Westchester Medical Center. 2014 Operating Budget

Westchester Medical Center 2014 Operating Budget December 4, 2013

WESTCHESTER COUNTY HEALTH CARE CORPORATION Operating Budget 2014 Table of Contents Page Executive Summary 1 Detailed Discussion of Revenue 3 Detailed Discussion of Expense 7 Comments on Consolidated Statements of Net Position 9 Consolidated Statements of Operations 10 Consolidated Statement of Cash Flows 12 Consolidated Statements of Net Position 13

1 WESTCHESTER COUNTY HEALTH CARE CORPORATION EXECUTIVE SUMMARY Overview General economic conditions, implementation of the Affordable Care Act (ACA) and regulatory changes continue to impact the health care industry. These industry-wide circumstances are further compounded by specific Westchester Medical Center (WMC) fringe benefit expenses including the NYS pension and post-retirement health insurance aggregating $59 million of expense for 2014. The NYS Pension alone amounts to 20.3% of employee salaries, far in excess of comparable health industry averages that approximate 7% of payroll. WMC s fringe benefit expenses amount to 49.4% of employee salaries, also substantially in excess of comparable industry averages. Despite these challenges, the 2014 WMC Strategic Operating Plan forecasts a bottom line profit of $2 million. These projected results will represent the ninth consecutive year of profitable bottom line performance. 2013 was the first year since 2009 that WMC experienced increased patient volumes. This solid and sustained increase throughout 2013 resulted from the focused investment in patient care areas such as cardiology, neurosciences, pediatrics and oncology. The 2013 growth in patient volume is particularly notable during a year where many hospitals have experienced a decrease in patient volume. The 2014 Strategic Operating Plan continues to build on the 2013 experiences reflecting growth resulting from the continued investment in neurosciences, pediatrics, orthopedics, transplant and the clinical decision unit (CDU). Overall patient volumes have been discussed with clinical leadership, and overall expenses have been forecasted based on anticipated utilization and inflation factors. Economic Health Care Environment Over the past few years much emphasis has been placed on quality initiatives, patient outcomes and improvement in population health. These areas of emphasis will continue as the baby boomers age-out and retire and use more health care services. Besides the direct reductions in hospital reimbursement, hospital revenue has been reduced as a result of challenges to the need for services resulting in denials of reimbursement and challenges to the need for admission. In 2013, observation evaluations have been an emphasis in an attempt to limit reimbursement for questionable admissions. CMS has enacted a Two Midnight policy in an attempt to more objectively define the requirements of inpatient admissions. As a result, WMC is currently constructing a CDU adjacent to the existing emergency department in an attempt to cohort and better monitor and evaluate observation patients to determine, if in fact, inpatient care is necessary. The CDU will be fully operational in 2014. 1

New York State Pension Expense The pension expense for WMC is increasing to $43.9 million for 2014, representing 20.3% 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 13.3% of payroll over comparable medical centers or $27.4 million. Health Benefit Expense Health benefit expenses are projected at $61.1 million for 2014 which includes a 7% increase in cost due to recent medical expense trends. Included in the health benefit expense is $15.0 million of health benefits for retired employees. Patient Volumes Inpatient discharges increased in 2013, due to expansion of services and new investments by the Medical Center over the past few years, despite increased emphasis by Federal and State programs to deny or reduce hospital stays. Volumes experienced in 2013 have been the basis for projected 2014 volumes with incremental volume projected for specific new projects or programs. In 2014, WMC will operationalize the CDU to better treat and monitor observation patients as well as gain the efficiency of a dedicated unit. Economic Stabilization Plan (ESP) As experienced over the last several years an ESP has been included in the 2014 Budget. This ESP is necessary to provide sufficient time to finalize strategies that will identify expense savings and revenue opportunities. SIGNIFICANT FINANCIAL TRENDS Significant financial trends from 2006 through Budgeted 2014 are set forth below: Bottom Net Days Cash Line* Deficit Cash On Hand 2006 Audited $62,093 $ (116,905) $ 100,134 60.2 2007 Audited 76,208 ( 34,728) 138,754 73.2 2008 Audited 7,299 ( 24,536) 116,571 56.0 2009 Audited 7,601 ( 16,935) 163,293 79.0 2010 Audited 6,416 ( 24,795)** 167,795 78.9 2011 Audited 4,952 ( 21,590)** 201,144 89.7 2012 Audited 226 ( 20,692) 190,852 84.1 2013 Projected 1,153 ( 19,539) 190,823 81.6 2014 Budgeted 1,976 ( 17,563) 189,338 77.8 *Before GASB 65 impact **Adjusted for implementation of GASB 65-write off of deferred financing costs. 2 2

Revenue Budget - 2014 Revenue projections use 2013 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 based upon actual rate changes implemented effective October 1, 2013. 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 & unless reversed in the next federal budget process will also occur and has not been budgeted. Expense Budget 2014 Expenses for 2014 have been projected based on the current staffing complement, a restructured work force. Contractually obligated salary increases have been included in budgeted amounts. NYS 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. DETAILED DISCUSSION OF REVENUE Hospital Net Patient Service revenue is budgeted to increase 1.9% from $807.5 million to $823.0 million. This net increase includes higher negotiated commercial managed care rates offset by known reductions in governmental reimbursement rates including Medicare and reinstatement of in-network status with various commercial payors. Medicaid Disproportionate Share is expected to decrease from $55.0 Million to $52.5 million based upon the statutorily required percentage reductions in the ACA. 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 in addition to the ACA reductions as noted above. Case Mix System Medicare: WMC s case mix continues to be very high. The 2013 projected Medicare case mix of 2.38 is.07 greater than the 2012 level. The 2014 budgeted Medicare case mix is expected to increase by.12 to 2.50 due to the Two Midnight rule which will reduce Medicare census by about 400 low case mix discharges. Non-Medicare: This case mix will again have a bifurcated system during 2014. In 2009, almost all payers were under the NYS All Payor (AP-DRG) system. 33

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 2013 case mix for Medicaid fee-for service, Medicaid managed care and linked payers as described above decreased from 1.82 to 1.72 during 2013 reflecting lower severity of patients admitted to WMC. 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 2.98 in 2013 compared with 2.95 in 2012. None of the commercial payors are operationally prepared to convert to the new NYS APR-DRG system or the Medicare system at this time. Details of all revenue changes for the Medical Center are identified below: Inpatient Revenue Projected to increase by 0.4%. Medicare acute inpatient revenue is expected to decrease by 1.1% or $1.5 million primarily due to the new Two Midnight rule (3.1% reduction); continuation of recently implemented Medicare 30 day re-admission measures that penalizes hospitals for excessive re-admits that will continue to effect WMC by 0.8% in 2013 and the Value Based Purchasing (VBP) offset of approximately 0.45%. These reductions will be substantially mitigated by a 1.5% trend factor increase and a new methodology for uncompensated care. The new 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 will be statutorily reduced by approximately 18%. The Medicare weights (case mix) are projected to increase by.12 to 2.50 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. As noted above, the 30 day re-admission offset is 0.8% in 2014. The VBP program commonly referred to as Pay for Performance (P4P), was originally incorporated in the Affordable Care Act of 2010. 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 4 4

established at 1% in 2013 and increases by.25% per year thereafter until reaching a 2.0% maximum in 2017. By 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 2014 thresholds (60%) related to the type of clinical patients cared for in the WMC Rehabilitation Unit between September 1, 2012 and August 31, 2013. WMC recently received notification from CMS that it will continue to qualify for the Medicare exclusion in 2014. By meeting these thresholds, WMC will retain approximately $7.0 million included in the inpatient revenue stream. Medicaid acute inpatient revenue is projected to increase 1% with no additional anticipated 2014 Medicaid cuts though there will not be any trend factor increases for 2014 consistent with prior years except for some minor capital add-on s. 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 2014 rates. All other NYS regulated payers, including Workers Compensation, No-fault and Corrections inpatient revenue are projected to increase by approximately 1%. Outpatient Revenue Projected to increase by 7.4% or $8.7 million based upon: Medicare rates are projected to increase 11.6% or $1.9 million in 2014 primarily due to the newly implemented Two Midnight rule which converts previously recognized and reimbursed inpatient procedures to outpatient. Medicaid rates are projected to remain constant with no additional Medicaid reductions. Commercial managed care rates are projected to increase by 8.0% or $6.8 million based upon WMC s negotiated rate agreements. NYS and Other Net Patient Revenue Based upon current NYS projections for their 2014 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. Inpatient Volumes are expected to increase selectively based upon specific initiatives. Changes resulting in projected increases of 232 discharges and $5.0 million, or 0.6% of increased revenue are detailed as follows: The increases to patient volume reflect modest growth trends in transplant, neurosurgery, pediatrics and orthopedics. 5 5

The reductions of 400 Medicare discharges due to the Two Midnight rule are not reflected in the volume changes since they will be converted to outpatient services and included in the Medicare rate changes above. Outpatient Volume No net increase 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 is budgeted to decrease $2.7 million primarily as a result of ARRA funding for electronic health record decreasing from $2.5 million in 2013 to $0.6 million in 2014, and HEAL Grant funding in 2013 of $1.5 million for Sound Shore due diligence, not recurring. 6 6

DETAILED DISCUSSION OF EXPENSE Overall, expenses before the Economic Stabilization Plan (ESP) are budgeted to increase by 4.1% or $38.1 million from 2013 projected levels of $922.9 million. The major components of change are detailed below: (000 s) 2013 Projected Operating Expenses $ 922,929 2014 Increases: Non-Controllable Fringe Benefits 7,467 Revenue Related + New Operations New and full year impact of expanded clinical services and related support costs 13,480 Labor Cost Additional Neuro Surgical ICU beds 1,257 New Clinical Decision (Observation) Unit 3,430 Labs 1,202 Other Depreciation 3,044 Labor Contractual Increases (NYSNA and CSEA) 1,457 Other, net 6,757 2014 Budgeted Expenses before Economic Stabilization Plan $ 961,023 Labor Costs Labor costs are budgeted to increase primarily due to additional clinical staffing and related support costs and contractual increases. 7 7

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 20.3% of payroll in 2014. The resulting expense is approximately $43.9 million for New York State Pension Plan cost. - Health benefit cost An increase in claims cost primarily due to healthcare cost inflation of 7% for employees and retirees, has resulted in this benefit cost increasing to $61.1 million in 2014. Depreciation and Amortization Depreciation and amortization has been calculated to be $48.1 million in 2014, an increase of $3.1 million from the 2013 level of $45.0 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 increase by $13.7 million primarily in Technical Services for restructuring of previous salaried employees. Decreases in medical supplies expense reflect better contractual agreements, as well as, a continuation of the initiatives started in 2013 for vendor negotiated decreases in the cost of supplies. Interest Expense Interest expense is budgeted to be $24.1 million in 2014, an increase of $200,000 from the 2013 expense of $23.9 million. Interest on long term debt, capital leases and deferred pension amounts are the significant components of this expense. 8 8

COMMENTS ON CONSOLIDATED STATEMENTS OF NET POSITION The net position has significantly improved over the past nine years. The December 31, 2014 budgeted net position of ($17.6) million represents an improvement of $164.3 million over the net position of ($181.9) million at December 31, 2005. Cash and Cash Equivalents Cash at December 31, 2014 is expected to approximate $189.3 million as compared to $190.8 million projected at December 31, 2013. 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 77.8 days cash on hand. Patient Accounts Receivable, net Projected balances at December 31, 2014 reflects 48.8 days revenue in accounts receivable. Capital Assets, net Projected balance at December 31, 2014 includes capital additions including assets financed with bond proceeds offset by depreciation expense. Accounts Payable and Accrued Expenses Projected balance at December 31, 2014 reflects 66.5 days expense in accounts payable. 9 9

WESTCHESTER MEDICAL CENTER 2014 OPERATING BUDGET CONSOLIDATED STATEMENTS OF OPERATIONS (IN THOUSANDS) 2014 2013 Increase Budget Projected (Decrease) OPERATING REVENUES: Total net patient service revenues $ 872,601 $ 843,986 $ 28,615 Medicaid Disproportionate Share Revenue.... 52,500 55,170 (2,670) Other operating revenue....... 19,903 22,639 (2,736) Interest Income 2,995 2,287 708 Total Revenues...... 947,999 924,082 23,917 OPERATING EXPENSES: Salary & Labor. 353,184 340,835 12,349 Fringe Benefits Partial Pension @ 7% of salaries. 18,315 17,074 1,241 Health Benefits 46,114 41,505 4,609 All Other 34,197 32,271 1,926 Sub-total Fringe Benefits... 98,626 90,850 7,776 Supplies and other expenses. 377,478 365,913 11,565 Malpractice insurance. 17,220 15,070 2,150 Depreciation and amortization 48,069 45,015 3,054 Interest... 24,077 23,868 209 Total Expenses.. 918,654 881,551 37,103 Net Income before Excess Fringe Benefit Costs and ESP.. 29,345 42,531 (13,186) Economic Stabilization Plan (ESP): Operational Improvements. 15,000 Total Economic Stabilization Plan 15,000 Net Income before Excess Fringe Benefit Costs.. 44,345 42,531 Excess Pension Cost (20.3% of payroll vs. 7% industry).. (27,369) (26,278) Excess-Post Retirement Health Benefit.. (15,000) (15,100) Net Income..... $ 1,976 $ 1,153-10 - 10

WESTCHESTER MEDICAL CENTER 2014 OPERATING BUDGET ISSUES 1- Regulated Reimbursement Rates (government programs and linked payors), are projected to change from a 2005 to a 2010 base year calculation. However, all rate changes are expected to be budget neutral on a statewide basis. 2- Excess Fringe Benefit Costs which are unique to WMC Excess Pension Cost (20.3% of Payroll vs. 7% industry) $27,369,000 Excess-Retiree Health Benefit $15,000,000 $42,369,000 3- Failure of Medicaid to reimburse its fair share of NYS Pension Plan cost. - 11-11

WESTCHESTER MEDICAL CENTER 2014 OPERATING BUDGET CONSOLIDATED STATEMENT OF CASH FLOWS (IN THOUSANDS) Budgeted Net Income $ 1,976 Add Back Non-cash Expenses: Depreciation and Amortization 48,069 Retiree Health ($15.0 vs. $13.6 million ) 1,400 Deferral of Pension ($43.9 vs. $33.0 million) 10,900 Cash Provided by Operations 62,345 Cash Used for Capital: Additions to Plant, Property & Equipment - Operations (20,000) Principal Payments on LTD - Bonds (9,915) Principal Payments Lease Financing (7,915) Net Cash Used for Capital (37,830) Cash Used for Balance Sheet Changes: Anticipated Reduction in Liabilities and Other Balance Sheet Changes (26,000) Net Cash Used for Balance Sheet Changes (26,000) Net Change in Cash (1,485) Cash, Beginning of Year 190,823 Cash, End of Year $ 189,338 12

WESTCHESTER MEDICAL CENTER 2014 OPERATING BUDGET CONSOLIDATED STATEMENTS OF NET POSITION (IN THOUSANDS) Budget Projected December 31, December 31, 2014 2013 Assets Cash $189,338 $190,823 Patient accounts receivable 123,734 121,078 Other current assets 55,710 51,935 Total current assets 368,782 363,836 Property, plant and equipment 323,178 303,184 Other non-current assets 148,723 176,697 Non-current assets 471,901 479,881 Total assets 840,683 843,717 Liabilities Accounts payable $68,790 $66,512 Accrued salaries 64,090 68,946 Other current liabilities 67,669 65,118 Total current liabilities 200,549 200,576 Long-term debt 421,908 428,884 Insurance liability 103,318 105,302 Other non-current liabilities 132,471 128,494 Total non-current liabilities 657,697 662,680 Net Position ($17,563) ($19,539) - 13-13