Legislative Appropriations Request for Fiscal Years 2010-11 Governor’s Office of Budget, Policy and PlanningLegislative Budget Board Friday, September 19, 2008David L. Lakey, M.D.Commissioner
Presentation Overview • Health Challenges in Texas • The DSHS Budget • Exceptional Items
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
U.S. Life Expectancy at Birth 1918 Flu Epidemic
Increased Life Expectancy Driven by Public Health Improvements 80 Increased years due to public health measures: 25 60 Increased years due to medical care advances: 5 40 77 years 47 years 20 0 1900 2000 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
Leading Causes of Death 1900 • Pneumonia • Tuberculosis • Diarrhea • Heart Disease • Intracranial Lesions 2005 • Heart Disease • Cancers • Cerebrovascular Disease • Chronic Lower Respiratory Diseases • Accidents
Leading Causes of Death Texas 2001 DSHS Center for Health Statistics
Actual Causes of Death*Shaped by Behavior *Texas 2001 Chronic Disease in Texas 2007, DSHS
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
Disaster Preparedness and Response • INSERT SLIDE ON HURRICANES Storms lined up across the Atlantic – September 2008
1 Dallas 3 2 4 Tarrant 9 El Paso 5 7 10 Travis Harris 6 8 Bexar Fort Bend Rate per 100,000 0.0 - 2.2 2.3 - 6.7 Webb Nueces State Rate: 6.7/100,000 11 6.8 - 15.2 15.3 - 29.0 29.1 - 69.4 County with Cases > 24 Hidalgo Cameron Source: Texas Department of State Health Services - Tuberculosis Statistics TB Case Rates in Texas, 2005
FY 2008-9 DSHS budget by source • $5.5 billion biennial budget
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
Maintaining Operational CapacityExceptional Item 1 • Biennial funding for crisis services • Progress in delivery of crisis servicesFY 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
Maintaining Operational CapacityExceptional Item 1 – Crisis Services SFY2008 Annual Target = 17% Percent of Persons Receiving Crisis Services Followed by a Psychiatric Hospitalization within 30 Days Already Better than Target Sources: DSHS Client Assignment and Registration (CARE) system. Note: SFY2008 YTD includes persons served with old + new GR.
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
Maintaining Operational CapacityExceptional Item 1 • 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
Maintaining Operational CapacityExceptional Item 1 • Rising costs across the agency • Laboratory • Hospital pharmaceuticals, medical supplies and food • Travel/fuel costs • Utilities
Maintaining Operational CapacityExceptional Item 1 * All figures in millions
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
Ensuring ComplianceExceptional Item 2 – Regulatory Services • 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
Ensuring ComplianceExceptional Item 2 – Regulatory Services Increase in licenses for the Division of Regulatory Services 2002 thru 2007 100.00% 95.00% 90.00% 83.07% 85.00% 80.00% 76.60% 75.00% 70.00% 65.00% 60.00% Summary of all Regulatory licenses 55.00% 50.00% Percentage of Increase 13038 - Food and Drug 45.00% 13039 - Environmental 40.00% 13040 - Radiation 35.00% 32.52% 30.76% 13041 - Professional Licensing 30.00% 24.49% 25.00% 13042 - Health Care Facilities 20.00% 15.00% 10.73% 10.00% 5.00% 0.00% Licenses by Regulatory Strategy
Ensuring ComplianceExceptional Item 3 – Health Care Data • 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 • 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
Ensuring ComplianceExceptional Item 3 – Health Care Data • 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
Ensuring ComplianceExceptional Item 3 – Health Care Data • 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
Health Care Data and AnalysisExceptional Item 3 * All figures in millions
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
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
Data SystemsExceptional Item 5 * All figures in millions
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
Disaster Recovery and Public Health PreparednessExceptional Item 6 * All figures in millions
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
Ensuring ComplianceExceptional Item 8 Building & Equipment Repair & Replacement • Hospitals must comply with Life Safety Code • Joint Commission accreditation • Replace only broken, unsafe or unusable equipment and patient furniture
Ensuring ComplianceExceptional Item 8 Infrastructure Description • 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.
Ensuring ComplianceExceptional Item 8 FY10-11 Capital Construction Needs • 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.
Ensuring ComplianceExceptional Item 8 Categories of Capital Equipment • Furniture • Medical/Adaptive • Food Service • Grounds • Heating • Air conditioning • Motorized • Emergency • Other • 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.
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
Moving Health ForwardExceptional Item 9 – Substance Abuse Percent of need met in Texas for DSHS-funded substance abuse treatment in SFY2007, adjusting for poverty (200% FPL). 2007 Texas Population (age 12+) 19,463,968 2007 SFY2007 Estimated Number Number Served in with Chemical Dependency DSHS-Funded 1,825,591 Substance Abuse Treatment Programs Who Are (including NorthSTAR) Also Poor 63,929 853,982 (7.5%) 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.
Fiscal Year 2005 Texas average monthly emergency room costs were 35 percent lower for Medicaid clients with substance abuse problems who received needed DSHS substance abuse treatment. Moving Health ForwardExceptional Item 9 – Substance Abuse ER COST OFFSET - $47 Average per Client per Month 35% REDUCTION 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.
Moving Health ForwardExceptional Item 9 – Substance Abuse • 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 TDCJ were 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)
Substance AbuseExceptional Item 9 * All figures in millions
Moving Health Forward EI 10 – Community Mental Health Offering services in the community • Expand community mental health crisis services • Develop transitional services for difficult-to-engage high-need individuals • Increase capacity for intensive services for current clients
Moving Health Forward EI 10 – Community Mental Health 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
Moving Health Forward EI 10 – Community Mental Health 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
Moving Health Forward EI 10 – Community Mental Health 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