Travis County Commissioners Court
Tuesday, August 24, 2010,
Item 17
Item number 17 is receive and discussion the proposed budget of the travis county health care district for fiscal year 2011 and the associated tax rate. Good morning.
>> good morning.
>> i'm trish young brown, travis county health care district doing business as central health. We have our board chairman dr. Tom kupit with us today. Mr. John stevens, our chief financial officer will actually -- john and i will be making the presentation and he's going to work that little machine over there and i trust that he's good on the clicker. Because i'm not very good at that. We are here to present our proposed budget for 2011.
>> before you get started, let me say this under your item, it gets kind of confusing, especially when you bring it in under the title of health and human services department, which is our hhs department, and you bring it under your particular title as the travis county health care district or other instead of using hhs, health and human services?
>> we would be happy to bring it under whatever you instruct us to do.
>> because this the future because it almost appears that you are working under hhs, health and human services department. Which you are not. You are independent. And so i just kind of wanted to make sure that so when people look at this, there won't be any confusion of the two different groups here.
>> we've been instructed in the past on matters regarding the health care districts to come through the health and human services department executive manager, so that's the process that we followed in the past, but we would be happy to change it.
>> it comes up under other. It appears to me that it's confusing. I just want to lay that out.
>> sure, happy to.
>> the health care district.
>> that's correct.
>> that's what i think it should be. It gets confusing.
>> i think that clarification is important, but i don't have an issue and i prefer it coming under a category rather than other, but that i think is an internal discussion for us and not actually a decision of the health care district at all. It's our procedures.
>> right.
>> but we can discuss that further. I just wanted to make clear it's not your decision which category you fall under in our agenda.
>> i don't know who put it there, but the bottom line is -- when i look at this, i think of looking at --
>> i think our county judge did.
>> the county judge did that? All right, well, it gets confusing. And it's a separate department. I'm just bringing it up as far as one of my requests. Thank you.
>> thank you.
>> okay, we're here to present the budget for central health for the fiscal year 2011. As you know, this is the same procedure we followed for the last five years where we bring to you the preliminarily approved budget that was considered by our board of managers last week, and they gave us authorization to come forward to present this preliminary budget to you prior to taking it to public hearing, two public hearings scheduled for september and i'll give those dates at the end of the presentation. We are presenting the budget for the travis county health care district, as commissioner davis pointed out, which is now doing business as central health, and we're going to go through several bullet points worth of information in this presentation. We're going to try to go as quickly as we can to respect your time. Top but we do have four components we expect to cover today. Our current year accomplishments. We try to give you a picture of what we've done last year and what our budget looks like and how that relates to our strategic plan and what we have planned for the next budget year. I'm going to ask john stevens, our chief financial officer, to do the numbers presentation and then i'm going to talk with you about our strategic activities in the upcoming year. Let me begin by something you some of the accomplishments that we've had in the current year. These numbers that you see are the first three-quarters of the current fiscal year 2010 in comparison to the first three-quarters of last fiscal year, 2009. And you can see that in terms of average monthly m.a.p. Enrollment, for the first thee quarters of this year we are up 50%. So we've done some -- made some significant efforts to increase enrollment in our medical assistance program. We have also increased the number of primary care visits both in community care and through the other providers that we have assisting us in the community. 17 to 18%. Over the first three-quarters of last year, our dental visits are up by 10.5%. Our behavioral health visits are up 63%. And the in-patient psychiatric hospital admissions are up 70% over last year, over 2009. Some of the ways that we've been able to accomplish this is through the implementation of a customer service call center. We're working with united way on this, and they are helping take some of the load off of our eligibility workers by helping provide phone appointments. Instead of having to come in in person for an appointment to explain benefits to the m.a.p. Participants and so on. We've also instituted a virtual m.a.p. Application process where some of our providers out in the community are essentially screening people for us and we then approve their admission into the m.a.p. Program, but that also cuts down on the length of time involved to get people enrolled. We've increased significantly some of our contracts for primary care, as you see there, and in particular increased capacity at lone star circle of care and at el buen. Wee also instituted a contract for patient navigation for mental health services and we are contracting with front steps for recoup are active care beds to aid in their transition when they've discharged from the hospital. This is an overview of our 2011 proposed budget. The property tax rate that we are proposing is 0719, as you see there, 7.19 cents per hundred dollars of assessed valuation, and that is the effective tax rate as determined by the travis central appraisal district. So in fact we have proposed two years effective. 2010 was also at the effective tax rate and our proposed tax rate for next year is at the effective. We are going to bring in about a million dollars in additional property tax revenue that comes from new property that's been added to the tax rolls. We have a slight increase in our seton lease revenue, which is the base revenue that seton pays us under the lease and the additional rent which are tied to disproportionate share and upper payment limit dollars that we receive. A slight increase in interest in settlement revenue and we are proposing this year to use 10.4 million in reserves but you'll notice as noted there at the bottom of the slide those are funds that we expect mostly or completely to be added through the surplus that we're going to incur this the current fiscal year. Looking on the expense side, our health care delivery budget is up 11.2 million over the current year. Administration is up slightly for total uses of funds proposed for next year at an additional 11.6 million. Just to show you what some of those significant changes are in the health care delivery program, we have added 1.4 million in debt service on the certificates of obligation that the commissioners court approved our issuing earlier this summer. We are expecting some increases in our pharmacy program both for the increased m.a.p. Enrollment that we're experiencing and also because we are now negotiating a new contract for a pharmacy benefits manager that we think will have some added cost to it. We're adding --
>> are we able to make those m.a.p. Eligibility determinations in a timely manner? I know at the state level and here at the county historically we've kind of -- we've been behind the i guess level of need and number of applications.
>> yes, i would say we substantially modified the processes that individuals go through to gain enrollment into that program and i think that's reflected in the 50% increase in enrollment. The amount of time it takes to get to process is decreased but the actual procedures we have in place permit multiple methods. Someone doesn't have to come directly to a m.a.p. Eligibility office, they can have it happen through a provider. There's a mail-in application for renewals. So we expect that some of the additional work that's going to be occurring over the next coming years also with the community action network around kind of an enhanced way to get people access to basic needs including health care will also help support i think continuing timely access to the medical assistance program. And we're using technology and processes to facilitate that. Can you speak to that for a moment? I know there is a grant proposal in place that includes m.a.p. Eligibility that's being administered, the lead administrating agency is the capital area food bank, so that there is a one-stop shop for eligibility determination across many different service lines so that if you are eligible for m.a.p. And you are getting in through the health care district, it can also serve as your eligibility for the food pantry, it can also serve as your eligibility for -- for other services across the spectrum including mhmr and various others so you don't have to be interviewed by each separate agency in order to get that emergency assistance that's going to help you stay in your job, stay in school, be the most productive member of our community that you can be.
>> yes, essentially what we're facilitating, commissioner, is the collection of the necessary information that each of those entities have to make determination as to who qualifies for their programs. But by collecting it in a single portal, if you will, and not making a individual take that date from from place to place, we're giving people access to the information so that they don't have to, as we refer to, kerr that portfolio -- carry that portfolio around.
>> that's the complaint we hear most often, someone says i'm having difficulty, i need medication tweaked or whatever, they end up having to take time off of work, sometimes days off of work to run the gauntlet, and we are attempting to reduce that gauntlet.
>> significantly.
>> to something manageable and appropriate.
>> yes. We have added a million dollars to our mental health expenditures. We have an additional 1.2 million, these are funds unallocated but examine we may need that would allow us to enter into contracts with additional providers. And we do have 3.7 million in additional payments budgeted next year to our providers, specialty care and primary care providers that includes community care. Although we are proposing at the effective tax rate since our tax roll, the existing tax roll has gone down, as you know, our rate has gone up slightly. And the numbers that you see here calculate the tax rate effect from that slight increase. Even though the average taxable value of a homesteaded single-family residence according to the tcad numbers we were sent recently, that value has actually declined. Our tax rate has gone up a little more than that. So we expect that for this average homeowner, so to speak, the tax bill would increase from 149.20 to 156.61, an increase of $7.41. But again, on the hole, there is no tax increase because our rate is going up in relation to the value, the decrease in assessed value.
>> do you know what your -- what -- among the big five how much you represent of big five on an average home?
>> no, you mean in terms of the total tax bill.
>> in terms of the total tax bill on a average home.
>> i don't know that just right off my head. I mean, we are roughly, i think, between 1/6 and 1/7, the county tax rate so whatever --
>> that would put you certainly under 5% of the total.
>> i think historically it's been around 3. We have a spread sheet that we track that, but i think that's been roughly where we've landed in terms of the total.
>> thank you.
>> lastly i'll show you a loot our capital improvement budget for next year. We have a total of 3.5 budgeted, 2.6 million for building improvements that includes continued capital maintenance at the facilities that we're leasing from the city. Some renovations, and we have some funds in there for service expansion sites if we determine that we do in the next fiscal year need to add some additional locations. We have 910,000 in information technology that includes a data backup facility, some new servers, some wireless at the community sites and so on. And i'm going to turn it over to trish at this point.
>> i'd like to take a moment just to walk through this strategic plan. I think that you will recall that when the district was first created, it began operations five years ago, we -- myself and the board members walked through a pretty detailed process to develop a strategic plan. We have recently gone through a process over the last nine months or so to create an updated three-year strategic plan. The high level summary of what you have in front of you in this presentation. This is the document, this is the work, the vision that guides the work that we do on a year to year basis. So when we develop our budget each year, we start with the strategic plan. We see what are the goals we're trying to accomplish, which of our activities fit within these goals and what's the budget required to accomplish those activities. So we want to take a minute to point out a couple things that are different from our prior strategic plan. Our vision has stayed the same, that central texas is a model healthy community. But our mission has been simplified. And our mission is now stated as central health creates access to health care for those who need it most. And we have adopted some revised values that we try to live by in terms of how we make decisions in our organization and also operate on a day-to-day basis which include springfieldship, innovation and collaboration. We believe that going to -- i think back to prior discussion tore the discussion prior to our presentation, transparency is important in trying to get information to the public about what we're doing with the funds that we spend on their behalf, how we're delivering services is important and we will continue to work on better ways to hopefully present the results of how we spend funds. It is a little thicky with health care when you are dealing with impacts to citizens but we're working on that. We have four goals that will guide our work in the coming years. The first being access, the second under technology, the third under quality, and the fourth under leadership. And of course access we continue as we've done in the last five years to try to increase the number of services available to patients as well as to increase number of patients that we conserve. We are focusing on technology as a specific goal and to maximize the use of technology to both inform health care decisions as well as help us deliver service and efficient -- in an efficient manner as possible. Quality involves strategicly investing in takes designed to improve health care outcomes, not just provide service but hopefully have good results from that service delivery. And leadership is centered around assuming a leadership role in the convening of health care needs for our community. Even though we do not have responsibility for the entirety of the health care delivery system in our community, we have responsibility for a very large part of it and we know that patients move in and out of the delivery system that we support and in and out of the private sector. So it's important that we focus on as coordinated a system as possible. Under access in the upcoming year, we're going to be focusing again on eligibility services, going back to your question, judge. We are transitioning our enrollment models to more of a community navigation health care linkage function. Understand of just trying to determine what someone is covered for, trying to help them gain access to those services, an important evolution to support our residents. We are expanding our call center functions to facilitate that and we have a very strong partnership with united way that has proven to be very effective for us and for our patients. And we're going to provide applications, to your pointed, judge, sometimes at the state level it's not an easy process or timely process to get through, but we know it benefits the patient and our community as a whole to assist patients in enrolling in medicaid and chips so we'll be coordinating efforts with other entities that are already in process of doing that for residents of our community.
>> [one moment, please, for change in captioners] specifically dermatology, ent, cardiology, and there's one more that i'm forgetting. That they can actually have the physicians be located in their community health center sites and provide those services. So that is what will be developed over the coming fiscal year is to actually get those providers in our ambulatory care settings and the health centers. So we're hoping that that will occur by the end of next fiscal year.
>> well, i -- when you came before the court a little while back, i -- there was some specific -- i had some -- well, i had some reservations, i guess, when you needed to, and it went through pretty quirks the transition from taking money from our general fund and of course using it because of requirements, i guess, federal requirements to draw down a certain amount of money from the federal government. I guess it's $25 million at that time. It's something that comes up under the requirements of property taxes and then of course i feel squeamish about it because the fact that i did not want to see travis county taking money from its general fund, that amount of money anyway, to be offset later by the federal government allowing money to be filtered back down through you and of course you pay back travis county. And of course, during that particular conversation we had -- at that time i asked the question about disproportionate share as far as that particular fund was concerned. And this is basically -- this is supposed to be used for that as far as what i understood. And is that correct?
>> yes. On the funds that were -- that health care district borrowed from travis county were for the specific purpose of drawing down federal dish and upl funds.
>> then i understood that the disproportionate share of money was basically for medicaid and medicare.
>> medicaid.
>> medicaid or medicare?
>> medicaid.
>> i thought it was both.
>> it's just medicaid.
>> just medicaid. Okay. Because i thought i heard both, and i can go back and review the tape, but at any rate, this money, is that anywhere -- i guess my question is this: if it's for medicaid, is there any indication on how many persons were served with the $25 million that you drew down, stuff like that, how many people were served previously with the same type of concept? I'm looking for number of clients. And it appears that in your budget, it appears that -- it suggests that you even have a special account where this money is supposedly going to brackenridge. And that's what is kind of confusing to me when i saw that in your budget request as far as it going to brackenridge. Is that -- can you explain that to me?
>> let me see if i can explain. I think i understand your question.
>> it's on page 3 in your budget, in your budget request. It has --
>> your question about -- first of all, you said you thought it involved medicaid and medicare. I think i can explain that to you. The dollars from the federal program are calculated based upon the difference that a hospital gets paid from medicaid and what it would get paid under the medicare payment rates. So what they're able to draw down is the difference between the two. That may have been why you remember hearing medicaid. It has to do with the calculations of how much money they're able to draw down. And it compares medicaid rates to medicare rates and lets them draw down the differential. Now, back to slide 3, and your question, sir, about payments to brackenridge?
>> yeah, payments to brackenridge. It was in the budget backup on page 3. Where it suggested it come from accounts --
>> the medicaid program.
>> 62.83 account.
>> yes. That is actually -- those are payments that are made to -- the 62 payee? I'm trying -- 62.83 and 62.84 are the amounts that are paid to the federal -- are paid to the federal government as the match. That's our -- that is the health care district's contribution for purposes of drawing down those federal funds. Those a lots are not paid directly to brackenridge, they're paid to the federal government. And in a very complicated process, the federal government sends back an amount that includes the amounts that we sent up plus some additional funds to match it. And those funds go back directly to the hospitals. If i had to draw you a map, we would be sending up money, it would be attaching a friend and then the original dollar and the friend would be coming back to the hospital. That's the best way to explain it.
>> and i guess my question then is is there any way possible that you can -- in other words, since we're serving medicare -- medicaid patients, is there any way possible to indicate how many patients we're serving? We're drawing down money and i understand that, but when i saw this and if i can understand what you've just said, which i do, but according to my sources, they said that it was told to them that it went to brackenridge. Now, i don't know.
>> well, the payments the dollars that are drawn down for -- i'm trying to make a very complicated program simple. There are two types of funds that are drawn down to federal programs. There's what's called the public dish and upl program. Those funds from that program are shared between the district and seton family of hospitals as additional rent under our lease arrangement with them, which is reflected in the -- if you go back to page 1, the funds under seton lease additional based on dish. So that's the public program. The private upl program, these funds under 62.83 and 62.84 are the amounts that get paid under this private upl program. Those are the dollars that go directly to the hospital.
>> but my final question, though --
>> [overlapping speakers]
>> hold it, commissioner, hold it, please. What i need to know, though, is the number of persons served for the amount of money. I'm trying to get to that number.
>> and let me see if i can explain to you the data that we have.
>> is that readily available?
>> no, it's not readily available. It's information -- because we don't provide services, that information has to be reported to us.
>> has to be what?
>> it has to be reported to us. So we do have a process of information that gets reported to the health care district that we are able to receive information around the cost of the services provided. And i would have to go back and check, sir, to see whether we actually -- i don't know that i would be able to tell you the number of individuals served, but we would be able to tell you how many hospitalizations, how many actual service events. Because we do not have data that basically take a single patient's record and if they had multiple visits, we couldn't consolidate that into one.
>> but there is available data that someone has that could actually tell me that according to the amount of money that we've had invested in there under medicaid, how many clients are actually served with the -- there the use of that money?
>> it would be based on the time frames reported and yes, we could do that.
>> it would be good to see because i try to associate money with service and then service rendered. And right now i'm kind of -- it's kind of foggy because there's no indication of that, yet you come before the commissioners court and ask us to --
>> can you give us that information by e-mail? Just send it to the whole court if you have it. You have a series of public hearings planned related to the budget. And they are?
>> john, do you have those dates?
>> i do.
>> i have one more question, judge.
>> we'll get back to you in just a minute. Let's progress here. Those public hearings are open to the public. Tell us where they will be and when. Now, there is a -- while you're looking for that, we do have a lot of information regarding the budget. This information is available to the public upon request.
>> it will be on our website, sir, and it will be at our public hearings in printed form.
>> if those who want a hard copy they can contact either the health care district or a member of this commissioners court.
>> yes, sir.
>> and we are free to copy this backup and distribute it upon request.
>> absolutely.
>> okay. Those public hearings?
>> september 1st at 5:30 p.m. At the boardroom of the hlt care district administrative offices, which is 1111 east cesar chavez. And again, on thursday september 9th, at 6:30 p.m. Here in the granger building at 314 west 11th street.
>> commissioner davis has another question.
>> just a final question. Also i'm concerned about the car allowances, the $5,000 for car allowance. I don't know -- maybe we have that somewhere else in the county. I don't really know.
>> a car allowance is --
>> tell me about the car allowance.
>> there are two ways in which you reimburse employees for the cost of using their private vehicles for their business purposes. One method is to reimburse them, they record the actual miles that they trief on a log and that log then gets signed and submitted and then gets paid on a rate that typically is based on the i.r.s. Reimbursement rate that the i.r.s. Sets. Another method, instead of having an employee go through that individual record keeping about actual miles driven, you can give them an allowance, which essentially says you will have this amount of money for that expense, and it's the employee's risk whether they incur expense more than that amount. It's simply one method over another. An allowance is an administratively more simple process for an employee because they don't have to keep track of their actual mileage. So you choose one or the other.
>> okay. Thank you.
>> when do you expect the court to take action on the proposed budget?
>> we are looking i think at september 21st.
>> any court member that has additional questions can contact you and get those answered?
>> absolutely.
>> prior to that date? Court members, any other questions or comments we'll we'll have other opportunities. That public hearing is right here in this courtroom. Thank you very much for coming.
>> music quickly, we do have three other time certains for the morning and we have had individuals come down for those items. Let's try to reach them.
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Last Modified:
Tuesday, August 24, 2010, 2010 2:30 PM
