 70,984 21% 22,673 7% 331,841 Clinic Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

2,073 6,484 2,516 1,095 12,168 Clinic
CY'03 undup pts

17% 53% 21% 9% Clinic
60% female

n/a n/a n/a n/a

M/G/R Svc Area 00 Pop. 24,486 8% 21,586 7% 26,741 8% 249,367 77% 322,180 Clinic
PHHS Community Health

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

4,730 1,263 2,504 2,839 788 12,124

39% 10% 21% 23% 6%

49% 53% 71% 71% 67%

Self-Pay Medicaid Medicare Other Total

13,267 15,123 2,828 981 32,199

41% Plan Members Aug 2003 47% 9% Health First 3,651 3% Kids First 739 Total 4,390

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001 M/G/R Svc Area Dallas Co. Texas U.S. n=149 n=1,165 n=10,693 n=148,758 High Blood Pressure 31.0% 28.6% 30.4% 32.3% High Cholesterol 31.8% 25.3% 25.8% 26.5% Diabetes 7.9% 11.1% 13.4% 13.5% Asthma 14.9% 15.5% 15.8% 16.0% Stroke 2.1% 2.6% 2.7% 2.8%

Clinic - Top Diagnoses
26.6% 6.6% 5.7% 3.3% 2.2% 2.1% 1.8% 1.5% 1.4% 1.4% 1.2% 1.2% 1.2% 1.1% 1.1% 1.1% 1.0% 1.0%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 9.6 14.0 18.0 30.7 30,587 25.0

With 2003 number and percentage of encounters ROUTIN CHILD HEALTH EXAM 8,574 HYPERTENSION NOS 2,140 DMII WO CMP NT ST UNCNTR 1,828 ACUTE URI NOS 1,069 DMII WO CMP UNCNTRLD 706 LONG-TERM USE ANTICOAGUL 676 Influenza 578 OTITIS MEDIA NOS 489 ROUTINE MEDICAL EXAM 449 (2.8 Ped, 2 Internist, RECURR DEPR PSYCHOS-MOD 435 2.8 family practitioner DEPRESSIVE DISORDER NEC 399 2 lead) BENIGN HYPERTENSION 398 GYNECOLOGIC EXAMINATION 381 ALLERGIC RHINITIS NOS 360 EXT ASTHMA W/O STAT ASTH 343 VIRAL INFECTION NOS 341 AC SUPP OTITIS MEDIA NOS 324 ACUTE PHARYNGITIS 319

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
M/G/R Svc Area CONGESTIVE HEART FAILURE CHRONIC OBSTRUCTIVE PULMONARY DISEASE SECONDARY ALCOHOL DEPENDENCY AND ABUSE SECONDARY DRUG DEPENDENCY AND ABUSE KIDNEY AND URINARY TRACT INFECTIONS BACTERIAL PNEUMONIA INJURIES DEHYDRATION, VOLUME DEPLETION CELLULITIS DIABETES Dallas Co. M/G/R Svc Area ASTHMA ALCOHOL DEPENDENCY AND ABUSE DRUG DEPENDENCY AND ABUSE HYPERTENSION ANGINA CONVULSIONS GASTROENTERITIS Grand Mal Status and Other Epileptic Convulsions EAR, NOSE, THROAT INFECTIONS SECONARY NUTRITIONAL DEFICIENCIES Dallas Co.

570.5 426.8 357.0 314.8 278.1 270.3 260.8 225.6 188.2 171.1

620.1 429.1 569.8 445.4 259.9 281.6 233.7 176.6 231.2 255.1

167.8 127.3 123.1 83.9 68.3 64.0 56.2 27.7 26.0 25.0

218.4 146.8 96.5 89.3 62.0 63.5 45.9 36.8 26.7 36.2

2001 Reported Incidence of Infectious Conditions & Injuries
per 100,000 Salmonellosis Aseptic meningitis Chlamydia Gonorrhea Syphilis Tuberculosis
M/G/R Svc Area

Dallas Co. 6.0 11.7 449.6 271.4 29.1 11.9

U.S. 14.4 278.3 128.5 11.5 5.7

6.4 15.3 240.0 100.3 5.8 3.1

(Conditions listed are those with higher rates than county in 2001)

Maternal and Child Health
Dallas Co.

2001 Age Adjusted Death Rates
U.S. 65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8 83.9 80.2 84.5 5.3% 5.8% 5.7% 7.7% 7.8% 7.8% 6.3 5.5 6.4 10.2% 8.2% 11.4% Per 100,000 Cancer - 2001 2000 1999 Respiratory - 2001 2000 1999 Diabetes - 2001 2000 1999 Flu 2001 2000 1999 Septicemia - 2001 2000 1999 Alzheimers - 2001 2000 1999 Suicides - 2001 2000 1999 Cirrhosis - 2001 2000 1999
Dallas Co.

Dallas Co.

Fertility Rate - Births per 1,000 Females Age 15-44 2001 70.0 2000 68.6 1999 72.0 % Births to Teens Ages Less Than 18 2001 4.1% 2000 4.5% 1999 4.7% % of Births That Are Low Birth Weight 2001 7.2% 2000 6.7% 1999 7.7% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 5.8 2000 4.4 1999 5.2 % Of All Births (?) With No & Unknown Prenatal Care 2001 4.7% 2000 5.7% 1990 6.2%

160.3 182.4 222.5 37.9 46.9 61.9 16.4 26.1 27.2 17.5 25.0 26.1 8.8 13.1 15.8 20.1 29.1 29.4 8.63 9.2 9.45 9.0 6.5 5.4

Dallas Co. 177.4 202.7 194.5 39.2 42.9 46.0 20.0 26.5 23.5 19.1 23.1 17.1 10.0 12.5 11.5 21.2 23.7 19.3 10.31 8.4 10.7 8.5 9.2 8.7

U.S. 196.0 201.0 202.7 43.7 44.3 45.8 25.3 25.2 25.2 22.0 23.7 23.6 11.4 11.4 11.3 19.1 18.0 16.5 10.7 10.6 10.7 9.5 9.6 9.7

(Causes listed are those with higher rates than county for one, more years.)

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Garland Encounters by Zip Code
Water A rea County Line ZIP Code Boundary

C COPC Clinic
Dot-Density
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OAK WEST FY 2003 Total visits = 14,419 Visits per provider FY 2003 = 4,005 Visits per exam room 1,802 1.11 Nurses/MAs per provider 1.81 clerical staff per provider Oak West is a small, cramped clinic with an overflowing waiting room that serves Northwest Oak Cliff and South Oak Cliff in a facility owned by Southwestern UT. Oak West has exceeded its adult and geriatric adult visit capacity by 231 patients per month, yet has capacity for 150 additional pediatric visits per month, as defined by the Care Teams. (Pediatric monthly capacity is 1,014; adult monthly capacity is 216.) Clinical staffing includes family practice, pediatrics, and a part-time internist. Methodist Carlton refers newborns to Oak West and Baylor refers premature babies. The surrounding communities (NW and South Oak Cliff) have 263,502 people currently living below 200% federal poverty and 74,926 living below 100% federal poverty. The zip code that generates the highest ED visits at Parkland is located in this area. The empty Kaiser building is located in the same area and should be considered as a replacement facility for the existing Oak West site, along with WISH, and specialty/diagnostic services. However, deliberate strategies to attract an African American population should occur with relocation. South Oak Cliff has a minimum number of Medicaid primary care providers under contract with the State of Texas. Fifty six percent (56%) of the patients are Hispanic and 38% are African American, yet the South Oak Cliff area is 62% African American and NW Oak Cliff is 28% African American. In the current space, it may be difficult for Oak West to increase its attraction to the African American population given space constraints and community perception. Half of Oak West’s patients come from NW Oak Cliff and half from South Oak Cliff. Over forty percent of the clinical activity is routine child health exam and Medicaid covers 69.3% of the patients. The reported incidence of infectious conditions in NW Oak Cliff reveal a pertussis rate per 100,000 population that is twice Dallas County or 10.5 versus 4.2, an indicator that childhood immunizations must be improved in the area. The sexually transmitted disease rate in the Oak West service area (South Oak Cliff) is higher than any other part of Dallas County. The Chlamydia rate is 1,056 per 100,000 persons compared to a Dallas rate of 449.6 (Texas 327.9). Additionally, Gonorrhea is 871 compared to Dallas rate of 271 and Syphillis is 90 compared to Dallas rate of 29 per 100,000. These STD rates are very high and call for a concerted COPC effort, along with the Dallas County Health Department, to design a plan for a community campaign and patient level education. Screenings for Chlamydia should be started immediately in all COPC clinics that serve this geographic area. We note the teen birth rate is twice Dallas County, 10% of all births are low birth weight and 14.6% of births occur without or no or unknown prenatal care. The Age adjusted death rates per 100,000 for South Oak Cliff exceed Dallas County for many indicators: Stroke (88 S Oak Cliff /57 Dallas County), Flu (25/19), homicides (33/12), Heart (330/231), Cancer (246/177), Diabetes (30/20), Kidney disease (23/11). When Ambulatory Sensitive and Preventable Conditions are analyzed, the following conditions are notable: Congestive heart failure (980 S Oak Cliff /620 Dallas County), second drug abuse (940/445), second alcohol abuse (920/569), Diabetes (400/255), Asthma (340/218), pneumonia (335/281). These indicators identify a community with high levels of chronic illness in need of an ambulatory chronic disease management approach. Health Management Associates Appendix K-3

Oak West Health Center
Address 4444 S. Hampton Road Dallas 75232 Phone (214) 266-1450 Service Area S Oak Cliff (NW Oak Cliff border) Site Administrator Kerrie Watterson Lead Physician Renuka Khurana - peds FY03 Clinician Visits 14,419

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referals to: Colocated with: Hours: Adult, Pediatrics MHFP, Lab, Nutrition, Social Work, Child Life Red Bird (1.5 miles west), North Oak Cliff (4 miles north) Parkland, Children's, WISH, Bluitt (behavioral), Lancaster Comm., Methodist Charlton,Baylor WISH M-W 7:30 am - 6:00 pm, Th & Fri 8:00 am - 5:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland Methodist 44.2% 18.2% 42.4% 13.8% 12.6% 5.2% 22.9% 5.2% 22.1% 20.4% Charlton Children's 13.6% 0.0% 13.1% 10.8% 10.3% 12.8% 10.7% 11.9% 13.3% 8.8% Baylor St. Paul 5.1% 6.8% 4.2% 5.7% 5.9% 5.2% 7.7% 5.2% 8.2% 5.9% Other 12.0% 10.1% 47.9% 36.3% 21.4%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
S Oak Cliff 02 Pop. 114,267 62% 49,259 27% 17,030 9% 2,564 1% 183,120 S Oak Cliff 02 Pop. 14,495 8% 31,188 17% 79,387 43% 39,641 22% 18,409 10% 183,120 Clinic Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

2,229 3,321 255 60 5,865 Clinic 3,740 918 552 528 116 5,854

38% 57% 4% 1% Clinic
54% female

n/a n/a n/a n/a

S Oak Cliff 00 Pop. 38,774 25,366 22,830 94,217 181,187 Clinic

21% 14% 13% 52%

CY'03 undup pts

PHHS Community Health

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

64% 16% 9% 9% 2%

47% 52% 52% 31% 31%

Self-Pay Medicaid Medicare Other Total

3,664 10,229 541 322 14,756

25% Plan Members Aug 2003 69% 4% Health First 4,162 2% Kids First 527 Total 4,689

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001 S Oak Cliff Dallas Co. Texas U.S. n=106 n=1,165 n=10,693 n=148,758 High Cholesterol 16.8% 25.3% 25.8% 26.5% High Blood Pressure 42.5% 28.6% 30.4% 32.3% Asthma 28.6% 15.5% 15.8% 16.0% Diabetes 15.9% 11.1% 13.4% 13.5% Stroke 3.7% 2.6% 2.7% 2.8%

Clinic - Top Diagnoses
43.4% 4.4% 4.3% 3.6% 3.1% 2.6% 2.4% 1.5% 1.4% 1.2% 1.0% 0.8% 0.7% 0.6% 0.6% 0.5% 0.5% 0.5%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 3.6 4.5 7.5 3.4 15,663 8.0

With 2003 number and percentage of encounters ROUTIN CHILD HEALTH EXAM 6,399 ACUTE URI NOS 647 HYPERTENSION NOS 629 OTITIS MEDIA NOS 537 FOLLOW-UP EXAM NEC 462 Influenza 378 DMII WO CMP NT ST UNCNTR 361 VIRAL INFECTION NOS 225 NEED PRPHYL VC VRL HEPAT 202 (.8 Ped, .6 Internist, ASTHMA W/O STATUS ASTHM 180 1 lead, .5 nurse DERMATITIS NOS 154 practioner, .7 FP) ALLERGIC RHINITIS NOS 116 ACUTE PHARYNGITIS 97 ND VAC HMOPHLUS INFLNZ B 95 VIRAL ENTERITIS NOS 82 CONJUNCTIVITIS NOS 78 ND VAC STRPTCS PNEUMNI B 77 DMII WO CMP UNCNTRLD 77

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
S Oak Cliff CONGESTIVE HEART FAILURE SECONDARY DRUG DEPENDENCY AND ABUSE SECONDARY ALCOHOL DEPENDENCY AND ABUSE DIABETES CHRONIC OBSTRUCTIVE PULMONARY DISEASE BACTERIAL PNEUMONIA ASTHMA KIDNEY AND URINARY TRACT INFECTIONS INJURIES CELLULITIS Dallas Co. S Oak Cliff DEHYDRATION, VOLUME DEPLETION HYPERTENSION ALCOHOL DEPENDENCY AND ABUSE DRUG DEPENDENCY AND ABUSE CONVULSIONS NUTRITIONAL DEFICIENCIES Grand Mal Status and Other Epileptic Convulsions PELVIC INFLAMMATORY DISEASE ANGINA GASTROENTERITIS Dallas Co.

948.2 909.1 859.3 357.6 350.2 338.6 334.2 281.1 278.4 244.0

620.1 445.4 569.8 255.1 429.1 281.6 218.4 259.9 233.7 231.2

192.7 183.4 169.9 96.7 95.7 55.8 55.2 50.8 44.4 33.6

176.6 89.3 146.8 96.5 63.5 3.0 36.8 22.5 62.0 45.9

2001 Reported Incidence of Infectious Conditions & Injuries
per 100,000 Chlamydia Gonorrhea Syphillis Tuberculosis Esherichia coli Samonellosis Shigellosis Hepatitis B carrier Hepatitis C Submersion injury Streptococcal invasive disease Meningococcal infection Bacterial meningitis
S Oak Cliff

1056.2 871.6 90.1 45.8 1.1 8.2 10.9 18.1 211.0 1.1 8.2 4.4 4.4

Dallas Co. 449.6 271.4 29.1 11.9 0.6 6.0 8.4 13.9 114.4 0.1 4.8 1.7 4.2

U.S. 278.3 128.5 11.5 5.7 14.4 7.2 12.0

0.8

(Conditions listed are those with higher rates than county in 2001)

Maternal and Child Health
Dallas Co. Dallas Co. U.S. Per 100,000

2001 Age Adjusted Death Rates
S Oak Cliff Dallas Co. U.S.

Fertility Rate - Births per 1,000 Females Age 15-44 2001 84.7 83.9 2000 82.8 80.2 1999 79.0 84.5 % Births to Teens Ages Less Than 18 2001 9.5% 5.3% 2000 9.7% 5.8% 1999 9.3% 5.7% % of Births That Are Low Birth Weight 2001 10.0% 7.7% 2000 10.0% 7.8% 1999 10.6% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 7.8 6.3 2000 6.6 5.5 1999 8.8 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 14.6% 10.2% 2000 12.2% 8.2% 1990 16.0% 11.4%

65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8

Stroke - 2001 2000 1999 Alzheimer's - 2001 2000 1999 Flu 2001 2000 1999 Accidents - 2001 2000 1999 Suicides - 2001 2000 1999 Homicides - 2001 2000 1999 Heart - 2001 2000 1999 Cancer - 2001 2000 1999 Diabetes - 2001 2000 1999 Kidney Disease - 2001 2000 1999 HIV/AIDS - 2001 2000 1999

88.4 80.0 78.7 22.3 25.4 16.4 25.3 19.4 19.2 18.3 16.1 18.7 10.5 5.0 8.0 33.8 14.5 26.0 330.7 339.0 334.7 246.2 246.0 240.4 30.2 37.9 39.7 23.7 26.0 17.7 20.5 23.9 25.4

57.2 66.2 64.1 21.2 23.7 19.3 19.1 23.1 17.1 16.2 14.9 15.2 10.3 8.4 10.7 12.9 10.6 9.8 231.7 275.7 269.3 177.4 202.7 194.5 20.0 26.5 23.5 11.6 11.9 9.2 7.8 8.1 9.0

57.9 60.8 61.8 19.1 18.0 16.5 22.0 23.7 23.6 35.7 35.5 35.9 10.7 10.6 10.7 7.1 6.1 6.2 247.8 257.9 267.8 196.0 201.0 202.7 25.3 25.2 25.2 14.0 13.5 13.1 5.0 5.3 5.3

2001 Age Adjusted Death Rates
Per 100,000 S Oak Cliff Dallas Co. U.S.

Respiratory - 2001 2000 1999 Cirrhosis - 2001 2000 1999 Septicemia - 2001 2000 1999

50.3 34.0 35.0 16.9 8.6 8.5 15.6 12.0 15.3

39.2 42.9 46.0 8.5 9.2 8.7 10.0 12.5 11.5

43.7 44.3 45.8 9.5 9.6 9.7 11.4 11.4 11.3

Oak West Health Center
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Oak West Encounters by Zip Code
Water Area County Line ZIP Code Boundary

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Dot-Density
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SOUTHEAST DALLAS FY 2003 Total visits = 47,716 Visits per exam room 1,403 2.19 clerical staff per provider Visits per provider FY 2003 = 3,727 1.23 Nurses/MAs per provider

Southeast COPC is housed in a facility that was previously utilized as a hospital (Southeast Methodist Hospital) and was sold to Parkland for $1. There are two empty hospital floors in addition to empty space on the first floor. There are plans for WISH to occupy the first floor space. Unlike the other larger community based COPC clinics, Southeast clinical space is laid out like individual practitioner offices, which limits staffing flexibility (for example, sharing a RN or front desk staff when each individual provider has his/her own office suite). The most recent report on COPC productivity progress documents a serious problem at Southeast. Available capacity at Southeast for adult and geriatrics is averaging 240 additional appointment slots per month (total capacity is 2,364) and for pediatrics, 259 available appointment slots (monthly capacity 1,572). The underlying issues affecting this available capacity should be identified and addressed prior to any serious consideration of opening the Kaiser building in Southeast Dallas. When WISH relocates its services, the pediatric demand may increase, however, the available adult capacity is a concern because available appointments extend a month or longer. There have been prior discussions of leasing space to social service agencies to generate more activity in the building, as well as reconfiguring the clinical space to allow for more flexible staffing. According to the state Medicaid agency, the number of primary care providers serving the Medicaid population in Southeast is low. Southeast has one of the most active Community Boards. They have conducted voter registration drives, distributed school supplies, and advocated for running water in Sand Branch, a poor community that relied on well water. Thirty five percent (35%) of Southeast’s patients are on Medicaid, 44% are self-pay and 19% Medicare, the largest elderly population in COPC clinics. Patients living in Southeast Dallas generated twenty two percent (22%) of all pharmacy activity within COPC. This is one measure of chronic illness. The HIV rate in Southeast Dallas far exceeds the rate in Dallas County and is reported to be 126.2 per 100,000 population versus 45.5 (Dallas County). The Hepatitis C rate is higher than Dallas, as well. The top diagnoses at Southeast are hypertension and diabetes. Congestive heart failure leads the list of Ambulatory Sensitive Conditions in this service area and is greater than Dallas County, followed by pulmonary disease (discharges also greater than Dallas County) and alcohol and drug abuse. Age adjusted death rates show heart rates higher than Dallas County and the US. Similarly, Alzheimer's, homicides, and septicemia rates as causes of death were higher than Dallas and the US. Specialty referrals in highest demand for adults are dermatology, pain clinic, CT, podiatry and dental. For children, the highest referrals are neurology and GI. Both Mesquite Community Hospital and Medical Center of Mesquite refer uninsured patients from their EDs.

Health Management Associates

Appendix K-3

Southeast Dallas Health Center
Address 9202 Elam Rd. Dallas, 75217 Phone 214-266-1600 Service Area Dallas SE Svc Area Site Administrator Argentry Fields Lead Physician Deaina Berry - peds FY03 Clinician Visits 44,716

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours Adolescent, Adult, Pediatrics, Geriatrics Lab, Radiology, Pharmacy, Epilepsy, HIV, Mammography, Nutrition, Psychology/Psychiatry, Social Work Spruce (<1 mile south), Seagoville (6 miles southeast), South (6.5 miles northwest) Parkland, Children's, WISH, some Mesquite Comm., Med Ctr of Mesquite, Baylor, Doctors, Presbyterian TDHS, WIC M-F 7:30 am - 6:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland 39.4% 40.6% 12.3% 19.1% 21.1% Baylor Mesq. Comm Children's 13.0% 21.2% 0.0% 14.4% 9.9% 10.0% 14.0% 14.2% 17.2% 18.6% 11.1% 16.3% 18.0% 13.9% 10.4% Doctors 2.6% 1.1% 4.9% 6.9% 6.9% Presby 4.8% 4.5% 6.6% 3.7% 5.0% Other 19.0% 19.5% 30.8% 24.3% 24.7%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
Dallas SE Svc Area 02 Pop. 65,636 26% 86,751 34% 93,875 37% 8,140 3% 254,402 Dallas SE Svc Area 02 Pop. 23,393 9% 48,546 19% 118,987 47% 46,289 18% 17,188 7% 254,403 Clinic Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

5,810 6,262 3,278 311 15,661 Clinic
CY'03 undup pts

37% 40% 21% 2% Clinic
64% female

n/a n/a n/a n/a

Dallas SE Svc Area 00 Pop. 37,308 15% 30,681 12% 30,190 12% 147,270 60% 245,449 Clinic
PHHS Community Health

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

3,860 1,455 3,954 4,860 1,537 15,666

25% 9% 25% 31% 10%

50% 49% 71% 71% 70%

Self-Pay Medicaid Medicare Other Total

19,758 15,745 8,399 1,017 44,919

44% Plan Members Aug 2003 35% 19% Health First 4,873 2% Kids First 665 Total 5,538

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001
Dallas SE Svc Area Dallas Co. U.S.

Clinic - Top Diagnoses
With 2003 number and percentage of encounters ROUTIN CHILD HEALTH EXAM 5,813 HYPERTENSION NOS 2,641 DMII WO CMP UNCNTRLD 2,382 DMII WO CMP NT ST UNCNTR 2,318 SCREEN MAMMOGRAM NEC 1,640 ACUTE URI NOS 1,549 BENIGN HYPERTENSION 1,340 ROUTINE MEDICAL EXAM 1,321 OTITIS MEDIA NOS 1,269 LONG-TERM USE ANTICOAGUL 1,230 DEPRESSIVE DISORDER NEC 678 ACUTE PHARYNGITIS 586 ALLERGIC RHINITIS NOS 570 PHARMACY 543 ASYMP HIV INFECTN STATUS 437 ASTHMA W/O STATUS ASTHM 436 LUMBAGO 434 HIV Disease 431 12.9% 5.9% 5.3% 5.2% 3.7% 3.4% 3.0% 2.9% 2.8% 2.7% 1.5% 1.3% 1.3% 1.2% 1.0% 1.0% 1.0% 1.0%

High Cholesterol High Blood Pressure Asthma Diabetes Stroke

n=135 n=1,165 n=148,758 21.8% 25.3% 26.5% 39.8% 28.6% 32.3% 19.1% 15.5% 16.0% 20.6% 11.1% 13.5% 3.7% 2.6% 2.8%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 12.8 (2 Ped, 3.8 Internist, 16.8 2.8 FP, 2 lead 29.0 2.2 nurse pract.) 43.8 40,035 34.0

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
Dallas SE Svc Area CONGESTIVE HEART FAILURE CHRONIC OBSTRUCTIVE PULMONARY DISEASE SECONDARY ALCOHOL DEPENDENCY AND ABUSE SECONDARY DRUG DEPENDENCY AND ABUSE KIDNEY AND URINARY TRACT INFECTIONS BACTERIAL PNEUMONIA DIABETES INJURIES CELLULITIS ASTHMA Dallas Co. Dallas SE Svc Area DEHYDRATION, VOLUME DEPLETION ALCOHOL DEPENDENCY AND ABUSE HYPERTENSION DRUG DEPENDENCY AND ABUSE CONVULSIONS GASTROENTERITIS ANGINA EAR, NOSE, THROAT INFECTIONS VACCINE Grand Mal Status and Other Epileptic Convulsions Dallas Co.

765.8 559.4 505.7 448.6 350.0 276.9 276.1 273.8 264.3 207.0

620.1 429.1 569.8 445.4 259.9 281.6 255.1 233.7 231.2 218.4

174.8 120.4 102.5 94.7 69.8 63.5 63.5 34.7 28.0 24.7

176.6 146.8 89.3 96.5 88.5 45.9 62.0 26.7 20.7 36.8

2001 Reported Incidence of Infectious Conditions & Injuries
per 100,000 HIV Syphilis Campylobacteriosis Hepatitis C Bacterial memingitis Meningococcal infection Pertussis Animal bites Aseptic meningitis Submersion injury Chlamydia Gonorrhea
Dallas SE Svc Area

126.2 25.6 5.6 126.2 5.9 1.9 4.8 41.5 16.4 0.4 401.2 247.1 Co. U.S. Heart 65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8 2001 2000 1999 Cancer 2001 2000 1999 Stroke 2001 2000 1999 Respiratory - 2001 2000 1999 Alzheimer's - 2001 2000 1999 Accidents - 2001 2000 1999 Flu 2001 2000 1999 Homicides - 2001 2000 1999 Diabetes - 2001 2000 1999 Suicides - 2001

Dallas Co. 45.5 29.1 2.9 114.4 4.2 1.7 4.2 20.5 11.7 0.1 449.6 271.4

U.S. 11.5

5.7

278.3 128.5 Dallas Co. 231.7 275.7 269.3 177.4 202.7 194.5 57.2 66.2 64.1 39.2 42.9 46.0 21.2 23.7 19.3 16.2 14.9 15.2 19.1 23.1 17.1 12.9 10.6 9.8 20.0 26.5 23.5 10.3 8.4 10.7 12.9 10.6 9.8 8.5 9.2 8.7 U.S. 247.8 257.9 267.8 196.0 201.0 202.7 57.9 60.8 61.8 43.7 44.3 45.8 19.1 18.0 16.5 35.7 35.5 35.9 22.0 23.7 23.6 7.1 6.1 6.2 25.3 25.2 25.2 10.7 10.6 10.7 11.4 11.4 11.3 9.5 9.6 9.7

Maternal and Child Health
Dallas SE Svc Area Dallas

2001 Age Adjusted Death Rates (per 100,000)
Dallas SE Svc Area

Fertility Rate - Births per 1,000 Females Age 15-44 2001 87.6 83.9 2000 85.3 80.2 1999 91.3 84.5 % Births to Teens Ages Less Than 18 2001 6.6% 5.3% 2000 7.7% 5.8% 1999 7.7% 5.7% % of Births That Are Low Birth Weight 2001 8.2% 7.7% 2000 7.9% 7.8% 1999 7.3% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 7.3 6.3 2000 5.6 5.5 1999 8.3 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 10.1% 10.2% 2000 8.1% 8.2% 1990 10.9% 11.4%

264.5 356.6 326.6 150.2 233.9 209.0 52.3 67.6 76.3 42.9 68.7 60.5 27.2 24.8 12.5 20.0 20.4 19.0 19.8 29.2 18.9 18.5 10.4 13.7 18.1 42.6 28.0 12.7 12.1 11.1 18.5 10.4 13.7 8.6 16.9 12.7

2001 Age Adjusted Death Rates (per 100,000)
Dallas SE Svc Area Dallas

Kidney Disease - 2001 2000 1999 HIV/AIDS - 2001 2000 1999

9.8 17.2 12.7 6.0 4.6 9.5

Co. 11.6 11.9 9.2 7.8 8.1 9.0

2000 U.S. 1999 14.0 Septicemia - 2001 13.5 2000 13.1 1999 5.0 Cirrhosis - 2001 5.3 2000 5.3 1999

Southeast Dallas Health Center
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GREATER VICKERY FY 2003 Total visits = 10,751 Visits per exam room 1,194 2.33 clerical staff per provider Visits per provider FY 2003 = 3,583 1.33 Nurses/MAs per provider

Vickery is one of only two COPC sites to offer weekend hours. On Sunday from 8am-6pm the clinic offers an urgent care center. The Vickery site was established in conjunction with Presbyterian Hospital. Presbyterian pays the monthly rent and contributes approximately $126,000 year to cover operating expenses. There is a general agreement at Presbyterian and PHHS that the facility is inadequate and needs to be relocated. Discussions to replace this facility should occur as soon as possible. Staff at Vickery consists of pediatricians and a family practitioner. Based on most recent reports, unused capacity averages 109 patient slots per month, out of a total appointment capacity of 1,010. The waiting room is shared with WISH and is overcrowded, hot and generally unpleasant. Approximately half of Vickery’s patients come from the Vickery corridor and 25% from the northern corridor. The Vickery service area has a Chlamydia rate of 625.5 per 100,000 population compared to 449.6 for Dallas County and 278.3 US. The Gonorrhea rate is higher than the Dallas rate, as well. In addition, the tuberculosis rate is five times higher than the US rate (24.9 vs. 5.7) and higher than the Dallas rate of 11.9 per 100,000 population. The Hepatitis B carrier rate is 17.3 per 100,000 population in Vickery, compared to 13.9 for Dallas and 12 for US. All of these reportable conditions point to the need for a collaborative effort between COPC and the Health Department to address the identification, treatment, and reduction of these infectious conditions. Secondary Alcohol abuse is the leading Ambulatory Sensitive discharge in the Vickery service area at 1033.5 discharges per 100,000 persons versus 569.8 for Dallas County. The drug dependency discharge per 100,000 is 225.8 versus 96.5 for Dallas County. The Injuries discharge rate is 459.3 compared to Dallas’ 233.7. PHHS and COPC must find additional referral sources to address alcohol dependency and abuse. The age adjusted death rate for stroke in Vickery service area is 71.4 versus 57.2 per 100,000 persons for Dallas County. The hypertension ambulatory sensitive discharge rate is higher than Dallas. Hypertension is also a top Vickery diagnosis, along with diabetes. The Alzheimer’s age adjusted death rate is 47.3 versus Dallas 21.2 per 100,000 persons. Vickery’s clinical staffing (2 peds, 1 family practice) is not designed to address the adult needs of the Vickery service area. It should be reconsidered to more appropriately address the health status of the population and community, including the high rates of drug and alcohol use.

Health Management Associates

Appendix K-3

Greater Vickery H. C.
Address 8224 Park Lane Dallas 75231 Phone (214) 266-0350 Service Area Vickery Svc Area Site Administrator Dia Copeland Lead Physician Denise Johnson - Family Practice FY03 Clinician Visits 10,751

Clinic Services, Other Providers, Clinic Hours
Modules: Other: Nearby Y&F sites: Spec. Referrals to: Colocated with: Hours Adolescent, Adult, Pediatrics MHFP, Lab, Class D Pharmacy, mammography, psychology, psychiatric, social work Woodrow (4 miles south), Kiosco (5 miles west), White Rock (6 miles southeast) Parkland, Children's, WISH Vivian Field (8 miles northwest) WISH, TDHS M-F 8:00 am - 5:00 pm, Sunday (urgent care) 8:00 am to 6:00 pm

2001 Hospital Market Share by Product Line - Service Area
Obstetrics/Delivery Neonatology General Medicine General Surgery Total Parkland 39.4% 40.8% 5.5% 12.1% 18.7% Presby Med. City 26.6% 10.7% 19.9% 10.0% 41.1% 15.2% 27.4% 17.0% 30.1% 13.6% Baylor Children's 6.1% 0.0% 5.1% 8.0% 4.9% 12.6% 8.7% 10.7% 7.7% 6.6% Doctor's 1.9% 1.3% 4.7% 4.6% 4.8% St. Paul 3.4% 4.6% 1.5% 1.7% 2.5% Other 12.0% 10.4% 14.5% 17.9% 16.1%

Demographics
Clinic
CY'03 undup pts

Poverty and Payer Source
Vickery Svc Area 02 Pop. 43,828 30% 38,663 26% 53,272 36% 11,806 8% 147,569 Vickery Svc Area 02 Pop. 13,134 9% 18,299 12% 81,163 55% 24,792 17% 10,182 7% 147,570 Clinic Under 100% FPL 100-149% FPL 150-199% FPL 200%+ FPL n/a n/a n/a n/a Clinic
CY03 Enctrs

Af Am Hispanic White Other Total

1,530 3,165 673 318 5,686 Clinic 2,680 551 1,185 1,051 215 5,682

27% 56% 12% 6% Clinic
58% female

n/a n/a n/a n/a

Vickery Svc Area 00 Pop. 21,398 15% 16,380 11% 15,347 10% 94,444 64% 147,569 Clinic
PHHS Community Health

CY'03 undup pts

> age 5 Age 5-14 Age 15-44 Age 45-64 Age 65 + Total

47% 10% 21% 18% 4%

48% 46% 69% 73% 69%

Self-Pay Medicaid Medicare Other Total

4,574 5,706 377 354 11,011

42% Plan Members Aug 2003 52% 3% Health First 3,217 3% Kids First 321 Total 3,538

2001 Prevalence of Chronic Conditions Survey
Source: National Research Corp. Market Guide, copyright 2001
Vickery Svc Area Dallas Co. U.S.

Clinic - Top Diagnoses
With 2003 number and percentage of encounters Routine child health exam 3606 Acute urinary tract infection 410 Hypertension 394 Diabetes mellitus not uncontrolled 381 Routine medical exam 337 Ottitis media 220 Benign hypertension 208 Fever 199 Follow-up exam Allergic rhinitis Diabetes mellitus uncontrolled Cough Recurring depression psychosis Asthma without status asthmatic Acute bronchitis Gyne exam Acute pharyngitis Urinary tract infection 191 142 133 128 125 124 113 112 107 103 32.7% 3.7% 3.6% 3.5% 3.1% 2.0% 1.9% 1.8% 1.7% 1.3% 1.2% 1.2% 1.1% 1.1% 1.0% 1.0% 1.0% 0.9%

High Cholesterol High Blood Pressure Asthma Diabetes Stroke

n=66 32.6% 27.1% 16.0% 15.9% 0.0%

n=1,165 n=148,758 25.3% 26.5% 28.6% 32.3% 15.5% 16.0% 11.1% 13.5% 2.6% 2.8%

Clinic Staffing
Providers Nurses/MAs Business/clerical Other Square footage Exam rooms 3.0 (2 Ped, 1 Lead - Family 4.0 Practice) 7.0 7.4 3,809 9.0

Discharge Rates - Ambulatory Sensitive & Preventable Conditions
Per 100,000 persons, 3-year Rolling Average 1999-2001
Vickery Svc Area SECONDARY ALCOHOL DEPENDENCY AND ABUSE CONGESTIVE HEART FAILURE SECONDARY DRUG DEPENDENCY AND ABUSE CHRONIC OBSTRUCTIVE PULMONARY DISEASE KIDNEY AND URINARY TRACT INFECTIONS INJURIES BACTERIAL PNEUMONIA ASTHMA DIABETES ALCOHOL DEPENDENCY AND ABUSE Dallas Co. Vickery Svc Area CELLULITIS DEHYDRATION, VOLUME DEPLETION DRUG DEPENDENCY AND ABUSE HYPERTENSION CONVULSIONS GASTROENTERITIS ANGINA SECONDARY NUTRITIONAL DEFICIENCIES PELVIC INFLAMMATORY DISEASE Grand mal Status and Other Epileptic Convulsions Dallas Co.

1033.5 617.4 467.1 397.3 226.0 459.3 265.6 222.3 377.6 358.3

569.8 620.1 445.4 429.1 259.9 233.7 281.6 218.4 255.1 146.8

340.0 314.8 225.8 183.9 100.6 82.4 68.2 63.8 52.5 48.2

231.2 176.6 96.5 89.3 88.5 45.9 62 36.2 22.5 36.8

2001 Reported Incidence of Infectious Conditions & Injuries
Vickery Svc Area Dallas Co. U.S.

Chlamydia per 100,000 Gonorrhea per 100,000 Syphilis Tuberculosis per 100,000 Campylobacteriosis Escherichia coli Salmonellosis per 100,000 Shigellosis, per 100,000 Hepatitis A per 100,000 Hepatitis B carrier, per 100,000 Legionellosis

625.5 328.6 17.9 24.9 2.8 0.7 6.9 8.9 6.2 17.3 0.7

449.6 271.4 29.1 11.9 2.9 0.6 6.0 8.4 4.4 13.9 0.1

278.3 128.5 11.5 5.7

14.4 7.2 3.7 12.0

(Conditions listed are those with higher rates than county for 2001.)

Maternal and Child Health
Vickery Svc Area Dallas Co. U.S.

2001 Age Adjusted Death Rates
Vickery Svc Area Dallas Co. Texas U.S.

Fertility Rate - Births per 1,000 Females Age 15-44 2001 84.7 83.9 2000 80.3 80.2 1999 85.8 84.5 % Births to Teens Ages Less Than 18 2001 4.0% 5.3% 2000 3.7% 5.8% 1999 4.2% 5.7% % of Births That Are Low Birth Weight 2001 8.1% 7.7% 2000 8.7% 7.8% 1999 7.8% 7.8% Infant Mortality - Infant Deaths per 1,000 Live Births 2001 5.9 6.3 2000 4.6 5.5 1999 7.7 6.4 % Of All Births (?) With No & Unknown Prenatal Care 2001 9.0% 10.2% 2000 10.4% 8.2% 1990 8.8% 11.4%

65.3 65.9 64.4 3.8 4.1 4.4 7.7 7.6 7.6 6.8 6.9 7.0 3.7 3.9 3.8

Stroke - 2001 2000 1999 Alzheimer's - 2001 2000 1999 Flu - 2001 2000 1999 Accidents - 2001 2000 1999 Suicides - 2001 2000 1999 Homicides - 2001 2000 1999

71.4 61.6 59.1 47.3 30.0 39.9 16.9 20.9 21.2 10.9 15.6 7.8 7.8 8.4 12.4 8.5 14.2 4.2

57.2 66.2 64.1 21.2 23.7 19.3 19.1 23.1 17.1 16.2 14.9 15.2 10.3 8.4 10.7 12.9 10.6 9.8

64.5 66.6 66.3 21.6 20.4 18.5 21.9 23.1 22.5 32.4 33.6 32.7 11.8 11.7 12.4 11.0 11.2 10.6

57.9 60.8 61.8 19.1 18.0 16.5 22.0 23.7 23.6 35.7 35.5 35.9 10.7 10.6 10.7 7.1 6.1 6.2

(Causes listed are those with higher rates than county for one, more years.)

$

Vickery Family Health Center
$ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $

$ $ $ $ $ $$ $ $ $ $

$ $$ $ $$ $ $$ $$ $ $ $ $$$ $ $ $ $ $$ $$ $$ $ $$ $ $ $ $ Vickery $ $ $$ $ $ $$ $$ $ $

C
$ $

C

$

$ $

C

$

$ $ $ $

C C
$ $ $

C C C
$ $

$

Vickery Encounters by Zip Code
Water A rea County Line ZIP Code Boundary

C COPC Clinic
Dot-Density
$ = 100 Vickery Encounters

Appendix K - 4
COPC - Service Standards
Range of Pts. Seen Per Session 10 - 15 8 - 13 8 - 12 6 - 10 8 - 10 6-8 8 - 15 6 - 13 6-8 4-6 Average Pts. Seen Per Hour 3.1 2.6 2.5 2.0 2.3 1.8 2.9 2.4 1.8 1.3

Pedi - Physician Pedi - Midlevel/Lead Adult - Physician Adult - Midlevel/Lead Adol - Physician Adol - Midlevel/Lead FP - Physician FP - Midlevel/Lead Geri - Physician Geri - Midlevel/Lead

Working Hours per Year Less Unavailable Time: PTO CME Unavailable Time (hrs) Time Available

Hrs per year 2080 240 40 280 1800

% of Time 100.0% 11.5% 1.9% 13.5% 86.5%

Non-Direct Patient Care Time Staff Physician (4% - 10%) Lead Physician (10% - 20%)

Ranges for Non-direct Patient Care Activities Minimum Hours Maximum Hours 72 180 180 360

Average Non-direct Time Less: Staff Meetings Forums Lead Meetings Total Standard Non-Pt. Care Activities Maximum amount of Negotiable Project Time

Staff Physician (5%) Non-direct 90 24 48 0 72 18 Staff Physician Maximum (10%) Non-direct 180 24 48 0 72 108

Lead Physician (15%) Non-direct 270 24 48 48 120 150 Lead Physician Maximum (20%) Non-direct 360 24 48 48 120 240

Maximum Non-direct Time Less: Staff Meetings Forums Lead Meetings Total Standard Non-Pt. Care Activities Maximum amount of Negotiable Project Time

NOTE: The usage of maximum non-direct patient care is reserved only for those high performers who consistently exceed service targets. Using the maximum non-direct patient care will require VP and Medical Director approval; specific projects/initiatives must be outlined for review.

Table 4.4a: Per FTE Physician – Staffing, RVUs, Patients, Procedures and Square Footage With Primary Care Only

Staffing, RVUs Patients, Procedures Square Footage Data and Count Mean 27 1.37 35 0.97 6* * 1* * 27 0.37 36 5.29 35 5.06 32 0.4 32 0.75 11 0.25 11 0.11 20 0.15 31 1.07 17 0.26 22 0.43 14 0.27 27 0.47 24 0.69 30 0.87 23 0.36 17 0.25 11 0.29 13 0.25 7* * 4* * 22 2,582 28 11,349 31 2,256

Practice Type Multispecialty Primary Care Only (per FTE Physician) Std. Dev. 0.24 0.09 * * 0.24 1.78 1.52 0.26 0.38 0.19 0.15 0.16 0.47 0.18 0.22 0.24 0.39 0.53 0.43 0.26 0.18 0.21 0.32 * * 1,623 4,281 1,195 1,286 5,227 1,081 0.09 3.13 3.05 0.1 0.41 0.02 0.03 0.01 0.45 0.02 0.17 0.04 0.16 0.13 0.26 0.11 0.09 0.04 0.04 * * 1,387 7,929 1,341 10th %tile 1.09 0.83 * * 0.15 4.28 4.25 0.19 0.5 0.12 0.04 0.04 0.71 0.12 0.25 0.1 0.18 0.23 0.52 0.17 0.14 0.13 0.08 * * 2,083 10,924 1,965 25th %tile 1.15 1 * * 0.32 5.16 5.05 0.32 0.69 0.18 0.05 0.1 0.98 0.21 0.43 0.17 0.36 0.5 0.82 0.27 0.18 0.2 0.16 * * 3,358 14,247 2,942 Median 1.32 1 * * 0.5 5.8 5.74 0.67 0.91 0.41 0.11 0.23 1.48 0.36 0.55 0.45 0.54 1.18 1.19 0.51 0.32 0.42 0.28 * * 6,088 17,882 4,162 75th %tile 1.5 1 * * 0.73 8.07 7.34 0.83 1.12 0.54 0.47 0.42 1.7 0.56 0.78 0.71 1.09 1.36 1.36 0.75 0.57 0.68 0.9 90th %tile 1.73 1

Total provider FTE/physician Prim care phy/physician Non spec phy/physician Surg spec phy/physician Total NPP FTE/physician Total support staff FTE/phy Total empl support staff FTE/phy General administrative Business office Managed care administrative Information technology Housekeeping,maint,security Medical receptionists Med secretaries,transcribers Medical records Other admin support Registered Nurses Licensed Practical Nurses Med assistants, nurse aides Clinical laboratory Radiology and imaging Other medical support serv Total contracted sup staff Total RVU/physician Physician work RVU/physician Patients/physician Total procedures/physician Square feet/physician

Copyright 2002. All Rights Reserved. Medical Group Management Association

Health Management Associates

Appendix K-5

COPC Staffing Tool June 25, 2004
East Dallas Health Center DeHaro DECISION CRITERIA Provider/Staffing Ratio (budgeted staff) Providers 1.00 Nurses and MAs 1.68 Business and Clerical 2.10 Provider/Staffing Ratio (current staff) Providers Nurses and MAs Business and Clerical Exam Rooms per Provider

Appendix A - 5
Senior House Calls

Bluitt Flowers

Southeast Garland Oak West

PPCC

Vickery

Youth and Family

ACC

Geriatrics

HOMES

1.00 1.53 2.14

1.00 1.42 2.17

1.00 1.31 2.27

1.00 1.46 1.88

1.00 1.25 2.08

1.00 1.67 2.33

1.00 1.33 2.33

1.00 1.20 1.26

1.00 1.55 1.36

1.00 2.31 1.15

1.00 0.36 0.36

1.00 1.27 1.27

1.00 1.71 2.28 2.10

1.00 1.07 2.06 2.67

1.00 1.33 2.17 3.25

1.00 1.23 2.19 2.66

1.00 1.63 1.86 2.60

1.00 1.11 1.81 2.22

1.00 1.33 2.33 2.67

1.00 1.00 2.00 3.00

1.00 1.20 1.26 n/a

1.00 1.36 1.36 0.00

1.00 2.31 1.15 0.00

1.00 0.36 0.36 0.00

1.00 1.27 1.27 n/a

Staffing Models Providers Nurses and MAs Business and Clerical Vacancies Providers Nurses and MAs Business and Clerical

14.3 24 30

13.1 20 28

12 17 26

12.8 16.8 29

9.6 14 18

3.6 4.5 7.5

3 5 7

3 4 7

12.5 15 15.8

11 17 15

2.6 6 3

2.8 1 1

5.5 7 7

2 3 2

6 1

1

1 1

1 0 2

0.5 1

1

1 1

0 2 0

DETAILED INFORMATION Square Footage Exam Rooms Adult Pediatrics Other 51,398 52,051 46,048 44,716 31,796 14,419 9,855 10,751 27,975 47,951 947 N/A 11,344

16 14

12 17 6

13 15 11

17 12 5

13 12 8

6 2

3 6

Other Patient Care Rooms Adult Pediatrics Other

3 4

1 1

1 2

3 1 1

2 1 3

2

Providers Pediatricians Internist Family Practitioner Podiatrists Leads Nurse Practitioners Physician Assistants Nursing Staff Lead RN's RN's LVN's Medical Assistants Patient Care Assistants Clinical Nurse Specialist Business Staff CSA's Financial Counselor Appointment Scheduler Medical Office Assistant Administrave Sec.& Assistants Management and Supervision Other

5.7 5.6

3.1 4

2.5 4 0.7 2 2.8

2 3.8 2.8 2 2.2

2.8 2 2.8 2

0.8 0.6 0.7 1 0.5

2

1 1

0.5 2 1 5 4 2 1 1 1.6 7 2 1 0.8 1 0.5 1 3

2 1

3 1 2

1

1

2 6 8 8

3 4 12 1

2 3 9 3

1 3.8 11 1

2 2 9 1

1 3.5

1 2 2

1 1 2

1 2 9 3

1 14 2 2

1 1 2 1 1

1

1 5 1

17 7 6

13 8 7

12 9 5

22 6 1

11 3 4

4 2 1.5

5 1 1

5 2

11.8 4

11 4

2 1

1

3 4

2 1

2 1 1

2 1 1

2 1

1 1

1

1 1

1

1 1 4

1 6.2

Language Assistants Social Workers Psychologist Psychiatrist Community Service

3 3 0.45 0.2 1

3 0.7 0.4 1

2 3 0.45 0.4 1

3 2 0.6 0.4 1

3 2 0.85 0.4 1

1 0.5 0 0

1 1 0 0

1 0.5 0.2 0.2

0 3 0 0

0 0 0 0

1 1 0.2

1

3.2

January - March 2004 EPIC REPORT Newborn Appointments Parkland to COPC
Dale Talley

APPENDIX K-6

% % Regular Appts Appts Appts Appts Kept Kept Kept
January February March April May June July August TOTAL 1,156 1,083 1,185 1,186 1,015 1,018 1,179 1,178 9,000 82.6% 86.0% 85.8% 85.9% 82.4% 84.3% 85.4% 84.5% 955 931 1,017 1,019 836 858 1,007 995 7,619 82.6% 86.0% 85.8% 85.9% 82.4% 84.3% 85.4% 84.5% 84.7%

% % High Ris Appts Appts Appts Appts Kept Kept Kept
33 33 40 40 52 35 57 35 325 92.6% 92.7% 98.4% 87.5% 78.1% 91.7% 94.7% 88.5% 31 31 39 35 41 32 54 31 293 92.6% 92.7% 98.4% 87.5% 78.1% 91.7% 94.7% 88.5% 90.2%

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