DSHS Legislative Appropriations Request for Fiscal Years 2010-11

DSHS Legislative Appropriations Requestfor Fiscal Years 2010-11 Presentation to the House Appropriations Subcommittee on Health and Human ServicesFebruary 23, 2009David L. Lakey, M.D.Commissioner

DSHS Legislative Appropriations RequestFiscal Years 2010-11 • Base Budget • $5,592,709,588 All Funds • Exceptional Items • $487,069,478 All Funds

DSHS Legislative Appropriations RequestFiscal Years 2010-11 FY 2010-11 DSHS budget by source $5.6 billion biennial budget

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

DSHS Legislative Appropriations RequestSummary

MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 • 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 - 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.   

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

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

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

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 $133,000 End stage renal $334,000 Dialysis $177,000 Pneumonia $148,000 Neck cancer $145,000 Cardiovascular $178,000

MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 – State Hospital Capacity • Examples of Other Operating Costs • Food • Equipment • Furnishings

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

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.

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

MAINTAINING OPERATIONAL CAPACITYExceptional Item 1 * All figures in millions

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

Summary of all Regulatory licenses 13038 - Food and Drug 13039 - Environmental 13040 - Radiation 13041 - Professional Licensing 13042 - Health Care Facilities ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services Increase in licenses for the Division for Regulatory Services 2002-2007 100.00% Texas is a growing state. From 2002 to 2007, the number of licenses in some programs increased by as much as 80%. 95.00% 90.00% 83.07% 85.00% 80.00% 76.60% 75.00% 70.00% 65.00% 60.00% 55.00% Percentage of Increase 50.00% 45.00% 40.00% 35.00% 32.52% 30.76% 30.00% 24.49% 25.00% 20.00% 15.00% 10.73% 10.00% 5.00% 0.00% Licenses by Regulatory Strategy

ENSURING COMPLIANCEExceptional Item 2 – Regulatory Services • 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. * All figures in millions

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.

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

ENSURING COMPLIANCEExceptional Item 3 – Health Care Data • 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 • 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 • 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 • 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 • 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 • 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 • 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 * All figures in millions

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 * All figures in millions

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

ENSURING COMPLIANCEExceptional Item 5 – Data Systems * All figures in millions

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

ENSURING COMPLIANCEExceptional Item 6 – Disaster Response Salmonella Saintpaul Outbreak

ENSURING COMPLIANCEExceptional Item 6 – Disaster Response • INSERT SLIDE ON HURRICANES Storms lined up across the Atlantic – September 2008

ENSURING COMPLIANCEExceptional Item 6 – Disaster Response Impact of Hurricane Ike

ENSURING COMPLIANCEExceptional Item 6 – Disaster Response * All figures in millions

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. * All figures in millions

ENSURING COMPLIANCEExceptional Item 7 – Stipends for Residents Psychiatrists and Child Psychiatrists, Texas - 2007

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.

ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities Infrastructure Description • 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.

ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities 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, $70.9 million has been identified as the most critical.

ENSURING COMPLIANCEExceptional Item 8 – Maintain Facilities 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 FORWARDLeading Causes of Death – Texas 2005 and 2001 DSHS Center for Health Statistics

MOVING HEALTH FORWARDActual Causes of Death* Shaped by Behavior *Texas 2001 Chronic Disease in Texas 2007, DSHS

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

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 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 * All figures in millions

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.

DSHS Legislative Appropriations Request for Fiscal Years 2010-11