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Tag Archives: HHSC

Over the past few months, the Texas Sunset Commission has issued reports and recommendations about each of the agencies under the Health and Human Services umbrella. For example, here’s a write up I did about their recommendations for the state supported living centers: http://wp.me/pZf7K-9t and here’s one for the Department of Aging and Disability Services: http://wp.me/pZf7K-9p /

The Texas Sunset Commission has completed its review and recommendations for the Texas Health and Human Services Commission (HHSC). The full report can be found here: https://www.sunset.texas.gov/public/uploads/files/reports/HHSC%20and%20System%20Staff%20Report.pdf . The Sunset Commission issued 15 recommendations pertaining to HHSC, only a few of which will I discuss in detail:
• Health and Human Services agencies should be consolidated
• Medicaid can be administered better
• Participation in Medicaid by providers is being discouraged
• There is a need to improve quality of health care
• There are too many advisory committees

Consolidation:
The Health and Human Services system has expenditures of almost $35 billion annually with 54,000 employees. This is spread out across five agencies. It is the Sunset Commission’s opinion in their report that the size and scope of the five agencies creates blurred accountability, fragmentation of programs and services, “organizational misalignment,” ineffective regulatory services, and some real challenges with the current organizational structure of the enterprise. For example, the report mentions that the Department of State Health services has a focus that is too broad, the existence of the Department of Aging and Disability Services is questionable after Senate Bill 7 (managed care), and the Department of Assistive and Rehabilitative Services has too narrow of a focus and some of its programs and services are duplicated by DADS.

As a result of the above, the Sunset Commission recommends:
• All the agencies be consolidated into one.
• Organize the new entity along functional lines:
o Central/support services (i.e. administrative support)
o Medical and social services
o State institutions and facilities
o Family and protective services
o Public health services
o Regulatory services
o Office of inspector general
• Establish a policy and performance office

Medicaid can be administered better:
The Sunset Commission found the Medicaid is fragmented because it is administered by DADS, DSHS, and HHSC. This leads to a lack of communication, a lack of policies and program administration, duplication, and inefficient delivery of services. The recommendation is to consolidate all the Medicaid programs (waivers, entitlement programs, YES waiver, etc.) to HHSC, which falls in line with the consolidation recommendation above.

Participation in Medicaid by providers is being discouraged:
According to the Sunset report, only 31% of physicians are willing to accept new Medicaid clients. The report finds that it is too difficult to enroll (it may take three to twelve months to navigate the state’s system and become enrolled as a provider), there are huge administrative burdens on the part of providers, and the reimbursement rates are low. As a result, the Sunset Commission is recommending that HHSC streamline and centralize the provider enrollment process, streamline the criminal history process and require a fast (10 day) turnaround.

Health care quality:
According to the Sunset report, there are 270 different initiatives to improve the quality and outcomes of Health and Human Services programs and services! This creates a lack of focus, administrative burdens, inefficiencies, and missed opportunities. The Sunset Commission recommends that HHSC develop a comprehensive, coordinated plan to ensure consistent approaches for improving the quality of health care and require HHSC to pilot incentive-based payments by managed care organizations.

Advisory committees:
HHSC has 41 advisory committees. In 2013 this amounted to 189 meetings, 16,700 staff hours, and cost the state $800,000. Most of these committees are established by legislation and have reporting requirements, which adds to HHSC’s administrative burden. There are six managed care advisory committees, four committees dealing with children, five committees dealing with quality matters, etc. Needless to say, there is a lot of duplication with questionable effectiveness. As a disclaimer, I’ve served on two of the children’s committees.

The Sunset Commission recommends that the advisory committees be removed from statutes, allowing HHSC to establish by rule those that are necessary. It recommends combining the four children’s committees into one. It also recommends that HHSC create a master committee calendar, meetings be streamed, and that meeting materials be accessible online.

I’ve only covered five of the recommendations, the Sunset Commission made 15 for HHSC. As you can see from this, though, the recommendations are huge in scope and needed. From here, it gets mired in politics. I have a feeling this is going to be the issue for the Legislature this spring. It is worth reading these reports and contacting your legislators and letting them know if you support these recommendations or not.

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Yesterday I participated in the Children’s Policy Council’s briefing for the Texas legislature.  The Children’s Policy Council (CPC) was established by the 2001 Legislature to help provide recommendations to the state about integrating services to children with special needs to provide the services that are needed in a more effective, cost-effective, and integrated way.   It’s membership is primarily parents of children with special needs, which allows it to provide a unique perspective to the state.  Every even-numbered year, the CPC produces a report with recommendations for the Legislature.  The 2012 report can be found here: http://www.hhsc.state.tx.us/si/C-LTC/2012-CPC-Leg-Report.pdf .

 

The CPC conducted a briefing based upon the recommendations found in the report to the Legislature and state agency employees in the state capital yesterday.   I’m happy to report that staffers from about 25 representatives and senators attended as well as staffers from the Department of Assistive and Rehabilitative Services, the Department of Aging and Disability Services, and the Health and Human Services Commission.

 

I discussed the need to fully fund Early Childhood Intervention (ECI).  I have covered a lot of the issues elsewhere (see: http://wp.me/pZf7K-7F for the most recent summary), but none of the CPC assumed knowledge on the part of the people attending the briefing.  I began by discussing what ECI is and what it does.  I explained that there is a narrow window (birth to age three) when services can be provided to children that might be less expensive and easier due to the fact that children are developing rapidly at this age.  Failing to address delays at this age doesn’t make them go away, it makes them someone else’s problem (the school districts and society’s) which becomes more difficult and more expensive as the child ages.

 

After that I covered the history.  Namely that the funding for ECI has been cut for several years.  In fiscal year 2010 it was 197 million dollars.  In FY2012 it was 163 million dollars.  In FY2014, DARS is asking for 145 million with an additional 40 million in exceptional items.  The result of this has had an impact on how many children receive services as well as who those children are.  As I have written about elsewhere, I explained the consequences of the Legislature’s short-sightedness with ECI and explained why it needs to be fully funded.

 

With one exception, all of the other presenters at this briefing were parents.  This was powerful as it provided a human face to the services and programs that the CPC is recommending.  One of the parents, Cheryl Fries, began her presentation by talking about her “D Day,” the day her family received the diagnosis of their child’s disability.  She told those attending the briefing that each parent of a special needs child has their D Day burned into their memory and that none of us asked to be part of this club, but we’re all members nonetheless.  I thought that was a powerful statement and I’m going to borrow that in the future.

 

The one exception was Dr. Carl Tapia, who is a pediatrician specializing in children with special needs.  He discussed the CPC’s recommendations for reforming acute Medicaid services.  The CPC has been involved in making recommendations to the state about redesigning both long term services and supports as well as acute Medicaid services.

 

I found the briefing to be a positive experience.  We had a good turnout and I felt that they were attentive and asked questions.  Now how things play out during the upcoming session is anyone’s guess…

The Texas Comptroller published a report on State Health Care Spending. The report begins by pointing out that between 2005 and 2009, the state’s spending on health care has increased by over 36%. Which is four times as fast as inflation and population growth. In 2009, the state spent over $30 billion on health care and this represents a third of all state spending.

The report is organized into background information, an analysis of how the state spends money on health care, cost drivers, and proposals.

Background:
In fiscal year 2009, the state’s spending on health care is split as follows:
• Medicaid and CHIP: 68%
• Other: 21%
• State Employee and Retiree Medical Benefits: 6%
• Mental Health Services: 3%
• Prisoner Health Care: 2%

State Expenditures:
Five state agencies account for the bulk of health care spending:
• Health and Human Services Commission (HHSC): 58%
• Department of Aging and Disability Services (DADS): 20%
• Other Agencies and Higher Education Institutions: 11%
• Department of State Health Services: 6%
• Employee Retirement System: 4%
• Department of Criminal Justice: 2%

HHSC and DADS primarily spend for Medicaid. The comptroller notes that:
• Non-disabled children make up most of the Medicaid population, 53% of beneficiaries, but only 29% of Medicaid spending on direct health care services.
• Aged, blind, and disabled account for 31% of Medicaid clients and 58% of the program’s expenditures.

DADS administers long-term Medicaid services for the elderly and disabled, this breaks down as follows:
• Nursing facilities: 35%
• Other services: 28%
• Home and community based services: 11%
• State school services: 10%
• Primary home care: 8%
• Community based alternatives: 8%

With regards to the Department of State Health Services, the Comptroller’s report is primarily concerned with the providing of mental health services.

The report points out that expenditures for state employees and retiree medical benefits rose by 34% from 2005 to 2009.

Cost Drivers:
A number of things are increasing the costs of health care:
• Technological advances in products, services, and drugs
• Health insurance pays approximately 85% of health care costs (with out-of-pocket costs making up at 15%), compared to only 45% in 1960.
• Increased reliance on specialists for medical treatment
• Shortages of health care professionals in West, South, and Panhandle areas of Texas
• Lifestyle choices
• Lack of access to prenatal care

With regards to state employee and retirees, the report notes that the following are driving up costs:
• Medical inflation: the amount paid for outpatient visits form 2008 to 2009 rose by almost 22%
• Increased emergency room usage
• Increased use of high-tech radiology
• Specialty drugs: the cost for specialty drugs increased by 694% from 2000 to 2009
• Aging of ERS members

Proposals:
The report has a number of proposals to help reign in health care costs. Later, we’ll discuss the legislative action required and the status of those bills as of 20 April 2011.
• Expand STAR and STAR+PLUS managed care plans
• Provide dental services in the managed care arrangement
• Convert HHSC’s primary care case management areas to the STAR managed care model
• Include Medicaid inpatient hospital services in the STAR+Plus plan
• Reduce hospital payments for preventable readmissions
• Institute a statewide smoking ban
• Create step-down alternatives for individuals who have been in state mental hospitals but do not require full hospitalization
• Undertake cleanliness initiatives in state hospitals
• Require state and higher ed employees to pay a portion of health care benefits based on their years of service
• Require tobacco users to pay more for their health insurance benefits
• Charge state employee dependents a higher premium if they turn down coverage offered by their employers to join ERS
• Allow ERS to offer varying plans to increase member cost sharing
• Allow retirees to opt out of ERS coverage in lieu of a Medicare supplemental policy paid by state funds
• Reduce prison terms for certain elderly, non-violent offenders
• Evaluate the Medically Recommended Intensive Supervision Program for potential savings
• Increase physician workforce

The table below shows each option, the estimated savings for the biennium in all funds, the bills that have been filed in the Texas Legislature to achieve these options, and their status as of April 20, 2011. At this late date, any bill that is not out of committee is probably dead.

Proposal Estimated Savings (all funds) Bills Status
Expand STAR and STAR+PLUS $732 million SB 23 (Nelson)

SB 1181 (Duncan)

HB 1645 (Zerwas)

Testimony taken in committee

Referred to committee

Left pending in committee

Dental Services $175 million SB 23 (Nelson)

SB 1181 (Duncan)

HB 1645 (Zerwas)

Testimony taken in committee

Referred to committee

Left pending in committee

Convert Primary Care Case Management to STAR $93 million SB 23 (Nelson)

SB 1181 (Duncan)

HB 1645 (Zerwas)

Testimony taken in committee

Referred to committee

Left pending in committee

Inpatient Hospital Services $58 million SB 23 (Nelson)

SB 1181 (Duncan)

HB 1645 (Zerwas)

Testimony taken in committee

Referred to committee

Left pending in committee

Preventable Readmissions Unknown SB 7 (Nelson) Received from the Senate
Smoking Ban $15 million HB 670 (Crownover)

SB 355 (Ellis)

Considered in calendars

Not again placed on intent calendar

Step Down Alternatives $6 million SB 7 (Nelson) Received from the Senate
Cleanliness Initiatives Unknown HB 1657 (Davis)

SB 620 (Nelson)

Left pending in committee

Received from the Senate

Employees Paying Portion of Expenses $112 million HB 1

SB 1

Scheduled for public hearing (Senate Finance committee)

In committee

Tobacco Users Pay More for Benefits $118 million HB 1166 (Zerwas) Left pending in committee
State Employee Dependents Unknown HB 3373 (Murphy) Left pending in committee
ERS Plan Flexibility Unknown HB 1766 (Crownover)

B 1362 (Laubenberg)

Report sent to calendars

Refereed to committee

Retiree Opt Out Unknown HB 3496 (Darby) Referred to committee
Elderly Prison Terms Unknown HB 3366 (White)

HB 3763 (Marquez)

Left pending in committee

Referred to committee

MRIS Program Unknown HB 3538 (Thompson)

HB 3761 (Marquez)

Left pending in committee

Referred to committee

Each of these options has significant ripple effects, it is worth reading the full report to see the Comptroller’s analysis of the pro’s and con’s of each option. The full report can be found here: http://www.window.state.tx.us/specialrpt/healthcare/pdf/HealthcareReport.pdf

State Senator Nelson filed SB 571 (see it here: http://www.capitol.state.tx.us/BillLookup/History.aspx?LegSess=82R&Bill=SB571) , which deals with efficiencies and cost-savings in the Texas health and human services agencies. In many ways it is a strange bill, it isn’t connected to any part of statutes and it is very loose and nonspecific, i.e. significantly open to interpretation. The idea of identifying cost savings and efficiencies is a laudable one, but for this to be dictated by the Legislature is concerning as they don’t understand how everything works on anything more than a superficial level.

The first thing to understand is that this bill (as of 2/11/11) is only filed. It will need to go to committee, be heard in committee, passed in committee, go to the Senate, be heard in the Senate, passed in the Senate, the whole process repeats in the House, then the Governor would need to sign. All this would need to be done before this bill becomes law.

With that said, it’s worth looking at this bill in some detail. The first part of the bill is part philosophical statement. In it, the Senator affirms the Legislature’s right to determine appropriations and to reduce or eliminate appropriations if it is necessary to achieve a balanced budget. Should this bill pass, it will trump any other statute to the contrary.

The second part of the bill is addressed to all health and human services agencies, though these aren’t identified. One would assume this means all Article II agencies, but since this isn’t specified it could be more broadly applied if desired. This part of the bill states that all these agencies “shall” identify efficiencies and reduce expenditures, and then includes manners in which this will be accomplished. To me this implies a need to report these things back to the Legislature. The means for accomplishing this include:
• Eliminating or modifying programs not funded or funded at a reduced level as a result of the FY12 and 13 budgets.
• Streamling functions, consolidating administrative and service functions
• Evaluating the fees for current programs and (my assumption) raising them if necessary to cover costs
• Maximize co-payment opportunities
• Renegotiate contracts
• Evaluate regulatory requirements (goes back to streamilining)
• Get Federal permission to streamline when necessary
• Shift the onus to primary care
• Evaluate the state medical assistance and children as well as the child health plan program (I’m assuming this refers to all the Medicaid and CHIP programs)
• Implement additional initiatives identified by the agencies

In addition, there are instructions to each of the Article II agencies.

For the Health and Human Services Commission:
• Streamline the eligibility determination process
• Evaluate the elimination of Temporary Assistance for Needy Families exemptions not required by Federal law (this is a Federal block grant): This is about $63 million a year for FY12 and 13.

For Department of Aging and Disabilities Services:
• Evaluate forensic commitment requirements to ensure that alleged offenders with intellectual disabilities are being served in the most appropriate and cost-effective setting (goes back to closing state supported living centers)
• Ensure clients are in the most cost-effective wavier program appropriate
• Streamline the waiver programs
• Perform utilization management and review for all community entitlement and wavier programs (in other words, eliminate the ones that do not have many people enrolled)
• Increase community based long-term care services while containing costs (this is interesting as both the Senate and House bills cut funding for this)
• Outsource waiver services to the community when possible

Both the Senate and House budgets are going to seriously decrease the services received to Texans. The long term implications will be abuse for elderly and disabled Texans at the hands of poorly paid, overworked providers. Lack of state assistance in the care of the elderly and disabled will burden families and insurance companies.

For the Department of State Health Services:
• Evaluate forensic commitment requirements to ensure that alleged offenders with a mental illness are being served in the most appropriate and cost-effective setting
• Streamline public health efforts
• Utilize residential units in state hospitals to provide cost-effective care and to maintain bed capacity
• Require hospitals which accept the state medical assistance program to charge state mental hospitals no more than the state medical assistance program fee for services
• Expand cost-effective models of care for mental illness
• Manage expenditures for drugs provided through the state mental hospitals
• Privatize a state mental hospital

There are pro’s and con’s to privatizing a hospital. Certainly outsourcing is a good way to reduce costs. The major cons are that you have a lack of accountability, a lack of control, and (of course) the hospital will be run with the idea of making a profit.

The assumption that anything having to do with the state can be made cost-effective is naïve and reflects a lack of understanding of how the state does business.

For the Department of Assistive and Rehabilitative Services:
• Evaluate the feasibility and cost-effectiveness of providing early childhood intervention services through the state medical assistance and child health plan program (i.e. Medicaid).

This would certainly shift the expenses involved with this program, it would also limit the people that would be served by it as Medicaid has eligibility requirements. Those people who would not be covered by these programs would be on their own. In addition, this shift is being evaluated at a time when the Senator has instructed HHSC to evaluate “… the state medical assistance and children as well as the child health plan program…”

For the Department of Family and Protective Services:
• Maximize use of the Department of State Health Services to provide mental health and substance abuse services that are purchased through CPS and adult protective services program.
• Make child care regulation more efficient.
• Redesign the foster care system so that it improves outcomes for children and families.
The first bullet directs DFPS to rely on DSHS during a time when DSHS is being told (in this bill) to privatize a hospital, make care more cost-effective, make drugs cost less, and pay providers less money. It seems a bit contradictory.

The second bullet probably isn’t possible given how the state of Texas operates, but it’s nice to say.

I think there’s a good intent behind this bill, but the bill is largely ignorant of how the state operates, it’s written in a way that it contradicts itself in several areas, and if it happened the way that it is written would have a serious impact on the services that Texans receive.

I think there needs to be a real serious dialog about what services Texas should provide to which citizens. Then there needs to be a real serious dialog about what state agencies are critical to providing those services, what can be eliminated, and what can be merged/streamlined. The Legislature also needs to realize that every one of the bills they file (almost) has a reporting requirement attached to it, which means that staff has to be hired/focused on generating those reports. This also needs to be prioritized so that the important information that the Legislature actually reads is delivered and the rest is dropped.