1 Legislative Appropriations Request for Fiscal Years 2010-11 Governors Office of Budget, Policy and...

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Legislative Appropriations Request for Fiscal Years 2010-11

Governor’s Office of Budget, Policy and PlanningLegislative Budget Board

Friday, September 19, 2008

David L. Lakey, M.D.Commissioner

2

Presentation Overview

• Health Challenges in Texas

• The DSHS Budget

• Exceptional Items

3

Health Challenges

• Maintaining public health activities, such as immunizations, sanitation and food quality

• Preventing and treating chronic disease

• Preventing and treating substance abuse and mental illness

• Preparing for and responding to public health threats, such as hurricanes, pandemic influenza and bioterrorism

• Monitoring and controlling infectious diseases

• Supporting the state’s health services delivery system

• Using health care data to improve services and guide decision-making

4

U.S. Life Expectancy at Birth

30

35

40

45

50

55

60

65

70

75

80

1900 1910 1918 1920 1930 1940 1950 1960 1970 1980 1990 2000

1918 Flu Epidemic

5

Increased Life Expectancy Driven by Public Health Improvements

Source: Ten Great Public Health Achievements – United States, 1900-1999 MMWR, April 02, 1999 / 48(12);241-243 http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm

47 years

77 years

0

20

40

60

80

1900 2000

Increased years due to

medical care advances:5

Increased years due to

public health measures:

25

6

Leading Causes of Death

1900

• Pneumonia

• Tuberculosis

• Diarrhea

• Heart Disease

• Intracranial Lesions

2005

• Heart Disease

• Cancers

• Cerebrovascular Disease

• Chronic Lower Respiratory Diseases

• Accidents

7

Leading Causes of Death

0 10000 20000 30000 40000 50000

Alzheimers

Flu & Pneumonia

Diabetes

Lower Respiratory Disease

Accidents

Stroke

Cancer

Heart Diseases

DSHS Center for Health Statistics

Texas 2001

8

Actual Causes of Death*Shaped by Behavior

0 5000 10000 15000 20000 25000 30000

Sexual Behavior

Homicide

DWI

Suicide

Drugs

Auto Accidents

Alcohol

Overweight/Obesity

Tobacco

Chronic Disease in Texas 2007, DSHS*Texas 2001

9

Impact of Mental Illness

• Individuals with schizophrenia have a 20 percent shorter life expectancy than the overall population

• Significant mental illness is often linked to obesity, smoking and substance abuse

• Underserved populations with MH or SA issues often go to ERs for treatment

10

Disaster Preparedness and Response

• INSERT SLIDE ON HURRICANES

Storms lined up across the Atlantic – September 2008

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TB Case Rates in Texas, 2005

Top 10 High-Morbidity Counties

Cases

Harris 380Dallas 224Tarrant 129Hidalgo 92Bexar 74Cameron 68El Paso 49Travis 48Webb 42Fort Bend 34

Webb

Harris

Hidalgo

Bexar

Travis

Nueces

Dallas

Cameron

El Paso

Tarrant

Fort Bend

9

1

8

2

7

4

3

6

5

11

10

Source: Texas Department of State Health Services - Tuberculosis Statistics

Rate per 100,0000.0 - 2.2

2.3 - 6.7

6.8 - 15.2

15.3 - 29.0

29.1 - 69.4

County with Cases > 24

State Rate: 6.7/100,000

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FY 2008-9 DSHS budget by source

• $5.5 billion biennial budget

37%

14%

44%

5%

General Revenue

General Revenue-D

Federal

Other

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Exceptional Items

• Stakeholder meetings

• In priority order, ranked according to:– Maintaining operating capacity in existing

programs– Ensuring compliance with current state and

federal requirements– Moving health forward in Texas

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Maintaining Operational CapacityExceptional Item 1

• Biennial funding for crisis services

• Progress in delivery of crisis services FY 2007 FY2008

– AAS Accredited Hotlines 1 38

– Mobile Crisis Outreach Teams 4 38

– Crisis Stabilization Units 3 3

– Extended Observation Units 3 6

– Crisis Residential Facilities 10 13

– Crisis Respite Facilities 4 14

– Outpatient Competency Restoration 1 4

15

20% 21% 22% 25% 26% 24% 24% 23% 20% 19%16%

10%16% 15% 15% 13% 13% 15%

10%5%

15%13%0%

25%

50%

75%

100%

SFY2006

Q1

SFY2006

Q2

SFY2006

Q3

SFY2006

Q4

SFY2007

Q1

SFY2007

Q2

SFY2007

Q3

SFY2007

Q4

SFY2008

Q1

SFY2008

Q2

SFY2008

Q3

Adults Children

SFY2008 Annual Target = 17%

Sources: DSHS Client Assignment and Registration (CARE) system. Note: SFY2008 YTD includes persons served with old + new GR.

Percent of Persons Receiving Crisis Services Followed by a Psychiatric Hospitalization within 30 Days Already Better than Target

Maintaining Operational CapacityExceptional Item 1 – Crisis Services

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Maintaining Operational CapacityExceptional Item 1 – Trauma Funding

• Maintain funding for trauma reimbursement

– Uncompensated trauma care at designated facilities

– Grants to EMS providers and regional systems

• Since the enactment of trauma reimbursement (2003-8):

– 1 additional Level I and 1 additional Level II trauma center

– 4 additional Level III centers and 53 new Level IVs

– Coverage has increased by 59 centers (31%)

– 31 additional counties served since 2003

17

Texas Designated Trauma Facilities2008

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• Annualized funding for Alberto N settlement services– Personal care services for children on Medicaid

• Align family planning reimbursement rates and service package with Medicaid– Potential loss of primary care services

• Cover increase in transportation costs for the rabies bait drop– Potential rabies in South and West Texas

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• Rising costs across the agency– Laboratory– Hospital pharmaceuticals, medical supplies and

food– Travel/fuel costs– Utilities

20


FY2010* FY2011*

08-09 Phased-In Services – Crisis Maitenance $13.7 $13.7

08-09 Phased-In Services – Trauma Funds $23.2

08-09 Phased-In Services – Alberto N $1.1 $1.1

Increased Costs $10.6 $13.3

Total: $25.4 $51.4

* All figures in millions

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Ensuring ComplianceExceptional Item 2 – Regulatory Services

• DSHS Regulatory Division ensure the safety of the products and services Texans use every day– Food– Hospitals, surgical centers and dialysis centers– Health professionals, including EMS, Medical

Radiologic Technicians, Professional Counselors

– Medical Devices– Radiation

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• Regulatory programs are supported by fees• Texas is a growing state

– From 2002 and 2007, the number of licenses in some programs increased by as much as 80%

• New licenses require compliance inspections, response to complaints, enforcement

• DSHS already uses risk-based inspections in most programs

• Total, Exceptional Item 2– FY 2010: $7.3 million– FY 2011: $11.5 million


23


Increase in licenses for the Division of Regulatory Services 2002 thru 2007

30.76%

76.60%

32.52%

10.73%

24.49%

83.07%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

55.00%

60.00%

65.00%

70.00%

75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Licenses by Regulatory Strategy

Per

cen

tag

e o

f In

cre

ase

Summary of all Regulatory licenses

13038 - Food and Drug

13039 - Environmental

13040 - Radiation

13041 - Professional Licensing

13042 - Health Care Facilities

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• Cancer Registry– Children’s cancer research– Helping communities assess risk

• Kelly Air Force Base, San Antonio

• Houston Ship Channel

• El Campo trichlorethylene

– Improving access to breast cancer services

Ensuring ComplianceExceptional Item 3 – Health Care Data

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• Birth Defects Registry– Evaluation of strategies to reduce risk of birth

defects– Evaluation of factors playing a role in survival

of children with birth defects– Participation in CDC’s National Birth Defects

Prevention Study– Identify areas where children with birth defects

have little access to pediatric genetics clinics


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• EMS/Trauma Registry– Evaluate local injury prevention planning– Analyze ambulance diversion patterns– Compare patients across service areas to

improve timeliness and quality of patient care– Identify hazardous environments, such as

dangerous intersections


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• Healthcare Associated Infections (HAI)– Leading cause of death from infectious disease – 200,000 infections and 8-9,000 deaths in Texas

each year– HAI deaths in Texas exceed those in

automobile accidents and homicides combined– Up to 60 percent of infections are preventable– Annual cost in Texas: more than $500 million


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Health Care Data and AnalysisExceptional Item 3

FY2010* FY2011*

Disease Registries – Chronic $4.1 $2.6

Disease Registries – Healthcare Acquired Infections Reporting

$1.5 $2.8

Newborn Screening Linkage $0.81 $0.26

Center for Health Statistics $0.122 $0.128

Recruitment and Retention $0.051 $0.051

Total: $6.6 $5.8


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Ensuring ComplianceExceptional Item 4 – Vital Records

• Vital Records – birth and death certificates• REAL ID Act of 2005

– Requires states to issue secure driver’s licenses and identity cards– Will require other states to verify validity of birth certificates for

individuals born in Texas– Consequences of not complying – Texans will have to prove

identity beyond a driver’s license in banks and federal buildings and prior to domestic flights

– Total:• FY 2010 $3.5 million• FY 2011 $3.2 million

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Ensuring ComplianceExceptional Item 5 – Data Systems

Maintain and Enhance Technology• 400 programs in 9 health regions, 11 state hospitals, and a major

laboratory• Patient records, client case files, pharmacy inventories and disease

registries at risk• Internet connectivity between offices unreliable• Major telephone outages• Impacts:

– Patient health care and client management for mental and behavioral health

– Preparedness and response activities– Protection of sensitive data– Data center consolidation

• FY 2010 $7.8 million• FY 2011 $6.3 million

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FY2010* FY2011*

Network Interoperability, Video & Voice Communications and Security

$6.2 $5.5

Seat Management $1.5 $1.5

Consolidated Heatlh Care Data Collection $1.2 $1.0

Clinical Mangement for Behavioral Health Services $2.7 $3.8

Client Record System – Capacity & Bandwidth $0.36 $0.30

Hospital Automated Medication Dispensing System

$3.6 $2.5

Total: $15.7 $14.6

Data SystemsExceptional Item 5

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Ensuring ComplianceExceptional Item 6 – Disaster Response

• Disaster Recovery and Public Health Preparedness– Expanding core response for all-hazards, natural or

manmade – hurricanes to salmonella

– Improve timeliness of laboratory tests, environmental analysis and disease surveillance

– Need to maintain skilled workforce for rapid deployment in event of emergency or disease outbreak

– Local Health Department Expansion

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Disaster Recovery and Public Health Preparedness

Exceptional Item 6

FY2010* FY2011*

Laboratory $2.0 $1.0

Local Health Department Expansion $0.45 $0.45

Behavioral Health positions in DSHS Regional Offices $0.64 $0.7

Public Health Emergency Preparedness Response $3.9 $3.4

Recruitment and Retention $0.76 $0.76

Total: $7.8 $6.3


Salmonella Saintpaul Outbreak

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Impact of Hurricane Ike

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Ensuring ComplianceExceptional Item 7

• Stipends for Psychiatric and Preventive Medicine Residents– Residency placement slots in state hospitals

• Only 6.4 psychiatrists per 100,000 Texans

– Preventive Medicine residencies to strengthen the workforce• 67.9 physicians per 100,000 Texans

– Cost-effective means of increasing medical care in underserved areas and in hospitals

– Physicians often remain in the community where they served as a medical resident

• FY 2010 $1.4 million• FY 2011 $1.35 million

37

Psychiatrists and Child Psychiatrists, Texas, 2007

Psychiatrists per 100,000 Population

00.1 - 5.15.1 - 10.710.7 - 19.619.6 - 36.5

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Building & Equipment Repair & Replacement

• Hospitals must comply with Life Safety Code

• Joint Commission accreditation

• Replace only broken, unsafe or unusable equipment and patient furniture

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• Eleven State Mental Health Facility campuses

• 3,032 acres, 552 buildings, 4.9 million square feet

• $866 million replacement value

• Average age is 55.2 years old.

• Most buildings were well built and remain structurally sound, but are in need of renovation to meet today’s standards and programmatic requirements.

• Over 84% of total building area is dedicated to patients and patient support.

Infrastructure Description


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• Identified deficiencies (deferred maintenance): $233 million

• $198.3 million in capital construction needs have been identified for FY10-11 funding for State Hospitals.

• Of that, $67 million has been identified as the most critical.

FY10-11 Capital Construction Needs

$233M

$198.30M

$67M

$0

$50

$100

$150

$200

$250

DeferredMaintenance

Needs Requested


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• Average Life Expectancy of most of the State Hospital capital equipment is 5 to 8 years.

• Average years of actual use for much of the State Hospital capital equipment is 11+ years, far surpassing its life expectancy, creating a potential risk to patients and staff.

Categories of Capital Equipment• Grounds• Heating• Air conditioning

• Motorized• Emergency• Other

• Furniture• Medical/Adaptive• Food Service


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Moving Health ForwardExceptional Item 9 – Substance Abuse

• Increase treatment rates to maintain provider base

• Increase treatment capacity to serve individuals

• Expand prevention services• Provide Medicaid outpatient benefit to

leverage federal funds

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Note:The % of need met is [the unique number of served] divided by [the number in need of treatment], Where [the unique number of served] is the distinct count of clients served in DSHS-funded substance abuse treatment programs during a year, and [the number in need of treatment] is the estimated number of persons with a substance abuse problem and in poverty during a year.And, [the number in need of treatment] is measured by applying the prevalence rates derived from various surveys to the general population in Texas.Data Sources:1. [the unique number of served]: Behavioral Health Integrated Provider System (BHIPS), DSHS.2. [the number in need of treatment]: (a) Population projections in Texas, (b) National Survey on Drug Use and Health for Texas, and (c) Texas School Survey of Substance Use.

2007

Texas Population(age 12+)

19,463,968

2007

Estimated Number

with Chemical

Dependency

1,825,591

SFY2007

Number Served in

DSHS-Funded

Substance Abuse

Treatment Programs

(including NorthSTAR)

63,929

(7.5%)

Who Are

Also Poor

853,982

Percent of need met in Texas for DSHS-funded substance abuse treatment in SFY2007, adjusting for poverty (200% FPL).


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Treated

$89

Untreated

$136

$0

$136

ER Costper Medicaid Client

per Month

ER COST OFFSET

- $46Average per Client per Month

35%REDUCTION

Texas monthly hospital emergency room costs are 35 percent lower for medicaid clients receiving dshs-funded substance abuse treatment who needed it.

Source: FY2005 ER Cost per Medicaid Client per Month for Those Who Needed Substance Abuse Services But Did Not Receive Them (Untreated) vs. Those Who Needed Substance Abuse Services and Did Receive Them (Treated): Initial data set consisted of all persons who had Medicaid paid Substance Abuse ER visits during FY2005. Clients were divided into those who received DSHS Substance Abuse services based on match between DSHS Substance Abuse dataset with Medicaid dataset. Dependent variable was Total ER costs or dates or service during FY2005. Data sources: DSHS Substance Abuse services = BHIPS, Medicaid ER = TMHP AHQP Claims Universe. Prepared by Research Team, Strategic Decision Support, HHSC, 3/23/2006.


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• Reduced use of medical services, leading to cost savings• Lower medical costs by reducing low birth weight

babies, Fetal Alcohol Spectrum Disorders and use of neonatal ICU

• Benefit to the child welfare system through services to women of childbearing age

• In 2006, twenty percent of inmates in TDCJwere convicted of drug offenses– That doesn’t count those convicted of other offenses

to which substance abuse was a contributing factor• Services eligible for Medicaid leverage state funds with

federal funds (40 percent state/60 percent federal)


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Substance AbuseExceptional Item 9

FY2010* FY2011*

Treatment Services $21.6 $21.6

Prevention Services $4.5 $4.5

Medicaid for Outpatient Substance Abuse Services $13.8 $13.8

Increased Contract Management Costs $0.91 $0.99

Total: $40.8 $40.9


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Offering services in the community

1) Expand community mental health crisis services

2) Develop transitional services for difficult-to-engage high-need individuals

3) Increase capacity for intensive services for current clients

Moving Health Forward EI 10 – Community Mental Health

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• Part 1: Community mental health services– Expand options to underserved communities

with crisis funds, assuring targeted services to children and adolescents

– Provide more Psychiatric Emergency Services Centers and Children’s Crisis Projects (e.g., Respite)

– Serve an additional 8736 individuals/year– Serve an additional 226 children/year


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Part 2: Transitional services for difficult to engage high-need individuals

• Goal is to break the cycle of crisis-stabilization-crisis

• Serves 4,163 adults/year

• Serves 630 children/year


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• Part 3: Increase capacity for intensive services for current clients

• Focus on difficult-to-serve clients transitioning from crisis

• Serves 1,984 persons in FY10 and 3,967 in FY11• Total, Exceptional Item 10

• FY 2010 $39.3 million

• FY 2011 $49 million


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Texas Monthly Hospital Emergency Room Costs Are 27 Percent Lower for Medicaid Clients Receiving

DSHS-Funded Community Mental Health Treatment Who Needed It

Untreated

$93

Treated

$68

$0

$93

ER Costper Medicaid Client

per Month

ER COST OFFSET

- $25Average per Client per Month

27%REDUCTION

Source: FY2005 ER Cost per Medicaid Client per Month for Those Who Needed Community Mental Health Services But Did Not Receive Them (Untreated) vs. Those Who Needed Community Mental Health Services and Did Receive Them (Treated): Initial data set consisted of all persons who had Medicaid paid Mental Health ER visits during FY2005. Clients were divided into those who received DSHS Mental Health services based on match between DSHS Mental Health dataset with Medicaid dataset. Dependent variable was Total ER costs or dates or service during FY2005. Data Sources: DSHS Mental Health services = CARE, Medicaid ER = TMHP AHQP Claims Universe. Prepared by Research Team, Strategic Decision Support, HHSC, 3/23/2006.


52Sources: DSHS Client Assignment and Registration (CARE) system. Note: SFY2008 YTD includes persons served with old + new GR.

Average Monthly Number of Persons Receiving Community Mental Health Front-Door Crisis Services Increasing

1,997 1,868

2,442 2,548 2,433 2,381

2,8852,609 2,692

2,859

3,940

0

1,000

2,000

3,000

4,000

5,000

SFY20

06 Q

1

SFY20

06 Q

2

SFY20

06 Q

3

SFY20

06 Q

4

SFY20

07 Q

1

SFY20

07 Q

2

SFY20

07 Q

3

SFY20

07 Q

4

SFY20

08 Q

1

SFY20

08 Q

2

SFY20

08 Q

3

IMPLEMENTATION OF CRISIS REDESIGN


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14,545 14,60112,664

26,319

43,629

28,047

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

SFY2006 SFY2007 SFY2008 YTD

Crisis Residential Crisis Outpatient

SFY2008 Annual Target = 16,467

SFY2008 Annual Target = 30,717

Number of Persons Receiving Crisis Services Per Year Funded by General Revenue Exceeding/Approaching Targets

Sources: DSHS Client Assignment and Registration (CARE) system and DSHS NorthSTAR Data Warehouse.Note: SFY2008 YTD includes persons served with old + new GR as of August 28.


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Community Mental Health Exceptional Item 10

FY2010* FY2011*

Psychiatric Emergency Centers & Childrens Respite Services $14.2 $14.2

Transitional Services $14.5 $14.5

Intensive ongoing services targeting recipients of transition services

$9.6 $19.1

Increased contract management 0.86 0.94

External Evaluation of Crisis Projects $0.21 $0.21

Total: $39.3 $49.0


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Moving Health ForwardExceptional Item 11 – Chronic Disease

– 70% of deaths are related to chronic disease– 10% of population have major limitations in daily

living– About 75% of health care costs come from obesity,

high blood pressure, cholesterol and Type 2 diabetes– Tobacco is implicated in 25,000 deaths in Texas

annually, about as much as alcohol, auto accidents and suicide combined

– Cost of $3.3 billion to Texas businesses in 2005– Health care costs for ERS have increased by 50 percent

since 2000

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Many of these conditions are preventable. We can reduce the disease burden and the economic burden by promoting:

– Avoidance of tobacco– Healthy eating– Physical activity– Maintaining a healthy weight– Controlling blood pressure and cholesterol


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1998

Obesity Trends* Among U.S. Adults(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2007

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: CDC Behavioral Risk Factor Surveillance System

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• Obesity

– Interventions to improve nutrition and increase physical activity

– Improved screening, diagnosis and treatment for cardiovascular disease and stroke

– Support of the Mayor’s Fitness Council Grant program

• Tobacco

– Expand cessation services for Texans who want to quit

– Increase partnerships with communities with anti-smoking activities

• Newborn Screening

– Expand detection of cystic fibrosis and case management


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Chronic DiseaseExceptional Item 11

FY2010* FY2011*

Obesity Prevention $3.3 $5.9

Tobacco Prevention $3.8 $4.7

Cardiovascular Council Projects $1.0 $1.0

Cystic Fibrosis $2.9 $3.4

Total: $10.9 $15.0


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Moving Health ForwardEI 12 – Infectious Disease

• Infectious Disease Prevention– Like chronic disease, early detection and

effective treatment are critical– Persons with these diseases can spread them– Interrupted treatment makes the disease more

difficult and expensive to treat– HIV, tuberculosis and sexually-transmitted

diseases are co-morbid

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• CDC recommends expanded testing for HIV– Earlier detection leads to earlier, more effective

treatment– Reduces the rate of transmission

• Texas is second nationally in TB cases• Exceptional 12 item includes

– Improved HIV testing– Expand improved testing for TB and STDs– Tuberculosis services– Upgrade cervical cancer screening


PLWHA

Deaths

New Cases

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

2001 2002 2003 2004 2005 2006

Year

Nu

mb

er:

PL

WH

A

0

1,000

2,000

3,000

4,000

5,000

6,000

Nu

mb

er:

New

Cas

es a

nd

D

eath

s

HIV/AIDS in Texas: Persons Living with HIV/AIDS, New Diagnoses of HIV/AIDS, and Deaths among those with HIV/AIDS

New diagnoses are holding steady. The number of persons living with HIV/AIDS is rising because they are surviving longer.


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Racial Disparity in Persons Living with HIV/AIDS in Texas, 2001 - 2006

22,439

16,388

23,119

15,18414,417

8,936

0

5,000

10,000

15,000

20,000

25,000

2001 2002 2003 2004 2005 2006

Year

Nu

mb

er

White Black Hispanic

196.7146.6

615.9

868.3

170.2128.4

0

100

200

300

400

500

600

700

800

900

1000

2001 2002 2003 2004 2005 2006

Year

Rat

e p

er 1

00,0

00

White Black Hispanic

The number (left graph) of black persons living with HIV/AIDS surpassed that of whites in 2005. The rate (right graph) in 2006 was 5 times higher for blacks than for others.


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In 2005, the incidence of Tuberculosis in Texas was 39% higher than the U.S. incidence rate

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Infectious Disease PreventionExceptional Item 12

FY2010* FY2011*

HIV/STD Viral Hepatitis Testing $4.4 $4.7

Tuberculosis Services $3.2 $3.6

Cervical Cancer Screen $0.53 $0.53

Total: $8.1 $8.8


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Other AgencyLegislative Appropriations Requests

• Health and Human Services Commission– Critical health care shortage positions

• Physicians, psychiatrists, nurses

– Waiting lists for Children with Special Health Care Needs, Children’s Mental Health Services

– Consolidated enterprise requests for technology and vehicles

• Department of Assistive and Rehabilitation Commission– Accessibility of information technology

• Comptroller’s Judiciary Section– Increase in number of Sexually Violent Predators monitoring

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Concluding Thoughts

• In the 21st century, Texas faces new and evolving health challenges

• There are effective ways of reducing the personal and economic toll of the disease burden

• What DSHS is presenting in its LAR represents our best effort to improve health for individual Texans and the state as a whole

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