If trends continue, the county's bureau of health services will finish the fiscal year $40 million over budget.

The news won't catch anyone by surprise - the health and hospitals system has come under budget only four times in the last 16 years - but members of a new board hoping to turn the troubled agency around were not pleased by the news Friday.

David Small, chief operating officer of the bureau, blamed the shortfall partly on the economy.

Small said a growing number of patients at the county's three hospitals and 16 clinics arrive without Medicaid or health insurance.

"We've seen a 5 percent shift from Medicaid to self-pay," Small said. "Most self-pays have no money."

Small and several members of the health and hospitals board said more needs to be done to convince patients to seek assistance in paying their bills.

Small said uninsured patients are asked by medical staff if they want to apply for public assistance. But the practice needs to be more widespread, he said.

Board member David Ansell said the new board, which met for only the second time Friday, needs a better understanding of the budget and ways to generate more revenue.

"We do need to get a better handle on the expense budget," Ansell said. "This raises the question of whether we're doing a good job of encouraging (patients to go into assistance programs)."

Member David Carvalho said he expects the board to get a better handle on the budget when the new fiscal year begins Dec. 1.

"We won't be able to hold management's feet to the fire until the next budget," Carvalho said. "I think this year's budget was unrealistic."

County chief financial officer Donna Dunnings responded that the budget passed in 2007 was based on many conversations with Bureau of Health officials.

"We consistently work with them to come up with numbers for revenues and expenditures," Dunnings said.

She said that roughly two-thirds of the proceeds of a $150 million tax anticipation note the county passed last month will go to the Bureau of Health. The note is to be repaid with  funds generated from the county's July 1 sales tax increase.

The shortfall comes despite a shrunken staff working overtime. The bureau has 300 jobs posted, and another 500 jobs need to be filled after that, Small said.

"Overtime costs are in line with the budget but trending up," he said. "We're using overtime in the best way we can."

The Health and Hospitals Board was created with the idea of appointing experts in the fields of business and medicine to create more efficiency in the county's health system.

Among the board's priorities are the hiring of a chief executive officer, a corporate compliance officer and developing a strategy for improvement of the system.

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