Travis County Commissioners Court
August 3, 2004
Item 3
3 is to consider and take appropriate action on policy and budget issues related to the rural medical assistance program for fy '04. And what I have in mind here also is to the board of managers regarding rmap if anything and that the (indiscernible) standards and the issues thated board needs to grapple with. The other thing about this is that typically we would give 30 days advance notice to be effective and it would be effective October 1. And notice really needs to be given by the first of September. And then the question is if you want to do it or whether Travis County should, depending on the decision.
>> judge, Commissioners, good morning. Sherry fleming, acting interim executive manager for health and human services. You have before you the backup from the department on the issue surrounding the rural medical assistance program. We have previously been before the court to talk about the -- our projections related to our ending balance in this program. If I could walk you through this backup for just a second, what we prepared for you is our best guess projection, and this would be through July, so these numbers are pretty much through the end of last week. Our expectation is that the budget for the rural medical assistance program in the best case will exceed the approved budget by $630,000. The mid range estimate is about $350,000. And that's why we're before you today to discuss with you. Previously staff had brought forward to the court a recommendation that we consider a policy change that might allow us to experience some cost savings within this fiscal year that would help maybe reduce that overage in some way. At this time because of the 30 day notice that's required, staff is basically withdrawing that recommendation in that we feel like there's not significant time left in the budget year for the court to see a significant savings from a policy change. Kelly's staff did participate in the briefing yesterday for the hospital district board of managers, and I have included at the back of your backup basically a couple of scenarios that were presented to the board of managers, and a very specific discussion was held with them about the budget implications of the policy decisions that they might make for this program. So it's my recommendation to the court today or our request that the court place an earmark on reserves for $350,000 for the remainder of fy '04 and defer the decision related to the policy to the hospital district board of managers.
>> so the decision about whether to implement those guidelines?
>> yes.
>> okay. Why would we ask the board of -- why don't we ask the board of managers what they wish to do? To me the question is if we make -- to make it effective October 1, either the board or Travis County needs to go ahead and give notice.
>> that's correct.
>> give 30 days' notice. And my position was that and is that the best thing to do is call it to their attention and say this needs to be addressed. And if our goal is to make it effective October 1, which is consistent with what we recommended to be the beginning of their fiscal year, that means action needs to be taken at the latest September 1 by the board or Travis County.
>> okay.
>> right?
>> yes.
>> assuming we give 30 days' notice, and I think we ought to. But for us to either have city standards county wide or county standards county wide, and the less expensive way is city standards county wide.
>> that's correct. The board of managers does have the posted agenda that includes this item, and they will be meeting again tomorrow, so we could request that they revisit this. They did receive a presentation into late afternoon yesterday, we made it to the budget implications of the policy changes. So we could go back to them tomorrow with the request from the court that they indicate their pleasure on this issue, whether they see this happening October 1, Thursday's notice, which would make it effective November 1. I think they had a pretty clear understanding of the budget implications of whatever decision they made, they were presented with several scenarios about the changes. And I think two of which you have there. One is the proposal that they look at, you know, raising everyone to the county standards, and you see the price tag attached to that. And then the next one would be having everyone be at the city standards, which is a projected savings to the hospital district of about $600,000. But they also received information that we will be basically moving -- we will be basically just changing how we pay for services for certain populations, so that they would have to take into consideration as well.
>> the reality is somebody was going to have to make this decision of either city standards county wide or county standards county wide. The reality is because this is so late in our fiscal year, that even though this Commissioners court is empowered to do exactly that, to make a call right now, the reality is it not going to help our budget this fiscal year at all. So the reality is that it ought to probably be deferred to that bo board of managers who will be empowered from October 1 to a budget, but the reit will a, as I知 sure mr. Collins will tell us, they've got things that they are doing right now in terms of empowerment on all of these kinds of issues. So to me that kind of says you ought to be deferred to the manager's to make this call since we're not going to get any impact on our end during this fiscal year.
>> if we talk to them about the need for a 30 days' advanced notice?
>> I believe so, judge.
>> if they wait until January one, the problem is they're looking at much higher cost, October, November, December. I think if they realize -- I see them moving to the county. The city standards county wide, and it also makes sense to me for one of us to make a plan to do it by September one to make it effective October 1. Now, they were given a whole lot of information to digest yesterday according to the agenda I saw.
>> absolutely, judge. I guess the question would be-- and I think it may be a legal question. I知 looking over that way. Is whether or not a decision made by the Commissioners court on this issue would be binding in any way to the board of managers. So we've changed the policy today. I think the board of managers still has opportunity based on their budget and their discussion on this issue to make a determination of what the policy for the district would be. So my question would be the impact of you making a decision one way or the other other than just to indicate your pleasure.
>> except in partnership with them.
>> right.
>> but I知 just -- we have been told that legally they need to have one standard district wide.
>> that's correct.
>> and the city thinks that if we adopt the county standard district wide that it will cost $13 million more.
>> and they've actually amended that, if you look in your backup, to $19 million.
>> see, I don't -- (indiscernible). If we're asking the district should we do this for you or do you want to wait and do it yourself, if we put it that way, my guess is they would say we would rather y'all to do it. And if we do it effective October 1, we have a chance to give notice to the affected people. The other thing is we need to describe how we provide services in another way, through other funding to roughly the same residents, then it makes sense to me. And if that is their future, assuming they know it, the -- the sooner they know it, the better. Christian has some cents to give.
>> two items. I was listening very clairely. 30 days was not explicitly articulated yesterday during the rather detailed presentation, but that doesn't mean it won't be expressed again tomorrow, but I do think it's fair to say that it is definitely on their radar screen for the board of managers. I believe they're fully cognizant of the implications and that they feel the responsibility to make a decision for '05. And on August 19th they will be presenting an '05 budget to the Commissioners court during a budget hearing, when I believe it is expected that this decision will have been incorporated into that budget presentation. So 16 days from now I believe that you will see the board of managers' conclusion on what they think the right thing do to do is. Is that fair, sherry?
>> I think it's absolutely fair. And I didn't include it in your backup, but part of the presentation to the board of managers yesterday was a third option where if you settle somewhere in the middle between the city and the county, here's the number that you're looking at. So I really believe that they have a very detailed and explicit explanation on what the budget implications are related to this policy issue. And so clearly I believe -- and I知 hoping for christian to shake his head -- that they understand that it will be impossible for them to set a budget without making a decision on this policy issue.
>> I just didn't think we should delay this, but the 19th is a work session.
>> it's a budget hearing work session. You'll be receiving a variety of departments, presentations and requests to Commissioners court. And on that day we scheduled the hospital district discussion. And then again on th 23rd, which would be the last day, which is -- allows everyone to lead into markup with a good understanding of the hospital district budget for '05 and the tax rate implications.
>> let me understand something. According to the last sheet where the assumptions are listed, if we remove the homeless, unemancipated minor and undocumented from, are we leaving them behind? Is that what we're saying? Whatever action we take and recommend to the hospital district, we're leaving those three groups behind?
>> what would happen is that they would revert to what is referred to as a zero percent pay, which means that they would receive services through the primary care clinics without having to pay a co-pay; however, they wouldn't have a hospital benefit, which means that if they sought services through the emergency room at brackenridge that if they did not have the ability to pay the costs associated with that visit would fall under the charity care arrangement that the city has with brackenridge, but that we don't contribute to. So if you think of the rural medical assistance program as insurance, they don't have coverage for hospital visits.
>> but they should get the same medical services that they need.
>> yes.
>> but those services are paid for in a different way.
>> that's exactly right. That was explained to the board of managers that if effect you're moving costs from one part of your program to another part of your program.
>> and the city now pays for the same groups of people in the way you just described.
>> through charity care payment.
>> this is moving it to the city's umbrella.
>> okay. And then -- but if it should be a public health issue, that would come under the interlocal between the county and the city interlocal for public health. Let's say that their health issue of these three groups is a public health disease or something that would spread to everybody, then that issue would be addressed by the public health interlocal between Travis County and the city of Austin, which will continue.
>> yes. Not under --
>> not under the hospital district.
>> in terms of services that might be required as a part of a public health issue, yes.
>> okay.
>> what is chc.
>> community health center.
>> community health centers clinic.
>> judge, is the suggestion that we think about this and we kind of. I think we're going to get there if we make the action or the board takes the action, but I think it ought to be in consultation that they present a budget to us accredited on the city standard whether we take that affirmative action or if, as you very appropriately suggested, the reality is they're going to have this decision shortly.
>> if they're coming the 19th, that's fine with me. If they have it by the 19th, we ask that question during that meeting.
>> okay.
>> now, I have a recommendation about the 350,000-dollar earmark. The question would be how would we cover this without an earmark? The second question would be, I guess, do we have this much money in the allocated reserve?
>> we probably have to get covered one way or the other. The earmark is a projection of what is going to occur. It was a range of 300 to 370. No more than three or four days ago. And 350,000 has been on the table about a reasonable expectation. The money's not there in the department. And so in essence it is a statement that the program is going to require more than it has budgeted in the adjusted '04 budget.
>> do we have this much in allocated reserves?
>> yes, you do.
>> any problem with moving it one week?
>> no. The reality is -- [overlapping speakers].
>> if we say it's not our problem, transfer the deficit, we can't do that. We have to be adults in this relationship and take care of our fiscal year and then they will start with another. But I think it sends a clear message that what we originally budgeted at the very beginning of the year clearly is not enough money to take over this same thing for next year. And there was an augmentation once and it was a bubble gum augmentation the second time. And that's just a signal to them about what it will take to take care of the exact same population.
>> and we have numbers from the planning and budget office that shows what we believe this this year, the '04 expenditures are going to be. And we assumed that there would have to be an additional $370,000 expended, which will then have to be part of the certified audit to determine what the tax rate reduction is based on '04 projections. We took the high end. Because we sought no less than 300,000, no more than 370 now, and these numbers as you know, these waves change their shape frequently. So we put 370 down to at least lock in certain kinds of expectations. Now it's 350.
>> what I have, and that is for the people that will be covered by the hospital district and are concerned about cost, not getting out of hand, then who is going to have the responsibility to educate the rest of the population about what we've done at the county? And that's educate people on how to use the health system in a much better way, given the fact that there are going to be some caps on the number -- if this is the policy that we've had -- that we pass, then the caps would take the number of medications or pharmaceutical prescriptions and other caps, then who is going to educate the population about how to utilize the health system in a much more efficient way? Is the hospital district going to do that? My expectation would be that they would. And when to go to the clinics -- or I guess which is most of the time -- rather than the emergency room. And the same issues that we've talked about here at the county on how to kind of put a cap on what we spend, you know, so that it doesn't keep getting larger and larger, there by affecting the raises that county employees get. And so I think it's still important to get those kinds of issues under control so that spending doesn't get out of control.
>> but the managers did receive testimony yesterday that historically the Commissioners court has not wanted to establish caps on the budget because that meant people would not receive the care. Now, that is -- that traditionally is now being passed over to the hospital board of managers. It will be their conclusion on how they wish to deal with that, whether to change it or to continue it.
>> well, I think we need to stress that we will continue to be interested in that issue because we don't want the spending to just go out of control because people don't know how to use the health system efficiently. And so I would think that -- I certainly would be interested in stressing the importance of that.
>> we can plan on getting phone calls and inquiries from county residents i'd say at least through the end of December. And we need to help with the education effort.
>> that's totally appropriate, judge. And we can do that. In response to Commissioner Gomez, I believe that there was abundant discussion about access issues with the board of managers on yesterday, and specifically the issue that because the primary care clinics are only open for a certain part of the day, it makes it impossible for people to always access those services and therefore they end up in the emergency room. So I think that that point was discussed and the fact that you have to have some urgent care system or extended hours in the primary care system if we were even going to make an attempt at impacting that most expensive way of health care services. So I think that issue was clearly a part of what they were discussing yesterday.
>> Commissioner, were you finished? Also, looking at -- I know we talked about caps possibly because there's only so much money that can go around. But since that is the case, that reality, we continue to emphasize -- I have and I think the whole Commissioners court is really concerned about out of county services, health care services that will be actually provided by Travis County and yet you have residents that are coming into Travis County to receive health care services. The question that I知 still trying to work on, and I think I mentioned it to all the board members that were appointed, and that is for some kind of legislation to have some kind of control as far as getting new language and new legislation passed to help us in this 10-county wide area. I think that -- I know that I知 trying to make sure we get some language going forward to access their concern because -- (indiscernible). ... As far as not having the proper cost sharing of persons that are receiving health care from adjacent counties in those hospital districts. So yes, we're talking about caps, but I think over all they need to be for our region as far as what we need to do on this. And again, I知 concerned about that and I just hope that the attitude of the board of managers is still looking at giving high priority to looking at supporting language hoping to be generated through this Commissioners court through our consultant to go to the state legislature an d say we need to control costs here. Because in my mind if we the pry taxpayers in Travis County will also h e to incur. And a lot of persons that i've talked to -- (indiscernible). ... As far as receiving health care that do not reside in Travis County. So those are some of the things that also need to be looked at. I understand the projections here. Somewhere along the line that's going to have to be addressed.
>> Commissioner, I believe a lot of cost drivers were discussed with the board of managers yesterday. And I believe that those discussions will continue as they move through their budget and even into the next fiscal year. They have a very -- I think they have a really good understanding of what some of the issues are that impact the spending in this area and the access to services and what changes might need to be made in order to make the system work more effectively.
>> we'll have it back on next week.
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Last Modified:
Friday, October 28, 2005 9:19 AM