Steven Litt, The Plain Dealer

CLEVELAND, Ohio – For the first time in its 181-year history, The MetroHealth System in September will be able to start operating inpatient facilities and offer a full menu of services outside of Cuyahoga County – a dramatic shift that will expand MetroHealth’s reach to more of the region’s poor and underserved patients, while helping the hospital compete with rapidly growing University Hospitals and the Cleveland Clinic.

But the change required the passage of a state law and Gov. John Kasich’s signature – all of which happened without any public discussion or awareness. State lawmakers, at the end of the legislative session, achieved it by shoehorning a two-sentence amendment into a bill that mainly deals with nurses’ powers to compel mental health evaluations and expands state oversight for private opioid treatment programs.

Then there’s the question of who will pay for MetroHealth’s out-of-county facilities. MetroHealth is Cuyahoga County’s hospital, funded in part by the county’s health and human services tax, which was renewed by voters in May. But MetroHealth CEO Dr. Akram Boutros says the hospital already has an accounting system in place that will protect taxpayer dollars from paying for the hospital’s out-of-county growth.

Here’s what you need to know about the change, how and why it happened, and what it means for the hospital and the region.

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Gus Chan, The Plain Dealer

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A new law allows MetroHealth to establish inpatient facilities and other health services in eight new counties, a dramatic change that will allow Cuyahoga County's public hospital to reach more underserved patients, while helping it compete in a rapidly changing healthcare industry.

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Why does MetroHealth want to expand into other counties?

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Until recently, state law permitted county hospitals to open only outpatient facilities outside of their home county – and only with the approval of the hospital’s governing board and the county government in which the new facility would be located.

But newly passed House Bill 111 includes a cryptic clause written to let MetroHealth set up inpatient facilities and related services in eight new counties -- Geauga, Lake, Lorain, Medina, Portage, Stark, Summit and Wayne.

MetroHealth wants to expand its operations outside of Cuyahoga County to provide healthcare to more underserved populations, Boutros said last week.

“Today, we have capability and capacity to help live our mission beyond the borders of Cuyahoga County,” he said. “We feel it’s a moral obligation for us to do that. MetroHealth’s mission compels us to provide care to those in need, whenever we can.”

But the decision also is rooted in the hospital’s need to be financially viable in a highly competitive market, Boutros said. And ensuring a healthy future for the safety-net hospital ultimately comes down to economies of scale, Boutros said.

“The bigger you are, the less cost per unit,” Boutros said. “So we’ve got to be able to, when necessary, reduce the total cost of these [services]. And that happens through regionalization.”

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Jeff Piorkowski, special to cleveland.com

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MetroHealth hopes that opening more facilities outside of Cuyahoga County will continue to produce healthy revenues, similar to gains seen as a result of recent acquisitions within Cuyahoga County, like the one shown here at Cleveland Heights Medical Center.

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So, how will MetroHealth decide where to expand?

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MetroHealth’s strategy is to identify each community’s unmet healthcare needs — a standalone emergency room, specialty services, or a labor and delivery unit, for example.

MetroHealth is considering five new locations outside Cuyahoga County where residents need specific services, but Boutros declined to say which communities and which services the hospital is exploring.

Those considerations are backdropped by a Northeast Ohio healthcare industry that has undergone rapid consolidation and regionalization in recent years, with the Cleveland Clinic and University Hospitals opening numerous locations throughout Greater Cleveland and beyond.

Until the passage of HB 111, Ohio Revised Code has prevented MetroHealth from doing the same, as it largely was prohibited it from operating outside its home county’s borders.

Since Boutros became CEO of MetroHealth in 2013, the hospital has expanded with new facilities and services within Cuyahoga County. Boutros credits those pursuits with helping to drive its financial health to a record year in 2017 — revenue increased 8 percent to nearly $1.1 billion. And so far in 2018, this year’s finances are beating last year’s record high, he said.

Boutros suggested that expanding the hospital’s footprint even further outside the county is a way to carry forward MetroHealth’s recent success.

The hospital intends on exploring partnerships with other hospital systems as it embarks on projects throughout the region, and could also strike deals with nursing homes, home care companies, insurers, physician groups and hospitals, Boutros said.

Cuyahoga County Council President Dan Brady said he supports MetroHealth gaining the ability to venture outside of the county and called the strategy a “bold” move. He noted that county taxpayer funds are still set aside for sole use inside the county.

“This is the kind of business model that allows MetroHealth to survive in a very competitive environment,” Brady said.

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Jackie Borchardt, cleveland.com

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The amendment that allows MetroHealth to expand to eight new counties was slipped into HB 111 in May by the Ohio Senate's Health, Human Services and Medicaid Committee. It passed with no public discussion about the drastic changes it would mean for MetroHealth.

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How did this happen without public awareness?

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The amendment in House Bill 111 has massive ramifications for Northeast Ohio’s patients and healthcare industry, but no public debate preceded its passage.

It was one of several amendments quietly slipped into the bill in May by the Senate Health, Human Services and Medicaid Committee. The amended legislation easily passed the Senate and House with no mention of MetroHealth during brief floor discussions in each chamber.

In an interview with cleveland.com, Committee Chair Sen. Dave Burke said that the amendment was not rushed through without a public vetting.

“We always let our bills rest. This is an amendment like any other amendment and it went to the floor,” Burke said.

Boutros noted that the provision in question was outlined in the bill’s full title – a 303-word convolution that includes every amendment in the bill. (The bill’s short title is “Authorize nurses to compel mental health evaluations.”)

“The bill went through the same exact process any other bill goes through. I think the bill was discussed,” Boutros said.

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Lisa DeJong, The Plain Dealer

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The amendment was added to HB 111 after Medina's mayor reached out to Senate President Larry Obhof in search of alternatives, following the Cleveland Clinic's decision to pull its maternity center out of Medina Hospital. The closing means patients must travel to one of three other Clinic locations, like the one shown here at Hillcrest Hospital in Mayfield Heights.

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But who, really, got this thing passed so secretly?

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Medina Mayor Dennis Hanwell is vying for a potential MetroHealth facility in his town, so he needed the law change. He said he pushed state legislators for the bill, and that they intended to get it done as expeditiously as possible.

Hanwell said he worked with Ohio Senate President Larry Obhof, who represents Medina, to handle the measure.

“It’s my understanding, and Sen. Obhof can clarify, that it was put in a bill that had some other healthcare related items in it, and it’s my understanding they felt it fit well within that bill.”

Obhof did not respond to cleveland.com’s requests for comment, nor did the office of Gov. John Kasich, who signed the bill June 29.

Former Cuyahoga County Councilman Rep. Dave Greenspan said he was asked to draft the amendment, but then handed it off to the Senate, where it was added to the bill.

While related to healthcare, the bill mostly centers on granting certain nurses new abilities to compel patients to submit to mental health evaluations and expanded oversight for private opioid treatment.

The Geenspan amendment was the only one related to county hospital regulations. While never naming MetroHealth, the amendment was worded in such a way that it only applies to MetroHealth, and not the state’s other county hospitals. The amendment permits public hospitals in charter counties to set up facilities in counties that neighbor charter counties. Cuyahoga and Summit are the only two charter counties in the state, and only Cuyahoga has a public hospital.

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David Petkiewicz, cleveland.com

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The passage of HB 111 means county officials will have no say over when and where MetroHealth chooses to expand. The county will decide only how much the hospital receives from the county's Health and Human Services levy fund. In this 2015 photo, County Executive Armond Budish, right, details for cleveland.com's editorial board proposed budget cuts for MetroHealth.

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It’s the Cuyahoga County hospital. Does the county have a say?

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The bill's passage means that Cuyahoga County officials will now have no direct say over when and where MetroHealth chooses to expand. That decision will be left to the hospital’s board of directors.

The county executive will still appoint those board members, and county council must approve them. County Council also reviews the hospital’s budget plans and decides how much money to allocate to MetroHealth from the county’s Health and Human Services levy fund, so if council members took issue with MetroHealth expansion plans, they could threaten to withhold tax dollars from the system during budget reviews.

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John Kuntz, cleveland.com

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MetroHealth CEO Akram Boutros, seen here high-fiving a nurse in the emergency room of the hospital's main campus, says Cuyahoga County taxpayer money will be spent only to care for county residents -- despite MetroHealth's plans to open facilities in other counties.

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How will Cuyahoga County dollars be affected?

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A public hospital operating outside county borders raises questions about how Cuyahoga County taxpayer dollars will be guaranteed for use within Cuyahoga County.

But Boutros said all Cuyahoga County money will continue to be spent solely on healthcare for residents.

MetroHealth received $32.4 million — about 2.8 percent of its current revenue — from the county’s Health and Human Services levy in 2016 and 2017, and will receive the same in 2018 and 2019, Boutros said.

That’s down from $40 million in 2014 and 2015.

Boutros said that money is placed in an account separate from the hospital’s general funds, and that account is used only for free care of the county’s indigent patients. He noted that MetroHealth in 2017 added $128 million of its own money, on top of the public dollars, to supplement free care in Cuyahoga County.

That money will remain in the separate account once MetroHealth begins expanding outwards.

Council President Dan Brady said he foresees no complications with how Cuyahoga dollars will be spent either.

“We do have an agreement, and they cannot spend county dollars outside of the county, so I don’t see anything wrong with this at all," Brady said. “[The money] is segregated...and well-documented."

Around the time the bill was moving through the legislature in May, the hospital’s board of trustees passed a resolution requiring that all levy dollars remain for the exclusive support of Cuyahoga County residents, Boutros said.

And if potential new ventures fail, Boutros said MetroHealth has $400 million in reserves that would be used to cover that shortfall, meaning Cuyahoga taxpayers wouldn’t be on the hook.

With the new ability to operate outside the county, MetroHealth is focusing on the possibility of moving into already-constructed facilities, rather than building pricey new ones from the ground up, Boutros said. Because those projects are significantly less expensive than building anew, Boutros said the reserves would easily cover any failed projects.

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Plain Dealer file

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Now that HB 111 has created opportunities for MetroHealth's expansion into other counties, competition between Cleveland's hospital systems will likely grow fiercer. The Cleveland Clinic and University Hospitals both have acquired community hospitals and healthcare facilities throughout Northeast Ohio at a breakneck pace.

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How does this affect the Cleveland Clinic and University Hospitals?

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Northeast Ohio’s healthcare industry has undergone a seismic shift in recent years as the Cleveland Clinic and University Hospitals have rapidly acquired other community hospitals and health services throughout the region. MetroHealth, too, has moved into new Cuyahoga County communities, but it has been unable to mirror the others’ expansions outside the county.

Now that HB 111 has created opportunities for MetroHealth’s expansion, competition between the systems will likely grow fiercer.

The Cleveland Clinic acquired Medina Hospital in 2009 and shut down its maternity center last summer as part of a decision to consolidate labor and delivery services to three of its other locations — Akron General, Fairview Hospital on Cleveland's West Side and Hillcrest Hospital in Mayfield Heights.

The closure meant that Medina County residents would have to venture outside the county for delivery. Community members rallied against the move and city council passed a resolution in strong protest.

“We begged and implored [them] to not take this away from the community to no avail,” Medina Mayor Dennis Hanwell told cleveland.com.

Hanwell asked Medina’s Ohio Senate President, Larry Obhof, for help, and at the same time, reached out to other health systems to fill the gap.

University Hospitals and Akron’s Summa Health System refused to step in, and Medina considered options with Wooster Community Hospital and OhioHealth Mansfield Hospital as well, Hanwell said.

That’s when the mayor turned to MetroHealth, where Boutros was interested in helping but was prohibited by state law from doing so.

So, Hanwell set to working with Obhof and others, and the amendment was then added to House Bill 111.

“We worked diligently to try to find any opportunity. Dr. Boutros, of all the folks we talked to, was the first to understand our need, and the void that was created when our maternity center closed,” Hanwell said. “It’s an answer to our prayer.”

Boutros wouldn’t say if Medina is one of the five communities in which MetroHealth is considering a move, but he did call the situation “problematic,” and noted that Medina County women have to travel up to 40 miles to give birth.

“If we were asked, we would consider filling a gap like that,” Boutros acknowledged.

Another regional healthcare gap emerged earlier this year when the Affinity Medical Center in Massillon closed its doors after its corporate parent exhausted efforts to sell off the hospital.

State Rep. Kirk Schuring, who represents that area, and was temporary speaker of the Ohio House just prior to the bill’s approval there, said he considered backing the bill because of what it might mean to Massillon’s hospital, but opted not to.

“The significance of that amendment was pretty substantial, and just to support it for what might be a remote possibility to do something in Massillon — that’s why I was hesitating.” Schuring said.

Schuring told cleveland.com that it now appears MetroHealth might not get involved in Massillon, but said that could change in the future.

Boutros did not weigh in on the possibility of MetroHealth in Massillon. But he did say that potential suitors must assess the community’s needs.

“Do the other providers in the area fill those [healthcare] gaps? If they do, you should not open another hospital. If they don’t, you should close those gaps. From what I’ve heard…there are multiple suitors for the facility offering different opportunities. I think the process Massillon is going through is a good one,” Boutros said.

Massillon Mayor Kathy Catazaro-Perry did not return a call for comment Friday.

Boutros further left open discussions of partnerships with the Clinic, UH or other systems. He also included the recently troubled Summa in Akron, which announced an upswing this year after a rocky 2017. It had initially projected a $60 million loss in operating income last year, but later said it only lost $28 million.

Boutros praised Summa for reorganizing its system and said its finances are now in the black, adding that it’s on its way to being a “solid performer.”

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Grant Segall, The Plain Dealer

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Medical Mutual of Ohio teamed up with MetroHealth to offer CLECare -- a health insurance product that offers its members most services at MetroHealth's network of hospitals and outpatient centers across Cuyahoga County, such as the Middleburg Heights outpatient facility shown here. The passage of HB 111 creates potential for CLECare to grow.

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What does this mean for the MetroHealth insurance product?

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CLECare, a new insurance product launched recently by MetroHealth and Medical Mutual Insurance of Ohio, has grown faster than expected.

MetroHealth provides CLECare members with most services — including tests, doctor visits and hospital stays — at its network of hospitals and outpatient centers across Cuyahoga County.

Because MetroHealth has been restricted to serving Cuyahoga County, though, employers outside the county, or those with employees living outside the county, were loathe to sign up.

New MetroHealth locations outside of the county means that CLECare will be more widely available to residents and employers throughout the region.

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HGA, Bostwick Design Partnership

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MetroHealth has started construction of a $1.2 billion transformation of its main campus that will modernize operations, add community health and fitness programs, and reshape fundamental methods of providing care. But the hospital's success could slow if it is unable to compete with the other major systems.

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How does regional expansion fit with the MetroHealth story?

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MetroHealth began as Cleveland’s City Hospital in 1837, created to serve the city’s chronically ill, elderly, mentally impaired and the poor, according to the MetroHealth website. In 1958 City Hospital became a county hospital and was renamed Cleveland Metropolitan General Hospital. Its new status allowed it to seek the financial support of taxpayers through a series of levies. The funds permitted the hospital to expand in both size and scope.

The Cuyahoga County Hospital System became The MetroHealth System in 1989. It’s governed by a 10-person volunteer board of trustees, appointed by the Cuyahoga County Council.

As Cuyahoga County's "safety net" hospital, MetroHealth holds to a mission of caring for all county residents, regardless of ability to pay. For that reason, the health system mainly serves Medicare, Medicaid and uninsured patients.



In 2008, MetroHealth faced a looming financial crisis because of rising charity care costs and falling reimbursements from Medicare and Medicaid, as well as private insurers. Then-CEO Mark Moran immediately began layoffs to help the system stay afloat. About 650 positions were eliminated over the next four years, using layoffs and leaving vacant positions unfilled, and closing the 144-bed skilled nursing unit at the former Deaconess Hospital in the Old Brooklyn neighborhood.

MetroHealth’s staff hadn’t seen such extensive layoffs since 2000, when about 190 employees were laid off to offset a budget shortfall driven mainly by the increasing cost of caring for the city’s poor.

When Boutros was hired in 2013, staffing, morale and the MetroHealth reputation were at a low. He came in with grand plans for the institution, which included more outpatient facilities and a long overdue renovation of the hospital’s main campus on West 25th Street.

Since then, the hospital has improved its financial outlook and debt rating by boosting operating income and successfully renegotiating reimbursement rates for its managed care contracts. The passage of the Affordable Care Act has led to less charity care. And in recent years, the hospital has reported budget surpluses.

Under Boutros’ tutelage, MetroHealth has reached farther into the community by hiring community health advocates to help identify public health problems facing Cleveland neighborhoods and to devise solutions. The health system launched primary care services inside Discount Drug Mart locations in Cuyahoga County, created school-based health centers in Cleveland and dispatched mobile units.

MetroHealth also opened new outpatient facilities and emergency rooms throughout the county, as well as community hospitals in Cleveland Heights and Parma.

As facilities have opened, the number of patients has increased and finances have improved. MetroHealth has added tens of thousands of patients since its reinvention, including through its health plan, MetroHealth Select, which is offered free to county employees.

And of course, MetroHealth has started construction of a $1.2 billion transformation of its main campus that will modernize operations, add community health and fitness programs, and reshape fundamental methods of providing care. The hospital is funding the project with self-issued revenue bonds, rather than tapping into taxpayer money.

MetroHealth’s recent success, however, could slow if it is unable to compete with the other major systems, and Boutros sees the ability to move into a wide geography as the natural progression of his mission to provide quality healthcare to the underserved.