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DSHS Legislative Appropriations Requestfor Fiscal Years 2010-11
Presentation to the Senate Finance CommitteeFebruary 11, 2009
David L. Lakey, M.D.Commissioner
2
DSHS Legislative Appropriations RequestFiscal Years 2010-11
• Base Budget
$5,592,709,588 All Funds
• Exceptional Items
$487,069,478 All Funds
3
DSHS Legislative Appropriations RequestFiscal Years 2010-11
$5.6 billionbiennialbudget
FY 2010-11 DSHS budget by source
4
DSHS Legislative Appropriations RequestFiscal Years 2010-11
• Exceptional Items 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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• State Hospital Capacity
• Mental Health and Substance Abuse Services
• Alberto N Settlement
• Family Planning Reimbursement
• Rabies Bait Drop
• Department Operational Costs
• Rio Grande State Center FTEs (funded through interagency contract)
$62.8 million GR/$83.9 million All Funds
MAINTAINING OPERATIONAL CAPACITYExceptional Item #1
FY2010* FY2011*
1. Maintain Current Operations $39.3 $44.6* All figures in millions
6
Waiting Lists for Clearinghouse (Non- Maximum Security) and Maximum Security (MSU)
0
20
40
60
80
100
120
140
160
180
200
Clearinghouse 115 153 34 67 192 82 47 57 142
MSU 124 122 137 168 110 25 58 39 36
May-06 Sep-06 Jan-07 May-07 Sep-07 Jan-08 May-08 Sep-08 Jan-09
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
Funding provided to add beds to the state hospital system.
SB 867 (80th Legislature) provides more flexibility for maximum security admissions.
Initial crisis services funding allocated.
7
ENSURING COMPLIANCEExceptional Items 2 - 8
FY2010* FY2011*
2. Regulatory Services $7.3 $11.5
3. Health Care Data $12.7 $12.3
4. Vital Records $3.5 $3.2
5. Data Systems $15.7 $14.6
6. Disaster Preparedness $16.8 $7.3
7. Stipends for Medical Residents $1.4 $1.4
8. Maintain Facilities $43.3 $27.5* All figures in millions
• Total of Exceptional Items 2-8 equals $104.9M GR/$178.3M All Funds
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ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services
Summary of all Regulatory licenses
13038 - Food and Drug
13039 - Environmental
13040 - Radiation
13041 - Professional Licensing
13042 - Health Care Facilities
Increase in licenses for the Division for Regulatory Services2002-2007
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
Texas is a growing state.From 2002 to 2007, the
number of licenses in some programs increased
by as much as 80%.
9
ENSURING COMPLIANCEExceptional Item 6 – Disaster Response
• Gaps in Public Health Response
• Key Personnel and Training– Equipment– Laboratory Courier System– Medical Special Needs
Shelter Capacity– Local Health Services– Border Public Health
Surveillance and Security
10
ENSURING COMPLIANCEExceptional Item 7 – Stipends for Residents
Psychiatrists per 100,000 Population
00.1 - 5.15.1 - 10.710.7 - 19.619.6 - 36.5
Psychiatrists and Child Psychiatrists,
Texas - 2007
11
MOVING HEALTH FORWARD Exceptional Item 9-13
FY2010* FY2011*
9. Substance Abuse Services $34.8 $34.9
10. Community Mental Health Services $38.4 $47.1
11. Chronic Disease $10.9 $15.0
12. Infectious Diseases $8.1 $8.8
13. Maintenance of Services - LMHAs $13.4 $13.4
* All figures in millions
• Total of Exceptional Items 9-13 equals $209.0M GR/$224.8M All Funds
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• Substance abuse and mental illness have a significant impact on Texans, their families and communities.
– The economic cost of substance abuse in Texas for 2007 is estimated at $33.4 billion including lost productivity, crime and the criminal justice system, premature death and morbidity, and the cost of substance abuse prevention and treatment.
– Individuals with severe mental illness have a life expectancy that is 25 years shorter than the overall population.
– Underserved populations with MH or SA issues often go to ERs for treatment.
• Additional funding will mitigate the effects of substance abuse and mental illness on Texans and Texas.
MOVING HEALTH FORWARD Exceptional Item 9 & 10
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0
10
20
30
40
50
60
Obese Normal Weight
Obesity Prevalence Trends in Texas Adults 1990 to 2007
~34% of Texans are normal weight
~29% of Texans are obese
Texas Comptroller: www.window.state.tx.us/specialrpt/obesitycost/summary/
MOVING HEALTH FORWARDExceptional Item 11 – Chronic Diseases
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Racial Disparity in Persons Living with HIV/AIDS in Texas, 2003-2007
The number (left graph) of black persons living with HIV/AIDS surpassed that of whites in 2005. The rate (right graph) in 2007 was nearly 5 times higher for blacks than for others.
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
22,71218,604
23,802
18,113
15,532
11,089
0
5,000
10,000
15,000
20,000
25,000
2003 2004 2005 2006 2007
Year
Nu
mb
er
White Black Hispanic
165.9200.9
891.1713.7
146.7 177.0
0.0
100.0
200.0
300.0
400.0
500.0
600.0
700.0
800.0
900.0
1000.0
2003 2004 2005 2006 2007
Year
Ra
te p
er
10
0,0
00
White Black Hispanic
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DSHS Legislative Appropriations RequestSummary
FY 2010 FY 2011
GR All Funds GR All Funds GR All Funds FTEs FTEs
1. Maintaining Current Operations $ 28,782,048 $ 39,268,566 $ 34,059,971 $ 44,627,245 $ 62,842,019 $ 83,895,811 87.5 87.5
2. Regulatory 7,279,996 7,279,996 11,506,211 11,506,211 18,786,207 18,786,207 57.7 133.7
3. Health Data Collection & Analysis 9,652,427 12,675,338 9,060,534 12,282,835 18,712,961 24,958,173 54.6 68.9
4. Vital Statistics 3,492,794 3,492,794 3,162,250 3,162,250 6,655,044 6,655,044 14.2 24.3
5. Information Technology Support for Critical Programs 15,654,867 15,654,867 14,635,242 14,635,242 30,290,109 30,290,109 12.1 12.1
6. Disaster Recovery and Public Health Preparedness 16,754,841 16,754,841 7,311,530 7,311,530 24,066,371 24,066,371 37.8 37.8
7. Stipends for Psychiatrist and Medical Residents 1,386,399 1,386,399 1,350,396 1,350,396 2,736,795 2,736,795 - -
8. Building & Equipment Repair & Replace 2,071,806 43,337,891 1,591,673 27,516,157 3,663,479 70,854,048 - -
9. Substance Abuse Services 27,050,629 34,796,731 27,195,549 34,872,984 54,246,178 69,669,715 15.2 15.2
10. Community Mental Health Services 38,430,919 38,430,919 47,105,578 47,105,578 85,536,497 85,536,497 16.2 16.2
11. Chronic Disease Prevention 10,748,330 10,889,491 14,867,553 15,024,604 25,615,883 25,914,095 27.3 27.3
12. Infectious Disease Prevention 8,079,969 8,113,423 8,759,736 8,793,190 16,839,705 16,906,613 35.7 35.7
13.Community Mental Health Services - Maintenance of Critical Services at LMHA
13,400,000 13,400,000 13,400,000 13,400,000 26,800,000 26,800,000 - -
182,785,025$ 245,481,256$ 194,006,223$ 241,588,222$ 376,791,248$ 487,069,478$ 358.3 458.7
Note: GR shown above includes GR and GR-Dedicated funds
EXCEPTIONAL ITEMFY 2010
Total Exceptional Items
Exceptional Items Summary
FY 2011 BIENNIAL TOTAL
Exceptional Items:
16
Issues for FY 2009
• FTEs– Funded from Interagency Contracts /Federal Funds
• Capital Budget Authority
• Medicare Part D Savings Use Plan
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HHSC Exceptional Items Affecting DSHS
• In the HHSC LAR– Medical Professional Recruitment and Retention
– Vehicles
– Information Technology
– Data Center Services Increased Costs
• In the HHS Consolidated Budget– Rate Increases for Providers
– Staff Recruitment and Retention
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• State Hospital Capacity
• Mental Health and Substance Abuse Services
• Alberto N Settlement
• Family Planning Reimbursement
• Rabies Bait Drop
• Department Operational Costs
• Rio Grande State Center FTEs (funded through interagency contract)
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1
20
Waiting Lists for Clearinghouse (Non- Maximum Security) and Maximum Security (MSU)
0
20
40
60
80
100
120
140
160
180
200
Clearinghouse 115 153 34 67 192 82 47 57 142
MSU 124 122 137 168 110 25 58 39 36
May-06 Sep-06 Jan-07 May-07 Sep-07 Jan-08 May-08 Sep-08 Jan-09
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
Funding provided to add beds to the state hospital system.
SB 867 (80th Legislature) provides more flexibility for maximum security admissions.
Initial crisis services funding allocated.
21
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
• Cost Drivers
– 24/7 psychiatric and medical care
– Maintaining capacity at 2477 beds
– Increasing competition for clinical staff in local markets
– Increased cost for pharmaceuticals
– Outside medical costs
– Increased cost of food
– Other unavoidable costs
22
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
• Inflation in Clinical Salaries– Competition in local markets for professions with
limited labor pool
– Average salary increase for clinical staff, rose by 6% above legislative pay increases (FY 2005-07)
– 64% of hospital employees are clinical staff
23
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
• Pharmaceutical cost increases– Psychiatric drugs (82% of purchases)
• 9% increase in cost
– All other drugs • 25% increase in cost
24
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
• Outside Medical Services– DSHS responsible for health care of patients
– Need for these services is difficult to predict
– Examples of individual patient medical costs in FY 2008:Cardiovascular $133,000End stage renal $334,000Dialysis $177,000Pneumonia $148,000Neck cancer $145,000Cardiovascular $178,000
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MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity
• Examples of Other Operating Costs– Food
– Equipment
– Furnishings
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MAINTAINING OPERATIONAL CAPACITYExceptional Item 1
• Mental Health & Substance Abuse Services– Sustain substance abuse treatment rate increase
in FY 2008 to stabilize provider base– Provide resources to sustain consumer-focused
mental health contracts
27
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1
• Alberto N Settlement– Funding provides personal care services for children on Medicaid.
– Funding was phased-in during FY 2008-09.
– This request maintains 2009 funding levels for crisis services.
• Family Planning Reimbursement Rates (Non-Medicaid)– Reimbursement rates for oral contraceptives are significantly lower
than costs.
– The department faces possible loss of providers due to increasing financial pressures meaning a potential loss of primary care services for women.
– This request would more closely align family planning reimbursement rates with costs.
28
MAINTAINING OPERATIONAL CAPACITYExceptional Item 1
• Rabies Bait Drop– Rabies vaccination bait dropped annually in South and West Texas
by airplane.
– This funding will cover an increase in transportation costs for the program.
• Rising costs across the agency– Laboratory
– Hospital pharmaceuticals, medical supplies and food
– Travel/fuel costs
– Utilities
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MAINTAINING OPERATIONAL CAPACITYExceptional Item 1
FY2010* FY2011*
State Hospital Capacity $19.7 $25.0
Mental Health and Substance Abuse Services 8.0 $8.0
08-09 Phased-In Services – Alberto N $1.1 $1.1
Family Planning Reimbursement $3.6 $3.6
Rabies Bait Drop $0.8 0.8
Increased Costs $3.2 $3.5
Rio Grande State Center FTEs (IAC) $2.7 $2.7
Total: $39.3 $44.6* All figures in millions
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ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services
• DSHS Regulatory Division ensures 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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ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services
Summary of all Regulatory licenses
13038 - Food and Drug
13039 - Environmental
13040 - Radiation
13041 - Professional Licensing
13042 - Health Care Facilities
Increase in licenses for the Division for Regulatory Services2002-2007
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
Texas is a growing state.From 2002 to 2007, the
number of licenses in some programs increased
by as much as 80%.
32
• Regulatory programs are supported by fees.
• Regulatory programs provide standards to protect the public’s health and safety.
• New licensees require resources for licensure processing, compliance inspections, response to complaints, and enforcement.
• DSHS uses risk-based inspections in most programs.
ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services
FY2010* FY2011*
Regulatory Services $7.3 $11.5* All figures in millions
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ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
• Funds are requested to improve the timeliness, completeness, and validity of health information collected through registries and disease surveillance systems.
• Using more effective technology to replace sub-standard systems will:– Improve the collection of information on cancer, birth defects, trauma,
lead poisoning, and occupational diseases.
– Make data more timely and readily available to the public and researchers for prevention efforts and measurement of communities’ health status.
– Make disease reporting for local hospitals and health providers more efficient.
• The funding will establish a health care associated infections reporting system.
• The funding will provide for linking of health information systems.
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ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
• Purpose of the Registries– Collect and analyze health information to improve the health
of Texans
• Uses– Public health and health-related research
– Analysis of health issues to guide appropriate public health strategies or prevention efforts
– Provide information to communities about environmental risks
– Provide information to assist in consumer decision-making regarding health care
35
• Cancer Registry– Collects, analyzes, and disseminates data on cancer in Texas
Type, extent, location and initial treatment Data for research, cancer prevention and control planning
– Meets national standards– Supports cancer prevention and research priorities, including
children’s cancer research– Helps communities assess risk
Kelly Air Force Base, San Antonio Houston Ship Channel El Campo trichlorethylene
– Provides significant information for national data set
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
36
• Birth Defects Registry– Collects, manages, analyzes, and disseminates data
Occurrence of birth defects Type of defect When and where diagnosed
– Identifies and describes patterns of birth defects in Texas, investigates clusters, and shares with researchers for epidemiologic studies
– Evaluates strategies to reduce birth defects risks and factors impacting survival of children with birth defects
– Identifies areas where children with birth defects have little access to pediatric genetics clinics
– Evaluates factors playing a role in survival of children with birth defects
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
37
• EMS/Trauma Registry – Collects, analyzes, and disseminates information on:
Emergency medical services runs Occurrence of trauma, including:
Spinal cord injuries Traumatic brain injuries Submersion injuries
– Investigates the causes of injuries, their distribution, health outcomes, and associated costs
– Analyzes ambulance diversion patterns
– Compares patients across service areas to improve timeliness and quality of patient care
– Identifies hazardous environments, such as dangerous intersections
– Evaluates local injury prevention planning
• EMS providers, acute care hospitals, and trauma centers report trauma cases to the EMS/Trauma Registry.
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
38
• Child and Adult Blood Lead Surveillance System– Works to prevent and eliminate child lead poisoning in Texas by:
Testing and monitoring children who are at risk for lead poisoning and ensuring treatment if necessary
Identifying and removing lead hazards in the child’s environment Educating the public and healthcare providers about lead poisoning and how it
can be prevented
• Additional funds will assist the Child and Adult Blood Lead program to:
– Replace an aging information technology system.
– Meet requirements for screening, notification, case follow-up, and outreach education.
– Improve the screening rate for Medicaid children (currently 20-30%).
– Meet obligations from the settlement of the Frew lawsuit.
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
39
• Occupational Disease Conditions Surveillance– The Texas Occupational Disease Reporting Act mandates
reporting of the two principal causes of work-related pneumoconiosis (interstitial lung disease), asbestosis and silicosis.
– These are diseases that lead to lung impairment, disability, and premature death.
– From 1968 to 1999, asbestos deaths among U.S. residents age 15 and over have increased from fewer than 100 to more than 1,250 annually, with no apparent leveling off to this trend.
– In 2005, there were 202 newly identified individuals with asbestosis and 138 new reports of silicosis in Texas.
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
40
• Healthcare Associated Infections (HAI)– Leading cause of death from infectious disease in the U.S.
– 200,000 infections and almost 9,000 deaths in Texas each year.
– Staph infections (including MRSA) account for 25% of HAI.
– In Texas, HAI-related healthcare costs are estimated at more than $500 million annually.
– Up to 60% of HAI infections are preventable through improved application of existing infection control recommendations and guidelines.
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
41
• Healthcare Associated Infections (HAI) - SB 288 required DSHS to:– Establish a Healthcare Associated Infections (HAI) Reporting System.
Hospitals and Ambulatory Surgical Centers
– Develop and publish a summary of infections reported by healthcare facilities.
– Provide education and training to healthcare facility staff.
– Provide accurate comparison of HAI data to help the public make informed decisions about choosing healthcare facilities.
• To implement SB 288, DSHS will:– Adopt CDC’s National Healthcare Safety Network as the HAI Reporting System.
National trend – many other states will use this system as well.
– Employ staff to analyze source of infections and ensure accuracy to reporting.
• Accuracy of information is critical:– Facilities will use the information to improve.
– Consumers will use the information to make choices.
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
42
FY2010* FY2011*
Disease Registries – Chronic $4.2 $2.6
Disease Registries – Healthcare Associated Infections Reporting
$1.5 $2.8
Blood Lead Testing & Follow-Up $6.0 $6.4
Newborn Screening Linkage $0.8 $0.3
Center for Health Statistics $0.12 $0.13
Total: $12.7 $12.3
* All figures in millions
ENSURING COMPLIANCEExceptional Item 3 – Health Care Data
43
ENSURING COMPLIANCEExceptional Item 4 – Vital Records
• Vital Records – birth and death records
• Federal mandates – The REAL ID Act of 2005:– Require states to issue secure driver’s licenses and
identification 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
• Enhancement of Texas’ death registration system
FY2010* FY2011*
Vital Records $3.5 $3.2
* All figures in millions
44
ENSURING COMPLIANCEExceptional Item 5 – Data Systems
Maintain and Enhance Technology• 400 programs in nine 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
45
* All figures in millions
FY2010* FY2011*
Network Interoperability, Video & Voice Communications and Security
$6.6 $5.8
Seat Management $1.5 $1.5
Consolidated Health Care Data Collection $1.2 $1.0
Clinical Management for Behavioral Health Services
$2.7 $3.8
Hospital Automated Medication Dispensing System
$3.6 $2.5
Total: $15.7 $14.6
ENSURING COMPLIANCEExceptional Item 5 – Data Systems
46
ENSURING COMPLIANCEExceptional Item 6 – Disaster Response
• Disaster Recovery and Public Health Preparedness– Enhancing response for all-hazards, natural or manmade –
hurricanes to salmonella
– Equipping staff for effective response and personal safety
– Improving timeliness of laboratory tests, environmental analysis and disease surveillance
– Maintaining skilled workforce for rapid deployment in event of emergency or disease outbreak
– Expanding local health services
– Enhancing public health surveillance and security on the border
48
ENSURING COMPLIANCEExceptional Item 6 – Disaster Response
• INSERT SLIDE ON HURRICANES
Storms lined up across the Atlantic – September 2008
50
FY2010* FY2011*
Public Health Emergency Preparedness Response $3.9 $3.4
Response Equipment $4.0 --
Laboratory $2.1 $1.0
Shelters – Renovation of State Facilities $4.0 --
Local Health Services Expansion $0.5 $0.5
Border Public Health Surveillance and Security $1.0 $1.0
Behavioral Health Positions in DSHS Regional Offices $0.6 $0.7
Recruitment and Retention $0.8 $0.8
Total: $16.8 $7.3
* All figures in millions
ENSURING COMPLIANCEExceptional Item 6 – Disaster Response
51
ENSURING COMPLIANCEExceptional Item 7 – Stipends for Residents
• DSHS is experiencing difficulty recruiting & retaining medical staff.
– Only 6.4 psychiatrists per 100,000 Texans
– 67.9 physicians per 100,000 Texans
• This funding will provide stipends for residency placements in state hospitals and for preventive medicine residents to strengthen the public health workforce.
• Medical residents are a cost-effective means of increasing medical care in underserved areas and in hospitals.
• Physicians often remain in the community where they served as medical residents.
FY2010* FY2011*
Stipends for Psychiatric & Preventive Medicine Residents $1.4 $1.4* All figures in millions
52
ENSURING COMPLIANCEExceptional Item 7 – Stipends for Residents
Psychiatrists per 100,000 Population
00.1 - 5.15.1 - 10.710.7 - 19.619.6 - 36.5
Psychiatrists and Child Psychiatrists,
Texas - 2007
53
ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities
Building & Equipment Repair & Replacement
• Hospitals must comply with Life Safety Code and Joint Commission accreditation standards.
• Broken, unsafe or unusable equipment and patient furniture must be replaced to provide a safe patient environment.
54
• 11 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
ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities
55
• 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, $70.9 million has been identified as the most critical.
FY10-11 Capital Construction Needs
$233M
$198.3M
$70.9M
0.0
50.0
100.0
150.0
200.0
250.0
DeferredMaintenance
Needs Requested
ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities
56
• 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
ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities
57
MOVING HEALTH FORWARDLeading Causes of Death – Texas 2005 and 2001
0 10,000 20,000 30,000 40,000 50,000
Flu & Pneumonia
Alzheimers
Diabetes
Lower Respiratory Disease
Accidents
Stroke
Cancer
Heart Diseases
Number of Deaths
2001
2005
DSHS Center for Health Statistics
58
MOVING HEALTH FORWARDActual 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
59
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
60
Treated
$89
Untreated
$136
$0
$136
ER Costper Medicaid Client
per Month
ER COST OFFSET
- $47Average per Client per Month
35%REDUCTION
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.
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
61
• 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 does not 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)
MOVING HEALTH FORWARDExceptional Item 9 – Substance Abuse
62
MOVING HEALTH FORWARDExceptional Item 9 – Substance Abuse
FY2010* FY2011*
Treatment Services $15.6 $15.6
Prevention Services $4.5 $4.5
Medicaid for Outpatient Substance Abuse Services $13.8 $13.8
Increased Contract Management Costs $0.9 $1.0
Total: $34.8 $34.9
* All figures in millions
63
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
• Impact of Mental Illness – Individuals with severe mental illness have a life
expectancy that is 25 years shorter 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.
– One-third of military service members returning from current conflicts are affected by PTSD, major depression or traumatic brain injury.
64
• Mental Health Crisis Services were phased-in for 2008.
• The base bill maintains 2009 funding levels for crisis services.
• Crisis mental health services funded by the 80th Legislature have been implemented and are showing indicators of success.
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
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
65
Sources: DSHS Client Assignment and Registration (CARE) system and DSHS NorthSTAR Data Warehouse, 10/02/2008.
16.9%(17,247)
21.0%(17,706)
19.6%(17,888)
91,36884,199
102,162
0%
10%
20%
30%
40%
SFY2006 SFY2007 SFY2008
0
25,000
50,000
75,000
100,000
125,000
Percent of Crisis Service Episodes Followed by Psychiatric Hospitalization
Number of Crisis Service Episodes
SFY2008 Annual
Target = 17%
Percent of Crisis Service Episodes Followed by a Psychiatric Hospitalization within 30 Days
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
66
El Paso
Tropical
Nueces County MHMR
Austin-Travis County MHMR
Bluebonnet
Tri-County
Spindletop
Burke Center
Heart of Texas
Central Plains
Betty Hardwick
Hill Country
West Texas
Helen FarabeeTarrant County MHMR
Areas Currently Funded for Expanded Crisis Services
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
Need for Crisis Expansion
67
• Part 1: 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 8,736 individuals/year
– Serve an additional 226 children/year
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
68Sources: 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
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
69
Sources: DSHS Client Assignment and Registration (CARE) system, DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), and DSHS Behavioral Health Integrated Provider System (BHIPS).
19,478
22,710
20,712
3,340(16%)
3,633(16%)
3,254(17%)
0
5,000
10,000
15,000
20,000
25,000
30,000
SFY2006 SFY2007 SFY2008 YTD (Q1-Q3)
Nu
mb
er o
f P
erso
ns
Number of Persons Receiving Front-Door Crisis Services
Number Transitioning to On-Going Services
Need for Transitional Services
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
70
• 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 FORWARDExceptional Item 10 – Mental Health Services
71
Average Monthly Service Package Distribution for Adults after
Receiving Crisis Services(03/2008-05/2008) ADULT RDM LEVELS OF CARE
Level 1 Pharmacological Management, Patient and Family Education, and Routine Case Management
Level 2 Pharmacological Management, Patient and Family Education, Routine Case Management, and Counseling
Level 3 Psychosocial Rehabilitation
Level 4 Assertive Community Treatment
Need for Intensive Ongoing Services
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
72
• 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
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
73
• Veteran’s Mental Health– Training for public behavioral health
practitioners in evidence-based practices for PTSD
– Web-based application for simplifying determination of eligibility
– Support for coordination among agencies
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
74
FY2010* FY2011*
Psychiatric Emergency Centers & Children's Respite Services $14.2 $14.2
Transitional Services $12.5 $12.5
Intensive ongoing services targeting recipients of transition services
$9.6 $19.2
Veterans Mental Health Training and Coordination $1.1 $0.1
Increased Contract Management $0.9 $0.9
External Evaluation of Crisis Projects $0.2 $0.2
Total: $38.4 $47.1
* All figures in millions
MOVING HEALTH FORWARDExceptional Item 10 – Mental Health Services
75
MOVING HEALTH FORWARDExceptional Item 11 – Chronic Diseases
– 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, high cholesterol and Type 2 diabetes
– Tobacco is implicated in 25,000 deaths in Texas annually
– Cost of $3.3 billion to Texas businesses in 2005
76(*BMI 30, or about 30 lbs. overweight for 5’4” person)
1998
2007
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: CDC Behavioral Risk Factor Surveillance System
Obesity Trends* Among U.S. Adults
MOVING HEALTH FORWARDExceptional Item 11 – Chronic Diseases
77
• 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
MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases
78
• 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
– Early intervention to improve lung functioning
MOVING HEALTH FORWARD Exceptional Item 11 – Chronic Diseases
79
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
* All figures in millions
MOVING HEALTH FORWARDExceptional Item 11 – Chronic Diseases
80
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
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.
PLWHA
Deaths
New Cases
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
2003 2004 2005 2006 2007
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
81
Racial Disparity in Persons Living with HIV/AIDS in Texas, 2003-2007
The number (left graph) of black persons living with HIV/AIDS surpassed that of whites in 2005. The rate (right graph) in 2007 was nearly 5 times higher for blacks than for others.
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
22,71218,604
23,802
18,113
15,532
11,089
0
5,000
10,000
15,000
20,000
25,000
2003 2004 2005 2006 2007
Year
Nu
mb
er
White Black Hispanic
165.9200.9
891.1713.7
146.7 177.0
0.0
100.0
200.0
300.0
400.0
500.0
600.0
700.0
800.0
900.0
1000.0
2003 2004 2005 2006 2007
Year
Ra
te p
er
10
0,0
00
White Black Hispanic
82
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
In 2007, the incidence of Tuberculosis in Texas was 43% higher than the U.S. incidence rate and second only to California.
0
1
2
3
4
5
6
7
8
9
10
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007Year
Ca
se
s p
er
10
0,0
00
po
pu
lati
on
US Texas
6.3
4.4
Tuberculosis Incidence Rates,Texas and U.S., 1998-2007
83
Top 10 High-Morbidity Counties
Cases
Harris 397Dallas 219Tarrant 106Hidalgo 76Cameron 74Bexar 72Travis 55El Paso 40Webb 40Fort Bend 40
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
84
• 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 Item 12 includes:– Improved HIV testing
– Expand improved testing for TB and STDs
– Tuberculosis services
– Upgrade cervical cancer screening
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
85
MOVING HEALTH FORWARDExceptional Item 12 – Infectious Diseases
FY2010* FY2011*
HIV/STD Viral Hepatitis Testing $4.4 $4.7
Tuberculosis Services $3.2 $3.6
Cervical Cancer Screening $0.5 $0.5
Total: $8.1 $8.8
* All figures in millions
86
MOVING HEALTH FORWARDExceptional Item 13 – LMHA Services
• Increased Costs for Local Mental Health Authorities– Increasing cost for pharmaceuticals, laboratory services
and utilities
– Growing demand
– Increased efforts to keep individuals with mental illness out of the criminal justice system
FY2010* FY2011*
Maintenance of Services at LMHAs $13.4 $13.4* All figures in millions
87
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 Services– Accessibility of information technology
• Comptroller’s Judiciary Section– Sexually Violent Predator Monitoring Program