1. San Joaquin Valley Regional Association of CA Counties Health Care and the Affordable Care Act Hospital Viewpoint Stephen Walter, SVP/CFO Community Medical Centers-Fresno October 9, 2014

2. Healthcare and the Affordable Care Act About Community Medical Centers-Fresno, CA ACA, Goals, Health Care Industry, Resulting Impact ACA, Region, Safety-Net, Challenges Status of Hospitals in the SJV – OSHPD DATA 1Q and 2Q 2014 Access to Care; Providers and Hospital Beds What is Needed? – Payment Reform DSRIP – Delivery System Reform Incentive Pool for 2015?

3. Community Medical Centers CRMC 2 nd Largest Acute Care Hospital in California. CRMC Largest Safety-Net Hospital in CA Level 1 Trauma and Burn Center – Adults and Pediatric – Sac/LA Largest Provider for Specialty Care in SJ Valley Largest Private Employer in the SJ Valley- Over 7,000 Employees Largest Teaching Hospital in SJ Valley – UCSF – Over 300 Residents Invested over $1B in Plant and Equipment Last 12 Years

4. Affordable Care Act Main Goals- Uninsured, Access, Costs, Quality – “Triple Aim” Biggest Impact to Health Care since 1960s Not Perfect – Senate Only Version – “Modifications” House Republicans voted over 50 times to Repeal ACA Safe until 2016 – Obama Veto Kaiser Family Foundation say 3.4M Newly Insured in CA From 22% to 11% SJ Valley had the smallest gains in getting Medi-Cal/Covered CA NO LIHP in Fresno, Tulare; Latino Barriers, Safety-Net Numbers

5. ACA and Its Impact on Health Care Industry More Hospitals Will Become Part of a Health System More Physicians Will Affiliate With Hospitals More Providers Will Own Health Systems More Payments Will Move to VALUE-Based More Payments Will Become Fixed or Capitated

7. Hospital Overview in SJ Region Nine Counties – 36 Acute Hospitals – 17 Had Op Losses – Six Months 2014 Industry Trends – Consolidate, Value, Access, Population Health Sutter, Dignity, Adventist, Tenet, CMC (EMR, Seismic, Scale/Integration) Preventable Admissions – Safety Net – Impact of ACA Safety Net = Lower Reimbursement for Hospitals Valley Health Issues – Poorest Health and Fewest Primary Care Physicians Aging Population = Higher Hospital Bed Utilization Bed Capacity – CA Health Care Foundation 2008 Reduce DSH Funding to Safety Net Hospitals 2014-2020 State Conversion of Medi-Cal Payment to DRGs – Negative CHA/Deloitte – Unfavorable Current and Future Exposure

8. SJ Valley Hospitals – Operating Financials Top Five Winners Memorial – Modesto $34M; CRMC-Fresno $31M; Bakersfield Memorial $28M; Mercy Bakersfield $16M and Children’s-Madera $13M Top Five Losses SJ County $37M; Kern County $23M Mercy Merced $11M Adventist Kings/Fresno $9M Saint Agnes Fresno $7M Observations – Winners…System Strengths (Dignity, Sutter) Children’s Given a Distorted Medi-Cal Reimbursement. Losers…Counties, Regional Location, Stand-Alones and Districts No Provider Fee Monies in 2014 Source: OSHPD Hospital Financial Data 1Q and 2Q 2014

10. Seniors Growth in SJV Seniors 3X Hospital Days

12. ACA and Things to Fix… PAYMENT REFORM Medi-Cal Rates are TOO Low to Attract Doctors - Rates Recruiting Physicians to SJ Valley – CA Law Prevents Hiring Doctors Funding to Modernize Hospitals to Meet Seismic Affordable Health Care Plans for Agriculture Workers Care Model Programs to Address SJV Health Issues, i.e., Asthma Influence Medi-Cal 2015 Waiver DSRIP to Address Uniqueness of SJV Care Models to Focus on Population Health Interconnect Clinics, Hospitals and Providers with IT Hospital Provider FEE (QAF) – Make Permanent CA/CHA/CMS

13. DSRIP – SJV Mostly Missed Out, BUT… 2010 WAIVER $3.4B – Public Hospitals Benefitted Only New Medical 1115 Waiver Coming in 2015 Opportunity to Support the Private Safety Net Hospitals CSAC Representation on CA Dept Health Care Services

14. Thank you… Sources and Additional Info Beds for Boomers – California Health Care Foundation http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/S/PD F%20SnapshotBedsBoomers.pdf http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/S/PD F%20SnapshotBedsBoomers.pdf State of CA –Office of Statewide Health Planning and Development (OSHPD) http://www.oshpd.ca.gov/HID/DataFlow/HospMain.html DSRIP, California 2015 1115 Medi-Cal Waiver Transforming for Tomorrow-California Hospital Association July 2012 California and Its Counties Under the ACA: A Leadership Framework http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PD F%20CACountiesUnderACA.pdf