Travis County Commissioners Court
September 7, 2004
Item 9
9, consider and take appropriate action related to budget shortage with the
federally qualified health center, fqhc program, for f.y. '04.
>> > September 3rd, i've got it. Thanks, david.
>> thank you.
>> good morning, judge, Commissioners, cheryl fleming, interim
executive manager for health hematoma. On last -- health and human services.
Last Tuesday we came behalf to you alert you to a projected shortfall in the
line item that supports the federally qualified health centers, the fqhc.
Last Tuesday you requested additional information I think has been provided
to you just in hard copy but also by e-mail. I have with me today staff from
the city of Austin and i'll let them introduce themselves.
>> I am david norman, the administrator of the Travis County
community health centers. I've met with you before in a previous capacity
as the administrator of the m.a.p. Program.
>> pull that microphone a little closer to you.
>> can you hear me now?
>> yes.
>> thank you.
>> with me today is philip defalco, our financial manager
for the fqhc.
>> one development we've been alerted to since we discussed
this with you last week is that there has been additional revenue certified
by the auditor's office that will be -- that we will be able to apply toward
the projected shortfall of $153,000. The shortfall has been reduced by 73,500,
so essentially the request now is 79,500. And I think p.b.o. Is here if there
are any questions related to that additional revenue.
>> questions that came up last week which weren't answered
had to do with the use of temporaries, which is the most expensive way that
you can cover shifts. We got no information about how and why temporaries
were used in the county clinics in terms of we had were people being moved
around, could there not have been full-time employees for less money moved
around to the different clinics. There just seemed to be an automatic we're
going to use temporaries which is the most expensive way you mean fill any
need for extra bodies.
>> thank you. I didn't receive that question in time enough
to respond to you, but I know trish young called knee a few minutes ago and
submitted an e-mail response to you and let me know about that. So yes, we're
prepared to address that. First of all, we have had a 13% increase in average
monthly m.a.p. Enrollment. Resulting in additional patients accessing our
services in the community health centers. We have been squeezing additional
patients into our clinics, which are already over capacity. And in fact this
year our template capacity which is basically the number of patients a provider
can see in a certain length of time has been averaging well over 100% throughout
the year. In order to do that, we've had staff working overtime in the evenings
and also sometimes on the weekends just to try to keep the paperwork going.
We have been challenged with a high turnover rate in employees this year.
We've had situations in which some of the positions have actually been vacated
more than once. To give you a example, your own precinct with the Pflugerville
community health center, we had a charge nurse position which was vacant for
quite some time -- for quite a long time, and of course the private sector
market is creating a real challenge for us in keeping medical personnel positions
filled. But we finally filled that position. And during that period of time
while it was vacant we had to use temporary staff, agency staff to cover that
position. Then once the position was filled, we -- one of the challenges with
a clinic system is you can't just oughticly put the -- automatically put the
new person in the position, you have to orient them. So for about three weeks
the new person has to go into other clinics to be oriented to womens health,
pediatrics, et cetera, because in the county system we do everything. And
the people that often come from an environment where they do one type of medical
care. So we orient them, so during that three weeks or so, we have to orient
them, we still have to keep the temporary personnel in place. So you have
a double whammy there. You are paying temporary person as well as you are
paying the full-time salary of the new person you are orienting in training.
So that's the kind of situation -- well, that particular person quit during
orientation much after two weeks they said this is too much, I’m not going
to be able to handle this so we had to go back, recruit again, vacancy continues,
and we finally hire somebody, and so after three weeks of orientation. And
the good news is we were able to hire somebody and they will be in place next
week. But all during this period of time we have been, you know, that's the
challenge in a community health center scenario is that during vacancies you
have to bring in sometimes more expensive temporary agency personnel. And
you also when you finally do hire somebody, you are paying two for a period
of time.
>> are you having the same challenges over on the city side?
>> yes, we are.
>> so really the questions we were trying to get answered
--
>> yes, indeed. I was shared the question you had is we focus
-- we don't share back and forth. In other words, people who are hired temporary
are, you know, for county or -- for the county and the city are for the city.
We don't have a percentage or anything like that.
>> so the $153,000 shortfall is traceable directly to the
five county clinics.
>> yes, absolutely.
>> so it's not like our percentage of a whole.
>> no, that's correct. It's exactly -- it's traceable to
the five county clinics. So, and it's volume driven. The bottom line is we
have increased our capacity by -- by doing this additional work and by bringing
in some temporary people -- I mean provider time. We've seen -- this year
we will see 8% more -- have 8% more encounters than we did last year. We will
have about 15,500 encounters this year as compared to last year. The huge
increase we've had in enrollment in m.a.p. Comes after the previous fiscal
year. We saw 19 percentage enrollment in m.a.p.
>> question.
>> in part, higher volume of patients.
>> yes.
>> going to mean a higher volume of reimbursements because
it's fqhc.
>> yes.
>> does that off set the 153 or --
>> yes, it does. Yes, it does. And you've hit exactly on
what we came to share with you today. We had -- we have $188,532,000 in projected
-- in additional revenues that we can project that off set the additional
amount that we're asking for. In fact, as sherry just described with you,
73,500 has already been certified so that reduces our request to $79,500.
>> then where's the 188? 188 in new revenue, that ought to
more than cover 153,000 before we even got here.
>> that's correct.
>> why is only 73,000 or 79,000 being certified when you
are saying that there's really $188,000? Why are we only certifying the smaller
amount?
>> there's a lag in some of the collections and I think we
are anticipating that we're going to be about 188,000 over budget in revenue.
However, there is a lag in actually receiving that money. Primarily related
to the encounters with the medicaid managed care program.
>> this is probably a leroy question. Are we going to be
able to recognize that revenue at whatever point it does get here even if
it's fiscal year tpao euf? Is that going to be an accrual?
>> are we talking about --
>> there is more than enough revenue coming in from new encounters
to cover the full cost of the temporaries t problem is they are only certifying
a certain amount to occur at this moment so we would cover our obligation
in this fiscal year, but we have more money coming to us in fiscal year '05.
How do we account for the additional money?
>> well, the auditor's office would be working with the fqhc
to determine the amount of accrued revenue. And I don't think we have those
numbers yet, do we, for the year end, phil?
>> no, this is our estimate. At this point we have not submitted
the formal accrual document yet.
>> I don't want to have this revenue get lost if we don't
somehow recognize it and it can apply towards the f.y. '05 challenges. Second
question is whatever happened to the rebates? Is the rebate question a question
for the fqhc in terms of our share of rebates coming back on drugs and do
we have any indication as to how much that is and is that too money we can
get in '04 or is that money we need to get our handle on and make sure we
get our appropriate share of rebates from the manufacturers coming in '05?
>> I think that's the question that came up on Friday and
I don't think we've had an opportunity to pose that question to the city about
the rebates yet, Commissioner.
>> well, we talked about the rebates recently on the -- our
m.a.p. Calculation. I don't think that we had raised the question with the
city on the fqhc prescriptions and maybe, phil, do you have any --
>> that particular item relates to the r-map which is outside
of that technically from a fund perspective and we are -- have discussed that
and we're looking at -- there has been a rebate record understand the current
year and we're looking to find out if there's any more forthcoming.
>> but is there a rebate due the fqhc?
>> no.
>> how can we have rebates in our m.a.p. And not on prescriptions
in fqhc?
>> because the prescriptions filled through the rural map
program are filled through a p.b.m. And that's where the rebate is generated;
whereas the cost that's recorded through this fund is the drugs that are filled
at our city-run pharmacies.
>> no discounts.
>> right.
>> p.b.m. Stands for?
>> pharmacy benefit manager.
>> thank you.
>> pharmacy benefit manager.
>> t-h-a-n-k-s.
>> what is the -- this number change -- this is part of the
frustration. This number changes every time we ask. Are we now down to 79,500?
>> that's correct.
>> with the possibility accruals in '05 will make up for
it? In terms of funds?
>> I think that the issue here has to do with what the auditor
will certify in terms of revenue in the middle of the year. And I --
>> still certified if it falls in unbalance, it falls in
unbalance of fqhc.
>> yes.
>> I know [indiscernible] as much certified as possible.
What you need today though is this was a budget transfer request last week.
We need it for the discussion. The answer to our question really is that the
financial accounting for the county clinics is done separate from the city
clinics and where there's a shortfall you can directly trace it there.
>> yes, sir. Absolutely.
>> and I guess the real question has to do on the accrued
revenue would be from an operating basis how much time do we have that we
can actually -- the court could delay until they get some of the remaining
questions answered before we actually do a transfer into the fqhc. Do you
have a -- is a week or two going to create a problem there?
>> no.
>> okay. Let's see, we're at the 7th, so possibly a drop-dead
date on this could be, like, September 21st, maybe just so we -- is that pushing
it too far, phil, or do we want it back on the agenda for next week?
>> because now -- negative 79,000, right?
>> right.
>> so we need to figure out whether we can reduce that or
--
>> right.
>> here's my frustration. The original note we got from the
city, sherry's August memo, okay, gang, we're short $202,000. Then it dropped
down to 153. Now we're talking 79. We just want to get a handle on whatever
it is that we need to do because otherwise there are consequences for the
rest of our budget. Total frustration that the numbers keep changing.
>> I think the -- on the operating expense side we have been
fairly consistent through several months. It's the revenue offset that is
making the numbers change.
>> okay. Thanks.
>> anything further on this item today?
>> one week or two, judge?
>> let's say the 21st. That will give us a opportunity to
wait as long as possible probably.
>> okay.
>> so 9-21 we'll have this back on.
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Last Modified: Thursday, October 27, 2005 10:33 AM