Thursday, November 02, 2006
Chicago Tribune
by Judith Graham

Look across the country, and you won't find another major public health system governed like Cook County's.

In other areas, public hospitals have the freedom to offer signing bonuses to nurses or buy equipment on short notice when special deals become available.

Not in Cook County.

In other areas, public hospitals have boards of advisers or directors who devote enormous time and effort to planning for the institutions' future.

Not in Cook County.

Here, public hospitals are run by the government, and that means they are bound by county regulations, hobbled by outmoded business practices and captive to county politics. Practically, it also has meant the County Board president runs the county health system with little effective oversight.

The County Board's Health and Hospitals Committee rarely meets. At individual hospitals, monthly leadership gatherings are short and rarely focused on serious issues, a review of the minutes shows. And the full County Board doesn't exercise consistent, rigorous review, except in approving the budget.

Many observers say the setup has left the $830 million county health system adrift, without a clear plan for dealing with existing or future challenges, as financial pressures mount and growing numbers of needy county residents seek expensive medical services.

The only other major city that runs its health system in a similar way is Los Angeles, and that system is teetering on the brink of collapse.

Tens of thousands of needy, vulnerable residents depend on Cook County's health system for medical services. But in the last several years, long waits have become increasingly common, forcing many poor people to go without medical care or delay it until they're in crisis.

Meanwhile, inefficient operations are helping to undermine the financial viability of the county's public-health institutions, raising the prospect that services will be cut or taxpayers asked for more resources.

"It's a very bad situation, and it's going to get worse," said Dr. Whitney Addington, former president of the Chicago Board of Health.

Addington is among the community leaders calling for an overhaul of management and governance at the health system now that the nearly 12-year reign of former board President John Stroger is over.

Both candidates for County Board president in Tuesday's election acknowledge serious problems and support reforms. But neither has released a detailed plan of action.

The Bureau of Health Services is the single largest unit of county government; it includes Stroger Hospital, Provident Hospital, Oak Forest Hospital, a network of community clinics, medical care at the County Jail, and other functions.

To its credit, the health system has extraordinarily dedicated medical providers and delivers high-quality care. Few public health systems have an entirely new hospital--John Stroger's major achievement, named in his honor--or such an extensive network of clinics.

Cook County's health bureau has also benefited from the influence of Illinois' congressional delegation. Though federal cuts to public-health programs loom large elsewhere, Congress has protected hundreds of millions of dollars in annual funding for indigent care in Cook.

But a sense of crisis at the bureau is building as the cost of delivering medical care soars, demand for services escalates, and management is stymied by county regulations and political considerations.

Interim board president Bobbie Steele, a longtime Stroger ally who landed in the president's seat earlier this year after his stroke, has since become a vocal critic of many practices at the health system.

"Dismal" is how she described the system's finances in an e-mail to the Tribune.

Asked what fixes are needed, Steele suggested the county should fire "non-performing leaders and employees," reorganize the health system's finances and appoint an advisory committee to offer independent guidance.

Those recommendations echo the findings of a report on the county's Bureau of Health Services published this summer by the Institute for Healthcare Studies at Northwestern University's Feinberg School of Medicine.

That report concluded that the bureau's ability to fulfill its mission was being severely compromised by weak governance, poor planning and ineffective management.

"What you have is benign neglect by the county commissioners on the one hand and unbelievable meddling in the [health bureau's] operations by the president's office on the other hand," said co-author Patricia Terrell, former deputy chief of the county health system.

Notably, the president's office has controlled hiring throughout the system for positions ranging from medical clerks to financial managers and high-level hospital officials, she said.

The report found it particularly disturbing there was no long-term plan for responding to the shifting demographics of medical need in Cook County, including growing numbers of uninsured immigrants and working families without medical coverage in the suburbs.

Jerry Butler, head of the County Board's Health and Hospitals Committee, dismissed much of the Northwestern report as overstated. Administrators at the health bureau's facilities keep a close watch on operations, he insisted, and inspections by the state public health department and medical groups ensure care meets standards.

While strategic planning is "a wonderful thing in concept, it often points back to `where's the money?'" Butler said.

Dr. Daniel Winship, who is expected to resign Thursday after two years as head of the Bureau of Health Services, said that over the last year he has concentrated on reducing big problems in the bureau's pharmacy operations and addressing the need for more up-to-date information technology and financial billing and collections systems.

Todd Stroger, the Democratic candidate for County Board president, said he's committed to several reforms. But many question his willingness to upend practices entrenched under his father, John Stroger.

Among his priorities for the health system, Stroger said, are improving financial management, instituting a hiring system based on merit instead of political considerations and reducing what he called the bureau's "bloated bureaucracy."

"I strongly believe that professionalism must be enhanced and politics decreased," he wrote in response to Tribune questions. Stroger also said he would appoint a blue-ribbon commission to offer guidance on how to "reconstitute" the county health system into a more efficient operation and one that better matches resources to community needs.

Tony Peraica, the Republican candidate, came out swinging in his answers.

"The greatest challenge facing the county's health bureau relates to our ability and willingness to wrestle control of this $1 billion enterprise away from political hacks and put it under the stewardship of experienced, well-trained professionals," Peraica wrote.

"There is absolutely no legitimate reason that all hiring flow through the County Board president's office, as it has in the past," he added. Money saved from cutting political hires in middle management should be used to add workers closer to the front lines of service, he wrote.