Print 🖨

The Senate Finance Committee met on February 5, 2019, to discuss Article II – Health and Human Services. The Committee heard invited testimony on the Health and Human Services Commission, Office of the Inspector General, Texas Civil Commitment Office, and the Department of State Health Services.

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.

 

Opening Comments

  • Nelson – We must protect vulnerable populations but pay attention to the cost. Costs of healthcare have been increasing at an unsustainable pace.

 

Health and Human Services Commission

Mike Diehl, LBB

  • Reviewed LBB recommendations
  • Funding changes at HHSC mostly driven by changes in Medicaid and one-time funding for Harvey assistance
  • Reduction in Medicare client costs to the state due to changes in FMAP, feds are paying more

 

Samantha Brock, LBB

  • $7.5b for behavioral services in all funds
  • $54m in opioid specific federal grants
  • $185m in all funds for children’s mental health programs
  • $824.8m in all funds for state hospitals
    • $300m in ESF for FY 2019 for construction and hospital improvements

 

Rustin Dudley, LBB

  • 3 behavioral health boards at HHSC going through Sunset, if Sunset recommendations go through these would be consolidated with Board of Examiners of Psychologists
  • Article II agencies had active procurements valued at $153b
  • Reviewed rider recommendations and briefly reviewed exceptional items
  • Watson – Caseload cost growth, explanation why caseloads drop so significantly over the biennium?
    • Diehl – I would defer to the agency
  • Watson – Will the number of people served under waivers be lower for the 20-21 biennium than the 18-19?
    • Diehl – The slots will be lower starting August 2019 and continuing through 2021
    • Watson – So your projections are based on levels on August 2019?
    • Diehl – We are projecting based on the amount of people served to maintain the current appropriated level.
    • Watson – What would it cost to keep the number served the same as 2018?
    • Diehl – I don’t have that number but will follow up.
  • Watson – If the waiver is not approved by CMS what will be the additional cost in the upcoming biennium?
    • Dudley – Increase of $52.9m in GR
    • Watson – How much would it cost the state to just serve these women in Medicaid?
    • Dudley – I do not have that number I will get back to you
  • Watson – Question about ECI funding keeping up with population growth
    • Liz Prado, LBB – ECI is not an entitlement so if the legislature wanted to fund it at a certain level that is at their discretion
    • Dudley – The agency can also request transfer funds to cover any gaps
  • Watson – What are we limiting the number of children served with the Medically Dependent Children Program (MDCP) waiver?
    • Diehl – The rider puts a number of slots because that is not an entitlement it is a waiver program.
    • Watson – Do we have the specific number served by this program?
    • Diehl – I do not have that information
  • Nelson – What has been done after the consolidation from SB 200 last session?
    • Prado – We did a lot of cleanup after consolidation to figure out where things should be. Deleted a lot of riders that duplicated authority
    • Watson – Part of why I asked the questions is because things looked after consolidation.
  • Perry – Is there a waitlist for the MDCP kids?
    • Diehl – There is a waitlist, I can get more information about it.
  • Kolkhorst – FTE decrease of 791 in State Supported Living Centers, why is that and is there consideration of high turnover rates?
    • Brock – That was done to bring the FTE cap more in line with the actual fill rate while still providing a buffer
  • Hinojosa – How many people are being admitted vs how many are exiting?
    • Brock – I do not have that number with me.
  • Hancock – Can you give the long-term impact to the state of Medicaid? It looks ok in the short term but does not look as good in the long term.
    • Diehl – We can follow up with that
    • Nelson – Medicaid has grown exponentially and is crowding out a lot of other things.

 

Dr. Courtney Phillips, Exec. Commissioner, HHSC

  • Gave overview of agency
  • 40,000 FTEs, around $70b in funding

 

Trey Wood, CFO, HHSC

  • Reviewed HHSC budget requests
  • Exceptional items total $3.2b above base amount
    • 59 exceptional items
  • Kolkhorst – CFO said Texas has a slower increase in cost the rest of the nation, is that just Medicaid costs?
    • Wood – That means we have lower cost growth than other areas of the nation including Medicaid in other states and private insurance
    • Kolkhorst – Have you seen if there are duplicated efforts or have MCOs taken over full contracting function?
    • Phillips – You would not want to get rid of FTEs as you shift to MCO, you move the FTEs to other responsibilities
    • Kolkhorst – So in shifting to MCOs you don’t see in savings in HR and those cost drivers?
    • Phillips – I don’t have the exact percentages, but in my experience in other states we did not reduce FTEs we shifted them to different positions
  • Perry – Comments on lack of civil bed space for rural county sheriffs.
  • Watson – It appears we are getting rid of a program for high needs kids in foster care, what is happening with that rider? Also, it appears all MCO contracts are set to expire within the upcoming biennium, what are we doing to learn from past mistakes for how we deal with MCOs?
    • Watson – I want to make sure you are getting what you need to do what you want to do
    • Watson – I am for creating an external medical review process for families, how would you implement what you are asking for in exceptional item 18?
    • HHSC staff – We would insert an independent medical review organization that would happen in between our fair hearings process. It would be an independent medical opinion looking at the clinical judgement.
    • Watson – What would be the timeline for this?
    • HHSC staff – This process cannot extend the overall timeline for a client to get there fair hearing completed
  • Watson – Do you agree that the home meal delivery program saves enough money to cover the cost?
    • Wood – We would have to get back to you on that.
  • Watson – Question about overtime requirements
    • Phillips – During the government shutdown we were trying to frontload the February payments and there was some mandatory overtime.
  • West – Why was the women’s health program over budget?
    • Phillips – we will have to look into that and get back to you.
  • West – Office of Minority Health Statistics, how effective has that office been?
    • Phillips – I briefly met with the individual who ran that office, but I would like to look into that further and get you an answer on that.
    • West – What steps were taken to identify a university to take over the program?
    • Phillips – We have not identified one to take over that program, but we have reached out to some and some are already providing duplicate services
  • West – Asks after the agency meeting HUB goals
    • Phillips – We were at 18% and have gone down a few percentage points the past few years.
    • West – There was only $95k for African Americans out of $61m in the program, how is that possible?
    • Phillips – We have more work to do in terms of digging into that data, look into why some entities self-contract instead of using the HUB programs
    • West – We hear this story over and over again, the only difference between you and previous commissioners is that you are new. It appears your HUB organization is deficient. Nothing ever gets done on this issue. When will you start taking this issue seriously?
    • Phillips – We have a new HUB commissioner that we believe will do a better job.
  • Flores – Asks after state hospital funding for Austin and San Antonio hospitals as well as the split of the funding total
    • Wood – The $300m would be for one or the other
    • Flores – Are we on the same page we want to do both?
    • Phillips – Yes
    • Flores – And these are to expand the number of beds correct?
    • Phillips – Yes
    • Flores – Have you had any discussions about hubs in more rural areas? SASH serves 54 counties some of which are far away.
    • Mike Maples, HHSC – We have had many discussions about hospital locations and how to best access them. We have been looking at the hub and spoke model.
    • Flores – I want to make sure San Antonio and Austin get fixed.
  • Hinojosa – On SSLCs, asks the same thing posed to LBB about number of admittances vs number of exits for any reason.
  • Hinojosa – Do we still have a wait list for community services based on needs?
    • Wood – Yes we have a waitlist for many of our services
    • Phillips – as of May 31 it was 140,000 individuals on the waitlist. It was a little over 16,000 for the MDCP waitlist, to answer Sen. Watson’s question from earlier.
    • Hinojosa – Do we have the infrastructure in place for community-based services to accommodate that many people?
    • Wood – That is something we can get back to you on.
    • Hinojosa – Is there a waiting list for SSLCs?
    • Wood – No.
  • Nichols – Exceptional item 34 to do with sustainability of meals on wheels, how long has it been since the reimbursement rate on that program been adjusted?
    • Phillips – In 2007 in was increased by 0.7 cents (less than one cent)
    • Nichols – I know this seems small, but this program is important to many people.
  • Bettencourt – Exceptional item 9, you are trying to beef up procurement and contracts oversight function, I would encourage you to bring that function up as high in your org chart as you can, as that is billions of dollars in liability for the state.
  • Bettencourt – Exceptional item 31, performance management and analytics, this is an area that is critical to the success of the organization, and is relatively a very small budget item, if there are any other tools that you have learned from past experience please ask for them
    • Phillips – Measurement is very important, if you cannot measure it you cannot tell if something is working
  • Perry – The state committed $900m for bed space in rural areas, the discussion was that some of that would flow over into West Texas, but that is not the case. Emphasizes there are underutilized hospital bed space in West Texas, and these bed spaces can be used more efficiently than bed space in urban areas. Looking for innovative solutions that can solve this problem quickly and efficiently.
  • Kolkhorst – Some LMHAs had only 2 beds, it seems we have “39 fiefdoms” rather than taking a regional approach.
  • Kolkhorst – How are you functioning in SSLCs with some FTEs and funding missing?
    • Phillips – In November we had 42% turnover in SSLC. It is important to ensure we are not burning out staff. We have to do a lot of contracting and overtime
    • Maples – We spend about $80m in contracting and overtime
    • Kolkhorst – Who is your main competition for hiring?
    • Maples – Anywhere that hires nurses, when we are able to raise wages up to where the local competition is we are able to effectively hire and retain nurses.
  • Watson – For the rider we are operating under with regards to state hospitals, the committee decided this was a 3-biennium project, part of the money was for planning. The whole system is being analyzed, so we can work with local areas to ensure people aren’t brought to ASH or SASH form unreasonably far away.
  • Huffman – Some of the problems with jails and waitlists, SB 292 last session provided funds through a grant program to help with bed shortages in Harris County jails, that program was successful. We are working on some issues that will help the rural areas as they try to address these issues.
  • Huffman – I cannot find anything in your LAR for additional FTEs for CCLs, am I missing that?
    • Wood – It is under exceptional item 40.
  • Hinojosa – For the past 10 years we have been trying to improve the services, every year we hear about high staff turnover, lack of professional health care providers, when or how can we make progress in SSLCs?
    • Maples – The nature of the SSLCs are changing with the populations we are serving. Many of the people served come from specialty providers. We have made strides with DOJ, but it is a slower process than we would like, and it has been so far a nine year process.
    • Hinojosa – There seems to be a decline in populations, LBB recommended a reduction in funds, what are we doing to provide professional support to clients?
    • Phillips – Just because there is a reduction in number of people we are serving it does not necessarily mean there is a decline in funding.
    • Hinojosa – Comments on high turnover rate, a 40% turnover rate is not good for the service.
    • Philips – I agree, we are trying to reduce that rate.
  • Nelson – Recommends putting money into prevention in order to save money in later years.
  • Nelson – Question for LBB, has there been a decrease in statewide funding for mental health?
    • Brock, LBB – There has been a decrease related to one-time funding provided last session for facility increases and decline in federal funds.
    • Nelson – And that doesn’t include the $300m provided for state hospital funding?
    • Brock – That is correct.

 

Office of the Inspector General

Sylvia Hernandez Kauffman, Inspector General

  • $45.5m in GR, $110m in AF across biennium
  • Reviewed exceptional items
  • Hinojosa – Question about Medicaid fraud cases referred to AG’s office, are the outcomes of these cases tracked?
    • Kauffman – We have a new deputy director who is meeting regularly with the person in the AG office in charge of those cases, but we do not yet have data on the outcomes of those cases
  • Watson – Question for LBB, some resources currently going to OIG for audits could be rerouted to other agencies, how much money are we talking about and which agencies?
    • Diehl, LBB – That was a recommendation for the legislature, the amount would depend on the amount of audits
    • Watson – But you wouldn’t have put the recommendation in without a number in mid?
    • Prado, LBB – We did have some thoughts on this, we can continue to work with work groups on this
    • Watson – I would like to know before we start allocating funds if there is a more efficient way to allocate them.
  • Kolkhorst – How much have MCOs recovered outside of OIG’s work?
    • Kauffman – I believe internally it was $3m, half of which would come back to the state, but I do not know the external number.
    • Kolkhorst – I think it is important to have that 50/50 split and that we recover that.

 

Texas Civil Commitment Office

Marsha McLane, Exec. Dir. TCCO

  • Civil commitment has been reduced since we stopped hearing 100% of cases in Montgomery County
  • Concerned with caseload growth and facility capacity
  • TCCO staff – TCCO’s baseline request was funded in the base bill
  • TCCO staff – Reviewed exceptional items
  • Perry – Can you give me the percentage of the Hep C population?
    • McLane – Of 315 people in there we have 15 with Hep C

 

Department of State Health Services

Amy Ma, LBB

  • Biennial decrease of 5.4%
  • Reviewed LBB recommendations
  • Exceptional items total $119m in all funds
  • Nelson – SB 1 assumes no interest earnings from tobacco supplement funds, do we have any?
    • McGeady, LBB – There is a balance in the funds, but that balance is used for debt service.
    • Nelson – SO none will be appropriated to this agency?
    • McGeady – Correct.

 

John Hellerstedt, Commissioner DSHS

  • Reviewed exceptional items
  • Requesting more funding for State Public Health Reference Laboratory
    • Lab running at ongoing shortfall of around $8.9m per year.
    • $8m (around 90%) of the shortfall is from a newborn screening program.
    • In the past used HIV rebate money to cover the shortfall, but feds recently restricted what those funds can be used for.
  • Nelson – Do we have a plan for replacing the decrease in federal funds?
    • Donna Sheppard, CFO DSHS – Most of that decrease from the previous biennium comes from one-time payments for Harvey recovery, so we have been prepared for that
  • Campbell – Question on vital statistics program
    • Hellerstedt – We are basically pleased with the basic function of the program
    • Campbell – So we are working to make sure it is not over budget?
    • Sheppard – Yes
    • Nelson – Where is this data being stored physically? Need to ensure the safety of that data
    • Hellerstedt – Security of that data was the impetus for the creation of the vital statistics program
  • Hinojosa – If we were to increase trauma care to level one designation in certain areas of the state what would be the process?
    • Sheppard – Those funds are distributed through a formula
    • Hinojosa – But the formula does not kick in until the hospital has been in development for a year, what is the process for becoming level one designated trauma center?
    • Hellerstedt – That is something under the purview American College of Surgeons, it is a complex formula.
    • Hinojosa – A hospital trying to increase their designation from 3 to 1 has to meet certain criteria, but they have to invest the money upfront in order to meet these criteria?
    • Hellerstedt – Yes.
    • Hinojosa – And it is only after they have reached level one that they can qualify for formula funding?
    • Sheppard – We can get back to you on that
    • HHSC staff – I believe the formula you are talking about is a HHSC formula, HHSC works with DSHS
  • Kolkhorst – Regarding funds for maternal safety initiative, would that be used to expand the initiative to hospitals not currently participating?
    • Hellerstedt – They could be used in that way, the main thrust of the funding increase is to accelerate the progress of hospitals which are already participating.
    • Kolkhorst – That funding is not very often matched from the federal government correct?
    • DSHS staff – Yes we have some Title V funding, but we are using all we can use, and it has limited applications.
    • Kolkhorst – Are we so restrictive that rural hospitals cannot afford to be in LND?
    • Hellerstedt – No I don’t believe so, if you are designated at all you can qualify for Medicaid reimbursement
    • Kolkhorst – I have heard from constituents they are having trouble getting timely death certificates, is the backlog related with an increase in demand or with the transition to TxEVER?
    • Hellerstedt – The TxEVER transition took a lot of staff time, we are no looking to cut into that backlog, the current average for turnaround on death records is 15 days, we would like to get that to 1 day
    • Sheppard – For all records we are hoping to get to an 11-day turnaround
  • Bettencourt – What is your level of communication with UT medical branch in Galveston?
    • Hellerstedt – Their work is not directly related to our work, but we are aware of them.
    • Bettencourt – Question about Zika
    • Hellerstedt – We have a way to test for Zika
  • Bettencourt – Are you CPU bound for your data analytics team, that is a challenge for data analytics correct?
    • Hellerstedt – Yes it can be a challenge to use these antiquated systems
    • Bettencourt – Exceptional item 11 is important to update these antiquated systems
  • West – We have seen a lot of these agencies with antiquated systems and have seen many with trouble integrating data. I would like to see what DIR can do to address these issues, what cost efficiencies can DIR recommend and what would be the time frame.
    • Sheppard – We have been working with DIR.