Hallazgos & Recomendaciones
16 hallazgos
F1:
A Summary of the Access to Medical Care Reports: Sutter, Dominican and Watsonville hospitals had to submit yearly reports to be in compliance with the Access to Medical Care Agreement. A summary of these reports follows in this section. The Grand Jury found most of the computational errors to be minor in the reports. However, some of these errors resulted in a deficit rather than an excess.8 The corrected figures were used in the charts. A more detailed listing of the financial data is in the Appendix. Sutter Hospital Sutter Hospital 1996 to 2002 Performance Summary Total Agreed Upon Uncompensated Care 1996 - 2002 $5,052,356 Actual Expenditures to Meet Agreement 1996 - 2002 $3,701,931 Percentage Attained 1996 - 2002 73.27% Fiscal Year 2002 2001 2S000u#t#t#er H1o99s8pi1t9a97l 1996 2002 to 1996 Gross $39,850,799 ##### ##### ### ######### ###### #### ########## Net $13,966,391 ##### ##### ### $9,017,921 ###### #### $73,811,050 Agreed $977,647 ##### ##### ### $631,254 ###### #### $5,052,356 $1,000,000 Actual $54,208 ##### ##### ### $75,031 ###### #### $45A4g,8r5e1ed Upon A$c8tu0al0 ,000 $842,506 ##### ##### ### $478,579 ###### $0 $3,27 U 5 n ,3 c 4 o 3 mpensated Care (7% Uncompens $0 $0 $0 $0 $49,460 ###### (Note 1) $0 Except 1996 @ 5.5%) Actual $896,714 ##### ##### ### $603,070 ###### #### $4,317,609 $600,000 Cost to 45.96% ##### ##### ### 53.57% 69.00% #### N/A C$o4st0 o0f ,000 $412,130 ##### ##### ### $323,065 ###### #### $2,29A4c,7t5u0al Expenditures to Contribution $469,528 ##### ##### ### (Note 2) (Note (Note $1,40M7,e1e8t1 Agreement (Cost of A$c2tu0al0 ,000 $881,658 ##### ##### ### $323,065 ###### #### $3,70P1r,o93vi1ding Care + Commitmen ($95,990) ##### ##### ### ($308,190) ###### #### ($1,35C0,o42n5tr)ibutions) $0 02 01 00 99 98 97 96 8 See the Appendix. - 8 Hospitals and Charity Care Sutter Hospital Yearly Performance 2002 through 1999 Fiscal Year (Ending Dec 31) 2002 2001 2000 1999 Gross Revenue $39,850,799 $31,564,372 $31,818,412 $30,779,800 Net Operating Expense $13,966,391 $12,070,278 $11,451,133 $10,255,111 Agreed Upon Uncompensated Care (7% Except 1996 @ 5.5%) $977,647 $844,919 $801,579 $717,858 Actual Uncompensated Charity $54,208 $66,996 $122,582 $75,195 Actual Uncompensated Bad Debt $842,506 $998,947 $240,585 $308,146 Uncompensated Care Write-Off (No Clarification) $0 $0 $0 $0 Actual Uncompensated Total (Bad Debt + Charity+ Other Uncompensated) $896,714 $1,065,943 $363,167 $383,341 Cost to Charges Ratio 45.96% 49.29% 46.17% 44.12% Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $412,130 $525,403 $167,674 $169,130 Contributions to Exempt Organizations and Community $469,528 $415,600 $358,754 $163,299 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $881,658 $941,003 $526,428 $332,429 Commitment Excess (Deficit) ($95,990) $96,084 ($275,151) ($385,429) Sutter Hospital Yearly Performance 1998 through 1996 & Total Fiscal Year (Ending Dec 31) 1998 1997 1996 2002 to 1996 Totals Gross Revenue $22,705,186 $18,005,934 $11,165,252 $185,889,755 Net Operating Expense $9,017,921 $9,422,345 $7,627,871 $73,811,050 Agreed Upon Uncompensated Care (7% Except 1996 @ 5.5%) $631,254 $659,564 $419,533 $5,052,356 Actual Uncompensated Charity $75,031 $38,314 $22,525 $454,851 Actual Uncompensated Bad Debt $478,579 $406,580 $0 $3,275,343 Uncompensated Care Write-Off (No Clarification) $49,460 $537,955 (Note 1) $0 $587,415 Actual Uncompensated Total (Bad Debt + Charity+ Other Uncompensated) $603,070 $982,849 $22,525 $4,317,609 Cost to Charges Ratio 53.57% 69.00% 85.16% N/A Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $323,065 $678,166 $19,182 $2,294,750 Contributions to Exempt Organizations and Community (Note 2) $0 (Note 2) $0 (Note 2) $0 $1,407,181 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $323,065 $678,166 $19,182 $3,701,931 Commitment Excess (Deficit) ($308,190) $18,602 ($400,351) -$1,350,425 Note 1 - This was reported as $475,211 but "uncompensated care" is not allowed under the 5.5% alternative. Note 2 - This was reported as $631,704 in 1996, $613,507 in 1997, and $544,738 in 1998 but "Unpaid Costs of Government Programs" are not allowed. Hospitals and Charity Care - 9 Dominican Hospital Dominican Hospital 1996 to 2002 Performance Summary Total Agreed Upon Uncompensated Care 1996 - 2002 $24,179,454 Actual Expenditures to Meet Agreement 1996 - 2002 $29,408,253 Percentage Attained 1996 - 2002 121.62% Fisc 2002 ## ## ## 1998 1997 1996 2002 to Dominican Hospital Gros $456,841,306 ## ## ## $250,938,722 ####### ######### ####### Net $64,239,883 ## ## ## $42,522,518 ####### ######### ####### Agre $4,496,792 ## ## ## $2,976,576 ####### $2,900,600 ####### $d8,000,000 Actu $4,804,515 ## ## ## $1,891,319 ####### $1,631,459 ###A#g##re#ed Upon Actu $9,268,252 ## ## ## $2,804,999 ####### $4,539,076 ###U##n#c#ompensated Care $6,000,000 Actu $14,072,767 ## ## ## $4,696,318 ####### $6,170,535 ###(#7#%##) Cost 29.62% ## ## ## 42.22% 43.88% 43.80% N/A $Co4s,t0 00,000 $4,168,354 ## ## ## $1,982,785 ####### $2,702,694 ####### Cont $2,055,000 ## ## ## $1,006,000 ####### $1,539,000 ###A#c##tu#al Expenditures to $Ac2tu,000,000 $6,223,354 ## ## ## $2,988,785 ####### $4,241,694 ###M##e#e#t Agreement (Cost Com $1,726,562 ## ## ## $12,209 ####### $696,977 ###o#f# P##roviding Care + $0 Contributions) 02 01 00 99 98 97 96 - 10 Hospitals and Charity Care Dominican Hospital Yearly Performance 2002 through 1999 Fiscal Year (Ending June 30) 2002 2001 2000 1999 Gross Revenue $456,841,306 $330,472,517 $289,437,497 $272,662,515 Net Operating Expense $64,239,883 $46,725,331 $55,309,811 $51,081,651 Agreed Upon Uncompensated Care (7%) $4,496,792 $3,270,773 $3,871,687 $3,575,716 Actual Uncompensated Charity $4,804,515 $2,523,092 $2,611,204 $2,374,819 Actual Uncompensated Bad Debt $9,268,252 $7,212,450 $4,327,984 $3,739,328 Actual Uncompensated Total (Bad Debt + Charity) $14,072,767 $9,735,542 $6,939,188 $6,114,147 Cost to Charges Ratio 29.62% 36.46% 40.41% 40.44% Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $4,168,354 $3,549,579 $2,804,126 $2,472,561 Contributions to Exempt Organizations and Community $2,055,000 $415,600 $1,641,000 $1,357,000 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $6,223,354 $3,965,179 $4,445,126 $3,829,561 Commitment Excess (Deficit) $1,726,562 $694,405 $573,439 $253,845 Dominican Hospital Yearly Performance 1998 through 1996 & Total Fiscal Year (Ending June 30) 2002 to 1996 1998 1997 1996 Totals Gross Revenue $250,938,722 $244,016,884 $235,816,649 $2,080,186,090 Net Operating Expense $42,522,518 $44,104,443 $41,437,136 $345,420,773 Agreed Upon Uncompensated Care (7%) $2,976,576 $3,087,311 $2,900,600 $24,179,454 Actual Uncompensated Charity $1,891,319 $3,046,679 $1,631,459 $18,883,087 Actual Uncompensated Bad Debt $2,804,999 $2,955,040 $4,539,076 $34,847,129 Actual Uncompensated Total (Bad Debt + Charity) $4,696,318 $6,001,719 $6,170,535 $53,730,216 Cost to Charges Ratio 42.22% 43.88% 43.80% N/A Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $1,982,785 $2,633,554 $2,702,694 $20,313,653 Contributions to Exempt Organizations and Community $1,006,000 $1,081,000 $1,539,000 $9,094,600 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $2,988,785 $3,714,554 $4,241,694 $29,408,253 Commitment Excess (Deficit) $12,209 $627,243 $696,977 $4,584,681 Hospitals and Charity Care - 11 Watsonville Hospital Watsonville Hospital 1996 to 2002 Performance Summary Total Agreed Upon Uncompensated Care 1996 - 2002 $7,089,917 Actual Expenditures to Meet Agreement 1996 - 2002 $7,527,237 Percentage Attained 1996 - 2002 106.17% Watsonville Community Hospital 2002 to 1996 Fiscal 2002 2001 2000 1999 1998 1997 ### Totals Year $2,50G0r,o0s0s0 $0 ##### ##### ####### $0 ####### ### $802,797,026 Net $0 ##### ##### ####### $0 ####### ### $101,284,522 Agreed Upon $2,00A0g,0re0e0 $0 ##### ##### ####### $0 ####### ### $7,089,917 Actual $0 ##### ##### $653,169 $0 $753,698 ### $5,3U6n9c,9o7m7pensated Care Actual $0 ##### ##### ####### $0 ####### ### $14,6(747%,1)49 $1,500,000 Actual $0 ##### ##### ####### $0 ####### ### $20,017,126 $1,00 C 0 o ,0 st 0 0 0.00% ##### ##### 41.16% 0.00% 49.83% ### Actual Expenditures to Cost $0 ##### ##### ####### $0 ####### ### $7,5M27e,e2t3 7Agreement (Cost of $50C0o,0nt0ri0 $0 $0 $0 $0 $0 $0 $0 Providing Care + Actual $0 ##### ##### ####### $0 ####### ### $7,5C2o7n,2t3ri7butions) Com$0 $0 ##### ##### ####### $0 ####### ### $437,321 02 01 00 99 98 97 96 - 12 Hospitals and Charity Care Watsonville Hospital Yearly Performance 2002 through 1999 Fiscal Year (Ending Dec 31) 2002 2001 2000 1999 Gross Revenue $0 $254,350,140 $195,929,361 $141,120,162 Net Operating Expense $0 $25,488,782 $21,596,081 $20,361,845 Agreed Upon Uncompensated Care (7%) $0 $1,784,215 $1,511,726 $1,425,329 Actual Uncompensated Charity $0 $1,634,719 $1,057,600 $653,169 Actual Uncompensated Bad Debt $0 $4,967,008 $3,519,779 $3,165,288 Actual Uncompensated Total (Bad Debt + Charity) $0 $6,601,727 $4,577,379 $3,818,457 Cost to Charges Ratio 0.00% 29.27% 33.26% 41.16% Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $0 $1,932,325 $1,522,436 $1,571,677 Contributions to Exempt Organizations and Community $0 $0 $0 $0 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $0 $1,932,325 $1,522,436 $1,571,677 Commitment Excess (Deficit) $0 $148,111 $10,711 $146,348 Watsonville Hospital Yearly Performance 1998 through 1996 & Total Fiscal Year (Ending Dec 31) 1998 1997 1996 2002 to 1996 Totals Gross Revenue $0 $108,060,744 $103,336,619 $802,797,026 Net Operating Expense $0 $17,046,592 $16,791,222 $101,284,522 Agreed Upon Uncompensated Care (7%) $0 $1,193,261 $1,175,386 $7,089,917 Actual Uncompensated Charity $0 $753,698 $1,270,791 $5,369,977 Actual Uncompensated Bad Debt $0 $2,016,985 $978,089 $14,647,149 Actual Uncompensated Total (Bad Debt + Charity) $0 $2,770,683 $2,248,880 $20,017,126 Cost to Charges Ratio 0.00% 49.83% 49.81% N/A Cost of Providing Care (Cost Ratio X Actual Uncompensated Total) $0 $1,380,631 $1,120,167 $7,527,237 Contributions to Exempt Organizations and Community $0 $0 $0 $0 Actual Expenditures to Meet Agreement (Cost of Providing Care + Contributions) $0 $1,380,631 $1,120,167 $7,527,237 Commitment Excess (Deficit) $0 $187,370 ($55,218) $437,321 Hospitals and Charity Care - 13 Response: Santa County Board of Supervisors PARTIALLY AGREES. The charts presented by the Grand Jury have been moved to Attachment A of this response. Many of the “computational errors” the Grand Jury noted were essentially rounding errors. Depending on the number of decimal places used in recalculating the charity care reports, the end results will vary. The Grand Jury used two decimal places to recalculate reports while the hospitals used five decimal places (or more) when they prepared the reports. When multiplying numbers in the millions of dollars by percentages, rounding differences can total several hundred dollars or more. The Grand Jury’s charts apparently do not include Sutter contributions for uncompensated care in 1997 and 1998 or the unpaid costs of government programs for applicable years (the difference between the actual cost of providing care and the reimbursement from MediCal, Medicare, and Medicruz). These costs were approved and certified by the independent auditors overseeing hospital reports on compliance and accepted by the prior Health Director through 2000. Watsonville Hospital’s initial report in 1996 failed to place brackets around the final computation indicating that the hospital was in surplus rather than deficit. The auditor’s letter accompanying the reports attested to the accuracy of the computations. HSA should have required the hospital to correct the error. Because these agreements were unique, some of the categories of expenditures assisting the uninsured provided by the hospitals were not addressed in the original agreement or forms. These types of expenditures were put in various categories or new lines were added to the reports. HSA has worked with and will continue to work with the hospitals on these issues for possible revision in updated agreements. - 14 Hospitals and Charity Care
F2:
Uncompensated Care Incurred by the Hospitals in Santa Cruz County Total Uncompensated Countywide Hospital Bad Debt Dollars 2002 - 1996 Domin$ic3an,27W5a,t3so4n3ville Sutter Actual $18,883,087 $5,369,977 $454,851 Actual $34,847,129 $14,647,149 $3,275,343 $14,647,149 Dominican Watsonville Sutter $34,847,129 Total Uncompensated Countywide Hospital Charity Dollars 2002 - 1996 $454,851 $5,369,977 Dominican Watsonville Sutter $18,883,087 Response: Santa Cruz County Board of Supervisors PARTIALLY DISAGREES. The Grand Jury reports above are a summary of their revised reports deducting uncompensated care and unpaid costs of government programs and with their slightly different calculation basis. The most serious error in the Grand Jury charts, however, is the implication that all the hospitals are the same and should Hospitals and Charity Care - 15 have equal contributions when in fact they are very different in numbers of beds and gross budgets. In addition, the Grand Jury’s charts include the following errors: • The charts above do not adjust for the fact that Watsonville had submitted only 5 years of data instead of 7. This a significant issue when displaying a chart that says 1996-2002. Adjustments for relative size are critical to fairly compare contributions, and the Grand Jury’s chart misrepresents the relative contribution of each institution. • The Grand Jury’s charts did not include the uncompensated care and unpaid government program costs from Sutter 1996-2000 and thus do not reflect the independent auditors’ reports certified and submitted to the County. • Cost to chart ratios are significant in determining actual costs, and all direct services, billed or not, should have cost to chart ratios applied to them. Cost to chart ratios do not appear to have been considered in the charts or calculations of the Grand Jury. The following chart presents the cost to charge ratios of the three hospitals. The higher the percentage, the closer the charges are to actual costs of service delivery. Cost to Charge Ratios - Santa Cruz County 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 1996 1997 1998 1999 2000 2001 2002 DHSC SMSC WCH - 16 Hospitals and Charity Care • To accurately reflect the relative contribution of each hospital, it is necessary to take into account their different sizes and budgets, which the Grand Jury did not do. • Watsonville reports have not been audited since the new administration purchased the hospital. • The Grand Jury charts do not include the independent auditors certified expenditures for Sutter as discussed above, but do include Dominican’s certified expenditures including categories called “other contributions to the poor and broader community”. In summary, there are significant problems with the summary charts of the Grand Jury which are continued in findings 3 and 4. Below are the certified expenditures for the hospitals as submitted by the independent auditors. Final Auditor Community Certified Hospital FY END Method Required Provided Benefit Ex/(Def) DSCH 6/95 CC&BD $2,425,772 $3,122,749 N/A $696.977 6/96 CC&BD $2,900,600 $2,702,896 $1,539,000 $1,341,296 6/97 CC&BD $3,087,311 $2,633,802 $1,081,000 $627,491 6/98 CC&BD $2,976,576 $1,982,899 $1,133,000 $139,323 6/99 CC&BD $3,575,716 $2,472,713 $1,357,000 $253,997 6/00 CC&BD $3,871,687 $2,803,860 $1,641,000 $573,173 6/01 CC&BD $3,270,773 $3,549,867 N/A $279,904 6/02 CC&BD $4,496,792 $4,168,392 $2,055,000 $1,726,600 SMSC* 12/96 CC $419,534 $1,051,328 N/A $631,704 12/97 CC&BD $659,564 $1,291,673 N/A $632,109 12/98 CC&BD $631,254 $867,803 N/A $236,548 12/99 CC&BD $717,858 $169,148 $740,856 $192,246 12/00 CC&BD $801,579 $167,660 $661,700 $27,780 12/01 CC&BD $844,919 $525,385 $415,600 $96,066 12/02 CC&BD $977,647 $412,132 $469,528 ($95,987)** WCH 6/95 CC&BD $1,070,287 $1,347,785 N/A $277,498 6/96 CC&BD $1,175,386 $1,120,101 N/A See 6/97 6/97 CC&BD $1,193,261 $1,380,548 2 YR. AVG. $132,002 6/98*** N/A 12/99 CC&BD $1,425,329 $1,571,609 N/A $146,280 12/00 CC&BD $1,511,726 $1,522,620 N/A $10,894 12/01 CC&BD $1,784,215 $1,932,221 N/A $148,006 12/02 CC&BD $1,888,754 $1,942,092 N/A $53,338 CC&BD = Charity care and bad debt option selected *The methodology and interpretations used by Sutter Maternity and Surgery Center (SMSC) in the preparation of their reports submitted through December 2000 was Hospitals and Charity Care - 17 questioned in 2001. The methodology was settled and the outcome approved by the Board of Supervisors on October 18, 2001. **SMSC brought forward the 12/01 excess contribution to the 12/02 period to offset the remaining deficit after community benefit activities were credited. ***Watsonville Community Hospital changed ownership in September 1998. The new ownership changed the hospital’s fiscal year to end on December 31. Under the hospital’s new contract with the county, the charity care reporting obligation began with the fiscal year ending 12/99. Because of the change in ownership, no report was available for the fiscal year ending June 1998. The preceding table summarizes the reports submitted by the three local contract hospitals since the inception of their obligations to provide specified levels of care, bad debt, and community benefit activities. All hospitals have reported being in compliance with their obligations although both Dominican Hospital and Sutter Maternity and Surgery have had to rely on community benefits activities as well as charity care and bad debt. As can be seen from the above data, with the exception of Dominican Hospital in the 6/01 reporting period, the hospitals have demonstrated increasing inability to meet their obligations through the provision of charity care and bad debt alone. In fact, satisfying the obligation by using the option to provide 5.5% of net operating costs in charity care has never been effectively used by any of the hospitals.