BOARD OF HEALTH MEMBERS PRESENT:

Scott Starkweather – President

Jean Gastiger, R.N., N.P – Vice President

Linda K. Liston, M.D. – Secretary

Kevin Buick, J.D.

Dennis Diemer, D.V.M.

Julia Fauci

Todd Latham

John Olson, D.D.S.

David Phillips, M.D.

Jesus Romero

E. Sue Thompson, R.N.

BOARD OF HEALTH MEMBERS ABSENT:

None

Mr. Starkweather, President, called the DeKalb County Board of Health Meeting of December 2, 2008 to order at 7:38 p.m.

Guests of the meeting were introduced as follows:

Joseph Baumgart, M.D.

Ms. Freier, Administrator, DeKalb Clinic

Saira Rana, M.D., DeKalb Clinic

David Sui, M.D., DeKalb Clinic

All Board of Health members present introduced themselves to the guests present.

All staff members present introduced themselves to the guests present.  Staff members in attendance were:

Mrs. Karen Grush, DeKalb County Health Department, Administrator

Mrs. Jane Lux, DeKalb County Health Department, Assistant Administrator

Mr. Bob Drake, DeKalb County Health Department, Director of Environmental Health

Mrs. Bette Chilton, DeKalb County Health Department, Director of Personal Health Services

Mrs. Deb Rolf, DeKalb County Health Department, Director of Home Care

Mrs. Brenda Courtney, DeKalb County Health Department, Director of Fiscal Operations

Ms. Ruth Patton, DeKalb County Health Department, Director of Office Support

AGENDA

Mr. Starkweather asked if there were any changes or additions to the agenda.  Mrs. Grush requested that Financial Data be discussed after New Business as this discussion will be longer than normal and we have guests present to address the Prenatal Referral agenda item.

Mrs. Grush also stated that Executive Session could be deleted from the agenda because she was happy to report that the Union Contract has been signed.  The contract will be handed out to all staff next week. 

MINUTES

Mr. Starkweather and Mr. Latham pointed out that Dr. Liston’s name was listed as Ms. Liston in the minutes of September 23, 2008 under Executive Session and Adjournment.  The Recording Secretary, Ms. Patton, will correct said minutes.  There were no other changes and on a motion by Mr. Latham, seconded by Mrs. Gastiger, the Board of Health meeting minutes of September 23, 2008 were approved.  Motion carried.

Mr. Buick moved to approve the Executive Session minutes of the Board of Health meeting of September 23, 2008; seconded by Dr. Olson.  Motion carried.

DIVISION REPORTS

Mrs. Grush stated that there is a large backlog of unpaid bills by the state of Illinois of which she will cover in her Financial Data report.  Funding toward the purchase of a duplicating machine from the DeKalb County Community Foundation was not received.  However, we did receive $7,100 in funding from the Senior Services grant for the purchase of equipment for Home Care and the Community Outreach building.

Mrs. Grush went on to report that the furniture has started to be installed in the Community Outreach Building (COB) and should be complete in about two weeks.  The other departments inhabiting the building (Public Building Commission, Regional Office of Superintendents, Veteran’s Assistance, and Mental Health) will be moving in the week of January 5, 2009.  Home Care will be moving in on January 13, 2009.  Mrs. Grush stated that the January 2009 Board of Health meeting will be held at the new building. 

Ms. Fauci asked if there would be public tours of the building.  Mrs. Grush stated after everyone was settled in there would be an open house. 

Mr. Drake reported that he has no other information to report other than what was written in his report.  Ms. Fauci commented on the letter Animal Control received, complimenting Animal Control Officer Jennifer Eisman on how she managed an incident regarding a dog that was running loose.  Mr. Buick stated he missed the electronics pick up held in September and asked if there was any way he could have those disposed of now.  Mr. Drake stated there would be two electronic pick-ups next year.  Mrs. Grush added that due to the upcoming changes with the television conversion, it is most likely an additional collection would be scheduled in the spring of 2009. 

Mrs. Chilton reported that the health department had completed a successful influenza vaccine administration season.  There are not many doses left.  She also reported that due to the turn in the economy, our demand for services goes up due to people who become income eligible for some of our Personal Health Programs.  The staff has done a great job of handling the high volume. 

Mrs. Rolf reported that Home Care has nothing additional to report other than everyone is looking forward to moving into the new building.

Mrs. Zanellato reported that the Health Education Department had recently coordinated Catch Training for the State of Illinois, which was held at our Health Department.  Due to the financial problem facing the State of Illinois, their Catch Trainers are not allowed to travel and accrue mileage.  Fortunately, we have one staff member, Lindsey Hochgesang, and Nancy David from the Sycamore School District who are trained and qualified to present the training.  Normally the training is limited to 25 but over 39 people attended the training, some coming from as far as St. Louis, Missouri.

NEW BUSINESS

Renewal of Prenatal Referral Agreement with Dr. Joseph Baumgart

Each board member was given a copy of a letter written by Dr. Baumgart dated December 2, 2008 and addressed to Mrs. Grush outlining the past three years of progress and future goals for the I-Care Clinic.  Mrs. Grush started by giving the Board of Health the history of how the agreement between the Health Department and Dr. Baumgart started.  Almost 25 years ago, the prenatal referral program started as a small program through the Family Planning (FP) program.  Approximately 15 years ago, the State of Illinois established Family Case Management (FCM) programs in health departments to address the high infant mortality rate in Illinois.  The primary goal of FCM is to get low-income pregnant women in to physicians for prenatal care.   When the program first started, clients that delivered at Kishwaukee Community Hospital were seen by physicians on a rotating basis according to their percentage of total deliveries.  Clients had no choice which physician they would see but were assured a physician would care for them.  At one time, 14 physicians were in the referral program.  However, the program dissolved in 2004.  DeKalb Clinic chose to withdraw from the program for a variety of reasons.  At that same time, Kishwaukee Medical Associates felt they could not absorb DeKalb Clinic’s patients.  Therefore, in 2005 Dr. Baumgart was the only physician who would accept public aid patients delivering at Kishwaukee Hospital.  Mrs. Grush stated she called the federally qualified health centers in Rockford and Aurora to see if they would serve DeKalb County patients.  They did not feel they could absorb DeKalb County patients.  It was then that Dr. Baumgart came forward and proposed his I-Care clinics to serve all of the prenatal patients on Medicaid.  He agreed to add staff to his practice in order to absorb the additional patients.  He asked the Board of Health for a commitment to refer all the clients living north of Route 30 to his practice.  Dr. Hawkins was taking public aid clients living south of Route 30 and those clients were delivering at Valley West Hospital.  If clients didn’t want to see Dr. Baumgart they had the option of getting a physician on their own who would accept them as a patient.  The program with Dr. Baumgart as the sole referral physician evolved into our current practice.  Health Department staff tells the client that we can call and make an appointment for them to see Dr. Baumgart.  If they don’t want to see him, they could get a doctor on their own.  Mrs. Grush stated the Health Department takes in approximately 50 new pregnant clients a month.  In the last four months, we’ve taken in 205 patients of which 65 percent were referred to Dr. Baumgart, 15 percent chose to receive care outside of DeKalb County, 9 percent went to DeKalb Clinic, 6 percent went to Dr. Hawkins, and Dr. Dubrick accepted one patient.  In 2005, the Board of Health supported Dr. Baumgart’s efforts and entered into a three-year agreement with him.  The agreement expires December 31, 2008.  Therefore, Dr. Baumgart is here and DeKalb Clinic is here, both to address the Board of Health regarding this issue.

Dr. Baumgart stated he completely changed the nature of his practice to accommodate the current program.  He was a “ma and pa store” type of practice until the prenatal referral crisis occurred.  What really started everything is that the State of Illinois was in a bit of a recession, as is presently the case, and payment from state tax money was very slow.  The State of Illinois pays a discounted rate for public aid patients and payments were approximately six months behind.  The problem was not the poor patients of DeKalb, but the State of Illinois’ slow and limited payments.  All of this happened very quickly and the prenatal referral program had 10 patients a week that needed care.  When DeKalb Clinic decided to not take patients, there were lots of patients to be seen immediately.  Simultaneously, there was a malpractice crisis.  The malpractice insurance for Kishwaukee Medical Associates, a group of family practice doctors, was increasing at a prohibitive rate.  Thus, Kishwaukee Medical decided to get out of OB all together.  Dr. Baumgart was instantly presented with a decision regarding whether he could see all the patients.  Dr. Baumgart stated that he is the Health Department’s Family Planning Program Medical Director and also has done consulting work for NIU for 25 years, and has provided them clinical services for 10 years.  He went on to state that since he was given the opportunity to attend college and medical school in Illinois, as a physician in the community, he felt he had a responsibility to the community.  He also takes mission trips outside of the country and stated, “You don’t have to go very far to find people who need help”.  When the DeKalb Clinic decided to limit their care to Medicaid patients, it was not limited to only obstetrics, but all departments.  This caused a large number of patients in the community to be without care.  As a result, almost every physician’s office in the community was getting bombarded with public aid patients and therefore stopped accepting them.  This problem still exists today.  If one of his patients needs specialty care, he has a hard time finding a doctor to see them.  Quite often they have to leave the county to find care.  Although the cause of the problem was the State of Illinois and their slow payment, when physicians decided to stop seeing public aid patients, it didn’t hurt the State, it hurt the community and the patients.  To more than double his practice’s deliveries was quite costly.  He had to expand his medical staff, purchase new equipment, and remodel his practice at his own expense.  In order to provide the financial security that these expenses would be covered, he asked that the Health Department continue to provide patients to those physicians who did not abandon them through December 31, 2008, which included himself and Dr. Hawkins.  Due to his high volume of Medicaid patients, the State put his practice on a fast track payment system, which means he receives priority for payment.  This is helpful because, at the present time, a very large percentage of revenue for the practice comes from the State.  Public aid reimbursement for obstetrics is approximately 40 percent of private reimbursement.  One of his partners left the community when her spouse took a job in another town.  Subsequently, his other partner left when she felt the patient load on two physicians was too great and the patient mix was not to her liking.  When this happened, no group in town was willing to help cover these patients.  The only way he could take time off was to hire experienced obstetricians from outside the community.  The only way he can survive is to have a high volume of Medicaid patients.  He has been recruiting, but it’s not easy when you tell the individual you’re looking for someone to work in a practice with a high percentage of public aid patients.  He has found a physician who is coming because of his practice, not despite it.  She will join the practice this summer.  This same physician has a friend who is a certified nurse/midwife who will also be joining the practice.  To bring them aboard will cost money.  Without the continued volume, he will have trouble continuing to provide what he currently provides.  Dr. Baumgart went on to state that there is a current effort to set up a community clinic in the area to care for the needy.  The current projection for that clinic is to operate at a loss of several hundred thousand dollars a year.  However, with good old-fashioned private enterprise, he has been doing this in the community with no subsidy.  It works because he has the volume to make it work. 

Ms. Freier began her address to the Board of Health by asking if anyone remembered the newspaper headlines of two or three years ago that stated there were no obstetricians left in town.  Ms. Freier went on to state that the obstetricians from DeKalb Clinic had left either to move out of state or to go to another part of the county.  Consequently, they hired three locum tenens to cover until they could re-establish their OB/GYN department.  She stated that patients prefer a permanent physician, so the clinic wanted to bring permanency back to the community.  They subsequently hired three (3) full time OB/GYN doctors, Dr. Rana, Dr. Sui, and Dr. Upputuri, who cover for each other.  All of the doctors take on-call in the hospital program so that if there’s a patient that does not have a doctor, they deliver the patient.  The biggest percentage of deliveries at the hospital is public aid patients.  Doctors are needed to take care of them.  Some doctors in the community have chosen not to.  The three DeKalb Clinic doctors have chosen to step forward and say they want to help.  They’re all permanent physicians. They don’t want to relocate and they’ve been with clinic for over 2½ years.  DeKalb Clinic is building a new facility on Gateway Drive, a 71,000 square foot building.  It will accommodate a minimum of three (3) OB/GYNs with expansion flexibility to accommodate four or five.  At this point, DeKalb Clinic is trying to build three new doctors into the community.  They are asking to give patients the right to choose.  It shouldn’t be just one doctor or you can go elsewhere.  Ms. Freier went on to state that she and the clinic feel there should be equal consideration given to patients to say there is more than one doctor in the area to take care of them.  She feels it should be divided equally and the patients should have the right to choose. 

Mrs. Grush clarified the issue of choice.  Under the old system the patients did not have a choice.  However, they now have a choice.  We tell them that we can make an appointment or they can find a physician of their choice, and they are given a resource pamphlet listing the physicians.  Thirty-five percent of patients see someone other than Dr. Baumgart. 

Ms. Freier stated that DeKalb Clinic would like to request that we tell patients there are four (4) doctors in the community and we can make an appointment for you with one, and they can choose the one. 

Mr. Romero asked if the clinic stopped seeing Medicaid patients.  Ms. Freier stated that they stopped seeing OB patients because the OB doctors were leaving the community.  They stopped all OB except for the patients the locum tenens were seeing.  As far as the public aid throughout, the clinic takes care of some people on Medicaid, such as public aid foster care.  The Health Connect program was coming in and it was an elective program for providers to sign up for.  The public aid patients would be assigned if they didn’t choose a primary care provider.  The clinic, because the State was more than 12 months behind in payments, said they were not opting to sign-up for Health Connect.  It was a monetary issue as well as the fact that at their Convenient Care, which is a walk-in clinic, had patients coming in who called their friends.  They were calling public aid patients from Aurora, Rochelle, and outside DeKalb County telling them to come.  The pediatric department was to the point of saying some public aid patients did not keep their appointments, some have high risk issues, and they received no pay for them.  They felt they had no choice.  Under Health Connect, the State would assign patients to a physician so they were not abandoning them.  She stated they elected not to see public aid patients.  However, their surgeons, urologists, etc., are seeing public aid patients.  The only thing that changed was in primary care due to the Health Connect resource. 

Dr. Diemer asked Ms. Freier, “At one point in time you had too many public aid patients and now you don’t have enough?”

Ms. Freier replied they had doctors that left the OB practice and they had to wait until they rebuilt the team.  They’re seeing some of the public aid patients that call but because the OB patients go through the Health Department, and they are paid by our tax dollars when they do finally pay, patients should know there is more than one doctor readily available to care for them.  Now the team is built and they’re ready to start taking patients again.  OB patients need a choice. 

Dr. Diemer asked if they wanted to see more public aid patients than what they’re seeing now.  Ms. Freier stated they needed more OB patients. 

Dr. Olson stated that Dr. Baumgart had beefed up his office to fill the need we had.  He asked Dr. Baumgart what level of referral rate did he need to be able to continue.  Dr. Baumgart stated that in order to provide the level of care that he has been, it requires significant volume.  If he has a 25 percent reduction in referrals, he still has the same costs.  In addition, he’s bringing in two new staff members.  Dr. Baumgart asked Ms. Freier if the clinic now cares for public aid patients in all specialties, or is it limited to certain specialties?   Ms. Freier stated they provide public aid care for all except primary care. 

Ms. Gastiger asked when the infants of Medicaid moms are born, are they accepted by the DeKalb Clinic pediatricians?  Ms. Freier stated that if the mom or a sibling is an existing patient they are taken care of by a DeKalb Clinic physician.  If not, they can utilize Health Connect.  Ms. Freier stated they brought in three physicians on guaranteed salaries for two years to rebuild OB/GYN care in the community and that wasn’t free. 

Dr. Diemer asked if payment for care is different through the State for primary care versus a specialty. 

Ms. Freier stated they wait nine months to a year for all patients until the State finally sends us a check.  That includes the OB patients we are now seeing that are on public aid. 

Dr. Phillips stated that the State of Illinois pays pediatric rates of about 20 to 25 percent of the bill.  So for pediatrics, every Medicaid patient that comes in costs money. 

Dr. Diemer stated it is hard to understand why DeKalb Clinic is going after the OB/GYN patients but not patients with a general problem.

Dr. Phillips stated that obstetrics, as Dr. Baumgart said, has a 60 percent discount instead of an 80 percent discount.  If we were getting reimbursed at 40 percent we’d still be seeing pediatric Medicaid patients.

Ms. Gastiger stated the problem is the system.  We wouldn’t be having these discussions if we had a more equitable health care system. And the ramifications of the fact that we don’t are that we get into these problems. 

Ms. Fauci stated she thinks Dr. Baumgart has more than played the role of friend of the Public Health Department when all others refused to see these people. 

Ms. Gastiger stated she remembers sitting at this table when we really had a crisis and Dr. Baumgart stepped in to help.

Ms. Fauci stated it’s a thankless task.  Dr. Baumgart is a man who has truly helped us out.  We do have some doctors that serve as our friends and say I’m here to help, and Dr. Baumgart has certainly done that for us so I would say that we keep the system where he’s the first referral and then we offer the other doctors as a choice.

Ms. Gastiger asked Dr. Baumgart how he changed his office?

In response, Dr. Baumgart stated in order to accommodate the volume he set up special days geared to provide care to public aid patients.  They have a streamlined method with a team approach so no one gets backed up.  Patients with special needs see Dr. Baumgart, and others are seen by nurse practitioners.  His two nurse practitioners each have over 20 years experience.  They are very good and have a feel for what he’s trying to accomplish. 

Ms. Gastiger stated that a focused setting like that is often beneficial for low-income patients.

Dr. Baumgart stated the pediatrics side is a disaster.  Dr. Goswami tried to do the same things for pediatrics, but he reached a point when he could no longer provide care.  When there’s no pediatrician for a newborn, a doctor on rotation sees the infant for one visit, and then they’re on their own.  Health Connect is not available for babies.   And where it causes real problems is if you have a baby that’s born sick.  The difference between a pediatrician taking care of that baby from birth is that the doctor knows what the problems are and can provide the continued care moving forward because they know the history from the get go.  When a baby is let go after one visit outside the hospital it’s a terrible situation.  The one specialty in town where that’s not a problem is obstetrics.

Dr. Liston stated she thinks Dr. Baumgart has specialized even in his specialty.   He has provided the kind of care that the Health Department patients need.  She thinks that if the DeKalb Clinic, before they hired three obstetricians, had done a needs assessment of what this community needed, then they wouldn’t be trying to get more patients for the physicians they hired.  She doesn’t feel that the Health Department is responsible for providing them with patients so they can pay their physicians. She worries about a facility that’s already turning away public aid patients because to her it says they are financially motivated.  Dr. Baumgart makes it clear that his motivation is patient care and that he’s not in it for the money, he’s in it for the patients.  She clarified that she’s not talking about the physicians individually (speaking to doctors present); She knows they’re in it for the patients.  She stated, “I just get a little suspicious of administration sometimes.”

Dr. Phillips stated that because the DeKalb Clinic is a multi-specialty clinic, in the past the doctors had a tradition of supporting each other.  He stated that when their financial people looked back they found that the pediatric department had been losing money every year for 10 to 15 years.  In fact, the pediatric department would have been bankrupt eight years before he came here and would have been out of business because of that.  He said, “Having an open door to a payer that doesn’t pay or pays less than cost is putting ourselves out of business and then we can’t take care of anyone.”  That was really the issue.  It wasn’t that it was money driven or profit driven; it was a matter of survival. 

Dr. Baumgart agreed with Dr. Phillips.  Dr. Baumgart said, “If you don’t have the volume and you’re dealing with a patient population that doesn’t reimburse you what “the big boys” do you’re in trouble.  That’s why I’m asking to continue the relationship as it’s been because if I have a significant cut in volume, I can’t do it either.”

Ms. Fauci said to Dr. Baumgart he has a model that needs volume to sustain itself.

Dr. Liston stated she was in practice when she couldn’t get any of her patients to an OB provider.  Dr. Baumgart was the only person she could find for her public aid college students and couldn’t find providers in any other area either.  She thinks Dr. Baumgart has demonstrated individual integrity in terms of his motivation to take care of the needs of this community and he has a practice and it’s working.  She thinks the DeKalb Clinic should be mentioned as an alternative but we should support Dr. Baumgart. 

Dr. Sui stated overall we want the best practice and what’s best for the patient regardless of what their income is or their insurance.  There’s no discrimination. The main thing is the volume is too huge for one doctor.  Dr. Baumgart is seeing an average of 40 to 50 patients per month and then says he can provide equal quality of care to each patient, but I doubt it.  The national average for obstetricians is a delivery rate of 10 to 15 patients per month.  Now this one physician is overwhelmed and Dr. Sui said he wonders if the community will suffer because of that.  “I don’t feel that all these patients should be on one doctor’s shoulders,” he said. 

Dr. Liston asked Dr. Sui if he had heard of any problems regarding Dr. Baumgart? 

Dr. Sui stated he wouldn’t comment on this.

Mr. Starkweather stated he remembered during a Board of Health meeting about three months ago, there was a discussion about Dr. Baumgart requesting the DeKalb Clinic to cover some of his patients but then that fell apart.  He asked Ms. Freier if that was something she cared to comment on. 

Ms. Freier stated there was an agreement that if they covered for Dr. Baumgart, a number of patients would be offered to the DeKalb Clinic.  They didn’t reach a mutual agreement to be able to make it go forward.  She still feels the patients should have four choices for who they want to see.

Mr. Starkweather stated to Ms. Freier that as everyone knows, we did a long-term commitment with Dr. Baumgart.  He asked if the DeKalb Clinic would be willing to do a long-term commitment to accept obstetric patients on Medicaid?

Ms. Freier stated that’s why they are here tonight.  They are building a new building and accommodating the OB practice.  The biggest percentage of OB patients in the community is public aid patients.  They have the ability to service those patients, so yes, they would be willing to sign a long-term agreement.

Ms. Thompson asked Ms. Freier if they’ve looked at numbers to see if at what point they would be over saturated in OB with public aid patients that they would consider not taking anymore.  Ms. Freier stated that because of three full time doctors that are covering for each other, they do not have a limit to say after the first “X” amount we’re cutting it off.  We’re here as long as there are accommodations to give the patient the quality of care that they need. 

Dr. Olson asked to clarify that Dr. Baumgart asked for help from the DeKalb clinic in covering his practice but the DeKalb Clinic wouldn’t help him?

Ms. Freier stated there was an agreement that if they covered his practice they could have a few of the public aid patients.  The agreement did not come to a resolution.  There were just some differences, for example, access to records for quality of care to be specific. 

Dr. Sui stated that they have helped Dr. Baumgart before but the philosophy of Dr. Baumgart and Dr. Upputuri are not compatible which is why they decided to drop.  It wasn’t because they didn’t want to cover – Dr. Baumgart has asked him to cover and he has. 

Dr. Liston requested clarification of the difference in philosophy. 

Dr. Rana stated there are ACOG guidelines everyone follows.  There is a different threshold of comfort, which is higher or lower for some people.  Ultimately the patient care is pretty much the same. 

Dr. Liston asked how it would affect patient care?

Ms. Freier stated you can have different philosophies or different conservatism on how you treat your patients and that doesn’t mean that there’s going to be a negative result. But when you’re trying to work with each other, sometimes you disagree. 

Ms. Freier stated that the biggest issue was access to records.  When the patient comes in and she is delivering and she is high risk with a number of issues, the clinic needs access to her records.  

Dr. Baumgart stated that prior to 2005, the clinic and his office cross-covered each other for two years.  It was a different set of physicians.  Ms. Gastiger asked how did it work with records before?  Dr. Baumgart said it worked exactly the same as it is now. 

Dr. Baumgart stated that he didn’t feel it was fruitful to dissect how this didn’t work out.  That really wasn’t the issue (access to records) because there is a means for accessing the records.  That was never really discussed in any kind of detail.  The bottom line was that they tried to put something together and it didn’t work out.  He would have loved for it to work out, maybe they (DeKalb Clinic) would have loved for it to work out but it didn’t work out.   

Mrs. Grush stated to Dr. Baumgart that it is her understanding that he is on the fast track for reimbursement because of his high volume of public aid patients.  Dr. Baumgart said yes.  Mrs. Grush asked that if his percentage of patients is diluted, do we run the risk of him not being eligible for the fast track and a year from now have no one to deliver babies because the money is not coming in to pay for the care?

Dr. Baumgart replied yes, there is a negative effect on reimbursement.  Dr. Baumgart stated that the State of Illinois pays what it has in its treasury.  And that’s not just medicine, it’s everything.  In the case of medicine you’re being paid for something that’s already happened. 

Mrs. Grush stated that by diluting the percentage of patients Dr. Baumgart sees, he runs a far greater risk of having extended periods of time without public aid payments. 

Dr. Diemer stated Dr. Sui had a point about needing more people to help.  He thinks it’s just incredible that Dr. Baumgart can provide services for a county this size by himself and perhaps we do need more doctors that can provide care to the people. 

Dr. Baumgart stated that’s a point well taken.  He has great ancillary support.  He does have physician support in locum tenens he hires so he can go to meetings and get out of town.  He’s been trying to recruit for approximately two years and now has two people coming aboard.  But he also wants the Board to understand that he went to the DeKalb Clinic to try to solve that problem and for whatever reason it wound up not being the solution to the problem. 

Mr. Latham asked if there have ever been complaints against Dr. Baumgart?

Mrs. Grush stated there had been none to the Health Department.

Dr. Baumgart stated if a patient calls the office it can take a couple of months to get in and that’s true for private patients.  So he has lost private patients because he’s chosen to do this.  So the DeKalb Clinic gets some benefit from this because it’s a lot easier to get in to see someone there. 

Dr. Sui said that it’s not good to wait two months to see a doctor.

Dr. Baumgart said if he has a patient that has a problem he takes care of her in a timely fashion.  But he has had patients that have decided that they can get in a little faster somewhere else so they’ve gone somewhere else. 

All doctors left at 9:02 p.m., and a discussion was held among the Board members.

Dr. Diemer stated that he couldn’t grasp the concept of the doctors fighting over public aid patients.

Mrs. Chilton explained how the program currently operates.  The patients are not forced to see Dr. Baumgart.  We can set up an appointment with Dr. Baumgart while clients are here, or the client can make an appointment with another physician.  If we call for an appointment and it is a six week wait and the patient is a late entry, already far along in their pregnancy, the client might even say that’s a long time and the option would be given to call another physician.  We give clients the directory of resources with all doctors listed, and give them the option to call if they want to. 

Dr. Diemer asked if we were directing patients towards Dr. Baumgart.

Mrs. Chilton stated absolutely.  He is the primary referral within our program.

Dr. Olson stated that he and Mrs. Gastiger were on the Board five years ago and lived through the crisis and he feels we owe Dr. Baumgart. He stepped up to help us.

Ms. Fauci commented that Dr. Baumgart is sticking his neck out for these patients and his new doctors will share his mission in the community.  She thinks Dr. Baumgart is in it for the long term.  She doesn’t think the Board is being unfair and we should continue our arrangement with Dr. Baumgart

Ms. Gastiger stated this has been such a focus of Dr. Baumgart’s practice.  You can get a feel for that from listening to him.  In addition, some of these patients are challenging.  They are high risk, uneducated, low skilled mentally and physically, and there is a language barrier.  He has expertise and skill with the population.  And it sounds like the person he’s recruited is particularly strong in that area and that enhances care, not just the delivery but also the prenatal care, the office visits.  She’s more concerned about the prenatal care and the continuity of enhanced services and services directly geared towards the high-risk population that he serves.   

There was a discussion among board members about the model Dr. Baumgart has set up and how it works and how other practices work.

Dr. Phillips stated that what we’re really talking about is the Health Department making the phone call or the patient making the phone call.

Mrs. Grush stated that was correct – we could make an appointment for the patient while they’re here or they can call and make it on their own. 

Dr. Phillips asked why don’t we give the phone numbers of the doctors on the list and say here is the list, here’s the phone and you can make an appointment?  Mrs. Chilton responded that does occur.

Dr. Phillips stated that the idea of Health Connect was that the patients could pick the doctors they wanted to see. 

Mrs. Chilton said that Health Connect is not working.  Clients on Medicaid cannot get in to a local physician.  

Dr. Phillips said the problem was that it wasn’t funded.  Dr. Baumgart said he gets paid six months late.  The contract Health Connect offered the clinic was they were going to pay within 45 days and they are already 6 months behind, and the State of Illinois is over three years behind paying him.  He said that Blue Cross pays an OB 50 times more for the doctor to deliver the baby than for me (Dr. Phillips) to take care of the baby.  This is a problem for primary care, not OB.

Ms. Grush stated her concern is that Dr. Baumgart has established this practice and this is a difficult population.  They don’t always comply with care; they don’t always keep their appointments.  It isn’t because they’re irresponsible, it’s just that they lead chaotic lives. Dr. Baumgart’s practice has developed an expertise in dealing with this population.  We have loyalty to Dr. Baumgart.  He’s been at our side for 25 years.  Aside from our pregnant clients, he has been our Family Planning Medical Director; he has been the collaborating physician for our nurse practitioners.  If it weren’t for him it would be very difficult to get an OB/GYN person to give that program the dedication he’s given it, and we would have a hard time sustaining that program. 

Mrs. Grush explained that Ms. Freier had indicated DeKalb Clinic went out of the OB business because they didn’t have any doctors.  However, Mrs. Grush stated in looking through old notes, it was Dr. Wiley we were dealing with, not Ms. Freier as the administrator.  Dr. Wiley called Mrs. Grush because of lack of payment from public aid, which is why he stated they were getting out.  And then we got a letter from him stating they were not going to see public aid patients. That was a concern because if we change our practice, and providers don’t receive public aid payments, are they going to say they can’t see the clients?  What would we do then?

Ms. Gastiger stated that was her recollection also. 

Dr. Phillips stated the overwhelming majority of Medicaid patients were pediatric.  The Medicaid patients weren’t really shared in pediatrics.  At the time, the financial people said they were losing money, and three doctors were leaving.

Mrs. Thompson asked Mrs. Grush about Dr. Baumgart and clinics at the Health Department. Mrs. Grush stated that Dr. Baumgart does one clinic a month for the family program and he provides consultation for the nurse practitioners.

Dr. Phillips asked if they get paid for that or is their time voluntary.  Mrs. Grush stated that Dr. Baumgart gets paid only $1,600 a year to be the medical director for the program.  It is not a lucrative position.

Ms. Gastiger stated that this idea that we have to have a level playing field, that we have to refer equally, is not right.  She thinks that Dr. Baumgart’s level of commitment historically and what he will commit in the future makes this not level.  She said the clinic got out once before and she understands from a business point of view.  This is nothing personal but this is a tough situation and she wants to do what’s best for everyone and wishes there was a compromise but the compromise may have to be that the clinic is the default.

Dr. Liston asked if there were any complaints about Dr. Baumgart.  Mrs. Grush stated that there were no complaints under the current arrangement.  There had been a number of complaints under the old process because people were sometimes linked with doctors where the fit wasn’t good. 

Mrs. Chilton stated currently there are very few complaints.  The biggest complaint by case managers is how long it may take to get appointment.  But it is a good thing that he has people in his practice that know how to care for this population.

Dr. Diemer stated his concern is that patients wait.  Our number one goal is what’s best for patients.  He went on to state that everything he’s heard about Dr. Baumgart is that he’s a wonderful man.   But if they have to wait two months to get an appointment, is that what’s best for the patient?

Mrs. Chilton stated that waiting two months for an appointment is unusual. 

Dr. Diemer asked if it would be better to give them one choice or better to give them a choice to see four doctors.  Do we present them with their bios or do we just make the decision for them?

Mrs. Chilton stated the other reason many of our clients want us to make the appointment is because if left up to them, they may come back in a month without an appointment.  Making an appointment can be very difficult for this population and the astute person who wants to make a choice will say give me the list but many others have language barrier issues.  Dr. Baumgart accommodates the language barrier with bilingual staff.  A large percentage of our clients do not speak English.  Other providers complain that we didn’t clients with a translator. 

Mr. Romero stated a lot of patients are overwhelmed and intimidated by the language barrier.

Dr. Diemer asked Mrs. Chilton that, in her most honest opinion, is the current system, what’s best?

Mrs. Chilton stated the current system is working and she doesn’t know if another system would improve it. 

Dr. Diemer asked Mrs. Chilton,  “You don’t think that giving them the choice of four doctors would be better for the patient than doing what we’re doing right now? “

Mrs. Chilton stated no. 

Dr. Olson stated we’re not talking about the general population but the population that comes to the Health Department.  It is a special population.

Ms. Fauci worries about watering down the patients, as that’s the way Dr. Baumgart’s practice is surviving.  He has developed a specialization with this population.

Ms. Gastiger stated this is a temporary situation with him in terms of his staffing because when his other staff members start the wait will decrease.  There are concerns but this is a temporary situation.

The Board discussed the pros and cons of a written contract and the length of an agreement. 

Dr. Diemer commented that it seems we have a better comfort level with the current arrangement.

Dr. Olson asked Mrs. Grush when DeKalb Clinic had contacted her about this issue. 

Mrs. Grush stated they had contacted her in the spring.  Dr. Upputuri contacted her and wanted referrals.  She explained that we had agreement with Dr. Baumgart that expires December 31, 2008, and we would be addressing it in December. 

For a number of reasons, Mr. Buick stated he would not use the written agreement provided by Dr. Baumgart.

Mr. Olson stated he thinks the clients are better served with the system the way it is now than if we hand out a list of names.

Ms. Gastiger agreed.  She believes it’s a good system for the women and the Health Department – it’s for the common good. 

Dr. Phillips asked Mrs. Grush if other health departments call to make appointments for clients.  Mrs. Grush responded she doesn’t know about other health departments. 

Dr. Phillips asked if there was something that precludes making the phone call to physicians other than Dr. Baumgart.

Mrs. Grush stated that the agreement was that we would refer clients to Dr. Baumgart. 

Dr. Diemer asked Dr. Phillips if he would like everyone to get a list.

Dr. Phillips stated he would like to see every client having the phone call made for them. 

Ms. Fauci commented that she knows this is very difficult; she would like to vote.

Dr. Phillips asked what are we voting on?

Mrs. Grush stated we are voting on continuing the current process as it is; we don’t need to vote on the proposed letter of accord.

Dr. Olson made a motion that we continue the prenatal referral process the way we have been doing it for a two-year period, irrespective of the letter of accord. 

The roll call vote was as follows:

Mr. Starkweather – Yes

Dr. Liston – Yes

Mrs. Gastiger – Yes

Mr. Latham – Yes

Mr. Romero – Yes

Ms. Fauci – Yes

Mrs. Thompson – Yes

Dr. Diemer – Yes

Dr. Olson – Yes

Dr. Phillips – Abstain

Mr. Buick – No

The Board voted, not unanimously, to continue the current process as we have in the past, for two years irrespective of the letter of accord.

Report of Nominating Committee

Todd Latham, Chair, reported that Ms. Fauci has indicated she will not be serving another term on the Board of Health.  The County Board will appoint a replacement. 

Mr. Latham moved to request the County Board reappoint Mr. Starkweather and Dr. Liston for a second term on the Board of Health for the term January 1, 2009 through December 31, 2011.  Mr. Olson seconded the motion.  All in favor, none opposed. 

Mr. Latham nominated the following individuals as officers for 2009:

Scott Starkweather – President

Jean Gastiger – Vice President

Linda Liston, M.D. – Secretary

Mr. Phillips moved to accept the nominations.  Mr. Buick seconded the motion.  All in favor, none opposed.

FINANCIAL STATEMENTS

Mrs. Grush reported that, compared to this time in 2007, the Health Department is down nearly $450,000 in revenue/cash received.  Compared to 2007, Home Care is down approximately $150,000 in revenue from our low census in the summer.  One hundred thousand ($100,000) remains outstanding in Home Care payments that would have normally been received by now.  Grant receivables that normally would have been received by now are outstanding at approximately $100,000.  Public Aid reimbursement for services provided is outstanding at approximately $125,000.  She reported that the State is experiencing significant cash flow problems that are affecting every provider in the State.  At the moment, we are not experiencing cash flow issues because of our cash reserves that are there precisely for times like this.  She did state that she is concerned about next year and management is evaluating ways to conserve money.  For example, two nurse positions are open at the moment and filling them is on hold.  Mrs. Grush also stated that out of county travel and equipment needs will be examined closely before approval is authorized.

Ms. Gastiger moved to approve the Financial Statements for the months September and October 2008 and Claims for the months of October and November 2008.  Motion seconded by Ms. Fauci.  All in favor, none opposed. 

CORRESPONDENCE AND ANNOUNCEMENTS

As this would be Ms. Fauci’s last Board of Health meeting, Mrs. Grush recognized her service to the Board of Health and presented her with a plaque.

ADJOURNMENT

On a motion by Mr. Latham and seconded by Ms. Gastiger, the Board of health adjourned at 10:01 p.m.  Motion carried.

_____________________________________________

Linda K. Liston, M.D.

Secretary, DeKalb County Board of Health

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