Westchester Medical Center Operating Budget

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1 Westchester Medical Center 2012 Operating Budget December 7, 2011

2 WESTCHESTER COUNTY HEALTH CARE CORPORATION Overview Westchester Medical Center s (WMC) 2012 Operating Budget reflects significant reductions in expenses, including a reduction in force, to address the significant growth in the shortfall between revenues and expenses, particularly non-controllable fringe benefit costs. This Budget projects a consolidated break-even bottom line despite the economic challenges the entire healthcare industry faces. WMC s 2012 revenues have been reduced in excess of $90 million as a result of governmental reimbursement reductions over the last four years. To date, the Medical Center has mitigated this growing disparity between revenues and expenses through the introduction of expense efficiencies, cost containment, and increased negotiated reimbursement rates with managed care companies. Despite these economic challenges, WMC has continued to advance its investments in various quality initiatives. The 2012 operating budget provides for the recruitment of additional medical staff faculty, utilization of independent expert quality resources, clinical educational learning sessions and continuing alignment of clinical services. With respect to medical staff faculty, three physician executives have been recruited, in particular, to oversee clinical outcomes and identify areas for systemic quality improvements. Likewise, the 2012 capital budget provides for further investment in advanced medical equipment, infrastructure improvements and information technology, particularly technology that will establish a comprehensive electronic medical record. Economic Stabilization Plan (ESP) As regulated state and federal healthcare revenues continue to decline, along with significant increases in fringe benefit costs, aggressive cost saving measures must be identified and enacted. Currently the average salary and fringe benefits is $155,000 per FTE represented by NYSNA and $98,000 per FTE represented by CSEA. As staffing reductions are identified, every effort has been taken to assure that direct patient care positions have not been compromised. In fact, nearly all of the increased nurse staffing that was added subsequent to 2005 has been retained. Staff reductions amounting to approximately 310 FTE s valued at $30 million will be substantially implemented prior to December 31, These reductions will include 114 FTE s represented by NYSNA; 179 FTE s represented by CSEA; and 17 FTE s from the Non- Represented labor force. Additionally, the ESP has targeted $13 million of fringe benefit restructuring savings and a to be identified target of $18 million of additional expense reduction. 1

3 2012 also presents specific challenges to WMC as a result of the following increases in expense: New York State Pension Expense The pension expense is increasing to $49.5 million for 2012, representing a 23% increase over the 2011 pension expense of $40.2 million. The 2012 pension expense is 18.6% of projected salaries as compared to comparable New York area medical centers where pension expense is approximately 7.0% of payroll. This difference in pension expense for Westchester Medical Center employees amounts to an increase of $27.5 million over comparable medical centers. Furthermore, this expense is expected to continue to increase to $62 million for 2013 and nearly $70 million for Since 2006, the pension expense has increased from $18.1 million to present projections with substantially limited reimbursement from Medicare, Medicaid and other regulated payors. Health Benefit Expense Health benefit expenses are projected at $77.7 million for 2012, representing an increase of $6.1 million over the 2011 expense of $71.6 or 8.6%. Included in the health benefit expense is $20.4 million of health benefits for retired employees. This amounts to approximately $4,000 per retired employee. While this is not a universal benefit in the healthcare industry, those few institutions that do offer the benefit have an average cost of $950 per employee. A substantial portion of these expenses are not reimbursed by the regulated payors. Interest Expense $2.6 Million Increase The financing that will be completed in December 2011 will increase net interest cost by approximately $1.5 million. This will provide long term financing for a number of projects that support future revenue growth and restructuring of existing debt. Lease financing and deferred pension interest expense, account for the other components of this increase. Depreciation Expense - $5.4 Million Increase Depreciation expense increased as a result of facility improvements and capital asset acquisitions. Significant financial trends from 2006 through Budgeted 2012 are set forth below: Budgeted Projected Audited Audited Audited Audited Audited Income $ 74 $ 4,205 $ 6,416 $ 7,601 $ 7,299 $ 76,208 $ 62,093 Net Deficit (6,240) (6,314) (10,519) (16,935) (24,536) (34,728) (116,905) Cash 159, , , , , , ,134 Days cash on hand

4 Revenue Projections Revenue projections use 2011 as a base for patient volume, payor mix and case mix acuity adjusted for more normalized levels of patient volume, changes in contractual arrangements with payors, the additional 9 bed pediatric unit and volume increases related to investments in physician services. Medicaid revenue has been projected, factoring in Medicaid reductions implemented by N.Y.S to date, with additional reductions anticipated during Medicare revenue is projected based upon actual rate changes implemented on October, 1, 2011 with reductions based upon expected federal cuts. Expense Projections 2012 Expenses for 2012 have been projected based on the current staffing complement with savings initiatives as part of an Economic Stabilization Plan which includes a reduction in force. Contractually obligated salary increases have been included in budgeted amounts. Increases in the New York State pension fund expense, healthcare and other fringe benefit expenses have been budgeted based on actuarial and other analyses, recent trends and information provided by New York State. The budgeted 2012 expense level has risen over 2011 due to additional pension expense of $9.2 in New York State Pension Plan and health benefit costs of $6.1 million. Additionally, interest expense is budgeted to increase by $2.6 million as a result of the new bond and lease financings. Related depreciation expense increase of $5.4 million reflects facility improvements and equipment acquisitions during Offsetting these increased costs is the impact of the Economic Stabilization Plan (ESP) which includes a reduction in force and related fringe benefits. Detailed Discussion of Revenue Hospital Net Patient Service revenue is budgeted to decrease 4.0% from $771.5 million to $740.8 million. This decrease includes known and anticipated reductions in governmental reimbursement rates including Medicare and Medicaid offset by higher negotiated commercial managed care rates. Case Mix System Medicare: WMC s case mix continues to be very high. The 2011 projected Medicare case mix of 2.24 is equal to the 2010 level. The 2012 budgeted Medicare case mix is also expected to remain constant with minimal changes to the Medicare weights as issued by CMS. Non-Medicare: This case mix will again have a bifurcated system during In 2009, almost all payers were under the NYS All Payor (AP-DRG) system. On December 1, 2009, NYS moved to a nationally recognized Maryland system (APR-DRG s) that analyzes up to 30 diagnoses and procedure codes for every inpatient encounter. The system transitioned from the AP-DRG System with 682 3

5 Diagnostic Related Groups (DRG s) to 314 DRG s that are further divided into four sub-classes of severity [minor(1) to extreme(4)]. The APR-DRG system permits analyses of potentially preventable readmissions and complications and is utilized as a source for quality reviews and initiative programs. WMC s 2011 case mix for Medicaid fee-for service, Medicaid managed care and linked payers as described above decreased from 1.81 to 1.74 during 2011 as originally projected. Though there was a marked drop in the case mix, the base reimbursement rates were scaled sufficiently higher which results in budget neutrality on a state-wide basis and resulted in budget neutral WMC payments. The 2012 Medicaid case mix based upon the new APR-DRG system is being updated to incorporate more current hospital cost and statistical data which we expect to remain relatively constant and should not impact WMC. The Commercial payers will all continue under the current AP-DRG system until WMC renegotiates the individual current contracts and agreement is reached on rescaled inpatient rates. The commercial payer case mix reimbursement under AP- DRG s is None of the commercial payors are operationally prepared to convert to the new NYS APR-DRG system. Details of all revenue changes for the Medical Center are identified below: Inpatient Revenue Projected to decrease by 8.6%. Medicare acute inpatient revenue is expected to decrease by.6% or $.9 million primarily due to anticipated reductions in federal Medicare spending. The Medicare weights (case mix) are projected to remain constant at WMC will continue as an inpatient rehabilitation excluded unit for governmental reimbursement purposes, meeting the 2012 thresholds (60%) related to the type of clinical patients cared for in the WMC Rehabilitation Unit between September 1, 2010 and August 31, WMC recently received notification from CMS that it will continue to qualify for the Medicare exclusion in By meeting these thresholds, WMC will retain approximately $4.0 million included in the inpatient revenue stream. Medicaid acute inpatient revenue is projected to decrease 2.0% or $2.8 million (including the anticipated 2012 Medicaid cuts). The full year impact of 2011 Medicaid cuts implemented retroactive to 1/1/2011 and additional cuts on 4/1/2011 relating to a 2.0% across the board FMAP reductions to all Medicaid FFS revenue; and a reduction to all Medicaid and related payors inpatient rates for unnecessary re-admissions have all been reflected in the 2012 rates. In addition, there will not be any trend factor increases for 2012 in addition to taking away the % trend factor originally approved for both 2011 that also affects All other NYS regulated payers, including Workers Compensation, No-fault and Corrections inpatient revenue are projected to decrease by.1% or $0.2 million. 4

6 Outpatient Revenue Projected to increase by 5.9% or $6.2 million based upon: Medicare rates are projected to decrease 1.0% or $.2 million in Medicaid rates are projected to decrease by 2.0% based upon across the board Medicaid reductions as discussed above. Commercial managed care rates are projected to increase by 10.7% or $6.7 million based upon WMC s negotiated rate agreements. NYS and Other Net Patient Revenue Based upon current NYS projections for their 2012 & 2013 NYS budgets under Governor Cuomo, NYS has indicated further NYS budget deficits will require future cuts to Medicaid reimbursement. WMC has incorporated a preliminary $3.3 million anticipated reduction into the budget built into the Medicaid rates and Pool payments. Inpatient Volumes are expected to return to more normalized levels seen during 2010 Changes resulting in projected increases of 994 discharges and $26.0 million, or 3.4% of increased revenue are detailed as follows: The new nine (9) bed Pediatric unit along with other more normalized pediatric levels will add approximately 480 incremental discharges or $9.2 million in revenue. The balance of the increases to patient volume reflect modest growth trends. Outpatient Volume net increase of $3.0 million WMC is expecting to return to more normalized 2010 levels in ambulatory surgery and outpatient services during Other Operating Revenue Other operating revenue consists of contributions from the two Foundations, grant revenue from county, state and federal sources and various other sources such as reimbursement for interns and residents who rotate to other hospitals, rental income and licensing fees. Budgeted grant revenue for 2012 reflects a reduction of approximately $2.0 million in CPEP (Psych emergency services) grants due to the reconfiguration of certain services in 2011 and an increase in revenue for ARRA (American Recovery and Reinvestment Act) funds related to certain milestone achievements in implementing electronic health records. 5

7 Detailed Discussion of Expense Overall, expenses are budgeted to increase by 5.2% or $46.2 million from 2011 projected levels of $886.5 million before implementation of an Economic Stabilization Plan which reduces budgeted expenses by $61.0 million. After the ESP, expense will decrease from 2011 levels by $14.8 million or 1.7%. The overall expense changes include non-controllable cost increases of $17.0 million (Pension, Health Benefits, and Workers Compensation) and interest and depreciation expense of $8.0 million. The major components of change are detailed below: (000 s) 2011 Projected Operating Expenses $ 886, Increases: Non-Controllable Pension expense increase from 2011 level 9,888 Health Insurance Benefit costs 6,158 Workers Compensation 1,000 Other Labor Contractual (CSEA) and Step Rate Increases (NYSNA) 4,416 Interest 2,598 Depreciation expense 5,399 Other 16,707 Sub-Total Increases 46,166 Economic Stabilization Plan: Reduction in Force with related fringe benefits (30,000) Fringe benefit restructuring (13,000) Additional Savings to be identified (18,000) Total Economic Stabilization Plan (61,000) 2012 Budgeted Expenses: $871,672 6

8 Labor Costs Salaries, agency and per diem cost were projected to increase from $359.1 million in 2011 to $381.9 million in 2012 before implementation of the Economic Stabilization Plan. This primarily reflects contractual rate increases of $4.4 million for both CSEA and NYSNA and physician staffing costs offset by the impact of the 2012 reduction in force and other expense reduction initiatives included in the Economic Stabilization Plan. Fringe Benefit Costs Overall fringe benefit costs were budgeted to increase from $147.1 million in 2011 to $164.3 million in Major components of this increase include: - Pension cost Due primarily to market performance in 2008, and its resultant impact on the NYS pension plan, participating employers, including WMC, are being assessed 18.6% of payroll in 2012 rather than 15.8% assessed in The resulting increase in expense is approximately $9.2 million for New York State Pension Plan cost and $9.9 million in total pension expense. - Health benefit cost An increase in claims cost primarily due to healthcare cost inflation for employees and retirees, has increased this benefit cost from $71.6 million in 2011 to $77.7 million in 2012, an increase of 8.6%. Of this amount, $57.3 million is for current employees and $20.4 million is for retirees. - Workers Compensation Due to regulatory assessments and tariffs this cost has increased from $5.5 million in 2011 to $6.5 million in 2012, an 18.2% increase. The Economic Stabilization Plan includes a reduction to these projected costs by restructuring fringe benefits, including employee contributions, the impact of the Reduction in Force, as well as other expense reduction initiatives. Depreciation and Amortization Depreciation and amortization has been calculated to be $48.4 million in 2012, an increase of $5.4 million from the 2011 level of $43.0 million. This increase reflects recent and continuing investments in clinical equipment and construction related costs for renovation and new projects at WMC. Non-Salary Expense Changes Non-salary costs overall are expected to decrease by $1.8 million. Decreases reflect specific initiatives, including reductions in equipment maintenance costs, due to better contractual agreements, as well as, a continuation of the initiatives started in 2011 for vendor negotiated decreases in the cost of supplies. 7

9 Interest Expense Interest expense is budgeted to increase by $2.6 million. The bond financing, which will close in mid-december 2011, will increase interest cost by of $1.5 million net. Additional lease interest expense of $0.7 and interest on deferred pension payment amounts account for the other increases. CONSOLIDATED BALANCE SHEET COMMENTS The net deficit position has improved over the past seven years. The December 31, 2012 budgeted net deficit of $6.2 million represents an improvement of $175.7 million over the net deficit of $181.9 million at December 31, The projected balance sheet includes the impact of the planned bond financing which is expected to close in December This financing includes new money financing of approximately $64 million. This financing is projected to increase the cash balance by $14 million, assets restricted as to use for unused new financing proceeds of $45.1 million, deferred financing costs of $1.7 million and increased net debt obligations of $59.3 million. All of the above changes will be reflected in the December 31, 2011 balance sheet adjusted for debt service and use of funds during 2012 to arrive at the December 31, 2012 balance sheet amounts. Cash and Cash Equivalents Cash balances at December 31, 2012 are expected to approximate $159.6 million as compared to $165.0 million projected at December 31, The projected December 31, 2011 cash balance incorporates the payment of all operating expenses and required payments including debt service, tax payments, malpractice and pension payments. Patient Accounts Receivable, net Projected balances at December 31, 2012 reflects 61.1 days revenue in accounts receivable. Assets Restricted as to Use Projected decrease of $21.9 million at December 31, 2012 primarily as a result of the use of construction related funds. Capital Assets, net Projected balance at December 31, 2012 includes capital additions including assets financed with new bond proceeds offset by depreciation expense. Accounts Payable and Accrued Expenses Projected balance at December 31, 2012 reflects 81.6 days expense in accounts payable. 8

10 WESTCHESTER MEDICAL CENTER STATEMENT OF OPERATIONS 2012 OPERATING BUDGET (IN THOUSANDS) All Entities Combined Increase Budget Projected (Decrease) OPERATING REVENUES: Total net patient service revenues $779,279 $797,390 (18,111) Medicaid Disproportionate Share Revenue.. 64,000 70,000 (6,000) Other operating revenue ,130 20,067 4,063 Interest Income 4,337 3,254 1,083 0 Total Revenues , ,711 (18,965) OPERATING EXPENSES: Salary & Labor 381, ,117 22,828 Fringe Benefits Partial 7% of salaries 23,155 21,446 1,709 Health Benefits 57,319 51,261 6,058 All Other 35,830 34,692 1,138 Sub-total Fringe Benefits.. 116, ,399 8,905 Supplies and other expenses. 289, ,759 (1,128) Malpractice insurance 23,966 24,681 (715) Depreciation and amortization 48,385 42,986 5,399 Interest... 24,495 21,897 2,598 Total Expenses 884, ,839 37,887 Net Income/(Loss) before Excess Fringe Benefit Costs and ESP (12,980) 43,872 (56,852) Economic Stabilization Plan (ESP): Reduction in Force 30,000 Fringe Benefit Restructuring 13,000 Additional Savings -to be identified 18,000 Total Economic Stabilization Plan 61,000 Net Income/(Loss) before Excess Fringe Benefit Costs 48,020 43,872 Excess Pension Cost (16% of Payroll vs 7% industry-13.5% in 2011) (27,546) (19,367) (8,179) Excess-Post Retirement Health Benefit (20,400) (20,300) (100) Net Income.... $74 $4,205 9

11 WESTCHESTER MEDICAL CENTER Economic Stabilization Plan 2012 OPERATING BUDGET (IN THOUSANDS) Net(Loss) before Economic Stabilization Plan ($60,926) Economic Stabilization Plan: Reduction In Force FTE's Salaries Fringe Benefits Total NYSNA ,300 3,700 14,000 CSEA ,200 2,800 13,000 Non-Rep , ,000 Total ,000 Fringe Benefit Restructuring: NYSNA 6,000 CSEA 6,000 Other 1,000 Total 13,000 Additional Savings -to be identified 18,000 (Average staff reductions-10 FTE's per million) Total Economic Stabilization Plan 61,000 Net Income $74 10

12 WESTCHESTER MEDICAL CENTER Issues 2012 OPERATING BUDGET 1- Current Regulated Reimbursement Rates (government programs and linked payors), based on 2005 cost, fail to address a substantial portion of cost increases since Excess Fringe Benefit Costs which are unique to WMC Excess Pension Cost (16% of Payroll vs 7% industry) $27,546,000 Excess-Retiree Health Benefit $20,400,000 $47,946, Nursing Salaries continue to increase in the absence of a contract due to costs from experience step-increases of approximately $1.8 million or 1.1% 4- Failure of Medicaid to reimburse its fair share of NYS Pension Plan cost 5- Estimated Pension Expense for 2013 is $62.2 million, an increase of 54.7% over the current 2011 expense of $40.2 million 11

13 Westchester Medical Center Statement of Cash Flows Budget Year Ended December 31, 2012 (in thousands) Budgeted Net Income $74 Add Back Non-cash Expenses: Depreciation $48,385 Retiree Health ($20.4 vs. $9.3 mill ) $11,100 Deferral of Pension ($49.5 vs. $31.6 mill) $17,900 Cash Provided by Operations $77,459 Cash Used for Capital: Additions to Plant, Property & Equipment ($30,000) Principal Payments on LTD-Bonds ($9,200) Principal Payments Lease Financing ($8,700) Net Cash Used for Capital ($47,900) Cash (Used) for Balance Sheet Changes: Increase in DSH Receivable ($6,000) Anticipated Reduction in Liabilities and ($29,000) Other Balance Sheet Changes,net Net Cash Used for Balance Sheet Changes ($35,000) Net Change in Cash ($5,441) Cash, Beginning of Year $165,000 Cash, End of Year $159,559 12

14 Westchester Medical Center Balance Sheets 2012 Operating Budget (in thousands) Budget Projected December 31, December 31, Assets Cash $159,559 $165,000 Patient accounts receivable 119, ,045 Other current assets 51,089 54,842 Total current assets 330, ,887 Property, plant and equipment 324, ,768 Other non-current assets 184, ,648 Non-current assets 508, ,416 Total assets $839,091 $855,303 Liabilities and Net Deficit Accounts payable $64,535 $74,979 Accrued salaries 89,161 77,986 Other current liabilities 68,166 68,456 Total Current liabilities 221, ,421 Long-term debt 432, ,430 Insurance liability 93,455 96,924 Other non-current liabilities 97,623 98,842 Total non-current liabilities 623, ,196 Net deficit (6,240) (6,314) Total liabilities and net deficit $839,091 $855,303 13

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