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The subcommittee met to receive testimony regarding budget recommendations for the Department of State Health Services (DSHS) and the office of Violent Sex Offender Management. This report focuses only on discussion of DSHS.
 
Chairman Four Price noted budget recommendations for DSHS include $2.6 billion (all funds) for critical behavioral health and substance abuse.
 
Shannon Sibayan, LBB

  • The base bill includes $6.1 billion in all funds
    • A 6.2% decrease from last biennium
    • $3.3 billion in GR
  • Trauma Funds; $300 million decrease in appropriations due to a one-time transfer from trauma funds to HHSC for Medicaid expenditures last session
    • Recommendations include $115 million over the biennium from Trauma Funds account for uncompensated care provided by trauma facilities
  • Behavioral health; recommendations include an increase of $12 million for adult mental health services, an increase of $31 million in GR to expand community mental health crisis centers
  • State hospital facilities; one-time repair of state hospitals; base does not include these funds again
  • NorthSTAR; recommendations decrease appropriations due to Dallas County no longer contributing to the match program for NorthSTAR
  • Price asked if it is optional for Dallas County to participate
    • Yes
  • Introduced bill continues $37.8 million GR funding for family planning
  • Many riders were deleted because their requirements have been filled or they are duplicative
  • Rep. Cindy Burkett asked about Rider 6
    • The mental health community hospital Medicaid services rider was deleted because HHSC Rider 36 includes similar provisions; no dollars are taken out

 
Norma Herrera, LBB

  • GEER Report – Improved Data and Oversight­­­­ to Reduce the Prevalence of Early Elective Delivery of Newborns
  • Recommend requiring DSHS to modify the methodology it uses to estimate the rate of early elective deliveries to include use of administrative data for all payer types in THCIC data combined with birth certificate data
  • Recommend requiring DSHS to annually report the state estimate of early elective deliveries
  • Recommend requiring HHSC to regularly audit whether early deliveries are medically necessary
  • Recommend requiring DSHS to perform a study on effectiveness of strategies to reduce early elective delivery
  • Rep. Armando Walle asked what the fiscal implication is for early elected deliveries
    • Higher rates of maternal morbidity and higher costs due to lengthier NICU stays

 
Katherine Teleki, Sunset Advisory Commission

  • Only highlighting issues with fiscal impacts from the DSHS Sunset bill
  • Recommendations will eliminate 14 FTEs and have a negative impact to revenue of $836,000; mostly due to moving licensing programs from DSHS; license fees will not flow through the agency anymore
  • Burkett asked about the NorthSTAR recommendations
    • Sunset has recommended that the program be discontinued and align North Texas with the rest of the state with behavioral health integration; there are implications with DSRIP funding too because currently the way the program is funded and executed it does not allow for federal match for DSRIP, aligning the structure of the system with the rest of the state will change that
  • Sunset staff discussed the regulatory aspect of DSHS; the agency took part in very little regulatory activity; very few inspections and very few incidents; some programs need very little regulation but some programs need to have the quality of their regulation improved and since TDLR has a history of regulating licenses, some programs were moved there in recommendations

 
Kirk Cole, Interim Commissioner, DSHS
Bill Wheeler, CFO, DSHS

  • Cole began; the agency has a very wide scope
  • DSHS is one of the largest state agencies and has about 12,000 employees across the entire state
  • GR is about 40% of the DSHS budget; GRD is 24%; federal is about 36%
  • Largest component of budget is safety net services; kidney health care, family planning, breast and cervical screening; over 50% of budget
  • 36% of the budget is for mental health; public health is 8% and regulatory is about 2%
  • Walle asked why there is a fluctuation of immunization rates
    • Data is collected by a survey so there is change over the years; vaccine availability affects it some years; glad to see it is continuing to go up; right now about 0.76% of children in the state have exemptions for immunizations
  • Rep. Sarah Davis asked what reason most exemptions are for
    • Most are conscientious objectors
  • Have seen a decrease in infant mortality of about 38% since 1990; was one of Dr. Lakey’s priorities; still room for improvement
  • Legislature has shown some interest in reducing healthcare associated infection rates; from CDC the reports are that Texas HAI rate is significantly lower than the national base rates
  • Continuing to see decreases in smoking rates; need to keep up the effort on that
  • Expanded primary health care; DSHS received $100 million last session to provide services for women; served 147,000 women; will have a request to expand those services to serve additional women
  • Walle asked if providers are capable of taking on new patients
    • The services they are able to perform are significantly higher than what there is funding for; believe the expansion request is reasonable; there are some areas of the state where there aren’t enough providers so efforts will include trying to increase those numbers in those areas
  • Walle noted FQHC clinics are part of that effort; are they equipped to handle OBGYN services
    • About 7 years ago FQHCs got more involved in family planning; some do it better than others but they are definitely equipped to serve that program; some better than others
  • Davis noted two years ago roughly 60% of the funding put together for women’s health was for family planning; was that target reached
    • Probably just under the 60% mark; tried really hard to work with providers on strategies to reach that goal
  • Substance abuse services was also funded significantly last session; serving additional DFPS clients was one particular effort; served about 3,000 more of those clients in 2014 than 2013
  • Mental health services was another major investment last session; $300 million over the biennium; bulk of the money went into addressing waitlists; invested in some areas of the state where clients weren’t receiving a full array of services; the 5,000 person waitlist was taken down to virtually nothing for children; for adults there is currently a waitlist but no person who was previously on the wait list is on the current wait list
  • Price asked if the wait list increase could be attributed to the surge to increase awareness of available services
    • Some of it; there is a new public awareness campaign but it is hard to get a real number on that
  • Walle asked what cost avoidance benefits have been seen with the $300 million investment
    • Did not really calculate those; would have to develop a methodology
  • Walle interested particularly in the juvenile side; keeping kids out of the juvenile justice system with mental health treatment; additionally, interested in adult jail diversion
  • Walle asked if outreach to veterans is improving
    • Yes; another investment was specific to investing in veteran mental health services; funds are going to LMHAs to establish peer networks and provide community support
  • Burkett asked about housing as it relates to mental health services
    • Some funds were for supported housing; funds also went in for a state plan amendment for individuals who cycle through state hospitals regularly, a lot of those issues have to do with housing; believe about $12 million was used for those services
  • Since the Ebola event last year, some new processes have been undertaken to manage infectious disease; still monitoring individuals coming from certain areas of the world
  • Availability of data is a big part of the agency’s undertaking over the last few years
  • LBB covered the differences in the base bill versus last year’s appropriations; one top request is to address the disparity between the budgets for tobacco cessation; will also need some funding to address indigent caseloads
  • Burkett asked about NorthSTAR; how does Dallas County pulling out of the program affect funding
    • The program requires a County match; Dallas did not provide funding and the agency is trying to determine how to address the program funding without those dollars
  • Burkett noted one solution may be to integrate those populations into the program the rest of the state participates on
    • Trying to determine the right trade-offs to ensure the population’s needs are addressed
  • Price noted Sunset recommendations are not reflected in the base budget; what is the reason for the disparity on goal 4
    • Mainly trauma funding; a one-time injection of $300 million
  • The bill has about $12 million for the home and community-based waiver; want to keep the second year level going into the future; was included in the base bill
  • Walle asked about trauma center funding; what type of activities are those
    • Funds generally go to regional advisory committees that help to organize the trauma entities in the state; supports local EMS entity grants as well; does not go toward uncompensated trauma reimbursement; not specifically for trauma centers but for the support system
  • The base bill provides $600,000 above last session for vehicles but some still need to be addressed so there is a request
  • The base bill fully funds data center requests
  • Total GR request for exceptional items is around $400 million in all funds
  • Have a few items in HHSC exceptional item requests; information technology related to some systems and security related to those systems; state hospital safety and operations related to laundry and food software managed by HHSC; staff recruitment and retention related to salary increases for some state hospital employees
  • Also includes an item that will not cost the bill; some funding to reinforce the system that keeps track of vital records; requested funds last session and worked with DIR to replace those systems in a way that will not cost GR; there are convenience fees that are paid to get those records; those funds are available so working with the Comptroller to bank those fees in the vital records account to use them to replace the system; funds are exempt from BRE
  • Exceptional item to maintain FY15 service levels; tobacco cessation – $11 million; the difference between where the bill is today and what it needs to stay level from last biennium
  • Walle asked what type of services are out there for outreach and tobacco cessation and prevention
    • There are some statewide campaigns that push the message; there are also 12 coalitions in parts of the state doing more targeted efforts in their communities
  • Price asked if some of the money is used for the tobacco hotline
    • Yes; the money helps support funding that hotline and making it available to a broader group
  • Exceptional item for hospital cost increases; have seen staffing challenges in some areas of the state for state hospitals; overall, there is an increase in costs that occurs as a matter of other healthcare cost increases; cost increases are about 2.5% per year
  • Exceptional item for NorthSTAR caseloads; health insurance providers fee related to ACA; similar item to HHSC request; would be $1 million per year
  • Exceptional item to maintain and improve the state hospital system; hospitals are in a critical state; need to modernize the public mental health system; received a rider for a ten year plan last session to consider the future of the hospital system; identified 570 beds that the state is in need of today; factored in beds purchased for hospitals as well as community beds; projected an additional 600 beds would be needed over the next ten years; things can be done to reduce those needs such as investment in community care and investment in crisis services; study also identified five facilities that need to be replaced and four that need to be significantly renovated; total exceptional item cost is $2.5 billion over the ten years assuming the system is not fundamentally changed
  • Walle asked what it means to purchase a bed
    • Providing money to purchase local beds in the community to increase capacity
  • Sheffield asked if those beds are in a psychiatric facility
    • Not necessarily; they can be psychiatric beds in traditional hospitals as well
  • Rep. Dawnna Dukes asked if life safety issues in state hospitals is a historical item that is requested session after session
    • Yes; have received varying degrees of funding over the years; also, as funding comes in the situations change and other problems arise
  • Dukes asked for an explanation of Olmstead and why it is important for patients to be in the least restrictive environments
    • Lauren Lacefield Lewis, DSHS noted she will have to put together some information but in general, there is a committee that works across the HHSC enterprise to ensure people have access to intensive services, supporting people with housing services to ensure they aren’t in hospitals for an extended time period
  • Dukes noted that the Olmstead Act requires the state to provide the least restrictive environment possible and that those individuals have choice
  • There is an exceptional item to ensure preparedness for emergency response planning; statewide testing capacity for labs, etc.; components for epidemiology at the state and local level, proposing more in communities; funding for a response team of clinicians to handle infectious diseases
  • There is an exceptional item to enhance the expanded primary health care program; $20 million for the biennium; for women’s health; as explained earlier, response from providers was more substantial than the RFP was planned for
  • Rep. Matt Shaheen asked about NorthSTAR; Collin County is one of the counties that will be leaving the program; has DSHS thought through how funding would work for former NorthSTAR counties
    • Still being determined; Sunset directed the department to begin conversations with counties; should have county plans by mid-March; it is up to the legislature to direct how that money flows
  • An exceptional item for enhanced substance abuse programs; for substance abuse prevention and to address neonatal abstinence syndrome; about $45 million for the biennium
  • Dukes asked if DSHS has applied for federal grants or match programs for these programs
    • The bulk of funding is from a federal block grant; other opportunities become available over time
  • Dukes asked if the neonatal abstinence piece could be tied in with the Nurse Family Partnership program; based on demographics
    • Will look at that
  • Exceptional item for continued increased funding for community mental health services; HB 1 included $31.7 million for crisis services; crisis services would both fill existing gaps and continue current services; also includes mental health services in nursing homes and alternatives to long term care, asked for funding to help move people into the community to be served in the least restrictive environment; includes $2.5 million in GR for expansion and development of recovery-focused clubhouses, lots of stakeholders see successes in this model and there is data that shows effectiveness for keeping people out of hospitals; includes $4.8 million for relinquishment prevention, keeps families from having to give up their children to DFPS custody due to lack of services
  • Burkett showed particular interest in relinquishment prevention
  • An exceptional item to fund waiting lists; primarily children with special health care needs; funding was provided last session to move most priority 1 and 2 children off of waiting lists; asking for $11 million to bring another 550 off the lists over the biennium
  • Exceptional item for prevention and treatment of STDs; $6.1 million in GR to enhance testing, treatment, education and contact tracing
  • Exceptional item to improve prevention of chronic diseases; pediatric asthma management, potentially preventable hospitalizations, diabetes prevention and control, expanded tobacco prevention services; $26.1 million GR for the biennium