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participants' responses to this interview.
Mike Opat, Hennepin County
Civic Caucus, 8301
Creekside Circle #920, Bloomington, MN 55437
November 12, 2010
Verne Johnson (Chair, phone); David Broden, Paul Gilje, Jim Hetland
(phone), Sallie Kemper, Dan Loritz, Tim McDonald, Clarence Shallbetter,
of Opat's comments:
In this wide-ranging conversation, the chairman of the Hennepin County
Board of Commissioners discusses changes to the state's General Assistance
Medical Care (GAMC) law that affects the Hennepin County Medical Center (HCMC)
and how the hospital is responding to the new funding mechanism for
low-income, childless adults.
He addresses the
to out-state counties with significantly different priorities; the choice
to elect or appoint county sheriffs; and actions
is taking in response to looming budget cuts.
Welcome and introductions-Mike
Opat is the Chair of the Hennepin County Board of Commissioners, and has
served on the board since 1993. Hennepin is the largest county in
with more than 1.1 million residents and an annual budget of $1.7 billion.
governs the delivery of county services, approves Hennepin's budget and
property tax levy, establishes ordinances, approves contracts and appoints
key staff members.
As chair of the
Hennepin County Medical Center (HCMC) Governing Board in 2006,
Commissioner Opat led the transition of HCMC to Hennepin Healthcare
System, Inc., a governance change that gave the hospital greater autonomy
and operational flexibility. Also in 2006, he led the effort with the
Minnesota Twins to finance and build the new outdoor ballpark in downtown
He is a former
supervisor at the Hennepin Adult Corrections Facility and a Minnesota
Correctional Officer of the Year. He graduated from the
and earned a Masters in Public Policy from the Harvard Kennedy School of
Government. He lives with his wife and three children in Robbinsdale.
Comments and discussion-
During Opat's visit with the Civic Caucus, the following points were
The chair opened the discussion by explaining to Opat the Caucus format:
There have been 200-plus conversations to date on a wide variety of topics
of public importance, all listed on the Civic Caucus website. The Caucus
prepares a written summary of each conversation that, once reviewed and
approved by the speaker, is emailed to over 2,200 recipients. All state
legislators, including those newly elected, receive the summaries.
The focus of the
Caucus has been on the redesign of public services, understanding that the
state cannot simply cut or tax or grow its way out of the budget
shortfall. Rather, we need to find ways to do things more efficiently,
short term and long term.
As Hennepin County's
$1.7 billion budget covers such diverse areas as public safety, social
services, and the state's largest trauma hospital, we hope to learn of
some redesign efforts at the county level that might be replicated
elsewhere and serve to lessen the overall deficit.
to GAMC Compelled by Governor's Veto
Recently Peter Nelson from the Center of the American Experiment spoke
with the Caucus, and described a redesign of the state's General
Assistance Medical Care (GAMC) law that changed hospital reimbursement
from a fee-for-service basis to a lump-sum payment. (See:
"I would submit there
was much less policy motivation behind restructuring GAMC than simply a
reaction to the Governor's fiat," Opat said. Referring to Governor
Pawlenty's line-item veto of GAMC funding, he added, "We were facing a
line through the budget item, so we had to quickly salvage something to
restore some funding."
The law (and medical
practice) requires hospitals to treat emergencies-but not to provide
primary care to patients who are unable to pay. The options facing
stakeholders were to have no program at all for the care of this target
population, a smaller program, or an uncompensated-care pool. After some
deliberation, negotiators devised the Coordinated Care Delivery Service (CCDS)
model-providing a lump sum payment to participating hospitals for the care
of the childless poor.
systems had the option to enroll in the CCDS model, and at the end of the
day four did, all in the metropolis: Hennepin, Regions, Fairview, and
North Memorial. None of the outstate providers wanted to take on the risk
of bringing in a high-needs patient without fee-for-service compensation.
Opat related that
was active in the law's redesign: "We chose to go in and negotiate the
metrics around how much money would be available. I think we ended up
using '07 or '08 GAMC data to arrive at the proportions of how much each
patient would be reimbursed, and then placed a cap on the number of
enrollees." HCMC's cap is under 9,000 enrollees; Regions' is approximately
North Memorial's are lower.
a 'decent' public payer for services
"In the general scheme of reimbursements, nobody but a Saudi prince pays
the retail price for healthcare - Mayo gets some of those patients.
Commercial insurance provides sustainable payments. Medicare covers the
cost of care and Medicaid results in reimbursements less than the cost of
care. GAMC was a decent public payer but not a great public payer."
HCMC is a $650 million
operation each year. When GAMC was in effect, HCMC would receive about $50
million per year from GAMC to cover single adults, and an additional $20 -
$25 million per year from a property tax subsidy for others who could not
qualify for any program. These funds would help to cover the truly
signs of change in care at HCMC in response to the new model
The goal of the new lump-sum payment scheme is to encourage active
outreach and preventative care on the part of the participating hospitals,
instead of merely responding to emergencies as they come in the door. A
participant asked Opat whether HCMC is changing the way it delivers care
to the indigent, one-half year into a change in the model.
"I think so, yes,"
Opat replied, "but not enough yet." He described that the hospital has two
new outpatient clinics, and is attempting to reach out to people to incent
He was clear during
his remarks that while HCMC is working hard to make the most of the new
law, their ability to change rapidly is limited, and the new law was in
fact put together in a short amount of time. Once the veto came, changes
had to be made quickly.
Managers at HCMC
responded to form a response. "I don't know if I would hold it up as a
model just yet-maybe we need something more than a new clinic. Maybe we
need a van" to go around and find the people who would benefit from
preventative care. "But the attitudes around the program are good, and we
think we'll continue to improve it."
"We've got to get a
bit better at this," he said, "at reaching out to poorer people with
chronic conditions who need to manage their health."
There was one major
oversight in drafting the new program: excluding dental care. "I think
that was a big mistake. When I was working at the County Workhouse most of
the medical runs we made with guys in shackles were 20-somethings with bad
teeth. This is an area where preventative care is essential."
to primary care for the indigent may not decrease costs
Moving to more
primary care with the indigent population will decrease services delivered
in the emergency room, a participant observed. But will that save money
Opat replied that he
does not think so. "You never un-build a prison, and I've never seen an
emergency room get smaller." So while there may be more use of primary
care services, the infrastructure of the ER remains intact. Opat also
noted that the ER example may not be the best characterization.
"Improving the overall health of our population should be the continuing
governance changed to include an operating board for HCMC
"When I ran for office initially, I had no idea the County Board was
the governing board and for the hospital. I believe the same could be
said for most or all commissioners."
In the interest of
being good stewards, Opat wanted the Board to become more connected with
HCMC. "I thought that for an enterprise as big as HCMC, we ought to spend
more time at the hospital-get out of the government center, hold meetings
at the hospital."
They tried it for a
while and it didn't work.
So they set up a
separate hospital government task force that evolved into an operating
board that is involved much more closely with the hospital than the board
of commissioners could ever be. "The HHS Board is going very well-we're
more adroit now, more agile, and we're doing a better job running the
counties should look to changing their services
recent candidate for Lieutenant Governor and executive director of the
Association of Minnesota Counties, has proposed (http://tinyurl.com/39efv5x)
reforms for how counties handle services. "I think those reforms have to
do more with counties in greater Minnesota," Opat said. Hennepin County is
different and it is a challenge to compare it with outstate counties. "We
don't have much in common in terms of volume or character of services. I
think 87 counties are too many, but I think the other eighty or so should
reach that conclusion." It makes sense to have consolidation of services,
Opat said, and noted that he's told Mulder, "You want to consolidate
services and administrators but still have 87 sheriffs. That seems
inconsistent to me.
should be appointed
In response to a question about public safety, Opat replied that he
believes strongly that sheriffs should be appointed. They do not now have
sufficient incentive to save money. "They have authority on the expense
side but not the revenue side, and that's a bad balance. The crime rate is
down, the booking rate is down, but the Hennepin County Sheriff still
proposed an increase for 2011 and has more administrators than the
previous sheriff had in 2007."
of the state budget crisis, the nature of some social services may have to
Two weeks ago Ember Reichgott Junge told the Caucus that the state is
spending $1.5 billion on services for the developmentally disabled. She
said that Lutheran Social Services would be putting forth a proposal to
share the responsibility among the state and county governments and move
the disabled into private foster homes.
"I'm not aware of
it-I'd agree with her that there is a looming cost issue. Getting people
out of the state institutions and into the small Supported Living Services
(SLS) homes with staff to help them with their daily activities has been a
fantastic and quiet success. But there is coming a time when other models
than the four-person home model have to be considered.
County is working now in anticipation of future cuts in state aid
In the next legislative session everyone is saying there will have to be
cuts, a participant observed. One of the areas that seems to be targeted
are human services in general, while K-12 is seen as sacrosanct. The
counties are very exposed. What do you expect to do about it?
Opat said that the
county is trying to save money where possible using a variety of
approaches. It is not helpful to make despondent speeches about what's
going on in this state. We need to get over chronic worrying and do
"We've seen this
situation coming, so we've been preparing, controlling costs through
attrition, and finding ways to save money." The state has BOTH a revenue
problem and an expense problem, he said-it's not just an expense problem.
I look at it both ways: Surely revenues are off, but the answer in recent
years has only been to cut on the expense side. "If I were looking at the
State budget I'd look for ways to cut bureaucratic costs (and accept more
risk by decreasing some oversight), but I'd look for ways to raise
appetite for services grows with time
cautioned, that the appetite of society for human services grows over
time: "A few decades ago, no one spoke of ADHD (Attention Deficit
Hyperactivity Disorder). We didn't talk about supportive housing for
people with special needs as we do now. We didn't have as many disability
diagnoses. Our appetite has also grown for longer prison sentences.
government could reorganize by setting targets for others to meet
Should we try
something like Denmark, a participant asked-where the central government
sets certain budget targets by regions, then asks the local regions to
figure out how they will consolidate?"
"It's a thought," Opat
thought aloud; "there are a few things I'd be willing to give up."
for a changing role of the
Opat told the
Caucus that he believes there is a larger role for the counties to play in
economic development-and that the Itasca group is looking at that now. "In
addition, I think there is a role for us to play in Convention and
Visitors work." However, there are limits; he doesn't think the county
should be involved in running the airport.
We've also got to do
better with the lakes in Hennepin County," said Opat.
It is a
'long-shot' that the county will get involved with a Vikings
A participant asked whether the county is going to get into the work on
the Vikings stadium. "I think it's a long shot that we would get into it
any time soon. The problem is that they play only 10 games per year, it is
twice as expensive (as the Twins' stadium), and only the state receives
the revenues (taxes) the Vikings generate. There is little upside for the
county in this project."
The chairman thanked Mr. Opat for the visit, and for the good discussion.