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2019-11-13 PAG FinalPARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 1 ASSEMBLY The Partnership Advisory Group met for a meeting on Wednesday, November 13, 2019, at 5:30 p.m. in the Andre' Mallette Training Rooms at the New Hanover County Government Center, 230 Government Center Drive, Wilmington, North Carolina. Members present: Co -Chair Barbara Biehner; Co -Chair Spence Broadhurst; Vice Co -Chair Bill Cameron; Vice Co -Chair Dr. Joseph Pino; Members: Robert Campbell; Chris Coudriet; Cedric Dickerson; Jack Fuller; Hannah Gage; John Gizdic; Dr. Sandra Hall; Meade Horton Van Pelt; Dr. Chuck Kays; Tony McGhee; Dr. Michael Papagikos; Dr. Mary Rudyk; Jason Thompson; and David Williams. Members participating via telephone: Dr. Virginia Adams and Brian Eckel Members absent: Evelyn Bryant Staff present: County Attorney Wanda M. Copley; Clerk to the Board Kymberleigh G. Crowell; Assistant County Manager Tufanna Bradley -Thomas; Chief Financial Officer Lisa Wurtzbacher; Chief Communications Officer Jessica Loeper; Budget Officer Sheryl Kelly; New Hanover Regional Medical Center (NHRMC) Chief Communications Officer Carolyn Fisher; NHRMC Chief Strategy Officer Kristy Hubard; NHRMC Media Relations Coordinator Julian March; and David Burik, Navigant Managing Director. Co -Chair Biehner thanked everyone for being present and stated it is important the community understands the Partnership Advisory Group (PAG) is committed to an open and thorough process. The work ahead is going to take time. The PAG will be diligent to ensure the public is included and informed. While there is not time for public comments during the meetings, the email pagcomments@nhcgov.com is for everyone to utilize to share thoughts, concerns, and questions and the community is encouraged to use it. All emails will be able to be seen by the PAG. Information is also located on the New Hanover Regional Medical Center (NHRMC) website https://nhrmcfuture.org/stay-informed/. It is important for all to remember throughout this process that the PAG has to do what is in the best interest of the citizens, the healthcare providers of New Hanover County (NHC) and the surrounding communities, and what is best for NHRMC to fulfill its mission of leading our community to outstanding health. These are the guiding principles for the conversations to be held over the coming months. Co -Chair Broadhurst stated the responsibilities of the Co -Chairs and Vice Co -Chairs are to keep the PAG moving forward. Throughout the process, it is important for everyone to stay engaged and that dialogue takes place, while being respectful of each other. He then provided a brief overview of the agenda for the November 13, 2019 meeting. APPROVAL OF OCTOBER 29, 2019 MINUTES PAG Member Cameron MOVED, SECONDED by PAG Member Thompson to approve the October 29, 2019 minutes as presented. Upon vote, the MOTION CARRIED UNANIMOUSLY. ROLE OF ADVISORS TO THE PARTNERSHIP ADVISORY GROUP (SLIDES 4-7) NHRMC Chief Strategy Officer Kristi Hubard reviewed the information on the role of advisors of the PAG from slides 4-5 of the PowerPoint presentation (the presentation). Chief Financial Officer Lisa Wurtzbacher continued the presentation highlighting the timeline for financial advisor RFP information from slides 6-7 of the presentation: • November 15th: County/NHRMC send Financial Advisor RFP • December 2nd: County/NHRMC receive responses • Week of December 91h: County/NHRMC narrow list • Week of December 16th: PAG makes selection Ms. Wurtzbacher stated it is a compressed timeframe, but it is doable. The County's bond counsel, Parker Poe, has recommended five financial advisor groups that the RFP will be sent to which are Kaufman Hall, Ponder & Company, Hammond, Hanlon, Camp LLC, Cain Brothers, and Melio & Company. In response to questions, Ms. Wurtzbacher stated the companies are not local, they are national companies, and have dealt with healthcare/hospital systems. She also provided a brief overview of the role of Parker Poe and noted that Parker Poe serves on all hospital transactions as well as all general government transactions. REVIEW OF PAG PROCESS (SLIDES 8-10) Co -Chair Biehner reviewed the Phase I proposed content for meetings from slides 9-10 of the presentation. Co -Chair Broadhurst stated that the leadership team, Co -Chairs, and Vice Co -Chairs met to develop and refine the Phase I content as a guideline. The pace at which this is accomplished is up to the PAG. While the group wants to move through it in an orderly manner, everyone wants to do it right. This is the groundwork to develop the RFP. OVERVIEW OF HEALTHCARE LANDSCAPE (SLIDES 11-36) David Burik, Managing Director with Navigant, stated that Navigant has worked with NHRMC since 2004. He presented information from slides 11— 36 of the presentation about the healthcare landscape. PARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 2 In response to questions from slide 16 of the presentation reviewing how healthcare consumes a growing portion of the country's GDP, Mr. Burik stated that the government is the primary driver of moving from fee-for- service models to value -based care models. Value -based care is a subscription model. Approximately 709 of Medicaid beneficiaries are in a managed care plan. An insurance company reimburses "x" dollars per member per month to keep the recipients well. As far as Medicare, there is traditional Medicare and Medicare Advantage. Medicare Advantage is on a value -based care model and accounts for approximately 309 of all enrollees, with the percentage rapidly growing. The government as one of the largest payers in the country is pushing it. It is not employers, not individuals, it is the two biggest payers. Mr. Coudriet stated that North Carolina is the last large state going to managed Medicaid. Since 2007 or 2008, managed Medicaid has been utilized as it relates to behavioral health and developmental disabilities. Theoretically, on February 1, 2020, the entire mechanism for Medicaid payment in this state changes and at that time the state will be under managed Medicaid. It will affect all medical aspects, not just hospitals. In response to questions from slide 20 of the presentation, Mr. Burik stated that the reason there is more public, less private reimbursements are for two principal reasons: 1) a baby boom, so there are more people over the age of 65 than ever and that age is the only eligibility rule of Medicare; and 2) Medicaid expansion. 30 states have expanded Medicaid to include more people, however, they do not all pay the same. On average across the country, Medicare pays about 879 on the dollar, Medicaid is about the same, but private payers pay for 1459. When commercial is replaced by public, it goes from a profitable to an unprofitable case. In response to questions from slide 21 of the presentation, Mr. Burik stated that while older people do use the hospital more, if a hospital was all Medicare the rate would not cover all the costs. NHRMC Chief Financial Officer Ed 011ie confirmed NHRMC comes closer to breaking even on Medicare than many hospitals across the country because it is a sole community provider. In response to questions about the certificate of need (CON) not being in place in some states such as Texas, Mr. Burik stated healthcare delivery as it relates to indigent care is done in large county hospitals that receive tax support in the form of indigent and Medicaid with a small bit of Medicare and virtually no commercial. There are also medical schools. The commercial primarily goes to the private institutions. In Texas, there are larger public ("safety net") hospitals and there is actually more outpatient competition. There are more outpatient centers going after commercially insured outpatient procedures. As to the quality of care in the safety net hospitals/non-CON states and what the citizen tax burden is for healthcare in safety net hospitals using Texas as the example, Mr. Burik stated he and his team will research the questions and bring the information back at the next meeting. In response to questions, Mr. Gizdic confirmed that NHRMC serves seven counties and more than half of the patients are outside of New Hanover County. As it relates to the information on slide 22 of the presentation on recent and pending regulations, Mr. Burik will bring back information about the implications of the actions taken in Florida and Illinois. A brief discussion was held about the need to include information of how consumer costs can be reduced on the private side when there is no 24/7 care, no indigent care, and charges are 209 less but yet there is a segment of the population that is not being served. There is a need to know the difference because NHRMC encompasses all facets of care under one roof. In regards to the information on slide 24 of the presentation, Mr. Gizdic stated that payments at NHRMC are approximately 909 fee-for-service and 10% value -based, which is not uncommon for the state. NHRMC does not have contracts in place yet with the Medicaid managed care companies. In the next 24 -months, NHRMC will be under managed Medicaid which will shift risk to it in the net value column. The contract with Blue Cross and Blue Shield of North Carolina (BCBSNC) is up in nine months and information points to BCBSNC systematically moving away from fee-for-service to value -based payments. He predicts the contract with BCBSNC in the next year will have the 90-10 split shift even further to where the 109 could increase to 309 to 409 like the national average. If so, there will need to be a shift in the hospital's business model. A brief discussion was held about how the value -based payment system works with the increasing cost of innovation in healthcare. Mr. Burik stated that medicine is very scientific and a lot of the innovation that is being discussed is digital. It is about how people communicate with their caregiver and information being available to the caregivers. Surgery is becoming outpatient which is an innovation and is already 659 outpatient. There are not many technologies saying more beds are needed. There are assets that have a 50 -year life that are in the process of being paid off while putting together what is needed for the new healthcare world. Further discussion was held about payments being made based on a value -based system rather than a fee- for-service system when looking at how strides have been made in medicine and non -communicable diseases because it is based on modifiable risk factors that doctors cannot necessarily modify. The value -based system is essentially an outcome based payment system where doctors cannot control the outcomes, it has not been proven to work, there will be a rise in administrative costs, and the burden will be on the doctors to figure it out. Mr. Gizdic commented that he estimates 90 cents of every dollar saved goes to the insurer and zero goes to the patient. Following the information on slide 25 of the presentation, a brief discussion was held about how the shift of a greater share of healthcare costs to employees is in direct conflict to the value -based outcome. Mr. Gizdic noted PARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 3 that the average deductible for a person with insurance is $3,300. A recent study stated that 700 of Americans do not have $400 in savings to cover an unexpected bill. This translates into bad debt for hospitals and healthcare providers. Mr. Coudriet stated that it is not just bad debt, it will also be delayed access to care which is going to work against the ability to keep people healthy over the next three or five years until it is an emergency. It was also noted those in the fee-for-service program with a high deductible are batching their healthcare expense while those in a pay -for -value care program even with the deductible are getting routine maintenance. Not every company offers that option. Following the information on slide 26 of the presentation, a brief discussion was held about why NHRMC cannot take tax dollars from the counties it serves. It was explained by various members that NHRMC does not take tax dollars from any of the counties. In order to do so, the model would have to be changed because it is owned by New Hanover County and there is no jurisdiction over the other counties. Mr. Coudriet stated the other counties could do it out of choice as there is no mechanism to compel the other six counties to require them to subsidize or cost -share. Mr. Gizdic noted that each of the counties also have a hospital in their respective communities. Following the information on slide 30 of the presentation, Mr. Burik stated that hospitals are seeking economies of scale and skill. Several hospitals have sought consolidation because they cannot do it on their own. In healthcare it is not exponential growth, it is slow but continues. A brief discussion was held about how consolidation often brings economies of scale and skill, and delivery of care can become cheaper. The question becomes when does a consolidated group become so big it cannot make up for the economies of scale because it cannot make up the shrinking dollar entering the systems. Mr. Burik stated the government is the largest payer and its goal is to have, he believes, gradual reduction in costs and increase in quality and maintain access throughout. He thinks the government is pretty content if there are no increases. It is not trying to take 400 out of the cost of hospitals, but rather is saying put a couple more Medicare people in there for no extra dollars. He also thinks the government is defining the cost gap in a manageable term, but the big systems will not be able to be successful in every market that they are in, in every product line. It is unsustainable at some point and the best answer is managed care but it is not clear how it will be done. At the request of PAG members, Mr. Burik will bring back information about which systems across the industry have successfully moved to new structures, new models, and have seen the quality of care improve. Mr. Burik concluded his presentation reiterating the following: • Healthcare is Growing and Changing, Presenting Multiple Challenges to Healthcare Providers: 1. Healthcare providers are receiving fewer payments for services: • Federal and state governments are the largest payers of hospital care, and will continue to be as the population ages • Governmental payers reimburse hospitals less than private payers 2. Healthcare providers are under increasing regulatory scrutiny: • Hospitals have been pushed into the regulatory spotlight, with a range of regulations 3. Payers driving Shift from fee-for-service to value -based care: • Private payers are changing how they purchase care, increasingly driving value -based arrangements and shifting costs to employees 4. Delivery of care shifting from inpatient to outpatient setting: • Patients are using healthcare services differently, demanding lower costs, greater accessibility to care, higher quality 5. In response to these challenges, providers have increased collaboration: • Consolidation with other hospitals provide economies of scale and skill; greater capital pool • Employment of physicians and alignment with physician groups (ACOS, CINs) • Vertical affiliation with payers (narrow networks and value -based payments) • Experimenting with innovative partnerships and restructuring of operating model A brief discussion was held about continuing the meeting past 7:30 p.m. as Mr. Gizdic's presentation will take longer than the time allotted. The general consensus of the PAG was to move forward to complete the items on the agenda. NHRMC STRATEGIC DIRECTION (SLIDES 37-67) Mr. Gizdic presented the strategic direction of NHRMC highlighting information from slides 37-67 of the presentation. As it relates to the facility priorities information from slide 45 of the presentation, Mr. Gizdic stated that Medicare defines major procedures as diagnosis related groups (DRGs). A recent study shows that Medicare is predicting that over the next five years, 400 of its DRGs will move from inpatient to outpatient. In response to questions about the expected population growth in Brunswick and Onslow counties, Mr. Gizdic stated that Brunswick County is more of a retirement population that is moving in and probably a different income level than Onslow County, which is primarily military and has base relocations and young families. Onslow County is primarily Tricare and Medicaid that is growing there. It is very different by county and each county's needs are different for services and demographics. In response to questions from slide 47 of the presentation regarding telehealth — NHRMC Home Care, Mr. Gizdic confirmed the readmission of patients with chronic conditions within 30 days of being released did not necessarily get readmitted for the same condition and there are no payments for readmissions. It was primarily Medicare patients, but it is not universal. There is no reimbursement for telehealth home care and it is the innovation PARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 4 no one wants to pay for, but it is reducing costs. All the money it saves leaves this community and goes back to Medicare, Medicaid, or BCBSNC and none goes to NHRMC or the patient. In response to questions from slide 51 of the presentation on accountable care, Mr. Gizdic stated that there was a cost to executing the NHRMC's ACO plan in overhead and it was all done manually. There will be a need for the systems and skills to be able to take these type of results across the entire population of southeastern North Carolina. In response to questions from slide 52 of the presentation on payer strategy, Mr. Gizdic stated that the premium for most Medicare Advantage plans is zero because the insurance company is trying to get that covered life in their plan. That is why it is attractive for Medicare beneficiaries to switch from traditional Medicare to Medicare Advantage because there is no premium for the individual. Medicare (CMS) is paying the insurance company a set amount for every Medicare beneficiary. The goal is to get as many covered lives, particularly healthy lives, covered in an insurance company's plan to grow its risk pool. Medicare Advantage is the fastest growing part of Medicare. Nationally it is about 30% and locally it is about half of that, so there is very limited Medicare Advantage penetration and was a way for NHRMC to experiment and learn. Right now it is only going to be in New Hanover County and it can be spread to other counties year after year if it is successful. NHRMC has to start learning how to function as a health system in this new world and this was a way to do it incrementally. Mr. Gizdic covered information from slides 53-58 of the presentation concerning health equity in attaining the highest level of health for all people, cultural competence, hiring and recruiting, identifying and targeting disparities, community partnerships, and how NHRMC is managing risk by starting with its employees. NHRMC is not only the largest employer in town, it is the largest consumer of healthcare in town. NHRMC spent $70 million on its own healthcare last year and it is trying to bend its own cost curve through some of these initiatives. In response to questions, Mr. Gizdic stated the health plan cost is $400 per beneficiary per month and does include the employee contributions. Regarding the strategic priorities as they relate to employee and provider engagement from slide 59 of the presentation, Mr. Gizdic stated there is a shortage of healthcare professionals, providers, and staff. North Carolina is ranked the second highest impacted state for healthcare professional shortage in the United States. This is due to everyone moving to the state. The population is growing and for example, there is a misdistribution of nurses in the northeast that are not leaving, but the population is coming down here. In response to questions from page 61 about the impacts of potential significant events, Mr. Coudriet stated that one penny on the New Hanover County tax rate generates in revenues today $3.4 million. The biggest tax increase the community has had over the course of two fiscal years was the equivalent of about a five and a half cent tax rate. Mr. Gizdic stated that NHRMC is more sensitive to these impacts than an average hospital because it is independent and standalone. If the impacts happen, the question is where does NHRMC go and what does it do to make up the difference. Currently the only options would be to go to the taxpayers or have a fire sale. He does not think it is highly likely that all of the impacts will happen at the same time. If one of them happens at $30 million or $50 million, that cuts the bottom line in half. As to whether it is possible to change the hospital's status if there is a shortfall to encourage private investment and still retain majority ownership of some form, Mr. Burik stated there are joint ventures that have been utilized. There are venture capitalists in ambulatory facilities, not hospitals. NHRMC already does a joint venture and could take businesses to make them a joint venture, the owners have to say yes we will do that. In NHRMC's case the bond holders do it too and probably would not be very interested in having items that are in the credit that are profitable, grow out of the credit. To do a material joint venture would probably require a look at the capital structure. Following the information from slide 62 of the presentation on the projected capital cash flow needs, Mr. Gizdic stated that NHRMC has almost $400 million in bonds. NHRMC is rated by Moody's and Standard & Poor's (S &P) as Al/A+ credit. To reach that, S&P has benchmarks you have to hit to maintain your rating. What they are seeing is that their average Al/A+ has an operating margin of 3.80% and has an average of 325 days' cash on hand in the savings account. It costs $3 million per day for NHRMC to keep the doors open. Fiscal year 2019 are real, pre - audited numbers and fiscal years 2020 and forward are projected numbers worked on with an independent financial advisor. NHRMC had a 6.98% operating margin in 2019, so it is beating the odds from an operating margin perspective. However, what NHRMC is told every year by S&P is that it does great in operating margin and market share, but has the weakest balance sheet of all A+s they see because NHRMC only has 242 days' cash on hand. S&P thinks NHRMC should have $240 million more in the bank to keep the rating. The 2020 numbers are real numbers and show a 6.4% operating margin which is what was approved by the NHRMC Board of Trustees for 2020, and NHRMC is on the decline already. It is going to generate $150 million in cash. Routine capital (routine maintenance of pumps, computers, etc) averages $60 million a year and will do so throughout the next 15 years. There are special projects going on which will wind down over the next three years. All the other items he mentioned earlier, the hospital in Scotts Hill, a replacement emergency department for Cape Fear, ambulatory facilities, etc. will cost approximately $50 million a year over the next few years to start those projects, and over next the next 15 years another $900 million. The chart shows what the capital appetite is for NHRMC. As margins are seen to continue to trend down and keep beating the odds in 2020, 2021, and 2022, assuming none of the catastrophic things happen, NHRMC gets down to the average in the next five years. As far as what it does to the cash balance, the organization PARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 5 will go from $838 million not being enough and deplete the days' cash on hand to 191 and NHRMC is now even further off by approximately $400 million. If that occurs, there is no chance S&P will keep the bond rating level the same, the interest rate on all the debt increases, and the margin goes down even further. He is not saying the doors will close, but there will be an erosion of the margin and it cannot close because of the population growth being seen. The bricks and mortar buildings have to stay open and there is a need to build more bricks and mortar facilities while transitioning into the new world of value. In response to questions, Mr. Gizdic stated that as it relates to starting with FY2021 and any if the assumptions discussed earlier about reductions in revenue were included, only managed Medicaid was included. If any one of the other assumptions were to occur, the net position is worse even if there is a small decrease or measurable decrease. What is being presented today is the best case scenario. Mr. Gizdic concluded the presentation stating in reference to slide 38 of the presentation, the reason for asking the question, which in his mind from his perspective is about one thing and one thing only: Is there a model, partner, an option for this organization that can bring resources to help do the following to fulfill the mission and achieve the vision through the strategic plan that has been set forward: Our Ambition: NHRMC Mission, Vision, and Values: • Our Mission: Leading Our Community to Outstanding Health • Vision for the Future: NHRMC is an industry leader in a new era of healthcare delivery. Our thriving community serves as a national model of achieving excellence for all. We are committed to: • Fostering a culture of transformation through empowerment, innovation, and inclusivity • Delivering exceptional quality and personalized experiences throughout the wellness continuum • Advancing health and vitality for all through a community integrated model of collaboration • Cultivating a diverse and extraordinary workforce dedicated to our mission • And Values: Ownership, Teamwork, Communication, Compassion Mr. Gizdic stated that to him, this is why the question is being asked. Mr. Coudriet stated that is the reason the County Commissioners charged them with going forward. This is what Mr. Gizdic, and he to a lesser extent, have been trying to talk about since July 23rd MEETING CALENDAR (SLIDE 68) Budget Officer Sheryl Kelly stated that prior to this meeting she sent out a draft meeting calendar which included the minimum number of meetings that would be required to accomplish all of the tasks in the charter. Upon further consultation, she is now presenting an updated draft calendar that includes two meetings in January and two meetings in February of 2020, whereas the prior calendar only had one meeting for each of those months. The idea was that the group could need additional meetings depending on the group's progression and it is beneficial to have the dates on the calendar. If the group is progressing at a faster pace, the meetings can be canceled if need be. The task of the PAG is to determine if the proposed weeks work for a majority of the group and to determine the most convenient day and time of the week to meet. Co -Chair Broadhurst expressed appreciation for the work that has been done to help keep the group on track. There is a lot of information to be absorbed and a lot of good questions are being asked. He thinks he speaks for the four chairs in that their commitment is to do whatever it takes to go through this process. As to the proposed weeks, the general consensus of the PAG is the that proposed weeks will work for a majority of the members. As to which day and time, after a brief discussion the general consensus of the PAG is that Thursdays at 5:30 p.m. will work for a majority of the members. Ms. Kelly stated based on the general consensus of the PAG, she will prepare the final meeting calendar and send it to everyone. MEETING 3 PREPARATION AND CLOSING REMARKS (SLIDES 69-81) Co -Chair Biehner stated a lot was learned during the meeting about the industry on a national level and local level. The groundwork is starting to be laid and again, it was very informational. She reviewed what information would be covered during the November 20th meeting from slides 69 to 81 of the presentation. She reiterated that the PAG does not have time to take public comments during these meetings as can be seen why from tonight's meeting. She encouraged everyone to please use the email address pagcomments@nhcgov.com and to stay informed from an educational basis through https://nhrmcfuture.org/stay-informed/. Co -Chair Broadhurst stated that in regard to the information request of Mr. Burik, the leadership will try to incorporate his information into the next agenda. While it will put more on it, he thinks there were very important points raised. If there is information the members need to get to the four co-chairs or discuss, Co -Chair Broadhurst encouraged the members to contact them. PARTNERSHIP ADVISORY GROUP NOVEMBER 13, 2019 MEETING PAGE 6 ADJOURNMENT There being no further business, Co -Chair Broadhurst adjourned the meeting at 8:25 p.m. Respectfully submitted, /final — approved/ Kymberleigh G. Crowell Clerk to the Board Please note that the above minutes are not a verbatim record of the Partnership Advisory Group meeting. 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