As Hawaii Health Systems Corp. founders, CIO/CFO Money Atwal mulls next move

Hawaii Health Systems Corp. East Region CIO and CFO Money Atwal.

As the state-run Hawaii Health Systems Corp. faces a $50 million budget shortfall, one of its key executives is mulling his options after laying claim to some of the system's most successful initiatives.

In September, HHSC East Hawaii Region Chief Executive Officer Dan Brinkman announced that Money Atwal, the region's chief information officer and chief financial officer, would take an indefinite leave of absence to pursue other interests.

According to Atwal, he's using the paid leave to spend more time with his family while also deciding where he will land next but would not comment on whether the financial struggles or leadership changes at HHSC factored into that decision.

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Atwal had been one of the system's most visible executives, after leading the East Region, which is comprised of the larger Hilo Medical Center and two other critical access hospitals, through a host of technological and procedural changes that earned the system major recognitions.

In announcing Atwal's leave in September, new CEO Dan Brinkman pointed to the outgoing executive's accomplishments, which administrators have acknowledged saved the system huge amounts of money.

"Money's legacy also includes significant improvements in our revenue cycle, development of data analytics and improved cost accounting," Brinkman said in a memo to staff obtained by the Hawaii Tribune Herald.

Perhaps highest on Atwal's list of achievements is the implementation of the the East Region's electronic health records system and the success it has had with meaningful use attestation and overall streamlining as a result. In fact, in September the Healthcare Information and Management Systems Society, which owns Healthcare Finance, named the Hilo Medical Center a 2015 Davies Award winner for not only the efficiency of its technological systems, but the millions in dollars saved due to the effectiveness of Money's initiatives. Hilo is also a HIMSS Analytics Stage 7 hospital, the highest achievement when it comes to EHR adoption.

"When I started as interim CFO we were 90 percent paper," Atwal said. "Now we're a Stage 7 hospital."

While the hospital's accomplishments don't go unnoticed, the financial reality of running rural, safety-net facilities in an age where healthcare favors scale is forcing the larger HHSC to scramble for new ways to shore up its balance sheet.

[Also: Are rural hospitals on the road to ruin?]

"Uncertainty abounds for (Hilo Medical Center) and other parts of the Hawaii Health System Corporation," analysts for First Hawaiian Bank wrote in a September report on the economic state of Hawaii Island. "It has been clear for years that the business model for state hospital facilities has not been sustainable. Revenues are not keeping up with costs, especially since the hospital system, like other parts of the state government, must increase funding of retirement promises."

Ballooning pension funding, staff raises negotiated by the state and well as declining reimbursement rates has led the HHSC to predict a $50 million shortfall in 2016, of which $7 million is tied to the East Region. The system has already laid off nearly 100 staffers in the East Region, many on the clinical side. Meanwhile, the subsidy paid by the state to support the system is shrinking. The system had asked for $156 million for 2016 but will only receive $106 million. And in 2017, the state plans to give the system $85 million. Legislators are still debating another $48 million appropriations bill that could fill the funding gap.

HHSC is also pursuing new public-private partnerships to keep the system going. Earlier this year, the state legislature approved the model of HHSC's Maui Regional Network, which has paved the way for Kaiser Permanente to partner with the hospitals there. Those negotiations are still underway.

Officials are now putting the same strategy to work in the East Region. On Oct. 22, the region's board voted to pursue a similar partnerships. It had already been informally negotiating with Adventist Health for a private-public partnership there.

Atwal said about 76 of East Region's patients are covered by Medicare or Medicaid.

"As a part of our next steps, we will be working to have legislation introduced and passed that will allow our region and other regions to enter into partnerships," East Region board Chairman Kurt Corbin said in a memo to employees after the meeting.

Atwal, however, will likely watch this unfold on the sidelines. While he may take on a new role within the HHSC, he said, he is using his leave to decide on whether to enter private healthcare instead.

Either way, his years working as a joint CIO/CFO has convinced him that wearing both hats is something he still wants to do. It's in that capacity where Atwal did some of his best work.

For example, East Region at one point faced ballooning accounts receivable days, which further slowed down the flow of cash for the system. At its worst, region saw close to 200 days in account receivables, he said, a terrible metric by all industry standards.

Wearing his CFO hat, Atwal said he looked first at staff procedures and training, finding big problems in how people were handling their accounts.

"Too many times we get focused on over-analyzing the data, but we took a pretty unique perspective and teamed with The Advisory Board to do education," he said.

Part of the issue was in how employees were trained. Atwal said turnover is low at HHSC, with some people working in positions they've held for up to 25 years. That meant there was a lot of legacy in the process, something that can be a drag in a change-heavy industry like healthcare.

For example, the system found too often its workers were picking and choosing when it came to chasing down accounts, targeting high dollar amounts and letting the smaller bills languish. But those can add up.

"We really got to the core of A/R and put together a very detailed and comprehensive training program, he said.

But that was only part of the solution. To complete the turnaround, Atwal leaned on his ability as CIO and found added solutions through technology by leveraging the relationship with Meditech, the electronic health record vendor he chose for the East Region's EHR rollout, to see what options they weren't taking advantage of with the software.

"The assumption with the account reps was the accounts they chose to focus on were the right ones," he said. "So we ended up automating queues and had them working on the accounts in the order that was given to them."

Atwal, who will be speaking at the Revenue Cycle Summit on December 7 and 8 in Atlanta, said automation was a major undertaking, but in doing so he was really able to find the gaps in the process.

[Learn more about the Revenue Cycle Solutions Summit]

Two-years after the program started, East Region cut its A/R days from 200 to 52 days at the hospitals and from 107 to 32 days at its clinics.

Atwal took on the double title several years ago after taking over the CFO role on an interim basis when the system lost its earlier finance leader. For him, the CIO/CFO combination makes perfect sense.

"Historically, CIOs and CFOs come from opposite sides of the business. One wants to spend and the other wants to save," he said. "For me, I have the left side and the right side constantly arguing in my head."

Atwal said he is hearing more about executives holding both of those roles. In fact, a search on professional networking site LinkedIn shows several healthcare executives are holding CIO/CFO offices in the United States.

But of course that's not the case everywhere, which is why Atwal said it's important that these key leaders align.

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"The CIO and the CFO need to get in each other's heads," he said. "Healthcare is now forced to show the return on investments."

With Atwal on leave, Brinkman, a former nursing administrator who took the CEO job in July, has announced a nationwide search for a new CFO. However, the CIO role was not mentioned in that announcement.

But Atwal says those jobs are more linked now than ever.

"Value is bridging the gap," he said. "I won't take a job again without being involved in both sides."

Twitter: @HenryPowderly