Sw- 541
Given the information provided and any other information/data you can garner from your research, complete a reasonably thorough SWOT Analysis on Golden Health System
Homelessness:A Healthcare Imperative to Address the Housing Crisis
Golden Health System
Financial Addendum
Golden Health
1 of 2
Average Membership 547,918 123,559
Member Months 6,575,013 1,482,702
Net patient services revenue $ 449,531,089 $ 117,573,155
Nonpatient revenues $ 9,129,700 $ 675,191
Total operating revenue $ 458,660,789 $ 118,248,346
FY19 Statements of Revenues over Expenses
Mission Hospital Golden Hospital St. Francis Hospital St. Mary’s Hospital
Excess of revenues over expenses $ 85,368,547 $ 3,946,090
Operating EBIDA $ 168,455,614 $ 12,944,410
EBIDA margin (%) 5.57% 2.02%
Total Member Dues $ 2,833,930,326 $ 592,324,719
Other Revenue $ 187,953,141 $ 48,311,801
Total Operating Revenues $ 3,021,883,467 $ 640,636,520
Salaries and wages $ 134,160,210 $ 61,794,422
Employee benefits $ 49,639,278 $ 22,863,936
Medical professional fees $ 60,104,062 $ 2,036,388
Purchased services $ 46,854,074 $ 15,422,381
Supplies expense $ 120,697,444 $ 2,445,877
Utilities expense $ 5,501,536 $ 1,313,406
Insurance expense $ 3,660,118 $ 1,117,921
Rentals, leases and maintenance $ 8,301,352 $ 1,284,155
Depreciation and amortization $ 23,780,875 $ 3,402,780
Interest expense $ 9,336,964 $ 265,631
Other expenses $ 27,946,583 $ 8,128,757
Corporate Allocations $ 4,596,519 $ 1,325,499
Total operating expenses $ 494,579,015 $ 121,401,153
Salaries & Wages $ 327,415,529 $ 14,871,467
Employee Benefits $ 151,852,528 $ 6,970,838
Worker`s Compensation Expense $ 9,626,820 $ 72,320
Medical Service Costs $ 317,081,853 $ 175,912,064
IBNR Accrual $ 4,834,918 $ 1,624,925
Pharmacy Rx Costs $ 250,892,664 $ 51,466,592
Inventory Adjustment/Obsolescence $ 1,234,116 $ 211,209
Prof Fees & Outside Services $ 52,021,910 $ 6,930,499
Medical Supplies $ 77,469,111 $ 4,368,822
Supplies $ 16,567,451 $ 1,029,074
General and Administration Costs $ 26,212,638 $ 2,933,177
Insurance $ 790,005 $ 139,163
Depreciation and Amortization $ 83,087,067 $ 8,998,320
Medical Group Costs $ 1,617,428,310 $ 361,161,961
Total operating expenses $ 2,936,514,921 $ 636,690,430
Excess of revenues over expenses $ (35,918,226) $ (3,152,807)
Operating EBIDA $ (2,800,387) $ 515,605
EBIDA margin (%) -0.61% 0.44%
Homelessness: A Healthcare Imperative to Address the Housing Crisis
Golden Health System
Financial Addendum
Golden Health
2 of 2
FY19 Operating Statistics
Mission Hospital Golden Hospital St. Francis Hospital St. Mary’s Hospital
Total Discharges 28,323 10,934 Acute Admissions 20,780 7,490
Total Patient Days 109,037 44,784 Acute Inpatient Days 128,460 44,348
Average Length of Stay 3.8 4.1 Acute Average Length of Stay 6.2 5.9
Average Daily Census 339 65 Adjusted Admissions 31,642 16,346
Adjusted Discharges 43,128 23,862 Adjusted Patient Days 175,808 70,598
Adjusted Patient Days 239,625 103,062 Inpatient Surgeries 7,549 2,113
Overall Case Mix Index 2.1 1.5 OP Surgeries 8,593 4,958
OP Surgery Cases 11,712 7,238 IP ER Visits 12,641 5,845
Emergency Department Visits 59,624 29,865 OP ER Visits 31,104 14,613
Observation Visits 15,978 7,214 Outpatient non-emergency visits 93,438 45,747
Other OP Volumes 127,355 66,784 Total hospital case-mix index 2.6 2.1
Inpatient Emergency Visits 17,230 8,533 Total Medicare case-mix index 2.4 2.1
Outpatient Emergency Visits 42,395 21,332 Average Daily Census 249 44
1
Homelessness: A Healthcare Imperative to Address the Housing Crisis
Golden Health System
This case study was prepared by the National Association of Health Services Executives (NAHSE) for the 24th Annual Everett V. Fox Student Case Analysis and Presentation Competition. This is a fictitious case that was developed as the basis for discussion in the Case Competition rather than to illustrate either effective or ineffective handling of an administrative situation. This adaptation is being used for educational purposes only. NAHSE retains and reserves all rights.
INTRODUCTION
Homelessness and healthcare are intimately entwined. Poor health can be both a cause and a result of homelessness. For families struggling to pay rent, a serious illness or disability can start a downward spiral into homelessness, beginning with a lost job, depletion of savings to pay for care, and eventual eviction. Once in a state of homelessness, many do not receive adequate medical care for their illnesses and ailments. Furthermore, homelessness assistance and support systems are often fragmented and difficult to navigate. Therefore, when a crisis occurs, these individuals and families become clients of a fragmented and under-resourced response system. As a result, people experiencing homelessness are three to four times more likely to die than the general population and have an average life expectancy between 42 and 52 years (compared to 78 years in the general population).[endnoteRef:1] [1: National Coalition for the Homeless, “Health Care and Homelessness”, https://www.nationalhomeless.org/factsheets/health.html]
For people experiencing homelessness, barriers to adequate healthcare services include lack of knowledge about where to be treated, lack of access to transportation, and lack of identification. Psychological barriers also exist, such as embarrassment, nervousness about filling out forms and answering questions properly, and self-consciousness about appearance and hygiene. The most common obstacle to healthcare, however, is the cost. Many homeless people simply cannot pay, and as a result, utilize hospital emergency rooms (where a single visit costs $1,233 on average[endnoteRef:2]) as their primary source of healthcare. In addition, people experiencing homelessness are five times more likely than non-homeless individuals to be admitted to a hospital and stay, on average, four days longer at a cost of $2,000 to $4,000 per day[endnoteRef:3]. [2: Nolan Caldwell, et. al., NIH, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0055491] [3: Healthcare Dive, “Hospitals tackling homelessness to bring down costs”, https://www.healthcaredive.com/news/hospitals-tackling-homelessness-to-bring-down-costs/510631/]
Nationally, an estimated 552,830 people experienced homelessness in 2018
[endnoteRef:4]
. California, in particular, is responsible for a quarter of the nation’s homeless population. In the San Francisco Bay Area, which is widely known for progressive culture, venture capitalism, and innovation, 882 people per 100k are homeless. In fact, San Francisco ranks second among US cities with the highest rates of homelessness[endnoteRef:5] and according to a recent survey completed by the city, San Francisco’s homeless population is now at an estimated 9,784 individuals[endnoteRef:6]. With these high rates, several large employers have reported struggling to find workers who can afford to live near work. According to the San Francisco Foundation, “housing has become the Achilles’ heel of one of the strongest economies in the world”[endnoteRef:7]. [4: National Alliance to End Homelessness, “State of Homelessness”, https://endhomelessness.org/homelessness- in-america/homelessness-statistics/state-of-homelessness-report/] [5: ABC News, “Data shows San Francisco has second highest homeless population in United States”, https://abc7news.com/news/data-shows-sf-has-2nd-highest-homeless-population-in-us/1407123/] [6: Cite and County of San Francisco, “Homeless Population”, https://sfgov.org/scorecards/safety-net/homeless- population] [7: Deloitte, “Consumer and Patient Engagement in Health Care”, https://www2.deloitte.com/us/en/pages/life- sciences-and-health-care/articles/consumerism-in-health-care-and-patient-experience.html]
Recently, California has taken steps to combat this issue. In early 2019, the state of California enacted SB 1152, which aims to reform the way homeless patients are discharged from hospitals. The bill states that when discharging patients who may be experiencing homelessness, California hospitals are required to develop a written plan for coordinating services and referrals with the county behavioral health agency as well as healthcare and social service agencies in the region. Essentially, SB 1152 has placed more onus on the healthcare system to support the population experiencing homelessness.
Recent Trends in Healthcare Utilization:
In addition to complying with state and local policy efforts to support the population experiencing homelessness, leaders in the healthcare industry are also looking at recent trends and innovations that can empower these patients to manage their most critical needs. Over the past decade patients of all types have taken an increasingly active role in directly managing their own health. Examples of these consumer trends include self-diagnosis –Levering resources such as the internet to supplement or replace medical advice. Medical substitutes – exploring organic treatment due to fear of side effects from mainstream medications. User/patient Experience – Increased preference towards healthcare experiences with short wait times and live help for any questions they may have. These trends represent an increase in consumerism as an important factor for patients to access timely healthcare information and services. Leveraging these trends, an innovative and total person approach to promote health amongst the population experiencing homelessness could be the key to addressing this population’s most critical needs in the future.
CASE ASSIGNMENT
Golden Health is a San Francisco healthcare system that is committed to improving the health of the communities it serves and advocating for those who are poor and vulnerable. The healthcare system, which has seen growth in recent years, is looking to bolster its efforts to support the population experiencing homelessness in its communities. To achieve this goal, Golden Health is seeking support to design a comprehensive approach to provide high quality, innovative services to this population while also reducing the total cost of care. Given the healthcare system’s proximity to Silicon Valley, the Golden Health Board is especially interested in innovative models involving new and emerging technologies and information systems. The Golden Health Board has promised to commit $100 million over the next 3 years towards these initiatives.
Golden Health has sent out a request for proposals (RFP). Consulting firms responding to the RFP are charged with designing an effective strategy to address the needs of the population experiencing homelessness.
Specifically, proposals should seek to:
1. Implement a strategic plan to improve healthcare outcomes for the population experiencing homelessness in Golden Health’s identified service area
2. Leverage recent trends in consumerism as well as new and emerging technologies and information systems to empower this population to manage their critical needs
3. Evaluate government resources and social services partnerships to connect this population to the right services at the right time
4. Ensure Golden Health’s homelessness initiative is financially viable within the next 3 years
Strategies must include the following:
1. Gap analysis and rationale for priorities to be addressed by the strategy
2. A 3-year implementation plan and defined timeline
3. Key performance measures/indicators of success around cost, quality, and access
4. Financial impact (Pro forma/investment analysis)
ORGANIZATIONAL OVERVIEW
Golden Health is a managed care organization and healthcare provider system headquartered in San Francisco, CA. Golden Health was founded in 1964 with two hospitals, Mission Hospital and Golden Hospital, and 25,000 members. In 1980, Golden Health acquired a small primary care practice and in 1987, opened the Mission Ambulatory Care Center adjacent to Mission hospital. Most recently, in 2016, Golden Health acquired two acute care hospitals and two multispecialty ambulatory care centers, effectively doubling in size. Today, Golden Health is comprised of 3,000 employed and affiliated physicians, 14,000 employees, and over 600,000 members in its managed care program. Since its inception, Golden Health has been committed to providing care to the most vulnerable populations.
Mission: To improve the health of the communities we serve, providing high quality and innovative health service, and advocating for those who are poor and vulnerable
Vision: We will become the trusted leader in total health, collaborating with our communities to achieve optimal health and well-being
Values: Human Dignity, Compassion, Innovation, Service, Stewardship
In addition to its founding Vision, Golden Health has a long-held vision to become a statewide managed care consortium focused on value-based care and population health. While Golden Health’s legacy facilities operate in a managed care model, its newly acquired hospitals and outpatient centers still operate in a traditional fee-for-service (FFS) model. Due to delays in infrastructure updates and market fluctuations, the acquired facilities are expected to continue operating in the FFS model for the next 3-5 years before they are converted into Golden Health’s managed care model. One of Golden Health’s top priorities is reducing uncompensated care across the system prior to growing its managed care model. See below for additional information about Golden Health facilities: (* = legacy facility)
Hospitals:
· *Mission Hospital: Established in 1964, Mission Hospital features Golden Health Cardiovascular Institute and is nationally recognized for its chest pain center and comprehensive cancer center. Mission Ambulatory Care Center is also located near the main hospital campus.
· *Golden Hospital: Golden Hospital includes state-of-the-art emergency and trauma departments. Oracle Ambulatory Care Center is also located near the main hospital campus.
· St. Francis Hospital: St. Francis Hospital has medical/surgical units, psychiatric beds, and subacute care. Recently renovated in 2005, St. Francis has been nationally recognized for maternal and child health.
· St. Mary’s Hospital: Established in 1947, St. Mary’s Hospital has been serving the region for more than 50 years and continues the spirit of providing care to the most vulnerable populations.
Ambulatory Care Centers:
· *Mission Ambulatory Care Center (connected to Mission Hospital): Specialties include primary care, cardiology, women’s health, urology, endocrine, physical therapy, and behavioral health.
· *Oracle Ambulatory Care Center (connected to Golden Hospital): Home of the Golden Health Institute for Orthopedic and Sports Medicine. Specialties include orthopedics, physical therapy, pain management, and urgent care.
· Lone Mountain Ambulatory Care Center: Specialties include primary care, orthopedics, pain management, neurology, women’s health, physical therapy, and behavioral health.
· Pacific Heights Ambulatory Care Center: Specialties include primary care, cardiology, podiatry, endocrine, and urgent care.
Primary Care Physician Group:
· With 15 locations across the region including a multispecialty ambulatory care center, Golden Health Primary Care Physician Group provides convenient access to care for the community.
FINANCIALS AND ECONOMIC OVERVIEW
Historically, Golden Health has operated with strong financial performance, yielding EBIDA margins above 5% in three of the last five years. However, last year, Golden Health realized a decline in total EBIDA. Golden Health attributes this, in large part, due to a rise in uncompensated care from individuals experiencing homelessness. The Chief Financial Officer estimates that approximately 10% of all ED visits and inpatient admissions are by patients experiencing homelessness, which average a cost of $1,400 per visit at Golden Health.
Golden Health operates on a June 30 fiscal year (FY). In FY 2019, Golden Health had a total operating revenue of $4.2 B and their operating income was $50.2 M. At the end of FY 2019, Golden Health had 671,476 members in the San Francisco market and plans to grow membership by 30% over the next five years, spurred by the planned conversion of its newest facilities and associated patient populations into its managed care model. Further detail on key performance and financial metrics are in the financial addendum.
· SERVICE AREA OVERVIEW
San Francisco is described as the cultural, commercial, and financial center of Northern California. San Francisco is the 13th most populated city within the United States, with 883,305 residents as of 2018. It is also the second most densely populated city, as it only covers 46.89 square miles. San Francisco is known for its landmarks, steep rolling hills, fog, and architecture. Golden Health’s facilities are strategically placed in dense areas of the city, allowing them to offer logistically convenient care to most of the city’s inhabitants.
Throughout the San Francisco Bay Area, health systems are investing resources on initiatives to benefit populations experiencing homelessness and decrease accompanying high medical utilization costs. Examples of other health systems mobilizing to address the housing crisis in San Francisco include:
Kaiser Permanente
In 2018, Kaiser Permanente launched a $200 million Thriving Communities Fund to take on housing instability and homelessness, among other community needs. Starting in 2019, the Thriving Communities Fund will have three distinct associated initiatives. The first will establish a $100 million loan fund that is focused on creating and preserving rental homes for low-income individuals. The second initiative will allow a 41-unit apartment building to remain affordable in a gentrifying neighborhood. Kaiser Permanente has committed to $5.2 million to this initiative. Lastly, Kaiser Permanente is working with identified local partners and governments to end homelessness for 500 individuals over 50 years old with at least one chronic condition. Kaiser CEO, Bernard Tyson, stated that “In the 21st century, we should not accept the whole concept of homelessness in our communities”.[endnoteRef:8] Kaiser Permanente believes its approach will allow them to deliver on their mission to improve not just the health of its members but also the communities they serve. [8: Los Angeles Times, “Kaiser Permanente to commit $200 million to help communities reduce homelessness”, https://www.latimes.com/politics/la-na-pol-kaiser-homelessness-20180518-story.html]
CommonSpirit Health
Recently, Catholic Health Initiatives and Dignity Health Systems completed a merger to become CommonSpirit Health. The Office of the CEO for the new health system stated, “We didn’t combine our ministries to get bigger, we came together to provide better care for more people”.[endnoteRef:9] California approved this merger with the requirement that CommonSpirit create a homeless health initiative in the state to support care for hospitalized homeless patients. CommonSpirit plans to invest $20 million over six years to continue support for affordable housing and programs to address homelessness. [9: Healthcare Dive, “Dignity-CHI merger creates largest nonprofit health system by revenue”, https://www.healthcaredive.com/news/dignity-chi-merger-creates-largest-nonprofit-health-system-by- revenue/547451/]
University of California San Francisco (UCSF)
UCSF has recently launched the Benioff Homelessness and Housing Initiative. Using a $30 million gift from Marc and Lynne Benioff, the initiative will focus on advancing and advocating for evidence-based solutions to homelessness. “The initiative will partner with the community to build a knowledge base of rigorous, research-driven solutions; amplifying the voices of people who have experienced homelessness; train the next generation of homelessness researchers; and serve as a resource for policymakers and communities that are working to align health and housing systems.”[endnoteRef:10] UCSF identifies this work as a game-changer because it will allow them to “collaborate with policy makers and people who run health systems at the local, state, and federal level to answer the questions that they haven’t had the resources or the time to answer and work to translate our findings into effective policies.” [10: University of California, San Francisco, “New Benioff Homelessness Initiative to Turn Research Into Action”, https://www.ucsf.edu/news/2019/05/414396/new-benioff-homelessness-initiative-turn-research-action
This case study was prepared by the National Association of Health Services Executives (NAHSE) for the 24th Annual Everett V. Fox Student Case Analysis and Presentation Competition. This is a fictitious case that was developed as the basis for discussion in the Case Competition rather than to illustrate either effective or ineffective handling of an administrative situation. This adaptation is being used for educational purposes only. NAHSE retains and reserves all rights.
]
SUMMARY
Homelessness will continue to be a public health issue that adversely affects the health and overall quality of life for millions of Americans. Issues involving mental health, substance abuse, transmission of communicable diseases and development of serious and complex medical conditions are more prevalent amongst the homeless population. This population of patients will continue to need proactive interventions and targeted efforts to improve their health status. Without increased effort by healthcare organizations, limited access to consistent and effective healthcare services will continue to burden this population and cause financial strain on the health system.
While legislation continues to be passed to fight the negative impacts of homelessness, healthcare organizations must continue to stand at the forefront of efforts to support this population. As a leading healthcare organization in one of America’s world-class cities, Golden Health will lead the way in its efforts to develop innovative strategies and initiatives for poor and indigent patients. With these efforts, Golden Health will set the standard for health systems across the country whose missions are to better the lives of the people experiencing homeless, until they are at such a time that they are no longer without a home.