Westchester Medical Center Operating Budget

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1 Westchester Medical Center 2015 Operating Budget December 3, 2014

2 WESTCHESTER COUNTY HEALTH CARE CORPORATION Operating Budget 2015 Table of Contents Page Executive Summary 1 Detailed Discussion of Revenue 4 Detailed Discussion of Expense 9 Comments on Consolidated Statements of Net Position 11 Consolidated Statements of Operations 12 Consolidated Statement of Cash Flows 13 Consolidated Statements of Net Position 14

3 WESTCHESTER COUNTY HEALTH CARE CORPORATION EXECUTIVE SUMMARY Overview The healthcare industry continues to face many operational and financial changes. Merger and acquisition activity has increased with many community hospitals becoming aligned with major medical centers while the implications of the Affordable Care Act (ACA) continue to unfold. During 2014, Westchester Medical Center (WMC) acquired the MidHudson Regional Hospital (MHRH), formerly the St. Francis Hospital and Health Centers. Continued employment of physicians has increased substantially, particularly as a result of the employment of the hospital based anesthesiologists. Additionally, WMC continues to expand its relationships with multispecialty physician groups. Concurrent with these changes, WMC has assumed a very significant leadership role in New York State, with the implementation of the Delivery System Reform Incentive Payment Program (DSRIP) throughout the Hudson Valley. While these factors continue to influence operations and strategic direction, WMC projects to conclude 2014 with a positive bottom line and forecasts a 2015 budgeted bottom line profit of $4 million, making 2015 the tenth consecutive year of profitability for WMC. Growth in discrete patient volumes, expansion of services at MHRH, controlled spending and strong reimbursement rates have all contributed to the continued fiscal stability of WMC. Westchester Medical Center Today With the acquisition of the MidHudson Regional Hospital in 2014, Westchester Medical Center s capacity to serve residents in its catchment area was increased and currently is as follows: Valhalla MidHudson Campus Campus Total Licensed Beds Budgeted Discharges 25,311 7,260 32,571 Budgeted Patient Days 194,178 42, ,313 Budgeted Operating Revenue $1.0 billion $.2 billion $1.2 billion -1-

4 Budgeted Revenues and Expenses The 2015 Strategic Operating Plan continues to build on investments in neurosciences, cardiology, orthopedics and transplant services. Overall patient volumes have been discussed with clinical leadership, and overall expenses have been forecasted based on anticipated utilization and inflation factors. New York State Pension Expense The pension expense for employees on the Valhalla campus who participate in the NYS pension plan is budgeted at $41.0 million for 2015, representing 18.8% of employee salaries. This assessment exceeds pension cost of comparable New York area medical centers where pension expense is approximately 7.0% of payroll. This excess pension expense for the Medical Center employees amounts to 11.8% of payroll over comparable medical centers or $25.6 million. Health Benefit Expense Health benefit expenses for employees on the Valhalla campus are budgeted at $65.3 million for This budget expense is based on recent medical expense trends. Included in the health benefit expense is $15.5 million of health benefits for retired employees. Patient Volumes Volumes experienced in 2014 are the basis for projected 2015 volumes with incremental volume projected for specific new projects, services or programs. Economic Stabilization Plan (ESP) As experienced over the last several years an ESP has been included in the 2015 Budget. This ESP is necessary to provide sufficient time to finalize strategies that will identify expense savings and revenue opportunities. Delivery System Reform Incentive Program (DSRIP) In April 2014, New York State Department of Health (DOH) and the Centers for Medicare and Medicaid (CMS) entered into an agreement for NYS to reduce projected Medicaid spending by $17 billion over 5 years and the federal government has agreed to reinvest $8 billion of these projected revenues into transforming the Medicaid program in NYS. $6.2 billion is allocated to the DSRIP program. Funding is only available to networks of provider organizations in a geographic area that are contractually bound to implement the DSRIP projects. These networks are called Performing Provider Systems (PPSs). WMC, as the Region s public hospital, has taken the lead in establishing a PPS for seven counties in the Hudson Valley as well as Delaware County. The WMC PPS has over 200 provider organizations in 400 plus locations from across the care continuum in its DSRIP network. In anticipation of WMC s leadership role in DSRIP, the Center for Regional Healthcare Innovation (CRHI) was established in September 2014 to organize and manage WMC s DSRIP response. CRHI has established itself as a best practice for emerging PPS entities in NYS and WMC expects to receive a substantial amount of funding under the DSRIP program beginning in April

5 SIGNIFICANT FINANCIAL TRENDS Significant financial trends from 2006 through Budgeted 2015 are set forth below: Bottom Net Days Cash Line Deficit Cash On Hand 2006 Audited $62,093 $ (116,905) $ 100, Audited 76,208 ( 34,728) 138, Audited 7,299 ( 24,536) 116, Audited 7,601 ( 16,935) 163, Audited 6,416 ( 24,795)** 167, Audited 3,206 ( 21,590)** 201, Audited 898 ( 20,692) 190, Audited 6,270 ( 14,422) 204, Projected* 4,008 ( 10,414) 189, Budgeted* 4,165 ( 6,249) 180, *Includes MidHudson Regional Hospital **Adjusted for implementation of GASB 65-write off of deferred financing costs. Revenue Budget 2015 Valhalla Campus Revenue projections use 2014 as a base for patient volume, payor mix and case mix acuity adjusted for selective changes to patient volume, and changes in contractual agreements with payors. Medicaid revenue has been projected to be flat, factoring in Medicaid reductions implemented by NYS to date. Medicare revenue is projected to increase by.9% based upon actual rate changes implemented effective October 1, The 2% Medicare sequestration adjustment that was effective 4/1/2013 remains in effect. In addition, there is a continuing Medicare physician rate reduction of 26.5% that only gets reprieved on an annual basis and unless reversed in the next federal budget process will also occur and has not been budgeted. MidHudson Regional Hospital MHRH began operation on May 9, Revenue projections utilized approximately eight (8) months 2014 base year data for patient volume, payor mix and case mix acuity adjusted for selective changes to patient volume, and changes in contractual agreements with payors. Medicaid revenue has been projected to be flat utilizing the Valhalla division s higher operating rate which includes a higher wage index, and the teaching component of the rate. These higher Medicaid rates will be effective for three (3) years beginning July 1, Medicare revenue is projected to increase by.9% based upon actual rate changes implemented effective October 1,

6 DETAILED DISCUSSION OF REVENUE Valhalla Campus Hospital Net Patient Service revenue is budgeted to increase 4.4% from $843.9 million to $881.5 million. This net increase includes higher negotiated commercial managed care rates offset by reinstatement of in-network status with various commercial payors. Medicare rates are slightly higher by.9% based upon the successful appeal of our wage index, trend factor increases offset by federally mandated reductions in uncompensated care reimbursement. Medicaid Disproportionate Share is expected to decrease from $57.5 Million to $54.0 million based upon reduced losses in the Medicaid and self-pay areas. Medicaid Disproportionate Share in total, when combined with MHRH ($3.5 million), remains unchanged. The calculation is still based upon actual hospital specific Medicaid and primary care self-pay losses subject to state budget plans and approval by CMS. The ACA reductions are currently expected to take effect in The original ACA reductions were postponed from beginning in The Advanced Physicians Services (APS) revenue is expected to increase from $42.7 million to $54.0 million primarily due to the startup of anesthesia services during Case Mix Medicare: WMC s case mix continues to be very high. The 2014 projected Medicare case mix of 2.47 is.06 greater than the 2013 level predominantly due to the Two Midnight rule which will reduce the Medicare census by approximately 400 low case mix discharges. The 2015 case mix is expected to remain the same as in 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 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 2014 case mix for Medicaid fee-for service, Medicaid managed care and linked payers as described above increased from 1.76 to 1.77 during 2014 reflecting slightly higher severity of patients admitted to WMC. The majority of Commercial payers will continue under the current AP-DRG system until WMC renegotiates the individual current contracts and agreement is reached on re-scaled inpatient rates. The commercial payer case mix reimbursement under AP- DRG s including Blue Cross is projected to be 2.65 in 2014 compared with budgeted 2.71 in Some of the commercial payors converted to the new NYS APR-DRG system or the Medicare system during

7 Details of all revenue changes for the Valhalla division are identified below: Inpatient Revenue Projected to increase by 3.5%. Medicare acute inpatient revenue is expected to increase by.9% or $1.5 million primarily due to the recently approved Medicare wage index reclassification appeal and a small trend factor increase offset by federally mandated reductions in uncompensated care reimbursement. The new uncompensated care methodology allocates 75% of the funds based upon a prospectively calculated fixed dollar amount among all hospitals in the country allocated based upon the number of Medicaid days and substantially reduces the old Disproportionate share methodology to 25% that is retrospective and has no ceiling. Effective 10/1/2014, the uncompensated care funds have been statutorily reduced by approximately 11%. The Medicare weights (case mix) are projected to remain the same at 2.47 as discussed above. The Medicare 30 day re-admission measurement penalizes hospitals for excessive readmits that will continue to affect WMC by 0.5% in 2015 and the Value Based Purchasing (VBP) penalty offset of approximately.5%. These reductions substantially remain the same in The re-admission penalty applies to excessive post-acute Medicare re-admissions related to Acute Myocardial Infarctions, Pneumonia and Heart Failure diagnoses re-admitted to any acute care hospital within 30 days. The maximum penalty is phased in to increase to 3% in 2015 and beyond. As noted above, the 30 day re-admission offset is 0.5% in The VBP program commonly referred to as Pay for Performance (P4P), was originally incorporated in the Affordable Care Act of This program is budget neutral for the Medicare program. Hospitals can receive an incentive from 0 2.6% (estimate) taken from hospitals that fall below the required parameters. The maximum rate reduction is established at 1% in 2013 and increases by.25% per year thereafter until reaching a 2.0% maximum in In 2015, the maximum penalty is 1.5%. In 2015, the two domains of VBP as discussed above will be expanded to four to include Outcomes and Efficiency in addition to Clinical Processes of Care and Patient Experience of Care. WMC will continue as an inpatient rehabilitation excluded unit for governmental reimbursement purposes, meeting the 2015 thresholds (60%) related to the type of clinical patients cared for in the WMC Rehabilitation Unit between September 1, 2013 and August 31, WMC recently received notification from CMS based upon a single evaluation incorporating the MHRH campus that it will continue to qualify for the Medicare exclusion in By meeting these thresholds, WMC Valhalla will retain approximately $7.0 million included in the inpatient revenue stream. Medicaid acute inpatient revenue is projected to remain flat with no additional anticipated 2015 Medicaid cuts though there will not be any trend factor increases for

8 consistent with prior years. The Medicaid cuts implemented retroactive to 1/1/2011 and additional cuts on 4/1/2011 relating to a 2.0% across the board FMAP reduction to all Medicaid FFS revenue; and a reduction to all Medicaid and related payors inpatient rates for unnecessary re-admissions continue to be reflected in the 2015 rates. Though NYS authorized the elimination of the 2.0% FMAP reduction, it is still pending subject to Federal/CMS approval as are all Medicaid rate changes. All other NYS regulated payers, including Workers Compensation and No-fault inpatient revenue are projected to increase by approximately 2.0%. Outpatient Revenue Projected to increase by 3.9% or $4.4 million based upon: Medicare rates are projected to increase 2.0% or $.3 million in 2015 primarily due to the trend factor increases. Medicaid rates are projected to remain constant with no additional Medicaid reductions. Commercial managed care rates including veterans are projected to increase by 5.0% or $4.0 million based upon WMC s negotiated rate agreements. NYS and Other Net Patient Revenue Based upon current NYS projections for their 2015 NYS budgets under Governor Cuomo, NYS has remained under the Medicaid spending cap though there is no certainty that future cuts to Medicaid reimbursement will not be proposed. Mid-Hudson Regional Hospital Hospital Net Patient Service revenue is budgeted to increase 84.2% from $83.3 million to $153.5 million or $70.2 million primarily due to the full year effect of this acquisition on May 9, 2014 which accounted for $45,166 of the increase. The remaining increases include higher negotiated commercial managed care rates offset by reinstatement of in-network status with various commercial payors. Medicare rates are slightly higher due to trend factor increases. Medicaid Disproportionate Share revenue is expected to be $3.5 million for this campus. The calculation is still based upon actual hospital specific Medicaid and primary care self-pay losses subject to state budget plans and approval by CMS. The ACA reductions are currently expected to take effect in The original ACA reductions were postponed from beginning in The Regional Physician Services (RPS) revenue is expected to be $3.3 million due to new services including radiology. -6-

9 Case Mix Medicare: MHRH s case mix is The 2015 case mix is expected to remain the same as in 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 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. MHRH s 2014 case mix for Medicaid fee-for service, Medicaid managed care and linked payers as described above is 1.56 and is expected to remain the same in The majority of commercial payers will all continue under the current AP-DRG system until WMC renegotiates the individual current contracts and agreement is reached on re-scaled inpatient rates. The commercial payer case mix reimbursement under AP-DRG s including Blue Cross is projected to be 2.40 in Some of the commercial payors converted to the new NYS APR-DRG system or the Medicare system during Details of all revenue changes for the MHRH division are identified below: Inpatient Revenue Projected to increase by 72.2% or $41.6 million. The full year inpatient effect of the acquisition effective May 9, 2014 is 53.3% or $30.7 million. Medicare acute inpatient revenue is expected to increase by $.5 million primarily due to a small trend factor increase. The Medicare weights (case mix) are projected to remain the same at 1.68 as discussed above. The re-admission penalty applies to excessive post-acute Medicare re-admissions related to Acute Myocardial Infarctions, Pneumonia and Heart Failure diagnoses re-admitted to any acute care hospital within 30 days. The maximum penalty is phased in to increase to 3% in 2015 and beyond. The 30 day re-admission offset is 0.65% in 2014 and increasing to.8% in The VBP program commonly referred to as Pay for Performance (P4P), was originally incorporated in the Affordable Care Act of This program is budget neutral for the Medicare program. The maximum rate reduction is established at 1% in 2013 and increases by.25% per year thereafter until reaching a 2.0% maximum in MHRH was penalized at the same rate as the Valhalla Campus due to the single campus provider number resulting in a.5%. Without the single campus provider number, MHRH would have been penalized 1.5%. -7-

10 In 2015, the two domains of VBP as discussed above will be expanded to four to include Outcomes and Efficiency in addition to Clinical Processes of Care and Patient Experience of Care. MHRH will continue as an inpatient rehabilitation excluded unit for governmental reimbursement purposes, meeting the 2015 thresholds (60%) related to the type of clinical patients cared for in the Valhalla/MHRH Rehabilitation Units between September 1, 2013 and August 31, WMC recently received notification from CMS on a joint review with the Valhalla campus that it will continue to qualify for the Medicare exclusion in By meeting these thresholds, MHRH will retain approximately $4.1 million included in the inpatient revenue stream. Medicaid acute inpatient revenue is projected to increase $1.2 million based upon our appeal with no additional anticipated 2015 Medicaid cuts though there will not be any trend factor increases for 2015 consistent with prior years. The 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 continue to be reflected in the 2015 rates. All other NYS regulated payers, including Workers Compensation and No-fault inpatient revenue are projected to increase by approximately 2.0%. Outpatient Revenue Projected to increase by 88.7% or $21.2 million based upon: The full year outpatient effect of the acquisition effective May 9, 2014 is 60.7% or $14.5 million. Medicare rates are projected to remain flat due to increases of 2.0% trend factor offset by the same percentage for the certified home health agency. Medicaid rates are projected to remain constant with no additional Medicaid reductions. Commercial managed care rates including Veterans are projected to increase $7.7 million based upon MHRH s negotiated rate agreements. NYS and Other Net Patient Revenue Based upon current NYS projections for their 2015 NYS budgets under Governor Cuomo, NYS has remained under the Medicaid spending cap though there is no certainty that future cuts to Medicaid reimbursement will not be proposed. Licensed Home Health Agency Revenue (LHCSA) The LHCSA is a separate licensed service and is expected to have net patient service revenue of $2.1 million up from $1.2 million due to the full year effect of the service. -8-

11 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. Other operating revenue also includes revenue for the Early Education Center at the MidHudson Regional Hospital, IAAF funds, the first component of State Medicaid Waiver redesign funding, as well as DSRIP funding for PPS redesign projects and initiatives in DETAILED DISCUSSION OF EXPENSE Overall, expenses before the Economic Stabilization Plan (ESP) are budgeted to increase by 15.4% or $164.4 million from 2014 projected levels of $1,064.7 million. The major components of change are detailed below: (000 s) 2014 Projected Operating Expenses $ 1,064, Increases: Non-Controllable Full Year MHRH Operations (additional 128 days of operations) 60,989 Fringe Benefits Pension and Health benefits Valhalla campus 5,951 Revenue Related and New Operations New and full year impact of expanded clinical services and related support costs 38,537 IAAF and DSRIP funded expenses 18,567 New Beds and Expanded Services 7,629 Other Malpractice 8,886 Impact of Inflation Drugs and Medical Supplies 4,781 Depreciation 2,636 Other, net 16, Budgeted Expenses before Economic Stabilization Plan $ 1,229,125-9-

12 Labor Costs Labor costs are budgeted to increase primarily due to additional clinical staffing and related support costs and contractual increases. Fringe Benefit Costs Overall fringe benefit costs are budgeted as follows: - 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 18.8% of payroll in The resulting expense is approximately $41.0 million for New York State Pension Plan cost. - Health benefit cost An increase in claims cost primarily due to healthcare cost trends for employees and retirees, has resulted in this benefit cost increasing to $55.9 million in 2015 for employees in the self-insurance plan. Non-Salary Expense Changes Besides the full year impact of MHRH operations, non-salary costs are expected to increase as a result of malpractice expense which is budgeted to increase $8.9 million due to additional physicians being covered, IAAF/DSRIP related expense of $18.6 million and cost increases in both pharmacy of $2.7 million and medical/surgical supplies of $2.0 million. Depreciation and Amortization Depreciation and amortization has been calculated to be $57.2 million in 2015, an increase of $5.2 million from the 2014 level of $52.0 million. This increase reflects recent and continuing investments in clinical equipment and construction related costs for renovation and new projects at WMC as well as a full year depreciation for assets at the MHRH campus. Interest Expense Interest expense is budgeted to be $25.3 million in 2015 which approximates the 2014 expense. Interest on long term debt, capital leases and deferred pension amounts are the significant components of this expense. -10-

13 IAAF and DSRIP funded expenses As mentioned previously, NYS received a Medicaid waiver in 2014; which made available $8 billion statewide to generally redesign the healthcare delivery system of NYS in an attempt to reduce inpatient admissions by 25% over the next five years. Funds are being provided through NYS to develop PPS Performing Provider Systems through two initiatives: IAAF Interim Access Assurance Fund This is the first phase of NYS Healthcare redesign. Funds have been provided to WMC primarily for behavioral health, in 2014 and DSRIP Delivery System Reform Incentive Payment Projects - NYS has begun providing planning awards for project planning and community needs assessments. Further, PPS networks have been formed to achieve long term goals of the initiatives. COMMENTS ON CONSOLIDATED STATEMENTS OF NET POSITION The net position has significantly improved over the past ten years. The December 31, 2015 budgeted net position of ($6.2) million represents an improvement of $175.7 million over the net position of ($181.9) million at December 31, Cash and Cash Equivalents Cash at December 31, 2015 is expected to approximate $180.1 million as compared to $190.0 million projected at December 31, The projected December 31, 2014 cash balance incorporates the payment of all operating expenses and required payments including debt service, payroll tax payments, malpractice and pension payments and reflects 70.2 days cash on hand. Patient Accounts Receivable, net Projected balances at December 31, 2015 reflects 49.5 days revenue in accounts receivable. Capital Assets, net Projected balance at December 31, 2015 includes capital additions financed from operations and leases offset by depreciation expense. Accounts Payable and Accrued Expenses Projected balance at December 31, 2015 reflects 67.8 days expense in accounts payable. -11-

14 WESTCHESTER MEDICAL CENTER 2015 OPERATING BUDGET CONSOLIDATED STATEMENTS OF OPERATIONS (IN THOUSANDS) Increase Budget Projected (Decrease) OPERATING REVENUES: Total net patient service revenues $ 1,094,393 $ 971,106 $ 123,287 Medicaid Disproportionate Share Revenue.. 57,500 57,500 0 Other operating revenue ,808 34,328 24,480 Interest Income 3,989 5,779 (1,790) Total Revenues ,214,690 1,068, ,977 OPERATING EXPENSES: Salary & Labor 499, ,533 78,702 Fringe Benefits Partial 7% of salaries 15,417 16,103 (686) Health Benefits 57,027 45,009 12,018 All Other 53,664 39,699 13,965 Sub-total Fringe Benefits.. 126, ,811 25,297 Supplies and other expenses. 458, ,622 45,254 Malpractice insurance 21,366 12,480 8,886 Depreciation and amortization 57,183 51,976 5,207 Interest... 25,324 25,351 (27) Total Expenses 1,188,092 1,024, ,319 Income before Excess Fringe Benefit Costs and ESP 26,598 43,940 (17,342) Economic Stabilization Plan (ESP): Operational Improvements 18,600 Total Economic Stabilization Plan 18,600 Income before Excess Fringe Benefit Costs 45,198 43,940 Excess Pension Cost... (25,583) (24,850) Excess-Post Retirement Health Benefit (15,450) (15,082) Net Income.... $ 4,165 $ 4,008 12

15 WESTCHESTER MEDICAL CENTER 2015 OPERATING BUDGET CONSOLIDATED STATEMENT OF CASH FLOWS (IN THOUSANDS) Budgeted Net Income $ 4,165 Add Back Non-cash Expenses: Depreciation and Amortization 57,183 Retiree Health ($15.5 v. $12.6 million) 2,900 Deferral of Pension ($41.0 vs. $36.3 million) 4,700 Cash Provided by Operations 68,948 Cash Used for Capital: Additions to Property, Plant & Equipment - Operations (30,000) Principal Payments on Long-term Debt - Bonds (10,726) Principal Payments on Lease Financing (8,386) Repayment of Line of Credit (12,357) Net Cash Used for Capital (61,469) Cash Used for Balance Sheet Changes: Anticipated Reduction in Liabilities and Other Balance Sheet Changes (17,345) Net Cash Used for Balance Sheet Changes (17,345) Net Change in Cash (9,866) Cash, beginning of year 189,969 Cash, end of year $ 180,103 13

16 WESTCHESTER MEDICAL CENTER 2015 OPERATING BUDGET CONSOLIDATED STATEMENTS OF NET POSITION (IN THOUSANDS) Budget Projected December 31, December 31, Assets Cash $180,103 $189,969 Patient accounts receivable 156, ,149 Other current assets 59,391 59,336 Total current assets 395, ,454 Property, plant and equipment 386, ,271 Other non-current assets 145, ,954 Total assets 926, ,679 Liabilities Accounts payable $85,178 $85,194 Accrued salaries 75,473 80,854 Other current liabilities 63,328 78,638 Total current liabilities 223, ,686 Long-term debt 466, ,967 Insurance liability 98, ,027 Other non-current liabilities 144, ,413 Total liabilities 933, ,093 Net Position ($6,249) ($10,414) 14

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