The Legislative Budget Board met on September 19 to hear from the Office of Inspector General and the Health & Human Services Commission concerning the agencies’ Legislative Appropriation Requests for the 86th Session and key exceptional items.
This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.
Office of the Inspector General Presentation
Sylvia Kauffman, Inspector General
- Gives overview of OIG cost recoveries
- 4% budget cut last year resulted in equivalent cut of 27 FTEs
- Federal authorities have repeatedly focused on program integrity, but program integrity risk is much different in managed care than FFS
- Identified $291 million in additional funds to be recovered, identified $39 million in cost avoidance
- Requested $24 million FY 20, $24.3 million in FY 21
- Also asking for 2 unexpended balance riders for budget and IT projects within the biennium; many IT projects take longer than 2 years
- Exceptional Item 1 – $6 million GR to support Medicaid Fraud & Abuse System
- Supports OIG monitoring & is statutorily required; more robust program will help to detect suspect behavior
- Will also allow purchase of additional analytics tools and expand support staff
- Exceptional Item 2 – $1.8 million GR to remediate automated system for the OIG
- Remediation will improve better operation and access to info, allow investigators more access to information
- Benefits program integrity uses this system frequently to identify up to 30% of recoveries
- With limited time to complete investigations, burdensome nature of
- $750k GR for 10 additional FTE salaries for TANF, WIC, etc.
- Not additional FTEs; OIG cannot fully fund these positions currently, could conduct more investigations with funded positions
Questions from Joint Legislative/LBB Panel
- Question – Regarding ASOIG remediation, Lar seems to also request additional FTEs along with this?
- Mostly IT contract staff to help remediate the system
Health & Human Services Commission Presentation
Cecile Young, Health & Human Services Commission
- Requesting $77.3 billion in base funding & $6.5 billion for exceptional items
- Provides overview of current HHSC spending & organizational cost; recently redid organizational structure to reflect proper hierarchy
Victoria Ford, Health & Human Services Commission
- In most recent biennium, HHSC implemented the Chief Policy Office and other changes in relation HHS transformation/SB 200
- HHSC is in process of reforming procurement process, management, & leadership
- 1115 Waiver has been renegotiated & has been focused on improving managed care contract management
Trey Wood, Health & Human Services Commission
- $2.1 billion in supplemental revenue need, but does not include HB 30
- HB 30 transferred $563 million to TRS, options include putting this into supplemental appropriation
- Current need projections show HHS will not be able to make provider payments by late 2019
- Gives overview of cost growth for acute care, growth for Texas Medicaid has been slower than national trends
- Total request is $33.2 billion in GR, $83.8 billion in All Funds
- For the presentation, exceptional Items were divided into 8 categories & highlights were provided in each category
- $2.8 billion in GR above baseline funding; categories focused largely on:
- Maintaining critical client services
- Addressing behavioral health needs
- Staying complaint with regulations
- 1 – Maintain Funding for Current Client Services
- Maintain Cost Growth in Medicaid Entitlement, Non-Entitlement, and CHIP programs, 60% of total request
- Maintain ECI services, includes normal caseload and cost growth & additional funds to sustain long-term and stabilize program
- SSLC cost growth and revenue losses
- Women’s Health Program placeholder, currently waiting on federal government response to 1115 waiver request for this program
Enrique Marquez, Health & Human Services Commission
- 2 – Compliance with state and Federal Regulations
- Electronic Visit Verification, computer tracking of home & community-based services, federal action has expanded scope
- Would fund improvements to EVV & ensure compliance by deadline
- Compliance with community integration for IDD individuals, reflects significant changes to day habilitation services, compliance deadline March 2022
- 3 – State and federal policy priorities for IDD individuals
- Maintain and build upon crisis services for IDD individual, includes service continuity and dedicated psychiatric services
- Promoting independence – funding for HHSC to divert or transition individuals from institutions to the community, ~2,500 slots
- Also request funding to reduce interest list for home and community-based services, 4,600 slots
Trey Wood, Health & Human Services Commission
- 4 – Contracting and Procurement
- Additional legal staff, procurement & contracting, contract oversight in behavioral health; placeholder pending review of processes
- Staff for Medicaid & CHIP, oversight of managed care contracts
- 5 – Capacity for Behavioral Health Services
- Expand capacity at renovated state hospitals
- Placeholder to fund state hospital planning & construction, discussion item for future state hospital
- Maintain services for mental health programs
- 6 – Protect Vulnerable Texans
- Major building, fleet, and equipment; significant need for vehicles and laundry equipment at SSLCs and state hospitals
- FTEs for regulatory services, 55 additional staff with 35 in childcare licensing
- 7 – Improve access to client services
- Increase attendant wages, $8/hour to $8.50/hour, also including alternatives to $.50 increase
- Recruiting & turnover, to address turnover state hospitals, SSLCs, and regulatory division
- 8 – Systemwide business enablement platform
- Transformation item, focused on providing common foundation to build replacement applications for different HHSC functions
Questions from Joint Legislative/LBB Panel
- Question – Could you provide update on consolidation of regulatory function
- Ford, HHSC – Regulatory division is now under my purview, moving forward everyday
- Currently looking at aligning business process, created division and clarified responsibilities; stable foundation exists for each program regulated
- Currently looking at similarities and overlap for functions/streamlining functions
- Transformation office is working closely with regulatory division to identify needs
- Question – Regarding utilization acuity changes, is this also related to caseload growth?
- Wood, HHSC – This can be built into baseline, so not included in that exceptional item
Public Testimony on HHSC LAR
Colleen Horton, Hogg Foundation
- Necessary to recognize interconnectedness of services needed by families; need for more hospital beds can’t be separate from need for more services
- Best way to open beds is to keep people from entering hospitals with supportive housing, step-downs, and rental subsidies
- Also, cannot be disconnected from needs for services amongst population typically not receiving these services, incl. substance abuse services
- Need to rethink services of IDD & improve mental health services for these individuals
- Provision of coordinated comprehensive care for individuals experiencing first-stage psychosis is strongly correlated with need for ongoing services
Dennis Borel, Coalition of Texans with Disabilities
- Filling all needs through appropriations is probably unrealistic, so need to think of provision of services
- Need to look at SSLCs from perspective of cost-effective services, 3k or less individuals for this system currently and huge amount of money is wasted
- Involuntary admissions to SSLC system are small, voluntary admissions are very small
- Interest list is now 140k individual waiting for waiver slots
- Legislature passed dental benefits in Medicaid study, study will show that individuals get sicker more without dental benefits; currently do not provide dental benefits
- Total increase for attendant wages in last 4 years is $.14/hour, leads to workforce shortage
Andy Homer, Texas CASA
- CASA currently receives $13.22 million, asked for an additional $2.25 million/year from HHSC
- Request is based on expected growth anticipated through next biennium
- Increased acuity in the system, CASA leverages funds highly, provides volunteer services at worth of ~$30 million
Gloria Terry, Texas Council on Family Violence
- Provides statistics on high levels of violence in Texas & shares experiences of some individuals involved with family violence
- 41% of requests statewide for emergency shelter go unmet, percentage is 75% in major urban areas
- Strong support for exceptional item of $3 million, recommending that LBB consider $6 million to allow for more housing and legal support services
Audra Conwell, Alliance of Independent Pharmacists of Texas
- Supported Rider 60 proposal last session, worked with others to complete report
- Rx drugs cost state $3.9 billion in FY17, $2 billion in rebates means net of $1.9 billion, improved PDL compliance could increase rebate
- Rider 60 report shows drug costs under managed care are growing faster than in FFS
- State and federal policy makers have shown interest in lowering drug pricing, current model incentivizes higher drug prices
Christopher Baird, San Antonio Clubhouse Member
- Provides overview of Clubhouse services for individuals with mental health issues
- Shares his personal experience of being involved with San Antonio Clubhouse
Susan Murphree, Disability Rights Texas
- Agree with need for funding to maintain services, excited to see efforts toward community-based services
- Need more HCS waiver slots, asks that funding for IDD individual in community settings be elevated
- Attendant wages are always very important, cannot sustain workforce without this
- Specialty services for IDD individuals should be developed in the community and not at SSLCs
Judith Joseph, Texas Occupational Therapy Association
- TOTA supports maintain ECI services, behavioral intervention for children with autism spectrum disorder, and pediatric telemedicine grant programs for rural Texans
- Would also like to see restoration of acute therapy cuts
Christina Green, Children’s Advocacy Centers of Texas
- Provides overview of CACT, HHSC LAR requests continued FY18-19 funding for FY20-21 with an exceptional item for additional funding; additional funding would help meet massive needs at CACs
- Currently investigating case load growth, without adequate resources CACs cannot meet demand
Kyle Piccola, The Arc of Texas
- Support many of the exceptional items, incl. attendant wages & other mental health services, focused on crisis mental health services
- Crisis services are important, without them sometimes only option is forced admission
- More crisis mental health services could offset need for law enforcement involvement
- Should have more methods to support community-based services
Lauren Gerken, The Arc of Texas
- IDD individuals have trouble locating work, high need exists for workers & high desire to work exists amongst IDD population
Ginger Mayeaux, The Arc of Texas
- Texas has typically funded promoting independence, diversion, and interest list reduction, but significantly cut independence funding and diversion, while completely reducing interest list reductions
- Supports additional funding for home and community-based services
Lee Johnson, Texas Council of Community Centers
- LAR reflects understanding of critical importance of ready access to mental health treatment
- Also reflects growing recognition that IDD individuals are at high risk of unmet mental health needs
- Placeholder for state hospital planning & construction should include strategies that reduce demand on state hospital beds
Debbie King, Meals on Wheels Association of Texas
- Supports $7.8 million exceptional item for higher meal rates
Shane Aguero, The Clubhouse Texas
- Seeking support of Clubhouse mission to help those with mental illness be successful
Amber Aguero, The Clubhouse Texas
- Asking for funding to expand current Clubhouses from 4 to 18
Jeffrey Dillen, Texas Association for Behavior Analysis
- Supports Intensive Behavioral Intervention & Applied Behavior Analysis exceptional items
- ABA is medically necessary for children with an autism diagnosis and can lead to cost savings for the state
- Supports licensure measures passed last session for behavior analysts
Jennifer Duke, Texas Medical Association, Texas Pediatric Society
- Supports ECI exceptional item, important for development of children
- Shares story of child helped by ECI
Josette Saxton, Texans Care for Children
- Supports early psychosis program exceptional item, possible for this to appear during childhood
- Supports RTC beds diversion to prevent entrance into CPS due to unmet mental health needs
- Support mental health community grants
- Surprised not to see any items related to the mental health needs of students
- Substance abuse prevention is also not reflected in the budget
- Also need to increase investment in psychiatric treatment centers and ensure quality of services
Will Francis, National Association of Social Workers Texas Chapter
- Fantastic that we are looking at increasing rates and expanding capacity for substance abuse treatment
- Would like to see more money in prevention, would also like to see HHSC approach this from a regional perspective & focus on community needs
Greg Hansch, NAMI Texas
- HHSC’s LAR includes many components that would improve mental health services
- Would like to see support for caseload growth and to avoid cost containment for Medicaid and CHIP
- Supports inpatient psychiatric workforce and capacity item, essential to continue current biennium’s progress
- Supports increased outpatient funding through community-based care
- Supports funding for mental health grant funding, state funding for Clubhouses is very effective, but supply is not meeting demand
Adriana Kohler, Texans Care for Children
- Supports strong investments into Medicaid and CHIP, will improve children’s care and access; reduces costs when interventions are early
- Investing in prenatal and postpartum care leads to substantial cost savings
- Supports ECI funding, substance abuse funding for caregivers and children
Stephen Aleman, Disability Rights Texas
- Supports IBI for children with autism spectrum disorders, highlights importance of intervention and substance abuse treatment
Ryan Van Ramshorst, Texas Medical Association
- Maternal health is an important funding priority, should find mechanism to extend service for 12 months after baby is born
- Medicaid behavioral health care is innovative, should support funding
- Should also look to Medicaid rates/funding, physicians often provide care at a detriment to themselves
Penny Mcelroy, Private Provider in San Antonio
- Facilities have difficulty finding staff for group homes, rates are not sufficient & not able to pay trained staff adequately
Mason Morgan, Providers Alliance for Community Services of Texas
- Testifies to inadequacy of rates for attendant staff, many other employers have significantly higher pay rates
- Appreciates addition of request for new slots, critical to fund mounting wait lists; critical to fund rate issue as well
Amanda Fredrickson, AARP Texas
- More attention needs to be placed on assisted living facilities; assisted living is licensed regulated only by the state, desirable option for many individuals and helps fill out continuum of care
- Supports regulatory services effort, quality monitoring program
- We’re not fingerprint checking staff involved in long-term care, only name checks; have many who would be excluded
- AARP supports individuals aging in place and meals on wheels support
Anne Dunkelberg, Center for Public Policy Priorities
- Reiterates support for ECI exceptional item, attendant wages increase
- Have ongoing concerns about provider supply for Healthy Texas Women, support whatever policy changes presented to improve/extend services for women
- Strongest tool for addressing working poor needs is some type of coverage program
- LAR and HHSC Administrator’s Statement refers to creating more robust system for IDD individuals; this is the level of rigor needed for all long-term and fragile individuals in Medicaid
- Will continue to support
Sarah Mills, Texas Association for Home Care & Hospice
- Association previously submitted recommendation to HHSC, several did not make it into LAR, incl. increases to fully fund rate methodology, reimbursement stream for ongoing costs related to EVV, attendant wage increases beyond the exceptional item, restoring therapy rate reductions
Rachel Hammond, Texas Association for Home Care and Hospice
- Association supports restoration of therapy rate reductions, HHSC claims not to have seen access issues as a result, but no data supports this
- Decreases in pay have caused therapy assistants staff to leave, funding needed to avoid workforce deterioration
Jason Barry, Barry Family Services
- Increasingly more difficult to provide services with compounding rate cuts year over year
- Recruiting staff is very difficult with rates available
Tyler Sheldon, Texas State Employees Union
- High turnover has plagued HHSC and cause difficulty for agency operations
- Pushes for an in-depth look at how to increase pay across the board at HHSC
Ruth Josenhans, PLAN Clubhouse
- Advocates for additional funding for Clubhouses
Beanca Williams, Volunteers of America
- Biggest challenge for group homes, etc. is maintaining staff; supports efforts of HHSC to move people into the community and reduce waiting lists
- Should restore & improve rates
Amy Granbury, Association of Substance Abuse Providers
- Supports expansion of prevention and intervention treatment services across the state, but currently services do not have the infrastructure to meet the needs of Texas
- Supports increased access to substance abuse and mental health services
Guillermo Lopez, Anybody Can ECI
- Shares experience with providing ECI, lack of resources, and caseload growth
Matt Moore, Children’s Health System of Texas
- Strongly supports fully implementing pediatric telemedicine grant program for rural Texas, could lead to significant cost savings, should incorporate into base budget
Terry Hitchcock, PLAN Clubhouse
- Shares experience with receiving services through PLAN Clubhouse, the Clubhouse model is effective and should be supported
Alyssa Sughrue, NAMI Texas
- Would like to see funding for student mental health & suicide prevention
- Access to mental health services needs to be improved for all family members, NAMI supports expansion of services for victims of family violence
- Should extend Medicaid coverage for 12 months postpartum
Karen Towery, Evergreen Life Services
- Direct care staff issues are pervasive, funding needs far outstrip funding coming in
- Rates that Evergreen can pay staff are less than many other introductory jobs
Linda Bailey, Evergreen Life Services
- Saw a funding reduction in 2012 that has not yet been restored, Evergreen is struggling with overtime issues, ability to pay staff, etc.