Case Contributors: Terri Menser and Ann Scbeck McAJ'eamey [201 8} Paul is a newly promoted chief nancial ofcer of the Columbus City Health System (CCHS). a large, established urban health system. He has been with the organization for nearly two dozen years, and has seen the healthcare environment shift greatly over that time. Given all the changes that have taken place since the passage of the Affordable Care Act, Paul is concerned about his ability to present a clear picture of the CCHS nancial situation to the board and to CCHS administrators. Not only is the reimbursement picture complicated due to the nature of thirdparty payments, but the introduction of nancial incentives and penalties based on organizational performance has hampered his ability to develop a reliable budget or forecast hospital nances. Given his promotion, Paul wonders whether he should use this transition as an opportunity to devise a better basis for the values estimated in the budget, along with accompanying metrics to monitor nancial performance. New metrics might be able to account for penalties and more closely align with "worstcase scenario" income forthe hospital. thus better preparing the best account forthe unknown dollar amount that will be reimbursed for care given the shifting mix of payers and variability in negotiated rates. Another concern involves the cost of tracking and reporting quality data. Since starting in his new position. Paul has tried to calculate the cost of the resources (e.g. additional labor) required to achieve the quality measures set by the Centers of Medicare a Medicaid Services {CMS}. and he has found the amount of work to be daunng. He has found the CCHS currently reports more than 1000 unique measures to 35 different organizations, reecting the reporting burden common to many healthcare organizations [Murray et al. 201?}. Paul understands the importance of population health and measuring quality, but he also knows that resources are limited. He is acutely aware of the nancial constraints facing CCHS. Paul thinks the time has come to improve the budget metrics so that CCHS will be better able to understand and report its nancial picture. He does not consider any of these policy changes to be eeting, and he believes they should be incorporated into the budgeting process. However. he is not sure how to do so. To get started with the process. Paul schedules a meeting with is analysts and asks them to come prepared to discuss how to improve their current budgeting process. $500, 000 has been set aside for CCHS to invest in population health, which Paul believes will help the organizaon to reach some of the CMS quality measures. He has asked senior executives in each department to make recommendations on how best to spend the funds, bearing in mind how potenal expenditures will affectthe organization's bottom line