San Joaquin Valley Regional Association of CA Counties

San Joaquin Valley Regional Association of CA Counties Health Care and the Affordable Care Act Hospital Viewpoint Stephen Walter, SVP/CFO Community Medical Centers-Fresno October 9, 2014

Healthcare and the Affordable Care Act • About Community Medical Centers-Fresno, CA • ACA , Goals, Health Care Industry, Resulting Impact • ACA, Region, Safety-Net, Challenges • Status of Hospitals in the SJV – OSHPD DATA 1 Q and 2 Q 2014 • Access to Care; Providers and Hospital Beds • What is Needed? – Payment Reform • DSRIP – Delivery System Reform Incentive Pool for 2015?

Community Medical Centers • CRMC 2 nd Largest Acute Care Hospital in California. • CRMC Largest Safety-Net Hospital in CA • Level 1 Trauma and Burn Center – Adults and Pediatric – Sac/LA • Largest Provider for Specialty Care in SJ Valley • Largest Private Employer in the SJ Valley- Over 7, 000 Employees • Largest Teaching Hospital in SJ Valley – UCSF – Over 300 Residents • Invested over $1 B in Plant and Equipment Last 12 Years

Affordable Care Act • Main Goals- Uninsured, Access, Costs, Quality – “Triple Aim” • Biggest Impact to Health Care since 1960 s • Not Perfect – Senate Only Version – “Modifications” • House Republicans voted over 50 times to Repeal • ACA Safe until 2016 – Obama Veto • Kaiser Family Foundation say 3. 4 M Newly Insured in CA • From 22% to 11% • SJ Valley had the smallest gains in getting Medi-Cal/Covered CA • NO LIHP in Fresno, Tulare; Latino Barriers, Safety-Net Numbers

ACA and Its Impact on Health Care Industry • More Hospitals Will Become Part of a Health System • More Physicians Will Affiliate With Hospitals • More Providers Will Own Health Systems • More Payments Will Move to VALUE-Based • More Payments Will Become Fixed or Capitated

Hospital Overview in SJ Region • Nine Counties – 36 Acute Hospitals – 17 Had Op Losses – Six Months 2014 • Industry Trends – Consolidate, Value, Access, Population Health • Sutter, Dignity, Adventist, Tenet, CMC (EMR, Seismic, Scale/Integration) • • Preventable Admissions – Safety Net – Impact of ACA Safety Net = Lower Reimbursement for Hospitals Valley Health Issues – Poorest Health and Fewest Primary Care Physicians Aging Population = Higher Hospital Bed Utilization Bed Capacity – CA Health Care Foundation 2008 Reduce DSH Funding to Safety Net Hospitals 2014 -2020 State Conversion of Medi-Cal Payment to DRGs – Negative CHA/Deloitte – Unfavorable Current and Future Exposure

SJ Valley Hospitals – Operating Financials • Top Five Winners • Memorial – Modesto $34 M; CRMC-Fresno $31 M; Bakersfield Memorial $28 M; Mercy Bakersfield $16 M and Children’s-Madera $13 M • Top Five Losses • • SJ County $37 M; Kern County $23 M Mercy Merced $11 M Adventist Kings/Fresno $9 M Saint Agnes Fresno $7 M • Observations – Winners…System Strengths (Dignity, Sutter) Children’s Given a Distorted Medi-Cal Reimbursement. Losers…Counties, Regional Location, Stand-Alones and Districts • No Provider Fee Monies in 2014 Source: OSHPD Hospital Financial Data 1 Q and 2 Q 2014

Seniors Growth in SJV Seniors 3 X Hospital Days

ACA and Things to Fix… PAYMENT REFORM • Medi-Cal Rates are TOO Low to Attract Doctors Rates • Recruiting Physicians to SJ Valley – CA Law Prevents Hiring Doctors • Funding to Modernize Hospitals to Meet Seismic • Affordable Health Care Plans for Agriculture Workers • Care Model Programs to Address SJV Health Issues, i. e. , Asthma • Influence Medi-Cal 2015 Waiver DSRIP to Address Uniqueness of SJV • Care Models to Focus on Population Health • Interconnect Clinics, Hospitals and Providers with IT • Hospital Provider FEE (QAF) – Make Permanent CA/CHA/CMS

DSRIP – SJV Mostly Missed Out, BUT… • 2010 WAIVER $3. 4 B – Public Hospitals Benefitted Only • New Medical 1115 Waiver Coming in 2015 • Opportunity to Support the Private Safety Net Hospitals • CSAC Representation on CA Dept Health Care Services

Thank you… Sources and Additional Info • Beds for Boomers – California Health Care Foundation http: //www. chcf. org/~/media/MEDIA%20 LIBRARY%20 Files/PDF/S/PD F%20 Snapshot. Beds. Boomers. pdf • State of CA –Office of Statewide Health Planning and Development (OSHPD) http: //www. oshpd. ca. gov/HID/Data. Flow/Hosp. Main. html • DSRIP, California 2015 1115 Medi-Cal Waiver • Transforming for Tomorrow-California Hospital Association July 2012 • California and Its Counties Under the ACA: A Leadership Framework http: //www. chcf. org/~/media/MEDIA%20 LIBRARY%20 Files/PDF/C/PD F%20 CACounties. Under. ACA. pdf