Transcript The William P. Hobby Policy Conference

900 Lydia Street - Austin, Texas 78702
Phone (512) 320-0222 – fax (512) 320-0227 www.cppp.org
Health & Human Services
Reorganization and the
Integrated Eligibility Initiative
One Voice:
A Collaborative for Health and Human Services
September 30, 2004
Celia Hagert, Senior Policy Analyst
([email protected])
Overview
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Reorganization/Consolidation of HHS
Agencies
Proposal to Use Call Centers for Eligibility
Determination
 Close local offices and replace with up
to three call centers and an Internet
application
 Significant new role for private providers
and their volunteers
Outsourcing of State Agency Functions
and Jobs
Major Concerns

Health and human services cuts that accompanied
reorganization shift responsibility to local
governments/private providers who do not have the
resources to replace services
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Proposal to Use Call Centers for Eligibility Determination
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As a result, 83 counties, 10 cities, and three public health
districts, and three chambers of commerce have passed
resolutions against the new law
Loss of local offices/jobs
Unreasonable expectations from local nonprofit providers who
do not have the resources to make up for loss of state workers
Could lead to less access to federal/state services, more dollar
loss
Outsourcing of State Agency Functions and Jobs
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7/16/2015
State/regional/local job loss
Raises concerns about accountability, ability of state to monitor
contractors, performance,
openness
Center for Public
Policy Priorities
3
Reorganization/Consolidation of HHS Agencies

Consolidated eleven HHS agencies into four
and placed them under the oversight of the
Texas Health and Human Services Commission
(HHSC).

Consolidated policy/rulemaking authority under
HHSC executive commissioner

Uniform organizational structure for HHS
agencies

Stripped individual agency directors of
policy/rulemaking responsibilities.

Replaced agency governing boards with
advisory councils—with no rulemaking authority.

Abolished most advisory committees.
Reorganization/Consolidation of HHS Agencies

Consolidated all administrative functions
(legal services, human resources, etc.) for
HHS agencies at HHSC.

Created new Office of Inspector General
at HHSC; consolidated fraud/abuse
functions (detection activities) for HHS
agencies at HHSC.

Changes in agency structure/functions will
occur at state, regional and local levels
The Health and Human Services
Enterprise
New powers & responsibilities of the Health and
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Human Services Commission:
HHS program/policy
HHS rate setting
All administrative functions for HHS agencies: legal, HR,
contracting, procurement, purchasing, etc.
Medicaid
CHIP
Vendor Drug Program
Eligibility services (Food Stamps, TANF, Medicaid,
including integrated eligibility project, TIERS)
Family violence
Child Nutrition
OIG
Ombudsman
7/16/2015
Center for Public Policy Priorities
6
The Health and Human Services
New agencies and responsibilities:
Enterprise
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Dept. of State Health Services, DSHS (health and
mental health services—includes state hospitals &
community services, alcohol and drug abuse)
Dept. of Aging & Disability Services, DADS (mental
retardation services—includes state hospitals &
community services, community care, nursing homes,
aging services)
Dept. of Assistive & Rehabilitative Services, DARS
(rehabilitation services, services for the blind/visually
impaired, services for the deaf/hard-of-hearing, early
childhood intervention)
Dept. of Family & Protective Services, DFPS
(child/adult protective services, child care regulation)
7/16/2015
Center for Public Policy Priorities
7
The Health and Human Services
Enterprise
Agencies that were abolished:
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Interagency Council on Early Childhood Intervention
Texas Commission for the Blind
Texas Commission for the Deaf and Hard of Hearing
Texas Commission on Alcohol and Drug Abuse
Texas Department of Health
Texas Department of Human Services
Texas Department of Mental Health and Mental
Retardation
Texas Department on Aging
Texas Health Care Information Council
Texas Rehabilitation Commission
Note: Cancer Council became independent entity, no longer an HHS agency; moved to
Article 1 of the budget (Gen. Govt.)
7/16/2015
Center for Public Policy Priorities
8
The Consolidated
Texas Health and Human
Services System
Governor
HHS Transition
Legislative Oversight
Committee
•2 Senate members
•2 House members
•3 Public members
•HHSC Commissioner, ex-officio
as directed by HB 2292, 78th Legislature
Health and Human Services Commission
Office of
Inspector General
Executive Commissioner
Health & Human
Services Council
Aging & Disability
Services Council
•
•
•
•
•
•
HHS Centralized Administrative Services
Medicaid
HHS Rate Setting
HHS Program Policy
Vendor Drug Program
CHIP
TANF
Eligibility Determination
Nutritional Services
Family Violence Services
HHS Ombudsman
Interagency Initiatives
Department of State
Health Services
Commissioner
• Health Services
• Mental Health Services
• State Hospitals
• Community Services
• Alcohol & Drug Abuse Services
DHS
MHMR
TDoA
7/16/2015
Agencies formerly providing programs
HHSC
DHS
Family &
Protective Services
Council
State Health
Services Council
Department of Aging and
Disability Services
Commissioner
• Mental Retardation Services
 State Schools
 Community Services
• Community Care Services
• Nursing Home Services
• Aging Services
•
•
•
•
•
•
MHMR
TCADA
TDH
THCIC
Assistive &
Rehabilitative
Services Council
Department of Family and
Protective Services
Commissioner
• Child Protective Services
• Adult Protective Services
• Child Care Regulatory Services
PRS
Center for Public Policy Priorities
Department of Assistive and
Rehabilitative Services
Commissioner
•
•
•
•
Rehabilitation Services
Blind and Visually Impaired Services
Deaf and Hard of Hearing Services
Early Childhood Intervention Services
ECI
TCB
TCDHH
TRC
9
7/30/03
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Agency Councils
New 9-member agency councils will replace
governing boards.
Councils do not vote; instead make
recommendations to their agency
commissioner/HHSC commissioner.
Must reflect ethnic and geographic diversity
of the state.
Meet quarterly
Draft of council roles/responsibilities and
new rulemaking process on HHSC’s
website at
www.hhsc.state.tx.us/Consolidation/Council
s/
7/16/2015
Center for Public Policy Priorities
10
Status of the Reorganization
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HB 2292 policy changes were effective on September1,
2003, or January 1, 2004.
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New agency commissioners appointed December 18,
2003.
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Organizational structure for new agencies approved.
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DFPS began operations on Feb. 1, 2004; DARS on
March 1, 2004.
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Call center “business case” released on March 25, 2004
DADS and DSHS began operations on September 1,
2004.
Many contracts awarded to manage
7/16/2015
Center for Public Policy Priorities
reorganization/implement
privatization provisions
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11
New Web Sites and Numbers
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www.hhs.state.tx.us — The commission's main site
provides information about all of the state’s HHS
programs.
www.dshs.state.tx.us — The Department of State Health
Services site.
www.dads.state.tx.us — The Department of Aging and
Disability Services site.
www.dars.state.tx.us – The Department of Assistive and
Rehabilitative Services site.
www.dfps.state.tx.us – The Department of Family and
Protective Services site.
HHSC also has a new hot line, (877) 787-8999 – a
centralized referral about health and human services
programs in Texas.
7/16/2015
Center for Public Policy Priorities
12
Major Concerns with Reorganization
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Massive centralization of power at HHSC raises concern
that HHS policy decisions will
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become less open to the public, in particular, the
advocates who look out for the interests of the people
these programs serve;
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more subject to the exclusive priorities of the governor,
over those of the legislature, and therefore more
susceptible to political considerations
Such a large agency (HHSC) will lead to
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more bureaucracy,
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confusion among stakeholders and the public over whom
to contact for a specific programs, and
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Bottlenecks in the rulemaking process
Major Concerns with Reorganization


Massive centralization of power at HHSC raises concern
that HHS policy decisions will

become less open to the public, in particular, the
advocates who look out for the interests of the people
these programs serve;

more subject to the exclusive priorities of the governor,
over those of the legislature, and therefore more
susceptible to political considerations
Such a large agency (HHSC) will lead to

more bureaucracy,

confusion among stakeholders and the public over whom
to contact for a specific programs, and

Bottlenecks in the rulemaking process
Major Concerns with Reorganization
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Loss of specialized HHS agencies will
mean
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less specialized attention and care for clients
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A lack of responsiveness to the advocates
and stakeholders who represent these clients
New agency councils have no authority
over policy direction or rulemaking at their
respective agencies:

New rulemaking process reduces councils to
a superficial advisory body with no real
opportunity to affect the debate
Call Centers & Proposed Integrated Eligibility
Model
 State’s proposal would move most eligibility functions for
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TANF, Food Stamps, and Medicaid to three call centers.
Total eligibility staff would be reduced by 57%, from
7,864 workers to 3,377
57% of local offices would be closed (from 381 to 164);
offices would become “Benefit Issuance Centers.”
Internet application
TIERS - New computerized eligibility determination
system and database (currently under pilot) would
support system
Use of 211 I&R network as gateway to call centers
Private, community-based organizations expected to
DONATE 600 volunteers & 1 million hours to help clients
navigate the new system.
Call Centers & Proposed Integrated Eligibility
Model
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Estimated savings of $389 million in state
and federal funds over five years, 46% of
which is state dollars.
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Original timeline proposed implementation
in September 2004 with overhaul complete
by 2006
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Timeline revised in July with start-up date
of May 1, 2005.
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Call Centers & Proposed Integrated Eligibility
Model
Request for Proposal (RFP) released in July for
1) call centers;
2) Operation and maintenance of TIERS (new
computerized eligibility determination system and
database); and
3) Health plan enrollment and EPSDT screening

Outsourcing of call centers would mean an even greater loss
of state jobs, although small workforce of state staff retained
to make eligibility decisions.
See http://www.hhsc.state.tx.us/Consolidation/Contracting/52904334/rfp_home.html
for more information about RFP
Key Concerns with Call Center Proposal
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Good ideas that should be implemented as enhancements,
not replacement
Too many untested assumptions:
--211 capacity
--Resources/ability/desire of CBOs
--Reliability of TIERS and other technology
--Ability of clients to use Internet/apply by phone
Timeline is overly aggressive with no real pilot phase.
Drastic/immediate reduction in staff without testing could lead
to less access or general system failure
Could reduce access for special needs clients; raises
concerns over potential ADA/civil rights violations.
Could jeopardize the billions of dollars in federal funding for
these programs. Over $17 billion in benefits, state and
federal, issued in 2004.
The “Non-Profit Tax:” Concerns over
Proposed Role for CBOs
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Staffing levels in proposed model are dependent on CBOs
assisting clients navigate the new system; yet no formal
enrollment process
Calls for unpaid volunteers, who may not be a reliable
workforce
No money for staff or the constant training that will be needed
Unclear what will be expected of CBOs: Will they take
applications?
No formal contracting process envisioned; decisions are left
up to private companies who bid on RFP
No discussion of the need for monitoring CBO performance or
penalties if CBOs fail to fulfill responsible assigned to them.
Raises questions about CBO liability or risks to CBOs of
taking on this role. No discussion of CBOs’ ability to:
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Meet statutory or regulatory requirements, such as a client’s “right to
apply without delay”
Comply with application processing timeliness
Key Concerns Over Proposed Staff Levels
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DHS offices are badly understaffed now; local offices and staff
in a constant struggle to do more for less.
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Eligibility staff at local DHS offices reduced 41% since ’97
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Caseload per worker increased 101%
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Inadequate staff levels at DHS eligibility offices have led to
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Poor customer service,
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Lawsuits, and
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Most recently, disruptions in services to Medicaid clients
as a result of a backlog in the processing of renewals.
New approach could jeopardize program integrity
Staffing Shortages at DHS Offices
Staff reductions increase workload at DHS offices
12,000
450
Number of workers
10,000
350
8,000
300
250
6,000
200
4,000
150
100
2,000
50
-
Aug-97
Aug-04
Nov-04
SOURCES: DHS Regional Information and Performance Report, August 14, 1997; DHS Regional
Summary Report, July 2003; DHS Program Budget and Statistics, November 2003.
Caseload per staff
400
Staffing Levels & Average Workload in Region 6
Region 6
State
% of total
staff/cases in
Region 6
# of Cases
204,761
1,176,324
17.4%
Total Staff
2,039
10,414
19.6%
180
191
283,481
1,473,964
19.2%
1,209
6,558
18.4%
375
345
295,485
1,527,161
19.3%
1,140
5,873
19.4%
416
387
% Reduction in # of Total Staff
-44%
-44%
% increase in workload per worker
131%
102%
Estimated # of staff under IE model
656
3,377
Estimated % change in # of staff
42%
42%
Estimated workload per worker*
723
673
Estimated % increase in workload per worker
74%
74%
Aug-97
Average # of cases per worker
Aug-03
Total Case Equivalents
Total Staff
Case Equivalent per Worker (workload)
Nov-03
Total Case Equivalents
Total Staff
Case Equivalent per Worker (workload)
IE Model
* assuming total workload stays the same
Staffing Levels & Average Workload in Region 6
Under IE Model
800
Number of Staff
700
2,000
Staff
600
500
1,500
400
1,000
300
500
200
Workload
100
0
0
Aug-97
Aug-03
Nov-03
IE Model
Average workload
2,500
Recommendations on Integrated
Eligibility Initiative
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New tools should be implemented as an enhancement, not
a replacement, to the current model.
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New approach and tools should be thoroughly tested before
local offices are closed or staff reduced significantly.
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New model should begin with an analysis of how many staff
are needed to run system smoothly
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Business case and proposed model should be revised with
full input from state eligibility workers, advocates, industry,
and other stakeholders.
See our full analysis at www.cppp.org/products/policyanalysis/brfbusinesscase42604.html
New Privatization Provisions
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Provides for privatization of certain
administrative functions for HHS
agencies, e.g., purchasing, human
resources
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HR contract awarded to Convergys in
June
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RFP for purchasing released in July.
Expansion of Medicaid Managed
Care will double the population
served under managed care
contractors (from current 1 million to
more than 2 million)
New Privatization Provisions
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Privatization of certain mental health/mental
retardation services: MR Intermediate Care
Facilities (ICF-MR), state schools, state hospital
Note: One bid received to operate state school
that was deemed inadequate; No bids received
to operate state hospital

Medicaid finger imaging pilot (see
http://www.hhsc.state.tx.us/OIE/MIP/032004_Update.htm
l)
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Prescription drug contracts
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Call center privatization, if cost-effective
See:
www.hhsc.state.tx.us/Consolidation/ICO/ico_TOR.html
for more information about these contracts and the
procurement process.
Major Concerns with
Privatization of Service Delivery
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Access - A more automated, impersonal eligibility
system with low-skilled and untrained staff could lead to
less access
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Jobs - Loss of state employee jobs, particularly in rural
areas
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Accountability - Will state be able to protect client rights
& hold private companies accountable for their
performance in operating these programs?
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28
Taxpayer dollars – Do private companies always offer
the best value when their bottom line is profit?
Long-Term Impact – What is the cost to the state if
things go wrong?
Recommendations for a
Sound HHS Outsourcing Process

Create privatization review board (with legislative and
public members) with authority over major HHS
outsourcing contracts
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Strengthen role of Transition Legislative Oversight
Committee created by HB 2292
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Develop objectives for outsourcing related to
achieving savings, improving service delivery, increasing
program integrity, and local impact that will govern
outsourcing decisions
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Require an independent cost-benefit analysis be
done prior to awarding a major contract to confirm that
these objectives will be met
Recommendations for a
Sound HHS Outsourcing Process
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Develop a standard testing and roll-out process
for new service delivery models that include
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real pilots,
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thorough evaluation, and
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solid fall-back option and safeguards if new
system fails
Develop a process similar to the state agency
rulemaking process for gathering public input
before major outsourcing decisions are
considered or made