Health & Human Services Reorganization and the Integrated Eligibility Initiative

1
Health Human Services Reorganization and the
Integrated Eligibility Initiative
900 Lydia Street - Austin, Texas 78702 Phone
[phone] fax [phone] - www.cppp.org

• One Voice
• A Collaborative for Health and Human Services
• September 30, 2004
• Celia Hagert, Senior Policy Analyst
• (hagert_at_cppp.org)

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Overview

• 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

3
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
• As a result, 83 counties, 10 cities, and three
  public health districts, and three chambers of
  commerce have passed resolutions against the new
  law
• Proposal to Use Call Centers for Eligibility
  Determination
• 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
• State/regional/local job loss
• Raises concerns about accountability, ability of
  state to monitor contractors, performance,
  openness

4
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
  councilswith no rulemaking authority.
• Abolished most advisory committees.

5
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

6
The Health and Human Services Enterprise

• New powers responsibilities of the Health and
  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
The Health and Human Services Enterprise

• New agencies and responsibilities
• Dept. of State Health Services, DSHS (health and
  mental health servicesincludes state hospitals
  community services, alcohol and drug abuse)
• Dept. of Aging Disability Services, DADS
  (mental retardation servicesincludes 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)

8
The Health and Human Services Enterprise

• Agencies that were abolished
• 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.)

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Governor
The ConsolidatedTexas Health and Human Services
System as directed by HB 2292, 78th Legislature

• HHS Transition
• Legislative Oversight Committee
• 2 Senate members
• 2 House members
• 3 Public members
• HHSC Commissioner, ex-officio

Office of Inspector General
Health and Human Services Commission
Executive Commissioner
Health Human 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

HHSC DHS
Assistive Rehabilitative Services Council
State Health Services Council
Aging Disability Services Council
Family Protective Services Council

• Department of Aging and Disability Services
• Commissioner
• Mental Retardation Services
• State Schools
• Community Services
• Community Care Services
• Nursing Home Services
• Aging Services

• Department of Family and Protective Services
• Commissioner
• Child Protective Services
• Adult Protective Services
• Child Care Regulatory Services

• Department of State Health Services
• Commissioner
• Health Services
• Mental Health Services
• State Hospitals
• Community Services
• Alcohol Drug Abuse Services

• Department of Assistive and Rehabilitative
  Services
• Commissioner
• Rehabilitation Services
• Blind and Visually Impaired Services
• Deaf and Hard of Hearing Services
• Early Childhood Intervention Services

MHMR TCADA TDH THCIC
ECI TCB TCDHH TRC
DHS MHMR TDoA
PRS
Agencies formerly providing programs
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 HHSCs website at
  www.hhsc.state.tx.us/Consolidation/Councils/

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Status of the Reorganization

• HB 2292 policy changes were effective on
  September1, 2003, or January 1, 2004.
• New agency commissioners appointed December 18,
  2003.
• Organizational structure for new agencies
  approved.
• DFPS began operations on Feb. 1, 2004 DARS on
  March 1, 2004.
• Call center business case released on March 25,
  2004
• DADS and DSHS began operations on September 1,
  2004.
• Many contracts awarded to manage
  reorganization/implement privatization provisions
  

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New Web Sites and Numbers

• www.hhs.state.tx.us The commission's main site
  provides information about all of the states 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, [phone] a
  centralized referral about health and human
  services programs in Texas.

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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

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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

15
Major Concerns with Reorganization

• Loss of specialized HHS agencies will mean
• less specialized attention and care for clients
• 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

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Call Centers Proposed Integrated Eligibility
Model

• States proposal would move most eligibility
  functions for 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 IR 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.

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Call Centers Proposed Integrated Eligibility
Model

• Estimated savings of 389 million in state and
  federal funds over five years, 46 of which is
  state dollars.
• Original timeline proposed implementation in
  September 2004 with overhaul complete by 2006
• 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/Con
  tracting/52904334/rfp_home.html for more
  information about RFP

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Key Concerns with Call Center Proposal

• 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.

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The Non-Profit Tax Concerns over Proposed Role
for CBOs

• 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
• Meet statutory or regulatory requirements, such
  as a clients right to apply without delay
• Comply with application processing timeliness
• Maintain required records and comply with privacy
  laws

21
Key Concerns Over Proposed Staff Levels

• DHS offices are badly understaffed now local
  offices and staff in a constant struggle to do
  more for less.
• Eligibility staff at local DHS offices reduced
  41 since 97
• Caseload per worker increased 101
• Inadequate staff levels at DHS eligibility
  offices have led to
• Poor customer service,
• Lawsuits, and
• 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

22
Staffing Shortages at DHS Offices

• SOURCES DHS Regional Information and
  Performance Report, August 14, 1997 DHS Regional
  Summary Report, July 2003 DHS Program Budget and
  Statistics, November 2003.

23
Staffing Levels Average Workload in Region 6
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Staffing Levels Average Workload in Region 6
Staff
Workload
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Recommendations on Integrated Eligibility
Initiative

• New tools should be implemented as an
  enhancement, not a replacement, to the current
  model.
• New approach and tools should be thoroughly
  tested before local offices are closed or staff
  reduced significantly.
• New model should begin with an analysis of how
  many staff are needed to run system smoothly
• 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/brf-businessc
  ase42604.html

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New Privatization Provisions

• Provides for privatization of certain
  administrative functions for HHS agencies, e.g.,
  purchasing, human resources
• HR contract awarded to Convergys in June
• 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)

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New Privatization Provisions

• 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.
  html)
• Prescription drug contracts
• Call center privatization, if cost-effective
• See www.hhsc.state.tx.us/Consolidation/ICO/ico_TO
  R.html for more information about these contracts
  and the procurement process.

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Major Concerns with Privatization of Service
Delivery

• Access - A more automated, impersonal eligibility
  system with low-skilled and untrained staff could
  lead to less access
• Jobs - Loss of state employee jobs, particularly
  in rural areas
• Accountability - Will state be able to protect
  client rights hold private companies
  accountable for their performance in operating
  these programs?
• 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?

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Recommendations for a Sound HHS Outsourcing
Process

• Create privatization review board (with
  legislative and public members) with authority
  over major HHS outsourcing contracts
• Strengthen role of Transition Legislative
  Oversight Committee created by HB 2292
• Develop objectives for outsourcing related to
  achieving savings, improving service delivery,
  increasing program integrity, and local impact
  that will govern outsourcing decisions
• Require an independent cost-benefit analysis be
  done prior to awarding a major contract to
  confirm that these objectives will be met

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Recommendations for a Sound HHS Outsourcing
Process

• Develop a standard testing and roll-out process
  for new service delivery models that include
• real pilots,
• thorough evaluation, and
• 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