Skip navigation

Tag Archives: Sunset Review

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.

Advertisements

State agencies in Texas are required to go through a review process (called the Sunset Review) to determine if they are still needed and to look at the agency’s performance. In general this occurs every 12 years. Currently, the Health and Human Services agencies in Texas are undergoing this process. This post deals with the Sunset Review’s report on the Department of Aging and Disability Services (DADS). This is not meant to be a comprehensive summary of the report, in fact you can access the report below:
https://www.sunset.texas.gov/public/uploads/files/reports/DADS%20Staff%20Report.pdf

DADS provides most of the long-term care and support for individuals with intellectual and developmental disabilities.

This post is going to deal with the following recommendations of the report:
• The state supported living centers
• Transitioning from state supported living centers to the community
• Ensuring adequate care in the community
• Enforcing violations
• Contract management

State Supported Living Centers (SSLCs):
SSLC residents account for less than 1% of the agency’s clients but represent 10% of DADS’ budget and 80% of its workforce. As of September 2013 there were 3649 residents and 13,906 staff being funded by almost $563 million. The report reviewed some of the issues with the SSLCs:
• No SSLC is in compliance with the Department of Justice settlement agreements from 2009. The SSLC range from being in compliance with 18% of the requirements (Richmond) to 40% (Lubbock).
• The number of confirmed allegations of abuse, neglect, and exploitation at SSLCs is shocking and in 2013 represented 15% of the population of the SSLCs.
• In 2002, the SSLC population was a little over 5,000 residents with a funding around $300 million. In 2013 that population was 3649 with appropriations coming close to $700 million.
• All of the SSLCS, except one, require infrastructure repairs that will cost more than the SSLCs are valued at. Only Denton is valued at more than the cost of its infrastructure repairs.
• Almost 10% of SSLC employees are injured annually.
• The average monthly cost for serving a resident of an SSLC is approximately $9500 than a community option.

As a result of the above, the Sunset Review report recommends the following:
• Close Austin SSLC by August 31, 2017
• Establish a closure commission to evaluate the SSLCs and determine five more to close
• Close five more SSLCs by August 31, 2022

Transitioning from SSLCs to the community:
The report notes that many individuals in SSLCs have complex behavioral, mental health, and medical issues. With that in mind, certain supports need to be in place to successfully move them from a SSLC to the community. As a result, the report recommends:
• Requiring DADS to establish crisis intervention teams statewide
• Require DADS (and HHSC) to reimburse services appropriately so that providers will open group homes to people with high medical needs
• Allow SSLCs to provide services to community clients

Ensuring adequate care in day habitat facilities:
This recommendation affects almost 35,000 individuals in community settings. The report finds that DADS doesn’t really monitor day habitat facilities and that the agency’s rules vary across program so there are no quality or safety standards. As a result, the report recommends:
• DADS develop basic safety and service requirements for community based programs. The report suggests things like running fire drills, running background checks on employees, following the client’s plan, etc.
• Require that abuse, neglect, and exploitation be tracked.
• Track data on services offered and deficiencies.

Enforce violations:
In fiscal year 2013, DADS took enforcement actions on only 225 out of 38,000 confirmed violations of state regulations, federal regulations, and Medicaid contracts. Among other issues, DADS has inadequate penalties to deter violations, has difficulty collecting them, and has a serious backlog in cases. The report recommends:
• Develop progressive sanctions for serious or repeated violations
• Repeal the “right to correct” provisions for providers and require DADS to define the criteria for their appropriate use.
• Authorize higher financial penalties to incentivize compliance.

Contract management:
DADS’s approach to managing contracts is fragmented which results in a lack of information, accountability, and inefficiency. This also creates cost over runs and project delays. The report recommends:
• Require DADS to consolidate all contract management
• Have the centralized contract management review and approve contract planning during the early stages of the procurement process
• Develop policies for the risk-based monitoring of contracts

Taken together, the findings and recommendations show you just how bad things are for individuals with IDD in Texas. The SSLCs are bad, the community settings are better but are unregulated and have little incentive to prevent/address deficiencies, and the agency has challenges with oversight and protecting/serving individuals with IDD. This report comes out while we’re transitioning people with IDD to managed care and it is chilling to think how much worse things can get under that system if they are already this bad.

The report provides some opportunities, however. First, realize that just because it is in the report does not mean that the state is going to act on it. This means contacting your legislator and dragging them, kicking and screaming, towards supporting its implementation. Second, the advocacy groups should be aligning some of their legislative foci around these recommendations. This way the Legislature hears the same thing from everyone. Third, SB7 (managed care) is only legislation, it is only a law. This means it can be changed via legislation. Maybe it’s time to get the Legislature to revisit it, slow it down even more, or even kill it in the upcoming session.